BURLINGTON HEALTH AND REHABILITATION CENTER
For profit - Limited Liability company
123 Beds
CHAMPION CARE
Data: November 2025
7 Immediate Jeopardy citations
Trust Grade
0/100
#264 of 321 in WI
Last Inspection: May 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Burlington Health and Rehabilitation Center has a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #264 out of 321 in Wisconsin, placing them in the bottom half of facilities in the state, and #4 out of 6 in Racine County, meaning only one local option is better. While the facility is improving, having reduced issues from 31 in 2024 to 25 in 2025, it still faces serious challenges, including a staffing rating of 2 out of 5 stars and a troubling turnover rate of 69%, which is well above the state average. The facility has incurred fines totaling $437,569, higher than 96% of Wisconsin facilities, indicating compliance issues. Furthermore, there were critical incidents such as the failure to properly execute advanced directives for a resident and allowing a resident on oxygen to smoke, both of which pose serious risks to resident safety. Overall, while there are some signs of improvement, the facility's poor ratings and serious incidents warrant careful consideration for families researching care options.
- Trust Score
- F
- In Wisconsin
- #264/321
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $437,569 in fines. Lower than most Wisconsin facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Wisconsin. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 112 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 18%
Review needed
31 → 25 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 31 issues
2025: 25 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 Wisconsin average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 69%
23pts above Wisconsin avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $437,569
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: CHAMPION CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (69%)
21 points above Wisconsin average of 48%
The Ugly 112 deficiencies on record
7 life-threatening 4 actual harm
Aug 2025
16 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 interview the facility did not ensure 1 (R27) of 3 Residents reviewed for indwelling catheters were treated with dignity and respect.*R27's urinary catheter bag was left uncov...
Read full inspector narrative →
Based on observation and interview the facility did not ensure 1 (R27) of 3 Residents reviewed for indwelling catheters were treated with dignity and respect.*R27's urinary catheter bag was left uncovered with yellow urine in the catheter bag visible to peers, staff, and visitors.Findings Include:R27's quarterly minimum data set (MDS) completed 5/31/25 documents R27 has an indwelling catheter.R27's comprehensive care plan documents:R27 has indwelling catheter due to diagnosis of Neurogenic BladderInitiated 11/23/24 Revised 6/11/25On 8/11/25, at 9:55 AM, Surveyor observed Certified Nursing Assistants (CNA) - X and (CNA) - Y bring R27 out of R27's room. R27 was in a wheelchair that was reclined. Surveyor observed CNA-X push R27 down the hall, turn left at the nurse's station, and continue pushing R27 down the hallway and placed R27 in the activity room. Surveyor observed other Residents in the activity room. Surveyor observed R27's catheter bag laying at the bottom of R27's legs with the urine side facing up which would be visible to other Residents, visitors, and staff. R27's foley catheter bag was not covered in a privacy bag.On 8/11/2025, at 3:06 PM, Surveyor observed R27 in the main dining room in a wheelchair. R27's foley catheter bag was hanging on the right side of the wheelchair with the urine side visible to other Residents, visitors, and staff. R27's foley catheter bag was not covered in a privacy bag. R27 was playing bingo. On 8/12/2025, at 11:48 AM, Surveyor observed R27 in the activity room and R27's foley catheter bag was covered in a privacy bag. Surveyor asked R27 if R27 prefers to have R27's bag covered in a privacy bag. R27 stated, Why would I want everyone to see my pee? On 8/12/2025, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E regarding R27's foley catheter bag. UM-E confirmed the expectation is have the foley catheter bag always in a privacy bag and not visible to other Residents, visitors, and staff.On 8/12/2025, at 3:17 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R27 did not have R27's foley catheter bag covered in a privacy bag on 8/11/25 on 2 different occasions in common areas resulting in R27's foley catheter bag visible to other Residents, visitors, and other staff.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not promote and facilitate 1 (R65) of 1 Resident's right to ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not promote and facilitate 1 (R65) of 1 Resident's right to self-determination through support of R65's choice about an aspect of R65's life that is significant to R65.R65 changed rooms in the facility on 7/25/25. R65 had boxes with items important to R65 on R65's dresser and closet area. R65 went to a group activity in a common area on 8/4/25. When R65 returned to R65's room, R65's boxes and items important to R65 were gone. R65 informed Surveyor that Social Worker (SW)-J and Nurse Technician (NT)-BB entered R65's room without permission and removed R65's items. Findings include:The facility policy with a last reviewed date of 7/1/25 titled, Resident Rights documents, in part: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The resident has the right to be informed of and participate in his or her treatment, including: . The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care. The right to be informed, in advance, of changes to the plan of care. The right to be informed in advance, of the care to be furnished and the type of caregiver or professional that will furnish care. The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including, but not limited to: . The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.R65 was admitted to the facility on [DATE].R65's Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents that R65 is cognitively intact.On 8/6/25 at 10:36 AM, R65 informed Surveyor that R65 changed room at the end of July. R65 stated that R65 thinks R65 had 3 boxes on his dresser. R65 pointed to the dresser in R65's room and Surveyor noted that there were no boxes on R65's dresser. R65 stated that R65 had 2 other boxes on the opposite corner in R65's room. Surveyor did not observe any boxes in R65's room. R65 stated that R65 went to a group activity and when R65 returned to R65's room, R65's boxes were gone. R65 stated that R65 found out that SW-J and NT-BB went in R65's room and tossed the room. Surveyor asked if R65 was told prior to the group activity that staff would be entering R65's room. R65 stated no. Surveyor asked what was missing from R65's room. R65 stated that R65 had emptied some of each of the boxes so they were not all the way full. R65 stated that R65 is missing a cup that R65 used to hold ink pens and sharpies. The pens and sharpies are gone too. R65 stated that there was a paper flag banner used at group party/activity at the facility and that was gone. R65 stated a small [NAME] ball that was also given away at a facility group activity was gone. R65 stated that these items did not have any monetary value, but it was sentimental. R65 stated that R65 had a collection of used plastic shopping bags that R65 uses on a regular basis and that was gone. R65 stated that R65 was missing some shelf food and a reusable tote bag as well. R65 stated that there is probably more but R65 can't remember everything that was in the boxes. R65 stated that all the staff needed to do was talk to R65. R65 stated that if R65 thought R65 had time to empty the rest of R65's boxes. R65 stated that R65 approached staff members about his room after the items were removed. R65 stated that staff told R65 that R65 was hoarding and that they needed to remove trash from R65's room. R65 stated that R65 asked staff to go through the boxes and belongings removed from R65's room. R65 was told that it was trash and that it had already been taken to the dumpster. R65 stated that R65 had given a list of missing items to Unit Manager (UM)-D and directed Surveyor to speak to UM-D.On 8/11/25 at 5:01 PM, Surveyor interviewed NT-BB. Surveyor asked if NT-BB had gone into R65's room to remove anything. NT-BB stated to R65 they were belongings but really it was garbage that R65 was saving. NT-BB stated that there was food that was sitting out greater than 24 hours and that was thrown away. NT-BB told R65, after the fact, that the next time R65 wants to save food, staff can label it and put it in the refrigerator. NT-BB stated that R65 had 2 empty pizza boxes and old medicine cups that NT-BB threw away. NT-BB stated that R65 was also stock piling and hiding facility silverware and dishes that NT-BB removed and took to the kitchen. Surveyor asked if NT-BB remembered a paper flag banner or [NAME] ball. NT-BB stated No. On 8/12/25 at 9:36 AM, Surveyor interviewed SW-J regarding R65's items being removed from R65's room. SW-J stated that SW-J just removed garbage. SW-J stated that SW-J care planned R65 as a hoarder. SW-J stated that there were no belongings removed from the room. SW-J stated that they removed old napkins, straws, cups with mold, about 30 facility plates, and empty cigarette packs. SW-J stated there was a box of garbage with a moldy sandwich and cookies removed. Surveyor asked if R65 was aware that SW-J was going to enter R65's room. SW-J stated yes and stated that it occurred on the same day that SW-J care planned R65 as a hoarder.R65's care plan initiated 8/4/25 documents: The resident has a behavior problem [related to] hoarding. Pertinent interventions include Encourage resident to express their feelings. Social services will go in resident's room to remove old food, drink, garbage, plates, silver wear, cups, etc.On 8/12/25 at 10:38 SW-J returned to Surveyor with a post it note dated 8/4/25 and reads, [R65] refused to clean room. Went in with nursing. Surveyor asked if R65 was involved in the care planning regarding hoarding. SW-J stated no, R65 was not involved in that decision. R65 has behaviors and SW-J indicated that it couldn't work like that because of R65's behaviors.On 8/12/25 at 1:31 PM, Surveyor asked R65 if SW-J spoke to R65 about R65's new care plan regarding hoarding and an intervention that stated SW-J can enter R65's room to room items. R65 stated Absolutely not.Surveyor noted that R65's right to be involved in R65's care planning process was dismissed by facility staff. On 8/12/25 at 10:32 AM, Surveyor asked UM-D about a list of missing belongings given to UM-D by R65. UM-D stated that UM-D spoke to R65 about the list and reviewed the list with Nursing Home Administrator (NHA)-A. Surveyor asked what was missing from R65's room. UM-D stated that R65 reported missing pens and clips. UM-D stated that there was a [NAME] ball missing which UM-D informed NHA-A about. UM-D stated that there was some shelf food missing as well. On 8/13/25 at 10:31 AM, Surveyor interviewed NHA-A. Surveyor asked if NHA-A had heard about R65's items missing in R65's room. NHA-A stated that NHA-A had heard that R65 wanted to speak to NHA-A, but NHA-A had not had a chance to speak to him yet but will speak to R65 soon. Surveyor asked if UM-D had provided a list of items that R65 was missing. NHA-A stated that UM-D and NHA-A are working to get R65's items back. NHA-A was aware of a [NAME] ball, pens and clips. Surveyor informed NHA-A that according to R65, R65 is also missing a collection of used shopping bags, a reusable tote bag, shelf food, and a paper banner that held sentimental value. NHA-A stated that NHA-A will follow up with that. Surveyor informed NHA-A of the concern that R65 went to a group activity and was not notified before staff entered R65's room to remove items. R65 returned to R65's room and R65 told Surveyor that R65's room was tossed. On the same day that staff removed items without R65's permission, R65 had a care plan intervention entered that SW-J can enter R65's room to remove items. SW-J informed Surveyor that SW-J did not review that care plan with R65 prior to implementation. R65 informed Surveyor that R65 did not know anything about that care plan intervention. Surveyor informed NHA-A that R65 has the right to self-determination about R65's room and the right to be involved in R65's care plan. NHA-A stated that NHA-A understood that R65 has those rights and stated that NHA-A will meet with SW-J and R65 to determine how to move forward.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 (R5, R...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 (R5, R34 and R65) of 3 residents.
*R5’s wall and heat register in R5’s room was observed to be coated with dirt and a thick layer of dust. R5’s curtains hanging over the heat register was observed to be coated with dirt and black spots.
*R34’s window in R34’s room was observed to have a thick white film and appears cloudy. The outside of the window was observed to be dirty. Near R34’s window, there is a cobweb with two dead flies hanging from it. R34’s window blinds appear to be broken and not functional.
*R65’s air conditioning and heating unit on R65’s wall in R65’s room was observed to be disconnected and coming off the wall on the left side. On the left side of the unit, Surveyor observed an exposed metal pipe covered in dirt and cobwebs. R65’s shared bathroom flooring is curved up to meet the tile on the walls. The flooring was observed to be peeling off the wall, exposing dirt and the dry wall behind it.
Findings include:
The facility policy with a reviewed/revised date of 7/1/25 titled “Safe and Homelike Environment” documents, in part: In accordance with residents’ rights, the facility will provide a safe, clean, comfortable and homelike environment… housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment…
1.) R65 was admitted to the facility on [DATE].
R65’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents that R65 is cognitively intact.
Surveyor reviewed R65’s electronic medical record. Surveyor noted that R65 had a recent room change at the facility and has been in R65’s current room since July 25, 2025.
On 8/6/25 at 10:36 AM, R65 informed Surveyor that the individual air/heating unit in R65’s room is ancient and loud. R65 stated that R65 has hit R65’s leg when walking on that side of the bed due to the way the unit is hanging. Surveyor observed the unit. Surveyor noted the left side of the unit was coming off the wall and hanging down lower than the right side of the unit. Surveyor observed a metal pipe from a previous heating unit/radiator to the left of the current individual air/heating unit in R65’s room. The metal piping is coming up from the floor and is covered with a thick layer of dirt. Surveyor observed cobwebs on the pipe, wall and air/heating unit. R65 directed Surveyor to R65’s bathroom. Surveyor observed what appeared to be laminate flooring covering the floor and curling up about 3 inches to meet the tiled wall. Surveyor observed the laminate flooring is peeling away from the wall in multiple areas. Surveyor noted where the floor is peeling away, there is dirt and dust covering the exposed areas.
On 8/13/25 at 11:18 AM, Surveyor interviewed Maintenance Director (MD)-F. Surveyor asked if MD-F had any concerns with R65’s room. MD-F stated that MD-F had not been into R65’s room since R65 moved in there. Surveyor asked if there is any scheduled work to be completed in R65’s room. MD-F stated that MD-F can look. MD-F looked in the computerized system to check. MD-F stated there is nothing scheduled. Surveyor informed MD-F of the concern that R65’s air/heating unit is detached on the left side and not connected flush to R65’s wall. MD-F was willing to enter R65’s room, but R65 had informed Surveyor that R65 did not want to be disturbed and wanted to sleep. MD-F and Surveyor entered a different resident room so that Surveyor could explain Surveyor’s observations. Surveyor informed MD-F of the concern of a metal pipe that is exposed on the left side of R65’s air/heating unit. Surveyor noted that in the current resident’s room, there is a covering noted over the old units’ metal piping. Surveyor pointed to the covering and informed MD-F that the covering observed is not present in R65’s room and R65’s metal pipe is exposed and covered in dirt and cobwebs. Surveyor informed MD-F of the concern that R65’s laminate flooring is peeling off R65’s wall in R65’s shared bathroom. MD-F thanked Surveyor for making MD-F aware.
On 8/13/25 at 11:30 AM, Surveyor informed Nursing Home Administrator (NHA)-A of the concerns that R65’s air/heating unit is detached on the left side and not connected flush to R65’s wall, that there is an exposed metal pipe coming up from the floor on the left side of the unit that is covered in dirt and cobwebs, and that the laminate flooring in R65’s bathroom is peeling off the wall exposing dirt. NHA-A stated that the maintenance department has ordered more new air/heating units in case they were needed, and they are waiting for them to come in. NHA-A indicated that NHA-A will address Surveyor’s concerns with MD-F.
2.) On 8/11/25, at 8:21 AM, Surveyor observed R5’s wall to the left of the bed. Surveyor noted the grids on top of the heat register where the air comes out, to be dirty and coated with thick dust. Surveyor noted the wall above the register grid to be black and coated in heavy dirt. Surveyor also noted, R5’s curtains hanging directly over the heat register to be coated with dirt and black spots scattered on the curtains.
On 8/13/25, at 9:01 AM, Surveyor interviewed Concierge Coordinator (CC)-K who indicates housekeeping, maintenance and herself make observations of resident rooms to ensure cleanliness and ensure equipment is working, prior to residents being admitted into the facility. CC-K states the facility has a couple resident rooms that require touch ups, and the facility avoids putting residents in these rooms. Surveyor notified CC-K of concerns with R5’s heat register, wall, and curtain being coated in dirt with multiple black spots. CC-K walked Surveyor down to R5’s room for observation. CC-K acknowledged these concerns and states she will be putting in a work order to have maintenance and housekeeping address these concerns. CC-K states R5 was recently admitted to the facility and the previous resident was in that room long term. CC-K states the facility is discarding curtains and placing blinds in resident rooms which tells her the previous resident was in R5’s room for a long time prior to R5 being admitted .
On 8/13/25, at 10:35 AM, Surveyor notified Director of Nursing (DON)-B of concerns above. DON-B acknowledged these concerns.
3.) R34 was admitted to the facility on [DATE].
On 8/13/25, at 10:16 AM, Surveyor observed R34’s windows. Both windows have a very thick white film on the inside, appearing very cloudy like, the window on the right is slightly up with a cobweb hanging from it with two dead flies hanging from it. The outside windows are very dirty on the outside. The windowsill in between the inside and outside windows are very dirty with debris. There is no cord on the right side to pull up the blinds on the windows. On 8/13/25, at 10:28 AM, Surveyor interviewed Housekeeping (HK)-T in regard to the process of cleaning Resident rooms. HK-T explained there is daily cleaning expectations and then every Resident room is deep cleaned on a monthly basis. HK-T explained a monthly calendar is maintained to schedule the deep cleans. With a deep clean, one of the expectations is that the windows are cleaned including the frame, inside windows, and windowsills. HK-T stated if the staff notice something is not working right or appears to be broke it would be passed on to maintenance. HK-T stated HK-T does not know why HK-T’s staff can’t clean the outside windows. HK-T does not if it is the maintenance department or an outside company responsibility to clean the outside windows. HK-T has sometimes asked permission from the facility to clean the outside windows. HK-T informed Surveyor that R34’s window was last deep cleaned on 7/28/25 and 8/26/25 is the next scheduled deep clean. On 8/13/25, at 10:44 AM, Surveyor and HK-T went to R34’s room. Surveyor received permission from R34 to enter and observe R34’s windows. It was determined the windows are extremely dirty on the outside. HK-T agreed that the inside sills should have been cleaned by the housekeeper and will follow up. HK-T agreed there is no pull strip to raise up the blind. HK-T had to pull the blind to the side to observe the extremely dirty window and the dirty windowsills. HK-T stated the windowsills between the inside and outside windows should have been cleaned in the deep clean and got missed. HK-T stated maybe it is because the blind would not open. On 8/13/2025, at 11:18 AM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A regarding R34’s dirty windows and broken blind. Surveyor shared with NHA-A that HK-T agreed the windows were extremely dirty, the sills between the inside and outside windows are very dirty with cobwebs and two dead flies and the blind is broken and cannot be raised up. NHA-A acknowledged the concern and has no further information to provide at this time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R53) of 2 residents with allegations of abuse were reported...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R53) of 2 residents with allegations of abuse were reported to the Nursing Home Administrator (NHA)-A per facility policy, the state agency and one or more law enforcement entities.*On 7/2/25, R59 informed 3 different facility staff members that CNA-FF was rough with R59. This allegation was not reported to the Nursing Home Administrator (NHA)-A, the state agency and one or more law enforcement entities. Findings include:The facility policy, with a last reviewed/revised date of 7/1/25, titled Abuse, Neglect and Exploitation documents, in part: It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property. Reporting/Response: . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. It is important staff feel comfortable to report all concerns by assuring that reporters are free from retaliation or reprisal. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.R59 was admitted to the facility on [DATE] with diagnosis that includes Cerebral Palsy.R59's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documents that R59 is cognitively intact. R59 uses a wheelchair and is dependent for transfers.On 8/7/25 at 8:48 AM, Surveyor interviewed R59. R59 informed Surveyor that a few weeks ago, R59's CNA, CNA-L, needed help getting R59 into the wheelchair. CNA-L went to get help from CNA-FF. Both CNA-L and CNA-FF returned to R59's room. R59 stated that during the transfer, CNA-FF was really, really rough. R59 stated that when R59 was put in R59's wheelchair, R59's feet got caught in some plastic on the wheelchair footrests. While CNA-L was trying to gently guide R59's feet, CNA-FF yanked the chair back hard. R59 stated that the yanking did not cause R59's skin to break but stated that the action really hurt. R59 stated that on other occasions, CNA-FF had been very rough with cares and was bossy and intimidating. Surveyor asked if R59 told anyone about what happened. R59 stated that R59 told CNA-L, a nurse and R59's Occupational Therapist (OT)-GG. R59 stated that OT-GG helped R59 fill out a grievance form. R59 stated that after [R59] informed staff about the concern, CNA-FF came back to R59's room and started apologizing. R59 stated that R59 thinks that administration told the staff member of R59's concern and that is why CNA-FF returned to R59's room. R59 stated that R59 felt intimidated.Surveyor reviewed the grievance log for the last 6 months and noted that there was no grievance logged about CNA-FF being rough with R59.Surveyor reviewed the Facility Reported Incident folders for the last 6 months and noted that there were no incidents documented about CNA-FF being rough with R59. On 8/7/25 at 9:01 AM, Surveyor interviewed CNA-L. Surveyor asked about the incident with CNA-FF. CNA-L stated that R59 is very sore when R59 wakes up in the AM. CNA-L stated that CNA-L works slower with R59 because of that. CNA-L stated that CNA-FF was helping get R59 into R59's wheelchair via the Hoyer lift. CNA-L indicated that CNA-FF yanked R59 from behind and caused R59 to start yelling about R59's feet. CNA-L indicated that CNA-L could not believe how CNA-FF was treating R59. CNA-L stated that CNA-L felt like CNA-FF was rough with R59 and many other residents during cares and transfers. CNA-L stated that other residents had complained about CNA-FF. Surveyor asked what residents complained. CNA-L indicated that CNA-L cannot recall specific names, but the residents are no longer at the facility. Surveyor asked when CNA-L last saw CNA-FF working at the facility. CNA-L stated that CNA-L had not seen CNA-FF in a while and stated, I hope [CNA-FF] doesn't come back for there [the residents] sake. Surveyor asked if CNA-L told anyone about the incident. CNA-L stated that it is a hard position to be in CNA-L was not sure what to do. CNA-L indicated that R59 told the Social Worker.Surveyor noted that CNA-L had concerns about CNA-FF being rough with R59 and other residents and did not report this allegation of abuse to NHA-A per facility policy.On 8/7/25 at 10:40 AM, Surveyor interviewed OT-GG. Surveyor asked if OT-GG recalled a time that R59 reported a CNA being rough. OT-GG stated that a few weeks ago, R59 reported to OT-GG that CNA-FF was rough during cares and a transfer. OT-GG stated that CNA-FF can be rough. OT-GG stated that R59 told OT-GG that CNA-FF pulled too hard during a transfer and hurt R59. R59 asked OT-GG for help writing a grievance. OT-GG indicated that OT-GG told R59 that they could write it out and contact the Social Worker. Surveyor asked who OT-GG gave the grievance to. OT-GG indicated that OT-GG would normally give it to the Unit Manager or the Social Worker, but OT-GG is not sure who OT-GG gave the grievance form to. On 8/7/25 at 1:10 PM, Surveyor returned to OT-GG and asked about the grievance form. OT-GG stated that OT-GG thinks that OT-GG helped R59 fill out the grievance form because R59 has such a hard time writing. OT-GG unsure where it ended up. OT-GG stated that OT-GG usually takes copies of everything. OT-GG began looking in office. After looking, OT-GG stated that OT-GG could not find the form and thinks maybe R59 handed it in. OT-GG stated that Surveyor should check with Unit Manager (UM)-D. OT-GG stated that a lot of times, the Unit Mangers will address the concern with the resident and then feel like that concern is complete and maybe that is the case with this, but OT-GG was not sure.Surveyor noted OT-GG was told by R59 that CNA-FF was rough with cares and transfers and did not report this allegation of abuse NHA-A per facility policy.On 8/7/25 at 1:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who was the nurse working on R59's unit on 7/2/25. Surveyor asked if R59 talked to LPN-G about another staff member. LPN-G stated that R59 informed LPN-G that CNA-FF was rough with cares and R59 does not like having CNA-FF as an aide and did not want CNA-FF as R59's aide. Surveyor asked if LPN-G informed anyone about R59's concerns. LPN-G stated that LPN-G told the Unit Manager. Surveyor asked if any documentation was completed after being told that by R59. LPN-G stated that LPN-G was not sure but stated that residents/staff usually have to fill out a grievance or incident report when something like that happens.Surveyor noted that on 7/2/25, a third staff member was told by R59 about CNA-FF being rough and this allegation of abuse was not reported to NHA-A per facility policy.On 8/7/25 at 11:20 AM, Surveyor interviewed NHA-A. Surveyor asked what the expectation is if a staff member is told by a resident that another staff member was rough and hurt them. NHA-A stated that they should follow the abuse policy and report it to me. Surveyor asked if NHA-A was informed about a CNA being rough with R59. NHA-A stated that NHA-A did not recall the incident of the top of NHA-A's head. NHA-A stated that NHA-A would get back to Surveyor.On 8/7/25 at 12:22 PM, NHA-A returned to Surveyor and provided Surveyor with a note completed and signed by UM-D regarding the incident. NHA-A stated that the incident occurred about 2 months ago. NHA-A indicated that the incident was not a report of rough with cares or transport but more of a preference that R59 had for transferring. NHA-A indicated that UM-D provided education to CNA-FF and watched CNA-FF and CNA-L complete a transfer after the fact. UM-D did ask R59 if UM-D could bring CNA-FF back to R59's room before allowing CNA-FF to return to R59's room. NHA-A stated that there is no documentation of the event aside from the note that given to Surveyor.The undated word document signed by UM-D documents: CNA came to get writer regarding resident [R59] and a transfer that happened. [R59] stated that CNA-L and CNA-FF were transferring [R59] and pushed on [R59's] leg when the transfer occurred. Writer asked [R59] to show [UM-D] where they pushed on [R59's] leg. [R59] stated [R59] was fine now just during the transfer it hurt. [R59] has chronic discomfort with transfers due to [R59's] cerebral palsy and leg pain in which [R59] is on pain medication for. [R59] stated [R59 has never had issues with [CNA-FF or CNA-L] but the transfer felt different today. Writer asked if [writer] could bring [CNA-FF] in to speak with us. [R59] agreed. [CNA-FF] apologized that [R59] experienced pain with the transfer. [R59] stated that [R59] understood that it was not done purposeful just wants everyone to be very careful when putting [R59] from Hoyer into chair due to the pain. Writer watched a transfer with staff and saw no issues. Staff is aware of not pushing on residents' leg to position [R59] into the chair.On 8/7/25 at 1:08 PM, Surveyor returned to UM-D and asked when UM-D signed the note regarding CNA-FF and R59. UM-D indicated that the transfer occurred on 7/2/25 and that is when the note was signed.On 8/11/25 at 8:53 AM, Surveyor interviewed SW-J who is R59's social worker. Surveyor asked if SW-J received a grievance from R59 on 7/2/25. SW-J stated that there is no grievance for that. Surveyor asked if SW-J had heard from R59 or another staff member that a CNA was rough. SW-J stated that SW-J never heard from any staff about another staff member being rough with R59. Surveyor asked what the protocol is if a resident reports that a staff member was rough. SW-J stated that SW-J would report that to the unit manager.Surveyor noted that SW-J told Surveyor that SW-J would tell the unit manager of a resident's report of a staff member being rough instead of the NHA-A per facility policy.On 8/7/25 at 10:43 AM, Surveyor interviewed CNA-S. Surveyor asked what CNA-S would do if a resident reported that a different staff member was rough with cares or a transfer. CNA-S stated that CNA-S would report that to a manager right away so they can start investigating.Surveyor noted that CNA-S told Surveyor that CNA-S would tell the unit manager of a resident's report of a staff member being rough instead of the NHA-A per facility policy.On 8/11/25 at 8:58 AM, Surveyor interviewed DON-B. Surveyor asked what DON-B would expect a staff member to do if a resident reported that a different staff member was rough with cares. DON-B stated that staff should report it to DON-B or NHA-A.On 8/13/25 at 2:50 PM, Surveyor informed NHA-A and DON-B of the concern that on 7/2/25, 3 staff members were informed by R59 that CNA-FF was rough. This allegation of abuse was not reported to the NHA-A per facility policy, was not reported to the state agency and was not reported to one or more law enforcement entities.
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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure that residents with pressure injuries received ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries from developing for 3 (R1, R16 and R53) of 5 residents reviewed for pressure injuries.
*R53 developed a facility acquired, Suspected Deep Tissue Injury (DTI) on 7/22/25. The pressure injury was incorrectly staged on 7/29/25 when it developed slough and continued to be staged as a DTI. The wound treatment was recommended to be changed but facility staff continued treating the wound with skin prep as previously ordered. On 8/5/25, the facility documented the same measurement of an unstageable wound and documented an area of DTI with a new measurement. With the changes in R53’s wound, R53’s care plan was not updated. On 8/13/25, Surveyor was provided with a late entry progress note from R53’s MD documenting a stage 2 wound in the sacral area. Surveyor noted the incorrect location and stage. The late-entry MD progress note documented that skin prep can be used as treatment as of 7/31/25. Surveyor noted that despite the late entry progress note, facility staff did not follow recommendations listed on the 7/29/25 wound assessment. On 8/14/25, Surveyor was provided a correction to the late entry progress note from R53's MD documenting R53's wound as an unstageable wound in the lower back, just to the right of the midline. During survey, Surveyor observed R53’s heels not floated as care planned.
*R1 is at risk for pressure injuries and has a history of pressure injury to heels. Surveyor observed R1’s heels resting directly on R1’s bed and not being floated.
*R16’s pressure injury treatments were not always completed as ordered during the months of July and August 2025.
Findings include:
The facility policy with a last reviewed date of 4/17/25 titled, “ Pressure Injury Prevention and Management” documents, in part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries… Assessments of pressure injuries will be performed by a licensed nurse and documented on the medical record. The staging of pressure injuries will be clearly identified to ensure correct coding on the [Minimum Data Set Assessment]… Training in the completion of the pressure injury risk assessment, full body skin assessment, and pressure injury assessment will be provided as needed… After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment… Basic or routine care interventions could include, but are not limited to: Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc,)… Provide appropriate, pressure-redistributing, support surfaces… Evidence-based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present… Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection wound be, wound edge and surrounding tissue characteristics… Interventions will be documented in the care plan and communicated to all relevant staff. Compliance with interventions will be documented in the weekly summary charting. The attending physician will be notified of: The presence of a new pressure injury upon identification. The progression towards healing, or lack of healing, of any pressure injuries weekly…
The National Pressure Injury Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance published “Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline” in 2019 which documents, in part: International NPUAP/EPUAP Pressure Ulcer Classification System defines a Suspected deep tissue injury as a “purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.” … NPUAP/EPUAP defines Unstageable pressure injury as full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage cannot be determined…
R53 was admitted to the facility on [DATE] with diagnosis that include: Chronic Obstructive Pulmonary (lung) disease, Heart failure, Stage 2 kidney disease, Depression and Metastatic melanoma (skin cancer) progressing to metastatic lung cancer, History of spinal fusion L2, 3-4 and disc herniation in 1998.
R53’s Annual Minimum Data Set (MDS) assessment dated [DATE] documents, R53 is moderately cognitively impaired. R53 is independent for bed mobility and chair to bed transfer. R53 is occasionally incontinent of bladder and always incontinent of bowel. R53 is not at risk for pressure injuries and does not have an unhealed pressure injury.
R53’s Pressure injury Care Area assessment dated [DATE] documents [R53] is at risk for pressure injuries [related to] incontinence, weight loss from disease process and limited mobility.
R53 has a guardian. R53 is on hospice which was started in June of 2023.
R53’s Potential for impaired skin integrity care plan initiated on 6/20/23 documents the following interventions: Assist to reposition approximately [every] 2 hours and [as needed]. Assist resident into chair as needed. Apply cushion to [wheelchair]. Barrier cream after each incontinent episode and [as needed]. Free float heels in bed. Lotion skin with cares. Monitor skin with all cares. Report any changes to nurse.
R53’s Certified Nursing Assistant (CNA) Kardex (provided during survey) documents, in part: Bed Mobility: the resident requires no assistance by staff to turn and reposition in bed an as necessary. Resident Care: Assist to reposition approximately [every] 2 hours and [as needed]. Free float heels in bed.
R53’s progress note dated 7/9/25 at 10:11 AM, documents, in part: Resident being sent to hospital [due to] being unable to keep any intake down. Hospice at bedside…
R53 was admitted to the hospital from 7/9-7/10/25.
R53’s hospital Discharge summary dated [DATE] documents, in part: … [R53] was sent to the emergency department . due to swallowing difficulties and apparent abdominal pain… [R53] had a CT scan that showed worsening metastatic disease and a thickened area of bowel concerning for infection versus mass. [R53’s] guardian was contacted who agreed with continuing hospice care… Will discharge back to [facility] under hospice care with medications as previously ordered.
R53’s Braden Scale Evaluation (an evaluation to predict pressure injury risk) dated 7/10/25 documents a score of 16 making R53 at moderate risk for pressure injury development.
R53’s progress note dated 7/10/25 at 5:06 PM documents, in part: … No skin issues noted…
R53’s progress note dated 7/11/25 at 10:57 AM documents, in part: … Resident slept on and off throughout shift. Continue to monitor.
R53’s progress note dated 7/13/25 at 12:25 PM documents, in part: … Spent most of this shift sleeping…
R53’s progress note dated 7/13/25 at 10:08 PM documents, in part: … Resident did not eat dinner… slept most of shift.
R53’s progress note dated 7/14/25 6:48 AM documents, in part: …Resident is currently in bed sleeping…
R53’s progress note dated 7/14/25 at 11:07 AM documents, in part: Resident sleeping throughout shift…
Surveyor noted facility staff documented multiple days after R53’s hospitalization that R53 was sleeping.
On 8/12/25 at 9:26 AM, Surveyor interviewed Licensed Practical Nurse (LPN)-G. Surveyor asked how R53’s health was after returning from the hospital to the facility. LPN-G indicated that LPN-G did not think that R53 would come back to the facility because R53 was so sick. LPN-G stated that R53 is not as mobile as R53 had been and indicated that R53’s health was declining.
On 8/12/25, Surveyor reviewed the last 30 days of R53’s CNA tasks documentation of R53 being turned and repositioned every 2 hours. CNAs are directed to complete this documentation every shift. The question asks Did you turn and reposition? Surveyor counted 3 out of the 30 days that CNAs documented an answer each shift, leaving the other 27 days without completed documentation each shift. Surveyor noted that the following shifts were documented as No, indicating CNA did not assist resident with turning and repositioning: On 7/13/25 at 11:54 AM, CNA charted No to turning and positioning. On 7/20/25 at 11:51 PM, CNA charted No to turning and repositioning. On 7/22/25 at 2:15 AM, CNA charted No to turning and repositioning. On 7/23/25 at 1:33 AM, CNA charted NO to turning and repositioning. On 7/24/25 at 2:10 AM, CNA charted No to turning and positioning. On 7/29/25 at 5:39 AM, CNA charted No to turning and repositioning. On 8/5 at 10:38, charted No to turning and repositioning.
R53's Nutrition progress note dated 7/14/25 at 1:38 PM documents, in part: readmitted post hospital stay for [nausea/vomiting] . Continues with variable intake 25-100% . Tolerating diet [without] issues per nursing, resident sleeping on attempt to visit. Magic cup [two times a day] and Mighty shake 4oz [three times a day] in place for nutrition support; accepts 100%. Skin intact. Resident with [history significant weight] loss, likely [related to] disease progression, variable intakes and Hospice care. Further [weight] loss anticipated and likely unavoidable. [Continue] current diet and . [continue] to offer food/fluids as tolerated and follow food preferences .
Surveyor reviewed R53's meal intakes for the last 30 days. Surveyor noted R53 eats 0 to 100% of meals. Surveyor noted that not every meal was documented by Certified Nursing Assistants.
R53’s progress note dated 7/22/25 at 12:50 PM documents: [Suspected Deep Tissue Injury (SDTI)] noted to lower mid spine. Area measures 2 [Centimeters (CM)] x 1.5 CM x 0 CM. Area noted to be dark purple and red in color and not blanchable. Skin surrounding wound noted to be light pink and blanchable. Area cleansed with normal saline and boarder foam dressing applied. Resident instructed that [R53] needs to lay on [R53’s] sides to sleep due to SDTI. Hospice ordered an air mattress for Resident as well. Will continue to monitor.
R53’s Initial Wound assessment dated [DATE] documents: Date wound was identified: 7/22/25. Where was the wound acquired? Acquired after admission to facility. Type of wound? Pressure. Vertebrae (upper-mid) Pressure 2 cm x 1.5 cm Suspected Deep Tissue Injury. 100% granulation… Resident has poor intake of food. Repositioning completed every 2-3 hours and as needed… Treatment in place, air mattress, repositioning every 2-3 hours and as needed. Physician notified…
R53’s skin integrity care plan documents the following interventions dated 7/22/25: Use pillows to prop, reposition and offload resident off of [R53’s] back every 2 hours. APM (alternating pressure mattress).
R53’s Braden Scale evaluation score dated 7/22/25 is 14 making R53 at moderate risk for developing a pressure injury.
R53’s MD orders dated 7/22/25 documents, DTI to lower mid spine: Skin prep and cover with foam dressing twice daily. Two times a day for wound care.
Surveyor reviewed R53’s Treatment Administration Record (TAR) and noted facility staff completed the treatment 2 times a day from 7/22/25 through 7/29/25.
R53’s Weekly wound assessment dated [DATE] documents, in part: Wound Measurement date 7/29/25. Pressure wound of Vertebrae (upper-mid) 2 cm x 1.5 cm Suspected Deep Tissue Injury. 50% granulation, 50% slough… Resident has slough present on wound. Treatment was changed to Dakin's quarter strength, skin prep, cover with calcium alginate and a border foam…
Surveyor noted that R53’s wound developed slough. The facility incorrectly staged the wound as a SDTI instead of an unstageable or stage 3 pressure injury. According to NPUAP/EPUAP pressure ulcer classification system a wound that develops slough is not a SDTI, this would be staged as an unstageable or stage 3 wound depending on the characteristics of the wound bed.
Surveyor reviewed R53’s care plan and noted that R53’s care plan was not updated with a new care plan intervention after R53’s DTI progressed to a pressure injury with slough.
Surveyor reviewed R53’s MD orders and noted facility staff did not enter the new recommended treatment change documented on the 7/29/25 wound assessment.
Surveyor reviewed R53’s TAR and noted facility staff continued treating R53’s wound that had developed slough with skin prep and border foam dressing from 7/29/25 through 8/5/25.
R53’s Weekly wound assessment dated [DATE] documents, in part: Wound Measurement date 8/5/25. Pressure wound of Vertebrae (upper-mid) 2 cm x 1.5 cm Unstageable. 50% granulation. 50% slough. Are abnormalities noted to wound edges/peri-wound? No… Resident has slough present on wound. Treatment was changed to Dakin's quarter strength, skin prep, cover with calcium alginate and a border foam. DTI distal to prior DTI noted measuring 2 x 1. Repositioning is being completed every 2-3 hours and as needed. Resident is on hospice and not able to take in nutrition appropriately. Resident on hospice services [related to] terminal lung cancer.
Surveyor noted that the measurement of the initial pressure injury remained the same as the initial wound assessment on 7/22/25 and weekly wound assessment on 7/29/25. Surveyor noted that the facility documented no abnormalities noted to the wound edges/peri-wound. Surveyor noted facility staff documented a measurement of an additional DTI distal to the prior DTI.
R53’s MD order dated 8/5/25 documents: DTI to lower mid spine: Cleanse with 1/4 strength Dakin's, skin prep to surrounding area, apply calcium alginate, [followed by] border foam dressing daily. One time a day for wound care.
Surveyor noted that the treatment change recommended on 7/29/25 and 8/5/25 was implemented by facility staff on 8/5/25.
Surveyor reviewed R53’s care plan and noted that R53’s care plan was not updated with a new care plan intervention after R53 developed an additional “DTI distal to prior DTI.”
On 8/7/25 at 10:39 AM, Surveyor observed R53 on R53’s back in bed. R53’s head of bed (HOB) is elevated 40%. Survey noted air mattress to R53’s bed is on and functioning. R53’s heels resting on bed and not elevated/floated.
On 8/7/25 at 1:06 PM, Surveyor observed R53 on R53’s back in bed. R53 has a pillow under R53’s left lower back. R53’s heels resting on bed and not elevated/floated.
On 8/11/25 at 12:59 PM, Surveyor observed R53 sleeping in bed. R53 has 2 pillows placed under R53’s back. Surveyor noted R53’s left heel was resting on bed and not elevated/floated.
Surveyor noted multiple observations of R53’s heels resting on the bed and not elevated/floated per care plan intervention.
On 8/11/25 at 8:25 AM, Surveyor interviewed CNA-EE. Surveyor asked what interventions were in place for R53’s heels. CNA-EE indicated that CNA-EE was not sure. CNA-EE stated that R53 gets cream on R53’s back. CNA-EE stated again that CNA-EE was not sure about what is done.
On 8/12/25 at 9:26 AM, Surveyor interviewed LPN-G. Surveyor asked what interventions were in place for R53’s skin. LPN-G stated that LPN-G would have to check the medical record. LPN-G looked in the electronic medical record and stated that R53 has an air mattress and is being turned.
Surveyor noted staff did not mention free floating of heels as part of R53's care plan interventions.
On 8/12/25 at 10:06 AM, Surveyor observed wound rounds with Unit Manager (UM)-D. R53 was observed sitting in R53’s electric wheelchair and leaning forward. After washing hands and donning gloves, UM-D removed the dressing with a date of 8/11/25 written on it. UM-D did not measure the wound. The wound was cleansed, and the treatment completed. A new dressing with the date of 8/12/25 was placed on R53’s pressure injury. Surveyor observed 2 separate wounds. Surveyor observed a dime size round unstageable pressure injury with 100% slough to the mid/lower back just to the right of R53’s spine. Surveyor observed a small purple DTI located on R53’s mid-spine to the left and above the unstageable wound. UM-D stated that R53’s wound started as a DTI and was dark purple. UM-D indicated that the area with slough opened up and a spot of purple remained to the upper left side in the peri-wound. UM-D stated with this assessment the small area/DTI is more separated from the original wound than it was in the previous week assessment. UM-D stated that R53 has an unstageable pressure injury and a DTI.
Surveyor noted that during the wound observation, Surveyor made no observations of any mass that could have potentially led to the development of the pressure injury. Surveyor noted UM-D did not point out any masses during the wound treatment of R53’s wounds.
After R53’s wound care was completed, Surveyor asked why UM-D thinks that R53 developed a pressure injury. UM-D stated that R53 is unable to eat normally, and it is hard to keep any food down because of R53’s stage 4 cancer diagnosis. Surveyor noted that UM-D made no mention of any mass that could have led to the development of R53’s pressure injury.
Surveyor asked about R53’s mobility after hospitalization. UM-D stated that R53 was in bed a couple days but then was getting up in R53’s wheelchair. Surveyor asked what interventions are in place for R53’s skin. UM-D indicated that R53 got an air mattress the day that the pressure injury was found. UM-D indicated that they did not place an air mattress on before that because it caused a fall risk for R53. Surveyor asked if measuring a wound is part of the weekly wound round. UM-D indicated they measure weekly. Surveyor asked why R53’s wound was not measured during the wound treatment observation. UM-D stated that UM-D completed the measurements earlier this morning. UM-D stated that the unstageable wound measured 1.5 cm x 1.5 cm, and the DTI measured 0.5 cm x 1 cm. Surveyor asked if the wound dressing dated 8/11/25 that surveyor observed at beginning of the wound rounds on 8/12/25 was removed and then replaced after measuring earlier this morning. UM-D stated that UM-D measured the wounds yesterday (8/11/25). Surveyor asked who enters the treatment orders if a treatment change is recommended for R53. UM-D stated that UM-D would enter the orders.
Surveyor reviewed R53’s electronic medical record and did not locate a pressure injury wound assessment or measurements documented dated 8/11/25.
R53’s Weekly wound assessment of the Unstageable pressure injury dated 8/12/25 documents, in part: Wound Measurement date 8/12/25. Pressure wound of Vertebrae (upper-mid) 1.5 cm x 1.5 cm. Unstageable. 100% slough. Are abnormalities noted to wound edges/peri-wound? No… Treatment in place. Area has 100% slough noted to be expected. Peri wound DTI 0.5 x 1.0 has separated from the peri wound intact skin separating between unstageable and DTI presenting as 2 areas instead of one…
R53’s Weekly wound assessment dated [DATE] documents, in part. Wound Measurement date 8/12/25. Type of wound pressure. Vertebrae (upper-mid) 0.5 x 1 Suspected Deep Tissue Injury. 100% eschar… Encouraging to turn and reposition every 2-3 hours and as needed. Peri wound DTI 0.5 x 1.0 has separated from the peri wound of the initial wound separating between unstageable and DTI presenting as 2 areas instead of one.
Surveyor noted that the facility documented a separate DTI and documented that the DTI had 100% eschar. According to NPUAP/EPUAP pressure ulcer classification system a wound that is 100% eschar is an unstageable wound. Surveyor noted during observation of R53’s wounds, that R53 had a small purple DTI. Surveyor did not observe eschar.
On 8/12/25 at 1:51 PM, Surveyor interviewed Director of Nursing (DON)-B, and UM-D. DON-B indicated that the Unit managers complete the wound rounds each week. DON-B, who is wound certified, oversees the wound program at the facility. The resident’s primary doctor with their colleagues and the medical director oversees DON-B’s wound program. Surveyor shared concern that R53 had a decline in R53’s health after R53’s hospitalization and R53 was not put on an air mattress to prevent pressure injury development. DON-B indicated that R53 was up and moving around soon after that hospitalization. The pressure injury developed because of R53 has not been able to eat and keep anything down. R53 has multiple contributing factors including, cancer, smoking, his kyphosis and positioning. DON-B indicated that Hospice is also involved in R53’s cares and did not order an air mattress. After developing the pressure injury, an air mattress was ordered and placed on R53's bed. Surveyor shared concern that after the wound developed slough on 7/29/25, the wound was staged incorrectly and still documented as a DTI. In addition, the treatment recommendations on the 7/29/25 weekly wound assessment were not implemented and staff continued to treat a wound with slough with skin prep. The next week on 8/5/25, R53 developed (what the facility documented) a DTI distal to prior DTI. DON-B stated that the development of slough is not worsening of the wound, the development of slough is to be expected. DON-B stated that the distal DTI documented with the unstageable wound on 8/5/25 was part of the original wound and that this was not a new area. DON-B stated there was not a good way to document the DTI assessment because it really was part of the original wound. Surveyor asked why the treatment change on 7/29/25 was not entered as an MD order. UM-D stated that UM-D would need UM-D’s computer and would have to look into it.
UM-D did not return to Surveyor.
On 8/12/25 at 3:05 PM, Surveyor informed Nursing Home Administrator and DON-B of the concern that R53 developed a DTI to R53’s back on 7/22/25. On 7/29/25, the wound was assessed with 50% slough and 50% granulation and was staged incorrectly as a DTI instead of an unstageable or stage 3 pressure injury. The treatment was recommended to be changed, and facility staff did not enter the order change. Staff continued to treat the pressure injury with slough and granulation with skin prep. On 8/5/25, there was an area documented by facility staff as a DTI and an area of unstageable pressure injury. After any changes in the wound, the care plan was not updated with new interventions.
On 8/13/25 at 8:21 AM, DON-B informed surveyor that the facility does an investigation after a resident develops a pressure injury. DON-B provided Surveyor with a folder that included the investigation, hospital records, and an Unavoidable vs Avoidable pressure injury form completed by R53’s primary MD.
The Verification of Investigation form signed by DON-B on 7/31/25 documents in part: … 7/22/25 Resident presented with bruising to lower-mid back vertebrae… suspected deep tissue injury… Resident is unable to sit fully upright due [to] lordosis/kyphosis, leaning to left which anatomically off loads pressure to affected area… Resident has had a progressive decline in condition which started in early July due to resident being unable to swallow, and insisting to go to ER for further workup… Resident had no skin concerns upon return on 7/10/25. Risk of adding air mattress would have caused increased injury as Resident continued self-transferring as care planned. Resident complained of pain to back on 7/22/25. DON questioned Resident if [R53] remained on gurney while in ER and resident stated “[R53] could not recall the type of bed it was.” Presentation of wound appeared to be a bruise however due to location and residents’ recent hospitalization [and] lack of intake, writer opted to classify discoloration as a DTI due to hospice service unable to rule out if area was truly a DTI vs metastatic changes based on [history] of melanoma and lung cancer, as lung cancer alone causes changes to integumentary system. [Registered Nurse/Assistant Director of Nursing] assessed back with bruise/DTI noted with MD contacted and treatment put into place. On 7/29/25, resident noted to have changes to area which opened presenting with slough, however, the peri wound had bruising/DTI remaining… considered changing wound to potentially a Kennedy ulcer/lesion based on resident’s lack of intake, history of metastatic melanoma which can present as a DTI and no other signs of pressure present… On 7/31/25…writer/DON… discussed with MD area of concern. MD/[Nurse Practitioner] agreed wound appeared to be unavoidable due to resident’s diagnosis/prognosis in which integumentary changes would be inevitable…
On 8/13/25 at 9:13 AM, Surveyor interviewed DON-B about the investigation folder. Surveyor stated that a week after developing a pressure injury, the wound progressed and developed slough. Surveyor asked why the treatment order change documented in the 7/29/25 wound assessment was not entered by facility staff as an MD order. DON-B stated that DON-B does not feel like the wound worsened. DON-B stated that treatment with skin prep is still appropriate. Surveyor asked why DON-B did not reach out to the physician if DON-B felt like the treatment order change was not necessary. DON-B indicated that UM-D would be entering the orders and DON-B could not speak for UM-D, but DON-B would talk to the doctor before changing an order. Surveyor asked if DON-B was not sure what the wound was (pressure, Melanoma, Kennedy ulcer or pressure related to hardware from previous spinal surgery), why did a physician not assess the wound. DON-B stated that the MD/NP’s are not always wound certified. DON-B stated that R53's pressure injury was discussed with MD on 7/31/25 when MD determined that the pressure injury was unavoidable.
On 8/13/25 at 12:58 PM, DON-B gave Surveyor a progress note entered by R53’s MD. The progress note entered into R53’s medical record on 8/13/25 at 12:47 PM documents, in part: Date of service 7/31/25… Chief complaint: The patient was seen at the request of the nurse. The patient has a wound on the lower back that came up just over a week ago. The patient has multiple comorbidities including [congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), hypertension] and low albumin levels. [R53] does not ambulate. [R53] has had surgery on his lower back in the past with insertion of hardware. The recommendations for wound care from 7/29/25 were reviewed and I had decided to continue with the previous wound care which was skin prep and foam. This was because of [R53’s] end stage COPD, [R53] being on palliative care and this particular wound care [is] much more comfortable for him… Physical exam: … SKIN. Positive: warm, dry, wounds. Notes: the patient has a stage 2 decubitus in the sacral area just to the right of the midline. The base has yellowish, with minimal drainage and a small surrounding area of redness. The pictures were reviewed as well… ASSESSMENTS AND PLANS: … Pressure ulcer of right lower back, stage 2: discussed with nursing… Discussed wound care. Will continue the skin prep with foam for now. The patient has multiple comorbidities, and the wound is likely to decline. The patient is on Morphine for pain which makes him lethargic and [R53] is unable to keep the weight off the wound. Given all [R53’s] comorbidities, the wound is likely to decline…Wound care with skin prep and foam.
Surveyor noted that the MD progress note documents that the MD assessment revealed a stage 2 sacral pressure wound. Surveyor noted that the location of the wound observed by Surveyor was on R53’s Mid back, not in the sacral area as documented in the MD progress note. Surveyor noted that the MD described the base of the wound as yellowish. According to the NPUAP/EPUAP slough is defined as yellow, tan, gray, green or brown. According to the NPUAP/EPUAP, a stage 2 pressure injury is described as Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red… Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Surveyor noted the wound described by MD is staged incorrectly. Surveyor noted that MD stated that the treatment will be skin prep and foam on 7/31/25. Surveyor noted that this recommendation came 2 days after the original recommendation for a change in treatment after the development of slough in the wound on 7/29/25.
On 8/13/25 at 1:05 PM, Surveyor returned to DON-B to discuss the MD progress note. DON-B stated that DON-B noted the discrepancy and had contacted the MD to correct it.
On 8/13/25 at 2:45 PM, NHA-A and DON-B were informed of the concerns regarding R53’s facility-acquired pressure injury that developed on 7/22/25. The pressure injury was incorrectly staged on 7/29/25 when it developed slough and continued to be staged as a DTI. The wound treatment was recommended to be changed but facility staff continued treating the wound with skin prep as previously ordered. On 8/5/25, the facility documented the same measurement of an unstageable wound and documented an area of DTI with a new measurement. With the changes in R53’s wound, R53’s care plan was not updated. A late entry progress note entered by R53’s MD documents a stage 2 wound in the sacral area. Surveyor noted the incorrect location and stage. The late-entry MD progress note documented that skin prep can be used as treatment as of 7/31/25. Surveyor noted that facility staff did not follow recommendations listed on the 7/29/25 wound assessment.
On 8/14/25, Surveyor received a corrected MD progress note with a date of service 7/31/25 that documents the following: The patient has an unstageable wound in the lower back, just to the right of the midline. The base has yellowish slough, because of which staging is not possible. There is minimal drainage and a small surrounding area of redness/discoloration… Pressure ulcer of right lower back, unstageable…
On 8/27/25, the facility provided Surveyor with an additional hospice note dated 8/27/25. The hospice note written by RN-SS documents: Writer spoke with [Name] NP (Nurse Practitioner) regarding the swelling to R53’s back. Two pressure injuries are still present. There is now a mass underneath the previous open areas. Writer suspects this is related to patient’s metastatic lung cancer and that tumor grown has been impeding wound healing. There has been swelling to the area for approximately the last two weeks. The area of swelling has gotten progressively larger and the mass has grown significantly the last five days. The are is hard, but not warm. Facility has been
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 F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure 1 (R24) of 4 Residents with limited range of moti...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure 1 (R24) of 4 Residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.*R24 was not wearing R24's right hand splint/ right elbow brace during the survey. There was no documentation R24 was provided with physician ordered neck exercises. Surveyor did not observe any range of motion being performed.Findings include:Surveyor reviewed the facility's Prevention of Decline in Range of Motion policy and procedure revised 11/11/24:.PolicyResident who enters the facility without limited range of motion will not experience a reduction in range of motion unless the Resident's clinical condition demonstrated that a reduction in range of motion is unavoidable.Policy Explanation and Compliance Guidelines1. The facility in collaboration with the medical director, director of nurses and as appropriate, physical/occupational consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including assessment, appropriate care planning, and preventive care.2. Assessment for Range of Motiona. Licensed nurses will assess Resident's range of motion on admission/readmission, quarterly, and upon significant change.B. Residents who exhibit limitations in range of motion, initially and thereafter, will be referred to the therapy department for a focused assessment of range of motion.c. Nursing assistants will report any significant changes in range of motion, as noted during daily care activities, to the Resident's nurse when any changes are noted.3. Appropriate Care Planninga. Based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motions.c. Care plan interventions will be developed and delivered through the facility's restorative program, or through specialized rehabilitative services as ordered by the attending practitioner.d. Interventions will be documented on the Resident's person centered care plan.e. A nurse with responsibility for the Resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record.f. Modifications to the plan of care will be made as needed.4. Preventive Careb. Staff will be educated on basic, restorative nursing care that does not require the use of a qualified therapist or licensed nurse oversight.iii. Encouraging Residents to remain active and assisting with any exercises according to plan of care.iv. Assisting Residents in adjustment to their disabilities and use of any assistive devices.R24 was admitted to the facility on [DATE] with diagnoses of Epileptic Seizures (brain has sudden, uncontrollable surge of electrical activity), Encephalopathy (group of conditions that cause brain dysfunction), Essential Hypertension (chronic condition of persistently high blood pressure), Dysphagia (difficulty swallowing foods), Gastrostomy Status (artificial opening in stomach used for feeding), and Depression (mood disorder that causes persistent feelings of sadness and loss of interest). R24 currently has a legal guardian.R24's Quarterly Minimum Data Set (MDS) completed 6/23/25 documents R24 demonstrates severely impaired skills for daily decision making. R24's memory was not assessed. R24 is dependent for upper/lower dressing, showers/bathing, mobility, and transfers. R24 has both upper and lower extremity range of motion (ROM) impairment on both sides. Splint or brace assistance is not documented on R24's MDS. R24 is always incontinent of bowel and bladder. R24 currently has a feeding tube.R24's current physician orders document:7/3/24 Continue to don (apply/wear) resting hand splint to right hand, complete range of motion as tolerated and have patient attempt to assist with upper body cares when possible.4/7/24 Do neck exercises frequently and gently three times daily: [NAME] to chest, chin to sky, ear to shoulder bilaterally, chin to shoulders bilaterally.R24's comprehensive care plan documents:R24 has an activities of daily living (ADL) self-care performance deficit due generalized muscle weakness Initiated 3/1/24 Revised 9/20/24Intervention: R24 has contractures of the right arm/hand, right lower extremity. Provide skin care to keep clean and prevent skin breakdown. Initiated 3/4/24 Revised 2/5/25R24's Kardex, instructions to nursing staff updated 8/1/25 documents (R24) is wear elbow brace to right elbow on AM (morning) off HS (at bedtime).Surveyor reviewed R24's Occupational Therapy Discharge Summary signed by Occupational Therapist (OT)-KK on 7/3/24.(R24) is demonstrating tolerance to resting splint for 7 hour intervals at this time when donned by therapy staff, inconsistent follow through for splint use with support staff presently. Continue to encourage daily donning of resting splint at this time for contracture management and prevention. Discharge recommendations by OT-KK: Continue to encourage involvement with self care routine, bed mobility, donning of splint and ranging of right upper extremity as tolerated. Surveyor reviewed R24's electronic medical record (EMR) and noted there is no documentation of R24's neck exercises being performed.On 8/6/2025, at 11:47 AM, Surveyor observed R24 in bed and observed R24 is not wearing a right hand splint.On 8/7/2025, at 11:37 AM, R24 is observed in bed and has no right hand splint on hand.On 8/7/25, at 12:47 PM, Surveyor observed R24's right hand. Surveyor observed R24's 2nd right finger is contracted under R24's thumb and all digits are contracted into R24's palm.On 8/7/2025, at 1:57 PM, per Kardex R24 should have a right elbow brace on, and Surveyor observed R24 with no right elbow brace on. On 8/11/2025, at 10:53 AM, Surveyor observed R24 in bed and observed R24 has no splint on R24's right hand or a right elbow brace on. Surveyor did not observe either the splint or the brace to be visible in R24's room.On 8/12/2025, at 1:27 PM, Surveyor asked Unit Manager (UM)-E about R24's splint, elbow brace, and the neck exercises. UM-E informed Surveyor that UM-E will need to look into it.On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R24 has not had R24's right hand splint and/or a right elbow brace on during observations. Surveyor has also not observed any range of motion exercises performed by staff, and there is no documentation in R24's electronic medical record of neck exercises being performed.On 8/13/2025, at 12:35 PM, UM-E shared that UM-E has never seen a therapist write a physician order and agreed there is confusion whether R24 should be wearing a right hand splint only, a right elbow brace only, or both. UM-E shared with Surveyor that UM-E has spoken to therapy and has gotten rid of the physician orders to eliminate discrepancies and OT and Physical Therapy (PT) will be assessing R24 for appropriate devices.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure each resident received adequate supervision and a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 (R8, R24 and R81) of 5 residents reviewed for falls.
*R8 requires the assistance of 2 with a toilet transfer. R8 was transferred to the toilet on 4/8/25 and left alone in the bathroom. R8 sustained an unwitnessed fall 2 minutes later. In interviews with Director of Rehab, Director of Nursing and other staff members, facility staff indicated R8 should not be left alone in the bathroom. R8’s care plan was not updated with a resident specific intervention after this fall.
*R24’s fall interventions were not in place during Surveyor observations.
*R81’s fall interventions were not in place during Surveyor observations.
Findings include:
The facility polity with a last reviewed/revised date of 12/3/24, titled “Fall Prevention Program” documents, in part: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls… Each resident’s risk factors, and environmental hazards will be evaluated when developing the resident’s comprehensive plan of care. Interventions will be monitored for effectiveness. The plan of care will be revised as needed. When any resident experiences a fall, the facility will : Assess the resident. Complete a pain evaluation and post-fall evaluation. Complete an incident report and include immediate intervention. Notify physician and family. Review the resident’s care plan and update as indicated. Document all assessments and actions. Obtain witness statements in the case of injury. Monitor residents’ condition and response to interventions as per standard of practice.
1.) R8 was admitted to the facility 6/1/2014 with diagnoses that include Hemiplegia/Hemiparesis (weakness on one side of the body) following a stroke, stage 2 kidney disease and epilepsy (seizure disorder).
R8’s Significant change Minimum Data Set (MDS) assessment dated [DATE] documents R8 is moderately cognitively impaired. R8 has impairments on one side of both of R8’s upper and lower extremities. R8 requires substantial/maximum assistance for personal hygiene and transfers. R8 has had one fall with major injury since R8’s last MDS Assessment.
R8’s Care Area Assessment for falls dated 3/1/25 documents, in part: [R8] had a recent fall and has a history of falls [related to] [stroke] and weakness.
R8’s care plan documents the following pertinent interventions: Assist of with toileting needs [as needed], initiated on 10/29/23. Prompt [R8] to toilet upon rising, after meals and [at bedtime] and per request at night. Keep urinal at bedside at night, initiated on 1/13/19. Toilet use: [R8] requires assistance x 2 [standing pivot transfer] with front wheeled walker. Assist x 1 with toileting hygiene. Prompt to use the bathroom every 2-3 hours and [as needed], initiated on 3/23/25.
R8’s Fall Risk Evaluation dated 2/12/25 documents a score of 8 which puts R8 at moderate risk for falls.
R8’s Occupational Therapy (OT) Evaluation and Plan of Treatment note dated 3/24/25 documents, in part: [R8] only [evaluated] to determine transfer status. [R8] required [minimum/moderate] assist of two with 2 wheeled walker to stand from toilet for safety. Ataxic gait pattern with knees buckling…
R8’s progress note dated 4/8/25 at 10:49 AM documents, in part: [R8] had an unwitnessed fall around 700 am. [R8] was discovered by CNA who alerted this nurse. [R8] was found in front of wheelchair, lying on [R8’s] left side, and the wheelchair was also on its side. Per [R8], [R8] forgot to lock [R8’s] wheelchair. Vital signs taken and documented .
R8’s fall investigation dated 4/8/25 documents, in part: This part of the investigation was filled out by CNA-NN. Did you observe the resident during your shift? Yes. Did you assist the resident with anything during your shift? Yes, restroom… What time was the resident last checked or seen by you? 2 [minutes] before fall. What was the resident doing at that time? Using restroom… How did you find out the resident fell? I heard it.
Surveyor noted that CNA-NN assisted the resident to the restroom [ROOM NUMBER] minutes prior to the fall. Surveyor noted that CNA-NN left R8 unassisted in the bathroom and R8 had an unwitnessed fall.
On 8/12/25 at 1:06 PM and 8/13/25 at 11:10 AM, Surveyor attempted to reach CNA-NN by telephone for interview. CNA-NN was unavailable.
R8’s fall investigation dated 4/8/25 documents, in part: This part of the investigation was filled out by Licensed Practical Nurse (LPN)-OO… Date of fall 4/8/25. Time of fall 7:10 AM. Location of where fall occurred: bathroom. Was fall witnessed. No… Description of fall: [R8] was found laying on left side with wheelchair tipped over behind… What did the resident/family report was the reason of the fall. [R8] reported losing [R8’s] balance, stumbling into unlocked wheelchair and falling sideways. When was the last time resident was rounded on? Less than five minutes before… [R8] reports losing [R8’s] balance. [R8] stood up to use sink and falling back into unlocked wheelchair…
Surveyor noted that LPN-OO documented an unwitnessed fall when R8 was left alone in the bathroom.
On 8/12/25 at 2:13 PM, Surveyor interviewed LPN-OO. Surveyor asked what happened when R8 fell on 4/8/25. LPN-OO stated that R8 was in the bathroom and tried to transfer back into the wheelchair. R8’s foot got caught and R8 fell on R8’s bottom. LPN-OO stated that the CNA had transferred R8 to the toilet and went to go answer a different residents call light. The CNA returned to R8’s bathroom and found R8 laying on the floor. LPN-OO stated that vitals and an assessment were completed, and the MD was notified. LPN-OO stated R8 did not sustain an injury with this fall. Surveyor asked what R8’s transfer status at the time of the fall was. LPN-OO stated that LPN-OO believed that R8 was a one assist. Surveyor asked if it is typical to leave resident in bathroom. LPN-OO stated it is normal.
R8’s Interdisciplinary Team (IDT) fall committee review dated 4/8/25 documents, in part: … Are interventions effective? Answer left blank. If not, why? Continues to self-transfer. Unsafe behaviors noted/observed? Yes. Care plan revisions: continue with plan of care, continues to self-transfer…
Surveyor noted the IDT team acknowledges that R8 “continues” to self-transfer. Surveyor noted despite the documentation of self-transfers continuing, a new care plan intervention was not documented in the IDT note.
Surveyor reviewed R8’s fall care plan and noted a new intervention was not placed after R8’s fall on 4/8/2025.
On 8/13/25 at 9:04 AM, Surveyor interviewed Nurse technician (NT)-BB. Surveyor asked what is R8’s toilet transfer status. NT-BB indicated that R8 does self-transfer quite a bit. NT-BB stated that R8 transfers alone onto the toilet and will call for help to get off.
Surveyor noted staff are aware that R8 has a history of self-transferring.
On 8/12/25 at 1:46 PM, Surveyor interviewed Unit Manager (UM)-D. Surveyor asked if staff could leave a resident alone in the bathroom if that resident's toilet transfer status is assistance x 2 with a standing pivot transfer with front wheeled walker. UM-D stated that staff do not have to stay in the bathroom, they don’t walk away but stand outside the door. UM-D stated that it would specifically say on the care plan if staff can not leave the bathroom. Surveyor asked about R8’s toilet transfer status. UM-D stated that R8 would typically self-transfer onto the toilet. Most of R8’s fall are when R8 is coming out of the bathroom. UM-D stated that R8 will now typically tell UM-D first before going to the bathroom so UM-D can get help or help R8.
Surveyor noted that R8 is known for self-transferring. Surveyor noted per UM-D staff would not have to stay with R8 while R8 is in the bathroom.
On 8/13/25 at 9:12 AM, Surveyor interviewed CNA-PP. Surveyor asked if CNA-PP would leave a resident alone in the bathroom if the resident’s toilet transfer status is assistance x 2 standing pivot transfer with front wheeled walker. CNA-PP stated that CNA-PP would not leave the resident alone and CNA-PP would stay with the resident the whole time.
On 8/12/25 at 9:26 AM, Surveyor interviewed LPN-G. Surveyor asked if LPN-G would leave a resident alone in the bathroom if the resident’s toilet transfer status is assistance x 2 standing pivot transfer with front wheeled walker. LPN-G stated that LPN-G thinks that staff should stay with the resident.
On 8/12/25, Surveyor interviewed Director of Rehab (DOR)-JJ. Surveyor asked when R8 was last seen by the therapy department. DOR-JJ stated it was on 3/20/25. Surveyor asked what R8’s transfer status was on 3/20/25. DOR-JJ stated R8 required minimum/moderate assist of two with 2 wheeled walker to stand from toilet for safety. Surveyor asked if staff should stay with R8 when R8 is transferred onto the toilet. DOR-JJ stated yes.
Surveyor noted some nursing staff, and the Director of Rehab stated that a resident whose toilet transfer status is an assist of two standing pivot transfer with 2 wheeled walker should not be left alone in the bathroom.
On 8/13/25 at 12:47 PM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor shared concern that R8 had a fall in the bathroom after being left in the bathroom by CNA. DON-B reviewed the fall investigation and noted that CNA-NN charted that CNA-NN was with R8 in the restroom [ROOM NUMBER] minutes prior to R8’s unwitnessed fall. DON-B agreed R8 should not have been left alone. Surveyor informed DON-B that R8’s care plan was not updated at the fall.
On 8/13/25 at 2:45 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concern that on 4/8/25, R8 was transferred to the toilet by CNA-NN, according to documentation, 2 minutes later, R8 sustained an unwitnessed fall. In interviews with Director of Rehab, DON-B and other staff members, facility staff agreed that R8 should not be left alone in the bathroom. R8’s care plan was not updated after the fall.
2.) R24 was admitted to the facility on [DATE] with diagnoses of Epileptic Seizures (brain has sudden, uncontrollable surge of electrical activity), Encephalopathy (group of conditions that cause brain dysfunction), Essential Hypertension (chronic condition of persistently high blood pressure), Dysphagia (difficulty swallowing foods), Gastrostomy Status (artificial opening in stomach used for feeding), and Depression (mood disorder that causes persistent feelings of sadness and loss of interest). R24 currently has a legal guardian.
R24’s Quarterly MDS completed 6/23/25 documents R24 demonstrates severely impaired skills for daily decision making. R24’s memory was not assessed. R24 is dependent for upper/lower dressing, showers/bathing, mobility, and transfers. R24 has both upper and lower extremity range of motion(ROM) impairment on both sides. Splint or brace assistance is not documented on R24’s MDS. R24 is always incontinent of bowel and bladder. R24 currently has a feeding tube.
R24’s Admission/Readmission/Routine Head-to-toe Evaluation completed 6/23/25 documents R24 is high risk for falling with a score of 16-60.
R24’s Fall Care Plan Documents: R24 is at risk for falls, accidents and incidents r/t generalized weakness, abnormalities of gait and mobility, and muscle spasms Created 3/1/24 Revised 9/20/24 -Anticipate and meet the resident's needs.4/8/24 Revised 9/20/24-Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Keep call light near left hand,3/1/24 Revised 10/10/24 -Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility9/20/24 -Encourage to wear appropriate footwear or gripper socks9/18/24 -Fall Mat beside the bed while in bed9/20/24-Follow facility fall protocol.3/1/24 Revised 9/20/24-Pt evaluate and treat as ordered or PRN.3/4/24 Revised 9/20/24-Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes.3/4/24 Revised 9/20/24
R24’s Care Card as of 8/1/25 documents: Keep call light near left hand. Fall mat beside the bed while in bed. Encourage to wear appropriate footwear or gripper socks.
On 8/6/2025, at 9:18 AM, Surveyor observed R24 in a low bed, call light within reach, head of bed elevated to 30 degrees. Surveyor observed a fall mat folded up against the wall.
On 8/6/2025, at 11:46 AM, Surveyor observed no fall mat on the floor next to R24’s bed.
On 8/7/2025, at 7:45 AM, R24 is in bed, with the fall mat next to the bed on the left side, R24’s
call light is draped over R24’s overbed table, which is pushed past the blue fall mat, way out of reach of R24.
On 8/7/2025, at 9:08 AM, Surveyor observed R24’s call light is still draped over R24’s overbed table not within reach of R24.
On 8/7/2025, at 10:56 AM, Surveyor observed R24’s call light still draped over the overbed table which is not accessible to R24.
On 8/7/2025, at 11:12 AM, Surveyor observed Licensed Practical Nurse (LPN)-II exit R24’s room. Surveyor asked LPN-II does LPN-II monitor for fall interventions for a Resident. LPN-II stated that CNAs should have put fall interventions into place when placing a Resident in bed. LPN-II will assess to see if fall interventions were in place at time of a Resident fall.
Surveyor observed R24’s call light not within reach on 8/7/25, at 10:56 AM, LPN-II was in R24’s room at 11:12 AM, providing care to R24's gastrostomy tube and did not adjust R24’s draped call light within reach of R24’s left hand in bed.
On 8/12/2025, at 8:54 AM, R24 is observed in bed, the fall mat is on the floor next to the bed, R24’s call light is observed behind and under R24’s pillow.
Surveyor notes that R24’s fall interventions of fall mat on floor next to bed and call light within reach were observed to not be implemented for safety.
3.) R81 was admitted to the facility on [DATE] with diagnoses of Essential Hypertension (chronic condition of persistently high blood pressure), Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar), Hypertensive Heart Disease (long term conditions developed from chronic high blood pressure), Chronic Obstructive Pulmonary Disease (lung disease that block airflow and make it difficult to breathe), Major Depressive Disorder (persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R81 has an activated health care power of attorney.
R81’s annual minimum data set (MDS) completed 7/3/25 documents R81’s brief interview for mental status (BIMS) score to be 5, indicating R81demonstrates severely impaired skills for daily decision making. R81’s MDS documents R81 has no range of motion impairment. R81 is independent with eating. R81’s MDS also documents R81 is dependent for upper and lower dressing, showers/bathing, mobility and transfers. R81is always incontinent of bowel and bladder.
R81’s Fall Care Area Assessment (CAA) completed 7/14/25 documents R81 is high risk for falls due to dementia and high-risk medications. R81’s CAA documents the goal is to avoid complications, maintain current level of functioning, and minimize risks.
R81’s Fall Care Plan Documents: R81 is at risk for falls, accident and incident r/t (related to) cognition-unaware of safety needs, incontinence Created 1/5/18 Revised 2/21/21.
-Soft touch call light - 5/8/20 Revised 10/23/23
-Anticipated and meet the Residents needs. Encourage the Resident to call for assistance - 1/5/18
-Be sure overbed table is within reach with all necessary items in place - 1/17/18 Revised 11/19/18
-Bed against wall - 11/17/21 Revised 10/29/23
-Body pillows on while in bed - 1/7/19
-Dycem to wheelchair - 5/16/18 Revised 9/27/18
-Fall assessment to be completed upon admission, after falls, quarterly, and as needed - 10/29/23
-Follow therapy recommendations for transfers and mobility - 1/5/18
-Frequently used items to remain within reach - 5/15/18 Revised 9/27/18
-Low bed with mat on floor - 4/19/18 Revised 11/19/18
-Offer snack around 4PM - 4/6/23 Revised 10/29/23
-Place call light within reach while in room - 1/5/18
-PT to screen for therapy needs, Resident to be offered to stay up in wheelchair after lunch - 9/20/24
-Review information on past falls and attempt to determine cause of falls - 10/29/23
-Scoop mattress - 7/10/23 Revised 10/29/23
-Updated MD as needed - 10/29/23
R81’s Care Card as of 8/1/25 documents: R81 is to have body pillow in bed, Dycem in wheelchair, low bed with fall mat. Scoop mattress. Keep personal items within reach while in bed. Offer snack around 4PM. Bed up against wall. Keep overbed table within reach, reminder signs in room to call for assist. Soft touch call light
On 8/6/2025, at 10:01 AM, Surveyor observed R81 in bed. Surveyor noted R81’s bed is positioned up and not in a low position, there is no mat on floor next to bed. R81's bed is pushed against the wall to the left (if looking at bed from doorway). Surveyor observed no body pillows on either side of R81. Surveyor noted there wasn't Dycem on the seat of R81's wheelchair. R81’s overbed table was pushed away from R81’s bed and not within reach of R81.
On 8/6/2025, at 1:26 PM, Surveyor observed R81 eating lunch with head of bed elevated. Surveyor observed R81’s bed in a regular/elevated position and not low as care planned. No mat was observed on the floor and no body pillows were observed on either side of R81.
On 8/7/2025, at 7:56 AM, Surveyor observed R81 in bed, which is in the regular/elevated position and not low. There is no mat observed on the floor next to the bed. Surveyor observed no body pillows on either side of R81.
On 8/7/2025, at 7:59 AM, Surveyor observed no Dycem in wheelchair outside of R81’s room and no Dycem in the rolling positioning wheelchair in R81’s room.
On 8/7/2025, at 11:23 AM, Surveyor observed R81 up in the rolling/positioning wheelchair. R81 was observed sitting on sling and Surveyor observed no Dycem in the chair.
On 8/7/2025, at 2:07 PM, Surveyor observed R81 up in the rolling/positioning wheelchair, in their room and there is no Dycem observed in the wheelchair. Surveyor observed, the call light is not within reach of R81.
On 8/11/2025, at 7:47 AM, Surveyor observed R81sleeping in a low bed, no mat on the floor and no body pillows on either side of R81.
On 8/11/2025, at 9:36 AM, Surveyor observed R81 in bed, which is in a regular/elevated position, no mat is observed on the floor next to bed and no body pillows on either side of R81.
On 8/12/2025, at 8:51 AM, Surveyor observed R81 in bed, regular/elevated position, the head of bed is observed to be elevated while R81 ate breakfast. Surveyor observed no mat on the floor and no body pillows on either side of R81.
Surveyor notes that R81’s fall interventions including a fall mat on the floor next to bed, call light within reach, body pillows on either side of R81, overbed table within reach, and Dycem in R81’s wheelchair were not implemented during observations during the survey.
On 8/7/2025, at 2:08 PM, Surveyor interviewed Certified Nursing Assistant (CNA)-QQ regarding Residents fall interventions. Surveyor asked CNA-QQ how does CNA-QQ know what fall interventions to put into place. CNA-QQ stated CNA-QQ would check the Resident care card.
On 8/12/2025, at 3:17 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that Surveyor had multiple observations of fall interventions not being in place during the survey.
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 F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R9) of 3 residents was provided pain management consistent ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R9) of 3 residents was provided pain management consistent with professional standards of practice.R9 reported being in constant pain that frequently affected sleep and day to day activities. R9 was consistently receiving Oxycodone for pain management, which was prescribed on [DATE], and later discontinued on [DATE]. R9 was documented as having pain 10 out of 10 and went without Oxycodone pain medication on [DATE] and [DATE], after Oxycodone was discontinued on [DATE], which resulted in R9 going to the emergency room (ER) for pain management on [DATE].Findings include:R9 was admitted to the facility on [DATE], and has diagnoses that include paralytic syndrome (a condition where there's a loss of muscle function, resulting in the inability to move part or all of the body), fracture of 1st cervical vertebra and 7th cervical vertebra (a break in the vertebrae in the neck, otherwise known as a broken neck), intervertebral disc degeneration of the lumbar region (breakdown of discs in spine causing pain in lower back), fibromyalgia (widespread muscle pain and fatigue), and chronic pain syndrome. R9's admission Minimum Data Set (MDS) assessment, documents R5's Pain Care Area Assessment (CAA), dated [DATE], documents R5 has near constant pain related to fractures.R9's Quarterly MDS assessment, dated [DATE], documents, R9 is cognitively intact. R9's pain assessment documents, R9 has a scheduled pain regimen and as needed (PRN) pain regimen. R9 is in constant pain frequently affecting sleep and day to day activities. R9's pain assessment documents a pain level of 7 out of 10. R9's care plan, documents, R9 has chronic pain related to fracture of first cervical vertebra/intervertebral disc degeneration, and lumbar region.Interventions include:R9's pain is alleviated/relieved by repositioning and pain medications (date initiated [DATE]).Interventions include:Anticipate R9's need for pain relief and respond immediately to any complaint of pain (date initiated [DATE]).Identify and record previous pain history and management of that pain and impact on function. Identify previous response to analgesia including pain relief, side effects, and impact on function (date initiated [DATE]).Monitor and document for side effects of pain medication (date initiated [DATE]).Monitor, record, and report to the nurse, loss and appetite, refusal to eat, and weight loss (date initiated [DATE]).Notify the physician if interventions are unsuccessful or if current complaint is a significant change from R9's past experience of pain (date initiated [DATE]). Surveyor reviewed the facility's list of grievances filed and notes R9 filed a grievance on [DATE]. The grievance details concern with medication administration for R9. The grievance summary of investigation documents the following:R9 concerned with oxycodone being discontinued. R9 did have Oxycodone in house, however, R9's prescription from admission expired. R9 is not willing to wait for the nurse to get a new prescription from the Medical Director (MD) and a reason with the nurses as residents' medications were still in house. Medications were not discontinued.The grievance summary of findings documents the following:R9 had medications in house. R9 is unwilling to wait for order.The grievance summary of the actions taken, documents the following:R9 demanded to be sent to the hospital. Nursing staff notified the hospital R9 did have an order for oxycodone and oxycodone was in house and R9 did not want to wait for nurses to make phone call to get prescription updated. Upon R9's return, medications were reviewed and reinstated as ordered.Surveyor notes the grievance documenting R9 had an order for Oxycodone however, Surveyor notes the grievance then states nursing staff had to contact the MD for an order. Surveyor reviewed R9's Medication Administration Record (MAR) for [DATE] which documents the following:Oxycodone Oral Tablet 5 mg (milligrams). Give 5 mg by mouth every 6 hours as needed for pain (start date [DATE], at 5:00 PM, with a stop date of [DATE] at 11:59 PM). Surveyor notes R9 received Oxycodone every shift [DATE] through [DATE], with the last dose of Oxycodone signed out on [DATE] at 1:00 AM.Oxycodone Oral Tablet 5 mg. Give 5 mg by mouth every 6 hours as needed for pain (start date [DATE] at 4:30 PM).Surveyor notes R9 did not have an order for Oxycodone from [DATE], at 11:59 PM, until [DATE], at 4:30 PM.Celecoxib Oral Capsule 200 mg. Give 1 capsule by mouth every 24 hours as needed for pain (start date [DATE], at 8:00 AM and discontinue date [DATE], at 12:09 PM).Surveyor notes R9 received Celecoxib on [DATE] and [DATE] with documentation of R9 having a pain level of 10.Celecoxib Oral Capsule 200 mg. Give 1 capsule by mouth every 24 hours as needed for pain (start date [DATE], at 4:00 PM).Pain evaluation every shift (start date [DATE], at 11:00 PM).Surveyor notes the following after reviewing R9's MAR:R9 did not have an order for Oxycodone from [DATE], at 11:59 PM, until [DATE], at 4:30 PM.R9's MAR documents R9 having a pain level of 10, 10, and 5 on [DATE] and a pain level of 6 on day shift on [DATE].R9's pain evaluation in [DATE] documenting pain from 0 to 10.R9 was documented of having pain level of 7 on [DATE], with no indication of Oxycodone or Celecoxib being administered for pain. Surveyor reviewed R9's Electronic Medical Record (EMR) which documents a progress note dated [DATE], documenting R9 requested to go to the emergency room (ER) for pain management. R9 was documented as not being happy with Oxycodone order being discontinued. R9 was notified Oxycodone was not available when requested and R9 placed a call to 911 and was sent out to the ER for evaluation. On [DATE], at 9:54 AM, Surveyor interviewed R9 who states the facility does not always have pain medication and R9 has been without pain medication in the past. R9 states R9 is working with therapy but unable to get out of bed due to lack of strength and pain management. R9 states R9 has been at the hospital before due to uncontrolled pain. On [DATE], at 10:14 AM, Surveyor interviewed Director of Rehabilitation (DOR)-JJ who states R9 often expresses pain throughout therapy sessions which often affects R9's therapy sessions. Therapy is working with R9 on techniques for mobility as it relates to R9's pain management and therapy goals. On [DATE], at 10:35 AM, Surveyor interviewed Director of Nursing (DON)-B to discuss R9's pain management. Surveyor asked DON-B about the grievance filed by R9 on [DATE] for pain medications. DON-B states R9 was receiving pain medications and did not go without pain medications. Surveyor reviewed R9's MAR with DON-B which documents R9 was receiving as needed (PRN) Oxycodone consistently in March and [DATE], and R9's Oxycodone order was stopped on [DATE], with last dose given on [DATE]. Surveyor noted to DON-B, R9 did not receive Oxycodone the rest of the day on [DATE] and [DATE] which then resulted in R9 going to the ER for evaluation for pain management. Surveyor asked DON-B why R9 went without pain medication and if there was documentation of facility staff contacting R9's MD to discuss pain management. Surveyor also asked DON-B why the grievance states R9 had an order for pain medication when Oxycodone was discontinued on [DATE]. DON-B acknowledged these concerns and states she will investigate it. Surveyor requested additional information if available and notified DON-B of concerns with R9's pain management which resulted in R9 going to the ER for evaluation.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure menus were followed and served as posted for 2 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure menus were followed and served as posted for 2 (R65 and R59) of 2 residents reviewed.
*R65’s meal tray did not match the facility’s planned menu on 8/7/25 breakfast tray, 8/11/25 breakfast tray and 8/11/25 lunch tray.
*R59’s food preferences were not followed. On 8/6/25 Surveyor observed white bread on R59's tray when white bread is one of R59’s dislikes. R59’s meal tray did not match the facility’s planned menu on 8/7/25 breakfast tray and 8/11/25 lunch tray.
Findings include:
The facility policy with a revised date of 10/2022, titled “Menus” documents, in part: Menus will be planned in advance to meet the nutritional needs of the resident/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. … Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. … Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas.
1.) R65 was admitted to the facility on [DATE]. R65’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R65 is cognitively intact.
On 8/6/25, at 10:36 AM, R65 informed Surveyor R65’s meals are not always served as ordered/planned. R65 stated the menus posted do not match what is served on R65’s meal tray.
R65’s MD (Medical Doctor) order dated 7/11/25 documents: Regular diet, regular texture, thin consistency diet.
On 8/7/25, at 8:33 AM, Surveyor observed R65’s breakfast meal tray sitting in R65’s room. Surveyor observed scrambled eggs, bacon and an English muffin. Surveyor observed R65’s meal tray ticket. Listed on the meal tray ticket is R65’s Room number, dining preference and diet. Surveyor noted that the meal served is not listed on R65’s meal tray ticket.
On 8/7/25 at 10:44 AM, Surveyor observed a posted meal menu on the wall of the entrance to the 200-unit hallway. The menu is typed and listed the following for breakfast is: Scrambled eggs. Bacon. Toasted English muffin. Cold cereal.
Surveyor noted on 8/7/25 R65’s tray did not match the posted menu. R65 did not receive cold cereal.
On 8/11/25, at 8:32 AM, Surveyor observed Certified Nursing Assistant (CNA)-EE delivering meal trays to resident’s room. CNA-EE removed the tray from the warmer, knocked on a resident’s door and delivered the tray to the resident’s tray table. Surveyor asked CNA-EE if CNA-EE had to do any checks before delivering the tray. CNA-EE stated that kitchen staff checks to make sure it is correct, and CNA-EE will make sure that the tray is correct as well.
On 8/11/25, at 8:38 AM, Surveyor observed CNA-EE deliver R65’s breakfast tray to R65’s room.
On 8/11/25 at 8:41 AM, Surveyor observed R65’s breakfast meal tray sitting in R65’s room. Surveyor observed scrambled eggs with ham and a blueberry muffin. Surveyor observed R65’s meal tray ticket. Listed on the meal tray ticket is R65’s Room number, dining preference and diet. Surveyor noted that the meal served is not listed on R65’s meal tray ticket.
On 8/11/25, at 8:43 AM, Surveyor observed a posted meal menu on the wall of the entrance to the 200-unit hallway. The menu is handwritten and listed for breakfast is Eggs with ham. Blueberry muffin.
Surveyor reviewed the week 4 planned menu that was printed and provided to Surveyor on 8/6/25. The planned menu documents for Breakfast on Day one of week 4 is: Cream of Wheat, Scrambled Eggs with Ham, Blueberry Muffin.
Surveyor noted the handwritten menu hanging on the wall of the entrance to the 200-unit hallway does not match the menu provided to Surveyors on entrance to the facility. Surveyor noted that on 8/11/25, R65’s breakfast tray did not match the planned menu provided to Surveyors on entrance to the facility. R65 did not receive Cream of Wheat.
On 8/11/25, at 12:53 PM, Surveyor observed R65’s lunch meal tray sitting in R65’s room. Surveyor observed a dinner roll, Turkey and gravy, sweet potato, mixed vegetables (peas, carrots, lima beans, corn) and a butterscotch pudding. Surveyor observed R65’s meal tray ticket. Listed on the meal tray ticket is R65’s Room number, dining preference and diet. Surveyor noted that the meal served is not listed on R65’s meal tray ticket.
On 8/11/25 at 12:55 PM, Surveyor observed a posted meal menu on the wall of the entrance to the 200-unit hallway. The menu is typed and listed for lunch is Oven Roasted Turkey, Roasted Turkey gravy, Roasted butternut Squash, Brussels Sprouts, Dinner Roll and Butterscotch Delight.
Surveyor noted on 8/11/25, R65’s lunch tray did not match the posted menu. R65 did not receive Brussel sprouts or butternut squash but received mixed vegetables instead.
On 8/12/25, at 1:31 PM, R65 informed Surveyor the facility does not let R65 know if they are changing the planned menu.
On 8/13/2025, at 11:55 AM, Surveyor informed Nursing Home Administrator (NHA)-A that R65’s meal tray did not match the posted menu during the above times during survey. No additional information was provided.
2.) R59 was admitted to the facility on [DATE], with diagnoses that include Cerebral palsy, right upper arm contracture and cancer.
R59’s Quarterly Minimum Data Set (MDS) Assessment, dated 8/2/25, documents a Brief Interview for Mental Status (BIMS) score of 15, indicating R59 is cognitively intact.
On 8/6/25 at 1:00 PM, R59 informed Surveyor that dietary gives R59 food that is documented in R59’s dislikes list. Surveyor observed R59’s lunch tray sitting on R59’s tray table. R59’s meal tray ticket located on R59’s tray table does not document what is on R59’s lunch tray but does document R59’s dislike list. R59’s dislike list documented on the meal tray ticket is: bread white, beef, sausage. Surveyor observed R59 eating lunch. R59’s lunch meal tray included: [NAME] bun, unidentifiable meat, carrots, green beans, squash, rice with string beans and gravy, coffee, red juice, and vanilla ice cream. Surveyor noted R59 had a white bun on R59’s lunch tray despite white bread being listed as a dislike on R59’s meal Tray ticket.
On 8/7/25 at 8:34 AM, Surveyor observed R59’s breakfast meal tray. R59’s breakfast meal ticket documents: Personal menu items 4oz yogurt cup. Dislikes as follows: bread white, beef, sausage, ground beef, hamburgers. Surveyor noted ground beef and hamburgers have been assed to R59’s dislike list. Surveyor observed: yogurt, English muffin, egg patty, bacon, and cranberry juice.
On 8/7/25 at 10:44 AM, Surveyor observed a posted meal menu on the wall of the entrance to the 200-unit hallway. The menu is typed and listed the following for breakfast: Scrambled eggs. Bacon. Toasted English muffin. Cold cereal.
Surveyor noted that on 8/7/25, R59’s tray did not match the posted menu. R59 did not receive cold cereal.
On 8/11/25 at 8:32 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-EE concerning the facility protocol for ensuring the meal served matches the diet ticket and what is on the menu. CNA-EE stated CNA-EE thinks dietary staff checks the tray before it leaves the kitchen and that staff that give out trays are supposed to also verify that all information matches as well.
On 8/11/25 at 8:43 AM, Surveyor observed a posted meal menu on the wall of the entrance to the 200-unit hallway. The menu is handwritten and listed for breakfast is: Eggs with ham. Blueberry muffin.
Surveyor reviewed the week 4 planned menu that was printed and provided to Surveyor on 8/6/25. The menu lists for breakfast on Day one of week 4 is: Cream of Wheat, Scrambled Eggs with Ham, Blueberry Muffin. Surveyor noted that the handwritten menu hanging on the wall of the entrance to the 200-unit hallway does not match the menu provided to Surveyors on entrance to the facility
On 8/11/25 at 8:50 AM, Surveyor observed R59’s breakfast meal tray. R59’s breakfast meal ticket documents: Personal menu items 4oz yogurt cup. Dislikes as follows: bread white, beef, sausage, ground beef, hamburgers. Surveyor observed scrambled eggs with ham and a blueberry muffin on R59’s tray. Surveyor noted that on 8/11/25, R59’s breakfast meal tray did not match the posted menu or R59’s meal preferences. R59 did not receive cream of wheat or yogurt listed on R59’s meal ticket.
On 8/11/25 at 12:49 PM, Surveyor observed R59’s lunch meal tray. Surveyor observed the following items: sweet potato, peas, carrots, lima beans, corn, white dinner roll, turkey and gravy. Surveyor noted R59 was served a white dinner roll despite white bread being listed on R59’s dislike list.
On 8/11/25 at 12:55 PM, Surveyor observed a posted meal menu on the wall of the entrance to the 200-unit hallway. The menu is typed and listed for lunch is: Oven Roasted Turkey, Roasted Turkey gravy, Roasted butternut Squash, Brussels Sprouts, Dinner Roll and Butterscotch Delight.
Surveyor noted that on 8/11/25, R59’s lunch meal tray did not match the facility’s posted menu. R59 received sweet potato and mixed vegetables and did not receive the roasted butternut squash and Brussel sprouts.
On 8/13/2025 at 11:24 Surveyor interviewed Dietary Manager (DM)-RR. DM-RR stated that DM-RR started filling in this week as the facility’s Dietary Manager because the previous Dietary Manager walked out. Surveyor asked how food preference slips are filled out. DM-RR stated nursing fills the preference slips out with residents. The slips are provided by the front desk receptionist. The slips are turned in and then given to the kitchen staff who will change the resident’s preferences. DM-RR indicated that DM-RR had not received any meal preference slips since starting. DM-RR stated that these issues were not addressed by the previous Dietary Manager because the Dietary Manager did not do the job.
On 8/13/25 at 11:30 AM, Surveyor interviewed the front desk receptionist, Receptionist-Z. Receptionist-Z stated that Receptionist-Z was not aware and has not received any meal preference slips from nursing.
On 8/13/25 at 11:55, Surveyor informed Nurse Home Administrator (NHA)-A that R59’s meal tray did not match the posted menu 2 times during survey and that R59’s dislike list is not being followed. NHA-A stated that NHA-A will follow up on the concerns. No additional information was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure residents were free from physical abuse for 1 (R59) of 5 reside...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure residents were free from physical abuse for 1 (R59) of 5 residents reviewed for abuse. This has the potential to affect all residents who resided on the unit where R59 lives from 7/2/25 through 7/9/25 when CNA-FF continued working and had access to facility residents after an allegation of abuse.*R59 informed Surveyor that CNA-FF was rough with a transfer on 7/2/25, had been rough with cares in the past and that CNA-FF was bossy and made R59 feel intimidated. On 7/2/25, R59 informed 3 different facility staff members that CNA-FF was rough with R59. This allegation of abuse was not reported to the Nursing Home Administrator (NHA)-A per the facility abuse policy. After the allegation of abuse, CNA-FF continued working at the facility from 7/2/25 through 7/9/25. During that time, CNA-FF was scheduled to work multiple times on R59's unit.Findings include:The facility policy, with a last reviewed/revised date of 7/1/25, titled Abuse, Neglect and Exploitation documents, in part: It is the guideline of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility has a zero-tolerance stance around founded abuse, neglect, exploitation and misappropriation of resident property. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigation include: Identifying staff responsible for the investigation. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations: Focusing the investigation on determining if abuse, neglect exploitation, and/or mistreatment has occurred, the extent, and cause: and providing complete and thorough documentation of the investigation. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation-This should include staying with the alleged perpetrator to ensure no further contact (verbal or physical) until removal from the facility/environment. Increased supervision of the alleged victim and residents, Room or staffing changes, if necessary, to protect the resident from the alleged perpetrator. Reporting/Response: . Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes. It is important staff feel comfortable to report all concerns by assuring that reporters are free from retaliation or reprisal.R59 was admitted to the facility on [DATE] with diagnosis that includes Cerebral Palsy.R59's Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] documents that R59 is cognitively intact. R59 uses a wheelchair and is dependent for transfers.On 8/7/25 at 8:48 AM, Surveyor interviewed R59. R59 informed Surveyor that a few weeks ago, R59's CNA, CNA-L, needed help getting R59 into the wheelchair. CNA-L went to get help from CNA-FF. Both CNA-L and CNA-FF returned to R59's room. R59 stated that during the transfer, CNA-FF was really, really rough. R59 stated that when R59 was put in R59's wheelchair, R59's feet got caught in some plastic on the wheelchair footrests. While CNA-L was trying to gently guide R59's feet, CNA-FF yanked the chair back hard. R59 stated that the yanking did not cause R59's skin to break but stated that the action really hurt. R59 stated that on other occasions, CNA-FF had been very rough with cares and was bossy and intimidating. Surveyor asked if R59 told anyone about what happened. R59 stated that R59 told CNA-L, a nurse and R59's Occupational Therapist (OT)-GG. R59 stated that OT-GG helped R59 fill out a grievance form. R59 stated that after R59 informed staff about the concern, CNA-FF came back to R59's room and started apologizing. R59 stated that R59 thinks that administration told the staff member of R59's concern and that is why CNA-FF returned to R59's room. R59 stated that R59 felt intimidated.Surveyor reviewed the grievance log for the last 6 months and noted that there was no grievance logged about CNA-FF being rough with R59.Surveyor reviewed the Facility Reported Incident folders for the last 6 months and noted that there were no incidents documented about CNA-FF being rough with R59. On 8/7/25 at 9:01 AM, Surveyor interviewed CNA-L. Surveyor asked about the incident with CNA-FF. CNA-L stated that R59 is very sore when R59 wakes up in the AM. CNA-L stated that CNA-L works slower with R59 because of that. CNA-L stated that CNA-FF was helping get R59 into R59's wheelchair via the Hoyer lift. CNA-L indicated that CNA-FF yanked R59 from behind and caused R59 to start yelling about R59's feet. CNA-L indicated that CNA-L could not believe how CNA-FF was treating R59. CNA-L stated that CNA-L felt like CNA-FF was rough with R59 and many other residents during cares and transfers. CNA-L stated that other residents had complained about CNA-FF. Surveyor asked what residents complained. CNA-L indicated that CNA-L cannot recall specific names, but the residents are no longer at the facility. Surveyor asked when CNA-L last saw CNA-FF working at the facility. CNA-L stated that CNA-L had not seen CNA-FF in a while. Surveyor asked if CNA-L told anyone about the incident. CNA-L stated that it is a hard position to be in CNA-L was not sure what to do. CNA-L indicated that R59 told the Social Worker.Surveyor noted that CNA-L had concerns about CNA-FF being rough with R59 on 7/2/25 and other residents previously and did not report this allegation of abuse to NHA-A per facility protocol.On 8/7/25 at 10:40 AM, Surveyor interviewed OT-GG. Surveyor asked if OT-GG recalled a time that R59 reported a CNA being rough. OT-GG stated that a few weeks ago, R59 reported to OT-GG that CNA-FF was rough during cares and a transfer. OT-GG stated that CNA-FF can be rough. OT-GG stated that R59 told OT-GG that CNA-FF pulled too hard during a transfer and hurt R59. R59 asked OT-GG for help writing a grievance. OT-GG indicated that OT-GG told R59 that they could write it out and contact the Social Worker. Surveyor asked who OT-GG gave the grievance form to. OT-GG indicated that OT-GG would normally give it to the Unit Manager or the Social Worker, but OT-GG is not sure who OT-GG gave the form to. On 8/7/25 at 1:10 PM, Surveyor returned to OT-GG and asked about the grievance form. OT-GG stated that OT-GG thinks that OT-GG helped R59 fill out the grievance form because R59 has such a hard time writing. OT-GG unsure where it ended up. OT-GG stated that OT-GG usually takes copies of everything. OT-GG began looking in office. After looking, OT-GG stated that OT-GG could not find the form and thinks maybe R59 handed it in. OT-GG stated that Surveyor should check with Unit Manager (UM)-D. OT-GG stated that a lot of times, the Unit Mangers will address the concern with the resident and then feel like that concern is complete and maybe that is the case with this, but OT-GG was not sure.Surveyor noted OT-GG was told by R59 on 7/2/25 that CNA-FF was rough with cares and transfers and did not report this allegation of abuse NHA-A per facility policy.On 8/7/25 at 10:58 AM, Surveyor interviewed UM-D. Surveyor asked if UM-D had received a grievance from R59 or heard about a concern that R59 had about a CNA staff member. UM-D stated that about a month ago, CNA-L and CNA-FF were transferring R59 and R59 was upset with the transfer. UM-D stated that CNA-FF did not push where R59 prefers to be pushed when completing a transfer. UM-D stated that there was not a formal grievance placed. UM-D stated that UM-D took CNA-FF back to R59's room after asking R59's permission. UM-D stated that they all talked, and everything was ok after that. UM-D stated that CNA-FF even took care of R59 after that incident. Surveyor asked if any other residents had concerns about CNA-FF cares. UM-D stated no. UM-D indicated that residents like CNA-FF. Surveyor asked if UM-D received a filled-out grievance form from OT-GG or from R59. UM-D stated that R59 did not want to do a grievance and UM-D did not receive a grievance from OT-GG.On 8/7/25 at 11:09 AM, Surveyor interviewed Social Worker (SW)-I. Surveyor asked if R59 or any other staff member reported a grievance for R59. SW-I stated that SW-J is R59's social worker. SW-I indicated that SW-I had not heard of any grievance for R59 but SW-J would be back to work next week and could address this with Surveyor.On 8/7/25 at 11:20 AM, Surveyor interviewed NHA-A. Surveyor asked what the expectation is if a staff member is told by a resident that another staff member was rough and hurt them. NHA-A stated that they should follow the abuse policy and report it to me. Surveyor asked if NHA-A was informed about a CNA being rough with R59. NHA-A stated that NHA-A did not recall the incident of the top of NHA-A's head. Surveyor asked if CNA-FF continues to be employed by the facility. NHA-A stated that NHA-A did not recall the name but stated that NHA-A would get back to Surveyor.On 8/7/25 at 12:22 PM, NHA-A provided Surveyor with a note completed and signed by UM-D regarding the incident. NHA-A stated that there is no documentation of the event aside from this note given to Surveyor.The undated word document signed by UM-D documents: CNA came to get writer regarding resident [R59] and a transfer that happened. [R59] stated that CNA-L and CNA-FF were transferring [R59] and pushed on [R59's] leg when the transfer occurred. Writer asked [R59] to show [UM-D] where they pushed on [R59's] leg. [R59] stated [R59] was fine now just during the transfer it hurt. [R59] has chronic discomfort with transfers due to [R59's] cerebral palsy and leg pain in which [R59] is on pain medication for. [R59] stated [R59 has never had issues with [CNA-FF or CNA-L] but the transfer felt different today. Writer asked if [writer] could bring [CNA-FF] in to speak with us. [R59] agreed. [CNA-FF] apologized that [R59] experienced pain with the transfer. [R59] stated that [R59] understood that it was not done purposeful just wants everyone to be very careful when putting [R59] from Hoyer into chair due to the pain. Writer watched a transfer with staff and saw no issues. Staff is aware of not pushing on residents' leg to position [R59] into the chair. On 8/7/25 at 1:08 PM, Surveyor returned to UM-D and asked when UM-D signed the note regarding CNA-FF and R59. UM-D indicated that the transfer occurred on 7/2/25 and that is when the note was signed.On 8/7/25 at 1:45 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-G who was the nurse working on R59's unit on 7/2/25. Surveyor asked if R59 talked to LPN-G about another staff member. LPN-G stated that R59 informed LPN-G that CNA-FF was rough with cares and R59 does not like having CNA-FF as an aide and did not want CNA-FF as R59's aide. Surveyor asked if LPN-G informed anyone about R59's concerns. LPN-G stated that LPN-G told the Unit Manager. Surveyor asked if any documentation was completed after being told that by R59. LPN-G stated that LPN-G was not sure but stated that residents/staff usually have to fill out a grievance or incident report when something like that happens.Surveyor noted that on 7/2/25, a third staff member was told by R59 about CNA-FF being rough and this allegation of abuse was not reported to NHA-A per facility policy.On 8/7/25 at 3:34 PM, Surveyor informed NHA-A of the concern that 3 staff members were told by R59 that CNA-FF was rough. This allegation of abuse was not communicated to NHA-A. NHA-A stated again that the incident was more of a resident preference with transferring and that UM-D educated, watched a transfer and after asking R59 if CNA-FF could come back to R59, UM-D took CNA-FF to R59, and CNA-FF apologized. Surveyor asked what NHA-A expects if a resident reported a staff member was rough with cares. NHA-A stated that NHA-A would expect the staff member/Unit manager to follow up with NHA-A. NHA-A continued and stated that NHA-A would then try to understand what rough with cares means from the resident. Surveyor asked if NHA-A had spoken to R59. NHA-A stated that NHA-A had not spoken to R59 about this incident.On 8/11/25 at 8:53 AM, Surveyor interviewed SW-J who is R59's social worker. Surveyor asked if SW-J received a grievance from R59 on 7/2/25. SW-J stated that there is no grievance for that. Surveyor asked if SW-J had heard from R59 or another staff member that a CNA was rough. SW-J stated that SW-J never heard from any staff about another staff member being rough with R59. Surveyor asked what the protocol is if a resident reports that a staff member was rough. SW-J stated that SW-J would report that to the unit manager.Surveyor noted that SW-J told Surveyor that SW-J would tell the unit manager of a resident's report of a staff member being rough instead of the NHA-A per facility policy.On 8/7/25 at 10:43 AM, Surveyor interviewed CNA-S. Surveyor asked what CNA-S would do if a resident reported that a different staff member was rough with cares or a transfer. CNA-S stated that CNA-S would report that to a manager right away so they can start investigating.Surveyor noted that CNA-S told Surveyor that CNA-S would tell the unit manager of a resident's report of a staff member being rough instead of the NHA-A per facility policy.On 8/7/25 at 10:36 AM, Surveyor interviewed Nurse Technician (NT)-BB. Surveyor asked what NT-BB would do if a resident reported that a different staff member was rough with cares or a transfer. NT-BB stated that NT-BB would report it right away. NT-BB stated that NT-BB would tell the Administrator, Director of Nursing (DON)-B, and the Charge nurse. NT-BB would then fill out an incident report. On 8/11/24 at 3:31 PM, Surveyor asked NHA-A when CNA-FF's last day of employment was at the facility. NHA-A stated that it was sometime around July 3rd. Surveyor asked why CNA-FF no longer works at the facility. NHA-A stated that CNA-FF was contracted through an agency and CNA-FF's contract had ended.Surveyor reviewed CNA-FF's punch card details for the month of July. Surveyor noted CNA-FF continued to work after the incident with R59 on 7/2/25. Surveyor noted that the last day CNA-FF worked at the facility was 7/9/25. Surveyor reviewed the facility staffing schedule and CNA-FF's punch card details from 7/2/25 through 7/9/25. The facility has a total of 6 units labeled one through 6. R59 is located on unit 1 of the facility. Surveyor noted the following schedule for CNA-FF: 7/2/25, CNA-FF worked from midnight until 6:30 AM, 6:45 until 2:30 PM and then returned at 10:15 PM to work the night shift. CNA-FF was on the staffing schedule to work on unit 1 (R59's unit) and 2 for both shifts. 7/3/25, CNA-FF worked from midnight until 6:31 AM and then returned at 10:06 PM to work the night shift. CNA-FF was on the staffing schedule to work on unit 1 (R59's unit) and 2 from midnight until 6:31 AM and was on the staffing schedule to work on units 3 and 4 when returning at 10:06 PM. 7/4/25, CNA-FF worked from midnight until 6 AM and from 6:15 AM until 2:30 PM. CNA-FF was on the staffing schedule to work on units 3 and 4. 7/5/25, CNA-FF worked from 6:32 AM until 10:32 PM. CNA-FF was on the staffing schedule to work on units 1 (R59's unit) and 2. 7/6/25, CNA-FF worked from 6:30 AM until 10:28 PM. CNA-FF was on the staffing schedule to work on units 3 and 4 for the first shift and units 1 (R59's unit) and 2 for the second shift. CNA-FF did not punch in for work on 7/7/25. 7/8/25, CNA-FF worked from 9:53 PM until midnight. CNA-FF was on the staffing schedule to work on units 1 (R59's unit) and 2. 7/9/25, CNA-FF worked from midnight until 6:34 AM. CNA-FF was on the staffing schedule to work on units 1 (R59's unit) and 2. Surveyor noted that CNA-FF continued to work on R59's unit 6 additional shifts after R59 reported to 3 different facility staff members that CNA-FF was rough.On 8/11/25 at 8:58 AM, Surveyor interviewed DON-B. Surveyor asked what DON-B would expect a staff member to do if a resident reported that a different staff member was rough with cares. DON-B stated that staff should report it to DON-B or NHA-A. On 8/13/25, Surveyor informed NHA-A and DON-B of the continued concern that 3 staff members were informed by R59 that CNA-FF was rough. This allegation of abuse was not reported to the NHA-A per facility policy. CNA-FF continued to work on R59's unit and had access to all residents residing in the facility after an allegation of abuse was made.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily livi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming for 7 (R15, R16, R24, R27, R34, R81,and R6) of 8 Residents reviewed for ADLs (Activity of Daily Living).
* R15, R16, R24, R27, R34, R81,and R6 did not receive showers at least one time a week.
Findings include:The facility’s Resident Showers policy and procedure reviewed/revised 6/11/25 documents:”Guideline: It is the practice of this facility to assist Residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.”
”Explanation and Compliance Guidelines:1.Residents will be provided with showers as per request and within reasonable accommodation, or as per facility schedule protocols(at least offered weekly) and based upon Resident safety.”
1.) R15 was admitted to the facility on [DATE] with diagnoses of Rhabdomyolysis(skeletal muscle breaks down rapidly), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Protein-Calorie Malnutrition (deficiency of both protein and energy), and Hyperlipidemia (high levels of fat particles in blood).
R15’s admission Minimum Data Set(MDS) completed 6/30/25 documents R15’s Brief Interview for Mental Status(BIMS) score to be 12, indicating R15 demonstrates moderately impaired skills for daily decision making. R15 has no ROM impairment. R15 requires set-up for eating and is always incontinent of bowel and bladder. R15 requires partial/moderate assistance for showers/bathing and substantial/maximum assistance for upper and lower dressing, mobility, and transfers. R15’s MDS documents it is somewhat important to choose between tub bath or showers.
R15’s Care Card as of 8/1/25 document R15’s shower days is on Wednesday AM.
R15’s care plan documents the intervention that R15 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Revised 6/30/25
R15’s ADL Care Area Assessment(CAA) for ADLS dated 7/7/25 documents the overall objective is improvement, maintain current level of functioning and minimize risks. There is no other documentation in R15’s CAA.
On 8/6/2025, at 1:15 PM, Surveyor interviewed R15. R15 informed Surveyor that R15 has not been receiving showers on a regular basis since admission. On 8/7/2025, at 2:14 PM, R15 informed Surveyor that R15 received a shower on 8/6/25, but stated that is the first shower R15 has received since admission to the facility. Surveyor reviewed R15’s electronic medical record(EMR) and notes that no showers sheets are uploaded in the system. Based on R15’s showers being on Wednesday, R15 missed showers on 6/30/25, 7/6/25, 7/13/25, 7/20/25, and 7/27/25.
On 8/12/2025, at 8:33 AM, Surveyor reviewed R15 and R16’s documentation of shower sheets that R15 received showers.
R15's shower sheets documented:
7/2/25-no Certified Nursing Assistant(CNA)- signature, MT-N signed but did not work that day according to the facility schedule.7/9/25-Certified Nursing Assistant(CNA)- signature, no nurse signature7/2/25-no Certified Nursing Assistant(CNA)- signature, MT-N signed but did not work that day according to the facility schedule.
7/16/25-no Certified Nursing Assistant(CNA)- signature, MT-N signed but did not work that day according to the facility schedule.7/23/25-Certified Nursing Assistant(CNA)- signature, no nurse signature7/30/25-no Certified Nursing Assistant(CNA)- signature, MT-N signed but did not work that day according to the facility schedule.
On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R15 had not been receiving a weekly shower. No further information has been provided by the facility as to why R15 did not receive showers on consistent weekly basis.
2.) R16 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Essential Hypertension(most common type of high blood pressure), Spastic Hemiplegia Affecting Unspecified Side(one side of body experiences muscle stiffness and weakness), and Insomnia(sleep disorder characterized by difficulty falling asleep). R16 is currently her own person.
R16’s admission Minimum Data Set(MDS) completed 7/14/25 documents R16’s Brief Interview for Mental Status(BIMS) score to be 13, indicating R16 is cognitively intact for daily decision making. R16’s MDS documents that R16 is always incontinent of bowel and bladder, that R16 is dependent for lower dressing, mobility, and transfers. The MDS documents that R16 requires partial/moderate assistance for upper dressing and showers/bathing. R16 currently has an unhealed pressure injury to the Coccyx. R16’s MDS documents it is very important to choose between a tub bath, shower, bed bath, or sponge bath.
R16’s Care Card as of 8/1/25 document R16’s shower day is on Tuesdays AM.
R16’s care plan documents the intervention that R16 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Revised 7/21/25
R16’s ADL Care Area Assessment(CAA) for ADLS dated 7/17/25 documents the overall objective is avoid complications, maintain current level of functioning and minimize risks. There is no other documentation in R16’s CAA.
On 8/6/2025, at 1:10 PM, Surveyor interviewed R16. R16 stated has not been getting showers on a regular basis. Surveyor observed R16’s hair to be greasy. On 8/7/2025, at 1:58 PM, R16 informed Surveyor that R16 did not get a shower on 8/5/25. R16’s hair appears to be greasy.
Surveyor reviewed R16’s electronic medical record(EMR) and notes that no showers sheets are uploaded in the system. Based on R16’s showers being on Tuesday, R16 missed showers on 7/8/25, 7/15/25, 7/22/25, 7/22/25, and 8/5/25.
On 8/12/2025, at 8:33 AM, Surveyor reviewed R15 and R16’s documentation of shower sheets that R15 and R16 received showers.
R16's shower sheets documented:
7/15/25-no CNA signature, nurse signed7/22/25-no CNA signature, MT-N signed but did not work that day according to the facility schedule.7/29/25-no CNA signature, MT-N signed but did not work that day according to the facility schedule.
On 8/13/2025, at 10:49 AM, R16 informed Surveyor that R16 received a shower late evening on 8/12/25.
On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R16did not receive a weekly shower per R16's plan of care. No additional information was provided by the facility as to why all R16 did not receive showers on consistent weekly basis.
3.) R24 was admitted to the facility on [DATE] with diagnoses of Epileptic Seizures(brain has sudden, uncontrollable surge of electrical activity), Encephalopathy(group of conditions that cause brain dysfunction), Essential Hypertension(chronic condition of persistently high blood pressure), Dysphagia(difficulty swallowing foods), Gastrostomy Status(artificial opening in stomach used for feeding), and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R24 currently has a legal guardian.
R24’s Quarterly MDS completed 6/23/25 documents R24 demonstrates severely impaired skills for daily decision making. R24’s memory was not assessed. R24 is dependent for upper/lower dressing, showers/bathing, mobility, and transfers. R24 has both upper and lower extremity range of motion(ROM) impairment on both sides. The MDS does not document that R24 utilizes a splint or brace and documents that R24 is always incontinent of bowel and bladder. R24 currently has a feeding tube.
R24’s Care Card as of 8/1/25 document R24’s shower day is on Fridays PM.
R24’s care plan documents the intervention that R24 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Revised 9/20/24
Surveyor reviewed R24’s electronic medical record(EMR) and notes the only shower sheets found were dated 8/1/25, 4/11/25, 4/18/25, 3/7/25, 2/7/25, and 11/1/24.
Surveyor noted that R24 did not have any documented showers provided for the month of July 2025, June 2025 or May 2025.
No additional information was provided as to why R24 did not receive showers per R24's plan of care.
4.) R27 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Neuromuscular Dysfunction of Bladder(nerves controlling bladder and urinary sphincter are damaged and not working correctly), Paraplegia(paralysis of lower half of body), and Schizoaffective(combination of schizophrenia and mood disorder symptoms including hallucinations and delusions and manic/depressive episodes). R27 is currently his own person.
R27’s quarterly minimum data set(MDS) completed 5/31/25 documents R27’s brief interview for mental status(BIMS) score to be 13, indicating R27 is cognitively intact for daily decision making. R27’s MDS documents R27 has range of motion impairment on one side of lower extremity. R27’s MDS also documents R27 requires substantial/maximum assistance for upper dressing and is dependent for lower dressing. R27 is dependent for mobility and transfers. R27 requires substantial/maximum assistance for showers. R27 has an indwelling catheter and is always incontinent of bowel.
R27’s admission MDS documents it is somewhat important for R27 to choose between a tub bath, shower, bed bath, or sponge bath.
R27’s Care Card as of 8/1/25 document R27’s shower day is on Thursday PM.
R27’s care plan documents the intervention that R27 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Revised 6/11/25
R27’s ADL Care Area Assessment(CAA) for ADLS dated 12/3/24 documents the overall objective is improvement, slow or minimize decline, maintain current level of functioning and minimize risks. There is no other documentation in R27’s CAA.
Surveyor reviewed R27’s electronic medical record (EMR) and notes the only shower sheets found were dated 1/30/25, 2/13/25, 2/20/25, 3/6/25.
Surveyor noted that R27 had no documented showers for May, June, July August 2025.
No additional information was provided as to why R27 did not receive documented showers per R27's plan of care.
5.) R34 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis(muscles under voluntary control to feel weak), Protein-Calorie Malnutrition (deficiency of both protein and Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), and Depression(mood disorder that causes persistent feelings of sadness and loss of interest). R34's admission Minimum Data Set(MDS) completed 7/22/25 documents R34's Brief Interview for Mental Status(BIMS) score to be 15, indicating R34 is cognitively intact for daily decision making. R34’s MDS documents R34 has no range of motion impairment. R34 is independent with eating. R34 requires partial/moderate assistance for upper dressing and substantial/maximum assistance for transfers. R34 is dependent for lower dressing and mobility. R34’s MDS documents R34 is receiving oxygen(O2) therapy. R34’s MDS also documents that R34 is at risk for developing a pressure ulcer and currently has one venous and arterial ulcer. It is somewhat important for R34 to choose between a tub bath, shower, bed bath or sponge bath.
R34’s Care Card as of 8/1/25 document R34’s shower day is on Friday PM.
R34’s care plan documents the intervention that R34 requires assistance by 1 staff with bathing/showering as scheduled and as necessary. Created 7/18/25 Revised 7/21/25
On 8/11/2025, at 12:45 PM, Surveyor interviewed R34. R34 informed Surveyor that R34 has not had a shower since admission.
On 8/12/2025, at 2:14 PM, R34 confirmed R34 has not received any showers since arriving at the facility R34 states R34’s leg is wrapped and “they haven't figured out a way to give R34 a shower. Why don't they shower me on my treatment days when its unwrapped”.
Surveyor reviewed R34’s electronic medical record(EMR) and notes that no showers sheets are uploaded in the system. Based on R34’s showers being on Friday, R34 missed 7/18/25, 7/25/25, 8/1/25, 8/8/25.
No additional information was provided as to why R34 did not receive showers per R34's plan of care.
6.) R81 was admitted to the facility on [DATE] with diagnoses of Essential Hypertension(chronic condition of persistently high blood pressure), Type 2 Diabetes Mellitus(adult onset of trouble controlling blood sugar), Hypertensive Heart Disease(long term conditions developed from chronic high blood pressure), Chronic Obstructive Pulmonary Disease(lung disease that block airflow and make it difficult to breathe), Major Depressive Disorder(persistent feelings of sadness, hopelessness, and a loss of interest or pleasure in activities), and Dementia(loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life). R81 has an activated health care power of attorney.
R81’s annual minimum data set(MDS) completed 7/3/25 documents R81’s brief interview for mental status(BIMS) score to be 5, indicating R81demonstrates severely impaired skills for daily decision making. R81’s MDS documents R81 has no range of motion impairment. R81is independent with eating. R81’s MDS also documents R81 is dependent for upper and lower dressing, showers/bathing, mobility and transfers. R81is always incontinent of bowel and bladder. somewhat important for R81 to choose between a tub bath, shower, bed bath, or sponge bath.
R81’s Care Card as of 8/1/25 document R81’s shower day is on Monday AM.
Surveyor notes there is no instructions in R81’s care plan or care card for nursing staff on what type of assistance R81 requires for showering.
Surveyor notes on 12/12/21 it is documented on R81’s care plan that R81 has a history of refusing showers/baths. There is no revisions and no updated interventions for R81 refusing showers. R81’s EMR has no documentation that R81 has been refusing showers and what approaches nursing staff has attempted.
Surveyor reviewed R81’s electronic medical record(EMR) and noted the only shower sheets found were dated 6/30/25, 2/1//25, 1/18/25, 4/28/25, 4/17/25,2/10/25, 1/20/25,11/18/24,10/31/24.
On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R81 had not been receiving a weekly shower. Surveyor requested documentation for showers given back to 11/2024 for R81. DON-B replied, Did the Residents tell you that?” Surveyor responded that 3 interviewable Residents confirmed they had not received showers. No further information has been provided by the facility at this time as to why R81 had not received shower on consistent weekly basis.
Surveyor was provided 6 documented showers for R81 in July and August. No other documentation that R81 received showers prior to July on a consistent weekly basis. On 7/21/25, and 7/25/25, the nurse signing off on R81’s shower sheet did not work that day according to the facility schedule.
No additional information was provided.
7.) R6 admitted to the facility on [DATE] and has diagnoses that include nontraumatic intracerebral hemorrhage in subcortical hemisphere, Cerebral Infarction due to occlusion or stenosis of small artery, chronic pancreatitis, Hyperglycemia, gastrostomy status, Hypertension, Chronic Kidney Disease stage 3 and dysphagia.
R6’s admission Minimum Data Set (MDS) dated [DATE] documents under Section F (Preferences for Routine & Activities):
How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath? Very important. Indicate primary respondent for Daily and Activity Preferences: Family or significant other. Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair): Dependent.
R6’s Care Plan documents: The resident has an ADL (Activity of Daily Living) self-care performance deficit r/t (related to) impaired mobility, CVA (Cerebrovascular Accident) with Right sided Spasticity/deficits - initiated 5/22/25. BATHING/SHOWERING: The resident requires assistance by 1 staff with bathing/showering as scheduled and as necessary.
On 8/11/25 at 3:07 PM, Surveyor spoke with R6‘s mother and Power of Attorney (POA) who reported she has complained about cares because there were times when she'd come in and R6 was in bed and both she and the linen was wet, and she has helped staff change her sometimes. R6’s POA reported she has not filed any grievances but does report concerns to the staff if she has any, and things have gotten better since she has voiced concerns. The POA reported she is not sure if R6 gets or has ever gotten a shower and believes staff only do bed baths because she doesn’t think there is enough help.
Surveyor reviewed R6’s medical record and was unable to locate any documentation or evidence R6 has received a shower since admission. Surveyor was unable to locate any progress notes indicating a skin check was completed during shower or any documentation regarding showers. R6’s Kardex indicates she is to receive a shower every Friday AM.
Review of the Certified Nursing Assistant (CNA) Point of Care (POC) documentation for the last 30 days revealed only 1 entry on 7/15/25 at 1:57 AM, which documented:
Question 1 - What type of bathing did resident receive? Options include shower, tub bath, bed bath, resident not available, resident refused, and NA (Not Applicable). Surveyor noted a check mark under “not applicable.”
Question 2 - Shower/bathe self: The ability to bathe self, including washing, rinsing, and drying self (excludes washing of back and hair). Does not include transferring in/out of tub/shower. Surveyor noted a check mark under “not applicable - not attempted and the resident did not perform this activity prior to the current illness, exacerbation or injury.”
On 8/12/25 at 3:20 PM, during the daily exit meeting, the facility was advised of concern there is no evidence R6 is receiving or has received a shower since admission. Surveyor advised of facility POC documentation the past month of only 1 entry documenting “NA.” Surveyor asked for shower sheets or evidence R6 has received showers. Director of Nursing (DON)-B reported she has seen R6 receiving a shower “because her office is just down the hall” but can't speak to how many times.
No additional information was provided as to why R6 did not receive any documented showers per R6's plan of care.
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 observation, interview and record review the facility did not ensure 5 (R15, R16, R27, R34, and R8) of 20 residents rec...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure 5 (R15, R16, R27, R34, and R8) of 20 residents received necessary care and treatment in accordance with professional standards of practice, a comprehensive person-centered care plan or facility policies and procedures.
*R15 was observed not wearing compression stockings during the survey per physician orders and R15's plan of care.
*R16 was observed not wearing compression stockings during the survey per physician orders and R16's plan of care.
*R27 was observed not wearing compression stockings during the survey per physician orders and R27's plan of care.
*R34 did not have a treatment completed to R34’s vascular/venous statis ulcer on 8/8/25. On 7/18/25, a physician order was obtained for R34 to receive an air mattress and R34 did not receive an air mattress until 7/21/24.
*R8 had an unwitnessed fall on 4/8/25 and no neurological checks were documented as completed for R8.
Findings include:
The facility’s Provision of Quality Care policy dated as reviewed/revised on 4/1/25 documents:
Guideline:
Based on comprehensive assessments, the facility will ensure that Residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the Residents’ choices
Explanation and Compliance Guidelines:
1. Each Resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being.
3. Responsibility for interventions on the care plan will be clearly identified.
4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the Resident’s care plan, and the Resident’s choices.”…
1.) R15 was admitted to the facility on [DATE] with diagnoses of Rhabdomyolysis (skeletal muscle breaks down rapidly), Type 2 Diabetes Mellitus (adult onset of trouble controlling blood sugar), Protein-Calorie Malnutrition (deficiency of both protein and energy), and Hyperlipidemia (high levels of fat particles in blood).
R15’s admission Minimum Data Set (MDS) completed 6/30/25 documents a Brief Interview for Mental Status (BIMS) score to be 12, indicating R15 demonstrates moderately impaired cognition. The MDS documents that R15 has no ROM (range of motion) impairment, that R15 requires set-up for eating and is always incontinent of bowel and bladder. The MDS also documents that R15 requires partial/moderate assistance for showers/bathing and substantial/maximum assistance for upper and lower dressing, mobility, and transfers.
R15’s physician order dated 6/27/25 documents that R15 is to have compression stockings to bilateral lower extremities, on in AM (morning), off at HS (bedtime). Two times a day for bilateral lower extremity edema.
R15’s Treatment Administration Records (TARS) documentation for R15’s compression stockings from June through August 2025 documents:
June 28th and 29th stockings are not signed as placed on R15. June 30th does not indicate the stockings were taken off R15.
July 6th and 14th does not indicate the stockings were taken off R15. July 22nd, 25th, 26th, and 27th stockings are not signed as placed on R15.
August 3rd and 10th stockings are not signed as placed on R15. August 6th, 7th, 11th, and 12th it is documented R15 is wearing the compression stockings on the TAR however, Surveyor observed no compression stockings on R15 those dates.
R15’s CNA (Certified Nursing Assistant) care card dated 8/1/25 documents that nursing staff are to place compression stockings to R15's bilateral lower extremities, on in AM and off at HS.
On 8/6/2025, at 1:15 PM, Surveyor observed R15 is not wearing compression stockings. Surveyor observed R15 wearing no-show socks and tennis shoes.
On 8/7/2025, at 2:14 PM, Surveyor observed R15 is not wearing compression stockings.
On 8/11/2025, at 10:29 AM, Surveyor observed R15 is not wearing compression stockings.
On 8/12/2025, at 2:18 PM, Surveyor observed R15 is not wearing compression stockings. R15 confirmed to Surveyor that nursing staff have not been putting compression stockings on R15.
On 8/12/25, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E regarding R15 not wearing compression stockings as ordered by the physician. UM-E stated the expectation if there is a physician order and it is on a resident’s care card, the compression stockings should be put on and if refused, it should be documented.
On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R15 was observed not wearing their compression stockings as ordered by the physician. Surveyor also informed NHA-A and DON-B that there is no documentation in R15's electronic medical record as to why R15 would not wearing their compression stockings.
No additional information was provided as to why R15 was observed not wearing compression stockings per physician orders.
2.) R16 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Essential Hypertension(most common type of high blood pressure), Spastic Hemiplegia Affecting Unspecified Side(one side of body experiences muscle stiffness and weakness), and Insomnia(sleep disorder characterized by difficulty falling asleep). R16 is currently her own person.
R16’s admission Minimum Data Set(MDS) completed 7/14/25 documents a Brief Interview for Mental Status(BIMS) score to be 13, indicating R16 is cognitively intact. R16’s MDS documents that R16 is always incontinent of bowel and bladder and that R16 is dependent for lower dressing, mobility, and transfers. The MDS also documents that R16 requires partial/moderate assistance for upper dressing and showers/bathing and that R16 currently has an unhealed pressure injury to the coccyx.
R16’s physician order dated 7/21/25 documents that R16 is to have compression stockings to bilateral lower extremities, on in AM, off at HS. Two times a day for bilateral lower extremity edema.
R16’s Treatment Administration Record (TAR) for July and August of 2025 for the use of compression stocking documents:
July 22, 25, 26, and 27 stockings were not documented as being placed on R16.
August 3 and 10 stockings were not documented as being placed on R16. August 6,7,11,12 it is documented the compression stockings are on, however, Surveyor observed R16 to be wearing compression stockings.
R16’care card dated 8/1/25 instructs nursing staff to place compression stockings to bilateral lower extremities, on in AM and off at HS.
On 8/6/2025, at 1:10 PM, Surveyor observed R16 is not wearing compression stockings. Surveyor observed R16 wearing only gripper socks.
On 8/7/2025, at 1:58 PM, Surveyor observed R16 is not wearing compression stockings.
On 8/11/2025, at 10:30 AM, Surveyor observed R16 is not wearing compression stockings.
On 8/11/2025, at 1:23 PM, R16 verified to Surveyor that compression stockings have not been put on today.
On 8/12/2025, at 2:18 PM, Surveyor observed R16 is not wearing compression stockings. R16 confirmed to Surveyor that nursing staff have not been putting compression stockings on R16.
On 8/12/25, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E regarding R16 not wearing compression stockings as ordered by the physician. UM-E stated the expectation if there is a physician order and it is on a resident’s care card, the compression stockings should be put on and if refused, it should be documented.
On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R16 was observed not wearing their compression stockings as ordered by the physician. Surveyor also informed NHA-A and DON-B that there is no documentation in R16's electronic medical record as to why R16 would not wearing their compression stockings.
No additional information was provided as to why R16 was observed not wearing compression stockings per physician orders.
3.) R27 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy(congenital disorder of movement, muscle tone, or posture), Neuromuscular Dysfunction of Bladder(nerves controlling bladder and urinary sphincter are damaged and not working correctly), Paraplegia(paralysis of lower half of body), and Schizoaffective(combination of schizophrenia and mood disorder symptoms including hallucinations and delusions and manic/depressive episodes). R27 is currently his own person.
R27’s quarterly minimum data set(MDS) completed 5/31/25 documents a brief interview for mental status(BIMS) score to be 13, indicating R27 is cognitively intact. R27’s MDS documents that R27 has range of motion impairment on one side of lower extremity and that R27 requires substantial/maximum assistance for upper dressing and is dependent for lower dressing. The MDS also documents that R27 is dependent for mobility and transfers, that R27 requires substantial/maximum assistance for showers and that R27 has an indwelling catheter and is always incontinent of bowel.
R27’s physician order dated 11/22/24 documents that R27 is to have compression stockings to bilateral lower extremities, on in AM, off at HS. Two times a day for bilateral lower extremity edema.
R27’s Treatment Administration Record (TAR) for R27’s compression stockings being placed on R27 for July and August 2025 documents:
July 22, 25, 26, and 27 compression stockings are not documented as being placed on R27.
August 3 and 10 compression stockings are not documented as being placed on R27. August 6,7,11,12 it is documented the compression stockings are on R27, however, Surveyor observed no compression stockings on R27.
R27’care card as of 8/1/25 instructs nursing staff to place compression stockings/tubi grips to bilateral lower extremities, on in AM and off at HS.
On 8/7/2025, at 9:02 AM, Surveyor observed that R27 is not wearing compression stockings or tubi grips.
On 8/11/2025, at 2:25 PM, Certified Nursing Assistant (CNA)-Q informed Surveyor that R27’s care card states R27 is to have compression stockings on, but did not want to wear them because R27 has bandages on. CNA-Q informed Surveyor that CNA-Q did not inform the nurse.
On 8/11/2025, at 3:06 PM, Surveyor confirmed that R27 is not wearing compression stockings and notes there is no documentation in R27’s electronic medical record as to why R27 is not wearing compression stockings.
On 8/12/2025, at 11:48 AM, R27 stated R27 is not wearing compression stockings.
On 8/12/2025, at 2:19 PM, R27 confirmed R27 is not wearing compression stockings and does not know why.
On 8/13/2025, at 9:34 AM, R27 is not wearing compression stockings and there is no documentation in R27’s electronic medical record as to why R27 is not wearing compression stockings.
On 8/12/25, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E regarding R27 not wearing compression stockings as ordered by the physician. UM-E stated the expectation if there is a physician order and it is on a resident’s care card, the compression stockings should be put on and if refused, it should be documented.
On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B the concern that R27 was observed not wearing their compression stockings as ordered by the physician. Surveyor also informed NHA-A and DON-B that there is no documentation in R27's electronic medical record as to why R27 would not wearing their compression stockings.
No additional information was provided as to why R27 was observed not wearing compression stockings per physician orders.
4.) R34 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis(muscles under voluntary control to feel weak), Protein-Calorie Malnutrition (deficiency of both protein and Native Coronary Artery(plaque buildup narrows the arteries that supply blood to the heart), and Depression(mood disorder that causes persistent feelings of sadness and loss of interest).
R34's admission Minimum Data Set(MDS) completed 7/22/25 documents a Brief Interview for Mental Status(BIMS) score to be 15, indicating R34 is cognitively intact. R34’s MDS documents R34 has no range of motion impairment, that R34 is independent with eating and that R34 requires partial/moderate assistance for upper dressing and substantial/maximum assistance for transfers. The MDS also documents that R34 is dependent for lower dressing and mobility that R34 is receiving oxygen(O2) therapy and that R34 is at risk for developing a pressure ulcer and currently has a 1 venous ulcer.
On 8/6/2025, at 9:28 AM, Surveyor interviewed R34. R34 stated that it took days for R34 to get an air mattress on the bed. R34 stated, “They knew I was coming; they should have had it ready”. R34 stated R34 laid on a metal frame for several days and now R34’s back hurts.
R34's physician order dated 7/18/25 documents an order for an air mattress for R34.
On 7/16/2025, Unit Manager (UM)-E documented 3/10 pain located at left lower extremity non healing wound. Non healing wound present on left lower extremity due to venous stasis.
On 7/20/25, Licensed Practical Nurse (LPN)-II documented that R34 requested an air mattress.
On 7/21/25, LPN-AA documented that R34 was transferred to a bed with an air mattress. R34 settled in well and slept well through the night.
On 8/11/2025, at 12:45 PM, R34 informed R34’s treatment didn't get done on 8/8/25. R34 stated R34 had to keep reminding them to get the treatment done, but it never did. Surveyor observed the wrap marked 8/6 on R34’s leg. R34 confirmed that R34 had to ask for an air mattress after being admitted to the facility. R34 stated R34’s back hurt laying on the metal bar of the regular mattress.
On 8/11/2025, at 12:52 PM, Surveyor brought LPN-R to observed R34’s bandage. LPN-R confirmed the bandage is marked 8/6. LPN-R stated to Surveyor LPN-R is not sure if able to get to the treatment today. LPN-R stated, “Have a lot to do yet. If I don’t get it done, it will go to PM shift, I don't have time to do treatments today”.
On 8/12/2025, at 1:32 PM, Surveyor interviewed Unit Manager (UM)-E. Surveyor asked UM-E why R34’s treatment had not been completed on 8/8. UM-E does not know why. UM-E agrees the bandage was marked 8/6 when observed on 8/11. Surveyor asked UM-E why R34’s air mattress was not placed on R34’s bed until 7/21/25 after R34 requested it and after a physician order for an air mattress was written on 7/18/25. UM-E informed Surveyor that UM-E will contact maintenance about a work order for an air mattress and get back with Surveyor.
On 8/12/2025, at 3:17 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R34 did not receive an air mattress until 7/21/25, despite a physician order on 7/18/25 and R34 requesting it. Surveyor also shared that R34 has not had R34’s treatment completed to R34’s venous stasis ulcer.
No additional information was provided by the facility in regard to why there was a delay in getting an air mattress for R34 and treatments have not been completed as ordered by physician for R34’s venous stasis ulcer.
5.) The facility policy with a last reviewed/revised date of 12/3/24, titled “Fall Prevention Program” documents, in part: When any resident experiences a fall, the facility will: Assess the resident . Document all assessments and actions . Monitor residents’ condition and response to interventions as per standard of practice.
The facility policy with a last reviewed/revised date of 7/10/25 documents, in part: It is the guideline of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Assess resident following a known, suspected or verbalized head injury… Example protocol for actual/suspected head injury may include: Every 15 min, for 1 hour, then; hourly for 4 hours, then’ every 8 hours (every shift) for 72 hours…
R8 was admitted to the facility 6/1/2014 with diagnosis that include Hemiplegia/Hemiparesis (weakness on one side of the body) following a stroke, stage 2 kidney disease and epilepsy (seizure disorder).
R8’s Significant change Minimum Data Set (MDS) assessment dated [DATE] documents R8 is moderately cognitively impaired. R8 has impairments on one side of both of R8’s upper and lower extremities. R8 requires substantial/maximum assistance for personal hygiene and transfers. R8 has had one fall with major injury since R8’s last MDS Assessment.
R8’s Care Area Assessment for falls dated 3/1/25 documents, in part: [R8] had a recent fall and has a history of falls [related to] [stroke] and weakness.
R8’s care plan documents the following pertinent interventions: Assist of with toileting needs [as needed], initiated on 10/29/23. Prompt [R8] to toilet upon rising, after meals and [at bedtime] and per request at night. Keep urinal at bedside at night, initiated on 1/13/19. Toilet use: [R8] requires assistance x 2 [standing pivot transfer] with front wheeled walker. Assist x 1 with toileting hygiene. Prompt to use the bathroom every 2-3 hours and [as needed], initiated on 3/23/25.
R8’s Fall Risk Evaluation dated 2/12/25 documents a score of 8 which puts R8 at moderate risk for falls.
R8’s progress note dated 4/8/25 at 10:49 AM documents, in part: [R8] had an unwitnessed fall around 700 am. [R8] was discovered by CNA who alerted this nurse. [R8] was found in front of wheelchair, lying on [R8’s] left side, and the wheelchair was also on its side. Per [R8], [R8] forgot to lock [R8’s] wheelchair. Vital signs taken and documented .
Surveyor reviewed R8’s electronic medical record for evidence of neurological checks being completed after R8’s unwitnessed fall. R8 has one neurological check completed on 4/8/25 at 1:47 PM.
Surveyor reviewed R8’s fall investigation dated 4/8/25. The first page of the fall packet revealed a “Checklist for Accidents/Incidents.” The checklist is arranged with a column of Nurse responsibilities, a column where staff can write in the completed date and a column for staff to put their signature for each responsibility. One of the nurse responsibilities on the checklist is, “[NAME] (sic) checks initiated (only if unwitnessed, resident hits head or states they hit their head). Surveyor noted that the completion date of [NAME] (sic)/Neurological check is blank and there is no staff signature.
On 8/12/25 at 2:13 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-OO. Surveyor asked about R8's fall on 4/8/25. LPN-OO stated R8 was found laying on the floor. LPN-OO stated that vitals and an assessment were completed, and the physician was notified. LPN-OO stated R8 did not sustain an injury with this fall. Surveyor asked what the neuro (neurological) check policy is for the facility. LPN-OO indicated that neuro checks should be completed after any unwitnessed fall. LPN-OO stated that LPN-OO did complete a neuro check but could not keep up with them due to her other nurse duties on the unit.
On 8/12/25 at 1:30 PM, Surveyor asked LPN-G what should be completed after a resident sustains an unwitnessed fall. LPN-G stated the resident is assessed, then, if safe, assisted back to chair/bed. LPN-G would inform the MD and the resident’s power of attorney. LPN-G that staff must fill out the fall packet and checklist. Neuro checks would be started after an unwitnessed fall.
On 8/13/25 at 9:04 AM, Surveyor interviewed Nurse Technician (NT)-BB. Surveyor asked what should be completed after a resident sustains an unwitnessed fall. NT-BB stated that the resident is assessed, vital signs completed, and neuro checks started. After caring for the resident, staff must fill out the fall packet. The packet contains a checklist with everything to complete including witness statements.
On 8/13/25 at 10:44 AM, Surveyor interviewed Unit Manager (UM)-D. Surveyor asked if UM-D could explain the facilities Neuro check policy regarding falls. UM-D indicated that neuro checks are started after an unwitnessed fall. The neuro checks are started right away and carry on for the appropriate amount of time. UM-D stated that the initial neuro check can be documented in the electronic medical record, but the rest of the neuro checks are documented on paper.
On 8/13/25 at 12:47 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked about R8’s neuro checks after R8’s fall. DON-B reviewed R8’s fall packet and did not locate any documented neuro checks. Surveyor alerted DON-B to the fact that the checklist in the fall packet is blank in the row related to neuro checks. DON-B acknowledged the row was blank.
On 8/13/25 at 2:45 PM, Surveyor informed Nursing Home Administrator (NHA)-A and DON-B of the concern that on 4/8/25, R8 was transferred to the toilet by a CNA according to documentation, 2 minutes later, R8 sustained an unwitnessed fall. Neurological checks were not completed per facility policy. No additional information was provided.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review the facility did not ensure the kitchen was storing and preparing food in a safe and clean manner. This has the ability to affect all 93 residents.The...
Read full inspector narrative →
Based on observation, interview and record review the facility did not ensure the kitchen was storing and preparing food in a safe and clean manner. This has the ability to affect all 93 residents.The walk-in freezer had buildup of thick ice on the floor, walls and ceiling including boxes of food in the freezer.Two fans in food prep area had buildup of red substance making the fan appear dirty and in disrepair.A bag of lettuce salad was opened with a date that was faded so it made the date unreadable. The lettuce was brown.The exhaust fan over the stove area had a buildup of dust.No beard restraint used for Dietary Staff (DS)-LL and Dietary Manager (DM)-MM.Findings include: The facility policy regarding dietary staff attire dated 10/2023 documents:1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained.On 8/6/25, at 8:50 a.m., Surveyor toured the kitchen. Surveyor observed the walk-in cooler with a thick buildup of ice along the ceiling, walls and floor of the freezer. There were boxes in the freezer had a buildup of ice. Surveyor did not walk in the freezer due to safety issues due to ice on the floor.Surveyor walked into the walk-in cooler and observed a bag of lettuce salad that was opened and dated. The date had faded off and made it unreadable. The lettuce was observed to look brown. On 8/6/25, at 11:00 a.m., Surveyor observed a fan mounted on the wall. The front covering of the fan was off and there was a buildup of red substance on the fan, making it appear dirty. The fan was above the food prep area.Surveyor observed a box fan, on a table facing a food prep area, that had the same buildup of red substance.The exhaust fan, above the stove, was thick with dust.Surveyor observed DS-LL, who had a mustache and beard, preparing food without a beard restraint in the kitchen. On 8/6/25, at 12:00 p.m., Surveyor observed DM-MM in the kitchen, assisting with meal prep. DM-MM has facial hair and did not have a beard restraint on.On 8/6/25, at 12:00 p.m., Surveyor interviewed DM-MM. Surveyor asked DM-MM, why did the walk-in freezer have a thick coating of ice all over. DM-MM stated about a month ago they got a new freezer and the company that installed the freezer place the temperature too cold and it froze everything. DM-MM also stated the freezer door wasn't closing well but maintenance fixed it. DM-MM stated he only orders three days' worth of freezer food items because of the state of the freezer. DM-MM stated Nursing Home Administrator (NHA)-A is aware of the state of the freezer. Surveyor explained to DM-MM observations made earlier in the day regarding the brown lettuce in the cooler, the fans and the exhaust fan. DM-MM stated daily, he usually will walk around and get rid of expired or old food items. DM-MM had no further explanation regarding the dirty appearing items. On 8/7/25, at 12:39 p.m., Surveyor interviewed NHA-A. Surveyor explained the concern of the walk-in freezer, old salad, dirty fans and exhaust fan and male staff without beard restraint. NHA-A stated he understood the concerns and stated the facility ordered plastic curtains for the freezer to prevent frost build up when the door opens. NHA-A had no additional information.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Staffing Data
(Tag F0851)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers...
Read full inspector narrative →
Based on interview and record review, the facility did not ensure it completed accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS). This had the potential to affect 93 of 93 residents residing in the facility.Staffing information for Quarter 2 (January 1 - March 31) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS triggering a one-star staffing rating for Quarter 2: January 1-March 31 of 2025.Findings include:Surveyor reviewed the PBJ Staffing Data Report, CASPER Report 1705D, for Fiscal year 2025 (run on 8/4/25) which indicated the Facility had a one-star staffing rating for the 2nd Quarter (January 1-March 31).The facility document titled Facility Assessment dated 06/20/2025, documents:Overall needs per shift daily (adjust as needed) under Ratio of staff to residents or #HPRD: Night shift: RN (Registered Nurse)-1, LPN (Licensed Practical Nurse)-1, CNA (Certified Nursing Assistant)-4. Evening shift: RN 1, LPN 3, CNA 7. Day shift: RN 1, LPN 3, CNA 7. The facility guideline document titled Nursing Service and Sufficient Staff dated 12/17/2024 and revised 02/05/2025 documents: Guideline: It is the guideline of the facility to provide sufficient staff with appropriate competencies and skill sets to assure Resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individual plans of care. The facility census acuity and diagnosis of the resident population will be considered based on the facility assessment. 7. The facility is responsible for submitting timely and accurate staffing data through the CMS payroll-based journal (PBJ) System.Surveyor reviewed the Facility's schedules from January 1, 2025, to March 31, 2025. Surveyor noted licensed nurses and certified nursing assistants present on each shift, for each unit. Surveyor noted these schedules included call ins, agency staff and staff who picked up shifts. Surveyor noted that several night shifts during the second quarter were documented as having 3 CNAs and not 4 CNAs, which could have potentially triggered the one star staffing rating from CMS. On 08/12/2025, at 8:12 AM, Surveyor interviewed Scheduler-M on staffing for the facility. Scheduler-M informed Surveyor staffing was based on acuity and census and Corporate provided a staffing ladder and daily staffing letter. Scheduler-M informed Surveyor the facility's corporate structure informed the facility of the daily staffing allowance.Surveyor asked Scheduler-M what the minimum staffing level for each day for the direct care staff was. Scheduler-M informed Surveyor it is currently 10-16 licensed staff including unit managers and 18 certified nursing assistants (CNA). Scheduler-M informed Surveyor the current daily staffing is 10 CNAs on day shift, 4 CNAs on evening shift and 4 CNAs on the night shift. Scheduler-M informed Surveyor the facility has had Registered Nurse (RN) every day and tries to have one RN every shift as direct care staff. Surveyor asked if the Director of Nursing (DON) is counted as an RN for direct care. Scheduler-M informed Surveyor no the DON is not counted as a direct care staff. Surveyor asked Scheduler-M who in the facility reports the Payroll Based Journal (PBJ) data to the Center for Medicaid and Medicare Services (CMS). Scheduler-M informed Surveyor that Scheduler-M was not sure.On 08/12/2025, at 10:30 AM, Surveyor interviewed Director of Nursing (DON)-B about the facility staffing. DON-B informed Surveyor that minimum staffing level is 7 CNAs on the day and evening shifts and 4 CNAs on the night shift. DON-B informed Surveyor that currently staffing levels are being adjusted based on census and acuity in the facility. DON-B informed Surveyor corporate reports the staffing data to CMS for the CASPER report. Surveyor informed DON-B that several night shifts during the second quarter were documented as having 3 CNAs and not 4 CNAs which could have triggered the one star staffing rating from CMS for the second quarter. DON-B informed Surveyor the facility runs staffing based on census and acuity and that 4 is the desired staffing but not the minimum and that the facility was not short staffed at that time. Surveyor asked DON-B if DON-B felt the staffing data was reported incorrectly for the CASPER report that was submitted to CMS by the facility's corporate structure. DON-B informed Surveyor she reviewed staffing with Scheduler-M and that the reporting to CMS was inaccurate.On 08/12/2025, at 1:15 PM, Scheduler-M provided Surveyor with schedules that documented that in January and February of 2025, on the days in question by Surveyor, the facility had at least 4 CNAs during the night shift. On 08/13/2025, at 9:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the facility triggering a one-star staffing rating from CMS for quarter two on the facility [NAME] reports from 1/1/25 through 3/31/25. NHA-A informed Surveyor that Corporate reports the PBJ data to CMS for the CASPER report. NHA-A informed Surveyor that NHA-A has been working on the staffing concerns with corporate and the report for the next quarter would document an accurate number of staff and address any reporting issues. No additional information was provided as to why the facility did not ensure that the accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers for Medicare & Medicaid Services (CMS) was provided to CMS from 1/1/25 through 3/31/25.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure a sanitary environment was maintained and the En...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure a sanitary environment was maintained and the Enhanced Barrier Policy was implemented to help prevent the development and transmission of communicable diseases potentially affecting 93 of 93 residents.
Enhanced Barrier Precautions (EBP) were not in place throughout the facility. Two of the six units provided signs and Personal Protective Equipment (PPE) for residents that required EBP; four of the six units did not implement EBP.
*R3 was in Contact Isolation and observations were made of staff entering R3’s room without putting on PPE.
*R1’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment.
*R16’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment.
*R34’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment.
*R27 had an indwelling urinary catheter with no EBP in place.
*R24 had a gastrostomy tube with no EBP in place. Medication administration was observed using the gastrostomy tube and staff did not put on PPE.
*R5 had an indwelling urinary catheter with no EBP in place and staff did not put on PPE when providing cares.
*R53’s wound care was observed with no EBP in place and staff did not put on PPE when providing the wound treatment.
*The sink in the contaminated laundry area was not functional and no other sink or hand hygiene methods were available to staff to use after sorting contaminated laundry and removing PPE.
Findings include:
The facility policy and procedure titled “Enhanced Barrier Precautions” dated 2/5/2025 documents: “Guideline: It is the guideline of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. … Explanation and Compliance Guidelines: … 2. Initiation of Enhanced Barrier Precautions: … b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) … 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident’s room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident’s room. … 4. High-contact resident care activities include: a. Dressingb. Bathingc. Transferringd. Providing hygienee. Changing linensf. Changing briefs or assisting with toiletingg. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline cathetersh. Wound care: any skin opening requiring a dressing …10. Enhanced barrier precautions should be used for the duration of the affected resident’s stay in the facility or util resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.”
In an interview on 8/11/2025 at 3:12 PM, Surveyor asked Director of Nursing (DON)-B what would denote a resident to be in EBP. DON-B stated residents that have multi-drug resistant organisms (MDROs) present would be placed in EBP. Surveyor requested the facility EBP policy and procedure.
On 8/12/2025 at 3:04 PM at the daily exit, Surveyor shared with DON-B the concern the facility was not following their own policy on EBP. Surveyor shared that any resident in the facility that met the criteria for EBP should be placed in EBP. DON-B stated there are two residents in the facility that currently have MDROs. DON-B stated any resident that meets the criteria for EBP on the units where the residents with the MDROs reside are placed in EBP. DON-B stated residents on the other four units have not been placed on EBP because they are not in close proximity to the residents with MDROs. Surveyor shared with DON-B the concern that the residents that meet the criteria for EBP and are not in EBP could be cross contaminated because PPE is not being worn to protect and prevent infections.
On 8/13/2025 at 8:17 AM, DON-B stated the EBP policy and procedure was reviewed extensively and are working on getting all the residents that meet the criteria for EBP carts with PPE and signs for their rooms in place. DON-B stated DON-B now understands the reasoning behind the EBP and will be working on carrying the protocol out.
1.) R3 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder characterized by changes in mental and cognitive function), diabetes, chronic obstructive pulmonary disease, dementia, depression, anxiety, and coronary artery disease. R3’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R3 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13. R3’s Power of Attorney (POA) was activated. Surveyor noted R3 did not have any documentation of a multi-drug resistant organism (MDRO) on R3’s diagnosis list.
R3’s Impaired Immunity Care Plan was created on 7/17/2025 and was placed on Contact Precautions (requiring anyone entering R3’s room to put on a gown and gloves) for an MDRO. The Care Plan did not document what MDRO was present.
On 8/6/2025, at 9:38 AM, Surveyor observed R3’s doorway to have an isolation cart with a sign documenting Contact Precautions. Surveyor asked Licensed Practical Nurse (LPN)-G passing medications in the hallway why R3 was in Contact Precautions. LPN-G was unsure but thought maybe R3 had VRE (Vancomycin-Resistant Enterococci).
On 8/6/2025, at 10:06 AM, Surveyor observed Activity Aide (AA)-P enter R3’s room. AA-P did not put on a gown or gloves prior to entering R3’s room. AA-P was in R3’s room for approximately three minutes and then left the room. AA-P did not perform any hand hygiene after leaving R3’s room. AA-P then entered another resident room and left the room pushing the resident in a wheelchair.
In an interview on 8/6/2025, at 11:01 AM, Surveyor asked AA-P what the different precaution signs on resident isolation carts meant. AA-P stated AA-P did not know what the different signs meant. AA-P stated if there is a sign on the door, AA-P does not go in. AA-P stated AA-P was new to the facility so was not really sure what the different signs meant.
On 8/6/2025, at 11:05 AM, Surveyor observed Certified Nursing Assistant (CNA)-O enter R3’s room. CNA-O did not put on a gown or gloves prior to entering R3’s room. CNA-O was in R3’s room for approximately four minutes. CNA-O did not perform any hand hygiene after leaving R3’s room. At 11:09 AM, Surveyor asked CNA-O if staff needed to wear any PPE when going into R3’s room. CNA-O stated you do not have to put anything on unless you are doing personal cares. CNA-O picked up the Contact Precaution sign but did not read the directions of use. As Surveyor was talking to CNA-O, DON-B walked past and told CNA-O that the sign says what should be worn. CNA-O responded to DON-B, “That’s what I said, right?” Surveyor noted the Contact Precaution sign documented a gown and gloves should be worn prior to entering R3’s room, which CNA-O did not do.
On 8/12/2025, at 10:49 AM, Surveyor shared with DON-B the observations of AA-P and CNA-O going into R3’s room without wearing any PPE as documented on the Contact Precaution sign or performing hand hygiene upon leaving the resident rooms.
2.) R1 was admitted to the facility on [DATE] with diagnoses of malignant carcinoid tumor of the stomach, malignant neoplasm of the right kidney, and hyperparathyroidism. R1’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R1 did not have an activated Power of Attorney.
R1 was admitted with Stage 3 pressure injuries to the left upper buttock, the left lower buttock, the left upper posterior thigh, the left lower posterior thigh, and the left ischium, and Unstageable pressure injuries to the left outer ankle, the left second toe, the right heel, and the left trochanter.
On 8/6/2025, at the time of survey, eight of R1’s nine pressure injuries that were present on admission had healed. R1’s Stage 4 pressure injury to the left trochanter had healed on 7/1/2025 and reopened on 7/8/2025.
On 8/12/2025, at 8:53 AM, Surveyor observed Unit Manager (UM)-C, UM-D, and UM-E provide wound care to R1’s left trochanter Stage 4 pressure injury. R1 did not have a sign for EBP or an isolation cart outside of the room. UM-C, UM-D, and UM-E did not put on a gown while providing wound care. Surveyor asked UM-E if staff should wear PPE when providing wound care. UM-E stated PPE is only needed for residents in EBP. Surveyor asked UM-E what the criteria is for someone to be on EBP. UM-E stated on the two units where residents are that have MDROs, any resident that has a tracheostomy, a wound, an indwelling urinary catheter, or anything else that would make them compromised would be in EBP. UM-E stated since there are not any residents with MDROs on R1’s unit, R1 does not need to be in EBP. Surveyor noted staff were not following the EBP policy and procedure or standards of practice.
3.) R16 had a pressure injury to the coccyx.
On 8/12/2025, at 8:41 AM, Surveyor observed UM-C, UM-D, and UM-E provide wound care to R16’s coccyx pressure injury. R16 did not have a sign for EBP or an isolation cart outside of the room. UM-C, UM-D, and UM-E did not put on a gown while providing wound care. Surveyor asked UM-E if staff should wear PPE when providing wound care. UM-E stated PPE is only needed for residents in EBP. Surveyor asked UM-E what the criteria is for someone to be on EBP. UM-E stated on the two units where residents are that have MDROs, any resident that has a tracheostomy, a wound, an indwelling urinary catheter, or anything else that would make them compromised would be in EBP. UM-E stated since there are not any residents with MDROs on R16’s unit, R16 does not need to be in EBP. Surveyor noted staff were not following the EBP policy and procedure or standards of practice.
4) R24 was admitted to the facility on [DATE] with diagnoses of Epileptic Seizures (brain has sudden, uncontrollable surge of electrical activity), Dysphagia (difficulty swallowing foods), Gastrostomy Status (artificial opening in stomach used for feeding). R24 currently has a legal guardian.
R24’s Quarterly Minimum Data Set (MDS) completed 6/23/25 documents R24 demonstrates severely impaired skills for daily decision making. R24’s memory was not assessed. R24 is dependent for upper/lower dressing, showers/bathing, mobility, and transfers. R24 is always incontinent of bowel and bladder. R24 currently receives feeding tube.
R24’s active physician order effective 4/4/25 document; Infuse feeding via pump at 65ml(milliliter)/hr (hour) with 260cc (cubic centimes) of water every 4 hours Jevity 1.5.
Surveyor notes that R24’s comprehensive care plan and Kardex did not contain documentation instructing nursing staff to don personal protective equipment (PPE) when providing cares to R24 or that R24 should be in EBP.
On 8/7/2025, at 11:12 AM, Surveyor observed R24’s door to be open. Surveyor observed Licensed Practical Nurse (LPN)-II hanging a bottle of tube feeding. Surveyor observed LPN-II maneuvering the tubing in the area of R24’s stomach. Surveyor observed LPN-II with no gloves or gown on. LPN-II informed Surveyor LPN-II is looking for the correct dressing to put on the tube feeding site because the last nurse did not put the correct one on. Surveyor observed LPN-II exited R24’s room and did not perform hand hygiene. LPN-II entered back into R24’s room with a new dressing. LPN-II put the dressing on the tube feeding site without wearing gloves or a gown. LPN-II went into R24’s bathroom and washed LPN-II’s hands before exiting R24's room.
5) R27 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy (congenital disorder of movement, muscle tone, or posture), Neuromuscular Dysfunction of Bladder (nerves controlling bladder and urinary sphincter are damaged and not working correctly), Paraplegia (paralysis of lower half of body). R27 is currently his own person.
R27’s quarterly minimum data set (MDS) completed 5/31/25 documents R27’s brief interview for mental status (BIMS) score to be 13, indicating R27 is cognitively intact for daily decision making. R27’s MDS documents R27 has range of motion impairment on one side of lower extremity. R27’s MDS also documents R27 requires substantial/maximum assistance for upper dressing and is dependent for lower dressing. R27 is dependent for mobility and transfers. R27 requires substantial/maximum assistance for showers. R27 has an indwelling catheter and is always incontinent of bowel.
R27’s active physician order effective 11/22/24 document: Foley Catheter cares every shift and as needed.
Surveyor notes R27’s comprehensive care plan and Kardex did not contain documentation instructing nursing staff to don personal protective equipment (PPE) when providing cares to R27 or that R27 should be in EBP.
On 8/11/2025, at 7:39 AM, Surveyor observed no sign on the door for EBP, and no PPE cart outside of R27’s room. Surveyor observed Certified Nursing Assistant (CNA)-X come out of the R27’s room. CNA-X informed Surveyor when asked that CNA-X had adjusted R27 in bed. Surveyor observed CNA-X was not wearing gloves or a gown.
On 8/11/2025, at 7:49 AM, Surveyor observed Medication Technician (MT)-N give medications in applesauce to R27 and raise R27’s bed. MT-N was not wearing gloves or gown at this time.
On 8/11/2025, at 9:39 AM, Surveyor observed CNA-X and CNA-Y exit R27's room. CNA-Y had gloves on but no gown. CNA-X had no gloves or gown on. CNA-Y informed Surveyor both CNA-X and CNA-Y emptied the foley catheter bag and provided other incontinence cares for R27. CNA-Y informed Surveyor there was no alcohol wipes so they could not clean the foley catheter. CNA-Y also informed Surveyor they would know if R27 required EBP because there would be a sign on the door.
6) R34 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis (muscles under voluntary control to feel weak). R34 is currently his own person.
R34's admission Minimum Data Set (MDS) completed 7/22/25 documents R34's Brief Interview for Mental Status (BIMS) score to be 15, indicating R34 is cognitively intact for daily decision making. R34 requires partial/moderate assistance for upper dressing and substantial/maximum assistance for transfers. R34 is dependent for lower dressing and mobility. R34 is at risk for developing a pressure ulcer and currently has one venous and arterial ulcer.
R34’s active physician order effective 7/23/25 document: Left Lower Extremity: cleanse with normal saline. Foam border Xeroform to wound beds foam border, Ulna Boot with zinc gauze foam border, cotton patting foam border Coban wrap. Change Monday, Wednesday, Friday and as needed for wound care.
Surveyor notes that R34’s comprehensive care plan and Kardex did not contain documentation instructing nursing staff to don personal protective equipment (PPE) when providing cares to R34 or that R34 should be in EBP.
On 8/11/2025, at 1:55 PM, Surveyor observed R34’s treatment to R34’s outer leg. Unit Manager (UM)-C and (UM)-E completed the treatment. Surveyor observed UM-C did not wear gloves when cutting the foam border with scissors. During the treatment, UM-C put gloves on, but upon exiting the room for more supplies, UM-C did not perform hand hygiene. UM-C and UM-E did not wear a gown during the treatment process.
On 8/11/2025, at 3:20 PM, Director of Nursing (DON)-B informed Surveyor EBP as only being for a Resident that is Multidrug-Resistant Organism (MDRO), Vancomycin-Resistant Enterocci, and Carbapenem-Resistant Enterobacteriaceae.
On 8/12/2025, at 1:32 PM, Surveyor interviewed UM-E regarding EBP. UM-E stated two Residents on Unit 5 and 6 have a MDRO. Other residents on Unit 4 have wounds, tube feeding, and foley catheters do not need EBP because they are not within the vicinity of the two residents with a MDROs. UM-E stated Centers for Disease Control and Prevention (CDC) is always changing EBPs. UM-E stated typically, anyone providing cares with an Intravenous Therapy, Foley Catheter, Tube Feeding should have PPE for EBPs but UM-E explained the Residents on Unit 4 do not require PPE because they are not in the vicinity of the two residents on Unit 5 and 6. UM-E stated the facility determined housekeeping should gown up when cleaning the rooms.
UM-E provided Surveyor with a sign that reads:EBPEveryone Must:Clean their hands, including before entering and when leaving the room.Providers and Staff Must Also:Wear gloves and a gown for the following High-Contact Resident Care Activities.DressingBathing/ShoweringTransferringChanging LinensProviding HygieneChanging briefs or assisting with toiletingDevice care or use:Central line, urinary catheter, feeding tube, tracheostomyWound Care: any skin opening requiring a dressing
On 8/12/2025, at 3:17 PM, Surveyor shared with Nursing Home Administrator (NHA)-A and DON-B the concern R24, R27, and R34 by CDC recommendations should have been in EBP. The facility provided no further information at this time as to why R24, R27, and R34 were not in EBP during the survey process.
8) R5 was admitted to the facility on [DATE]. R5’s Electronic Medical Record (EMR) documents R5 having a urinary catheter in place.
On 8/7/25, at 1:23 PM, Surveyor observed no sign or indication of R5 being placed in Enhanced Barrier Precaution (EBP). Surveyor knocked on R5’s room. R5 responded for Surveyor to enter R5’s room. Surveyor observed a staff member with no gown or gloves in R5’s room.
On 8/11/25, at 8:21 AM, Surveyor observed no indication for R5 having EBP. Surveyor observed no EBP sign or a supply cart with gown and gloves outside R5’s room.
On 8/12/25, at 2:28 PM, Surveyor observed no indication for R5 having EBP. Surveyor observed no EBP sign or a supply cart with gown and gloves outside R5’s room.
On 8/13/25, at 9:01 AM, Surveyor interviewed Concierge Coordinator (CC)-K who entered R5’s room without donning a gown or gloves for the interview. Surveyor observed no EBP sign or a supply cart with gown and gloves outside R5’s room.
On 8/13/25, at 10:35 AM, Surveyor notified Director of Nursing (DON)-B of concerns with R5 having a urinary catheter in place throughout the survey, with no EBP in place for R5 throughout the survey. DON-B acknowledged these concerns and indicates the facility is currently making changes with their EBP practice and will be putting residents with urinary catheters in EBP, however, the facility does not have enough supplies at this time and has ordered supplies. DON-B indicates, once the facility receives the EBP supplies, the facility will be putting R5 and all residents who have a urinary catheter, in EBP.
7) R53 was admitted to the facility on [DATE] with diagnosis that include Chronic Obstructive Pulmonary (lung) disease, Heart failure, Stage 2 kidney disease, and Metastatic melanoma (skin cancer) progressing to metastatic lung cancer.
R53’s Annual Minimum Data Set (MDS) assessment dated [DATE] documents R53 is moderately cognitively impaired.
R53 has a guardian. R53 is on hospice which was started in June of 2023.
Surveyor reviewed R53’s medical record and noted R53 developed a Suspected Deep Tissue Injury (DTI) on 7/22/25.
R53’s MD order dated 8/5/25 documents: DTI to lower mid spine: Cleanse with 1/4 strength Dakins, skin prep to surrounding area, apply calcium alginate, [followed by] border foam dressing daily.
Surveyor reviewed R53’s MD orders, Comprehensive Care Plan and Certified Nursing Assistant Kardex. Surveyor noted R35’s medical record did not contain documentation instructing nursing staff to put on personal protective equipment (PPE) when providing cares to R53.
On 8/7/25, at 10:39 AM, Surveyor observed R53’s room. Surveyor noted R53’s door does not have a sign indicating Enhanced Barrier Precaution (EBP) for R53 and PPE is not visualized outside of R53’s room.
On 8/11/25, at 12:59 PM, Surveyor observed R53’s room. Surveyor noted R53’s door does not have a sign indicating EBP for R53 and PPE is not visualized outside of R53’s room.
On 8/12/25, at 10:06 AM, Surveyor observed R53’s room. Surveyor noted R53’s door does not have a sign indicating EBP for R53 and PPE is not visualized outside of R53’s room. Surveyor entered R53’s room to observe wound rounds with Unit Manager (UM)-D. R53 was observed sitting in R53’s electric wheelchair and leaning forward. After washing hands and donning gloves, UM-D removed the old dressing and completed R53’s wound care treatment. While observing R53’s wound care treatment, UM-D and one other staff member assisting, did not wear a gown. Surveyor asked UM-D if UM-D needed to wear a gown while completing wound care. UM-D stated no.
On 8/12/25 at 3:05 PM, Surveyor informed Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the concern that EBP precautions were not followed and gowns were not worn while staff completed wound care on R53.
9) The only sink in the laundry department located in the contaminated laundry sorting room was not functional for 1-2 weeks with no other sink or hand hygiene methods available to staff to use after sorting contaminated laundry and removing personal protective equipment (PPE).
The Facility’s policy document titled; “Laundry” dated 05/29/2024 documents:
Policy:
The facility launders linens and clothing in accordance with CDC (Centers for Disease Control and Prevention) guidelines to prevent transmission of pathogens.
Definitions:
“Contaminated” refers to laundry which has been soiled with blood/body fluids or other potentially infectious materials or may contain sharps.
Policy explanation and compliance guidelines:
1. Aligning with principles of standard precautions, staff shall consider all previously worn clothing as contaminated.
2. The facility’s laundry area will provide readily available hand washing facilities and products as well as adequate PPE.
On 08/11/2025, at 12:42 PM, Surveyor was given a tour of the laundry process by Housekeeping Manager (HM)-T and Laundry Staff (LS)-U. Surveyor asked HM-T to explain the laundry process. HM-T informed Surveyor the dirty linens and clothing come down the laundry chute in bags (Surveyor observed laundry in hamper below chute in bags). HM-T stated the laundry staff separate personal items from the facility dirty linens and place them in these hampers for transport through the door to the washer.
Surveyor asked HM-T if the sink in the dirty sorting room was the only sink and means of hand hygiene in the department. HM-T informed Surveyor staff do not use the sink in the dirty chute room because there is no water to the sink, and it has been down a week or two and it is the only sink in the department. Surveyor asked HM-T how staff performs hand hygiene after handling contaminated linen with urine and feces before placing and removing their personal protective equipment (PPE). HM-T informed Surveyor we don't use this sink that often, but staff mostly used the employee break room across the hall to wash their hands. Surveyor asked HM-T to clarify that the staff must leave the dirty area and the department to perform hand hygiene after handling soiled facility laundry. HM-T informed Surveyor HM-T knew it is not ideal to walk across the hall to the employee break room and staff probably should not do it that way. HM-T informed Surveyor HM-T does make sure staff remove PPE before staff crosses over the hall to the employee break room to perform hand hygiene.
Surveyor asked LS-U to demonstrate how the process of dirty laundry to clean works and the use and removal of PPE was performed by staff. LS-U informed Surveyor gown and gloves and sometimes a mask are put on before staff go into the dirty laundry chute room. LS-U informed Surveyor LS-U brings the dirty clothes out of the dirty laundry room in the sorting hampers into the washer room and laundry is placed in different washers based on the settings listed on the wall. LS-U informed Surveyor the gown is then removed placed in the washer and then staff walk back to the dirty chute room to throw the gloves away because the trash container in the washer room is too close to the clean dryers. LS-U informed Surveyor LS-U walks back to the department exit door. LS-U informed Surveyor staff then walk across the hall to the employee breakroom and wash their hands in the sink. LS-U informed Surveyor LS-U does make sure LS-U’s gown goes into the washer before going out the door to wash hands in the employee break room. (Surveyor noted no hand sanitizing gel anywhere in department).
Surveyor asked HM-T if the broken sink had been reported to maintenance. HM-T informed Surveyor HM-T reported it last week.
On 08/11/2025, at 1:07 PM, Surveyor interviewed Maintenance Director (MD)-F. Surveyor asked MD-F if maintenance was aware of the broken sink in the dirty laundry room. MD-F informed Surveyor they were not informed until the end of last week. MD-F informed Surveyor it was scheduled to fixed by the end of this week.
On 08/13/2025, at 9:50 AM, Surveyor informed Nursing Home Administrator (NHA)-A about Surveyor’s concerns with the broken sink in the laundry area causing staff to leave the contaminated room to wash hands in the employee break room across the hall. Surveyor informed NHA-A no other hand hygiene methods were available to the staff according to the HM-T. Surveyor asked NHA-A if leaving a dirty room to go to the employee break room was an infection control concern. NHA informed Surveyor that “yes” that was a problem with infection control. NHA-A informed Surveyor MD-F informed NHA-A the laundry sink is fixed now, and proper hand washing was discussed with the staff.
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 F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not maintain an effective pest control program to address th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not maintain an effective pest control program to address the flies in the facility.
*R15 and R16 informed Surveyor that the facility has a problem with flies and R15 uses items in the room to ‘swat’ at the flies.
*Surveyor observed a fly flying around R34’s room during observation of a treatment to the right leg on 8/11/25.
*Flies were observed around R8 at mealtime during the survey process and R10 informed Surveyor that R10 had killed 18 flies in 3 days.
*R29 complained of so many flies they had to purchase fly strips to catch the flies in their room.
*R8, R35, R49, and R78 informed Surveyor at resident council on 8/11/25 the concern of numerous flies throughout the facility.
*Surveyors observed flies in resident unit hallways, the common dining room for residents, the conference room and in a resident's bathroom.
*During the tour of the kitchen, several flies were observed.
*The facility did not have a pest control company to service the facility for the months of May, June, and February 2025 and July of 2024.
This deficient practice has the potential to affect all 93 of 93 Residents residing in the facility at the time of the survey.
Findings include:
Surveyor reviewed the facility's Pest Control Program implemented 4/2/25 which documents:
. Guideline:
It is the guideline of this facility to maintain and effective pest control program that eradicates and contains common household pests and rodents. …
Explanation and Compliance Guidelines:
1. 1. Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis.
2. 2. Facility will ensure the appropriate chemicals are used to control pests but can be used safely inside the building without compromising Resident health.
3. 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated.
4. 4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. Flies. These will include indoor and outdoor methods that are deemed appropriate by the outside service and state and federal regulations.
5. 5. Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures, i.e. dumpster area.
1 1) Surveyor observed flies in R15 and R16’s shared room.
R15 was admitted to the facility on [DATE] with diagnoses of Rhabdomyolysis (skeletal muscle breaks down rapidly). R15 is currently her own person.
R15’s admission Minimum Data Set (MDS) completed 6/30/25 documents R15’s Brief Interview for Mental Status (BIMS) score to be 12, indicating R15 demonstrates moderately impaired skills for daily decision making.
2) R16 was admitted to the facility on [DATE] with diagnoses of Cerebral Palsy (congenital disorder of movement, muscle tone, or posture), Spastic Hemiplegia Affecting Unspecified Side (one side of body experiences muscle stiffness and weakness), and Insomnia (sleep disorder characterized by difficulty falling asleep). R16 is currently her own person.
R16’s admission Minimum Data Set (MDS) completed 7/14/25 documents R16’s Brief Interview for Mental Status (BIMS) score to be 13, indicating R16 is cognitively intact for daily decision making
On 8/6/2025, at 11:49 AM, R16 informed Surveyor there is a problem with flies in the room. R16 stated the flies land on the walls, sit on the chains hanging from the ceiling. R16 stated other people have complained. R16 stated R16 and R15 eat their meals in the room, and the flies landing on the food. R16 informed Surveyor the flies have bit R16.
On 8/6/2025, at 11:55 AM, R15 informed Surveyor R15 got bit by a fly on the ear. “I have to use my underwear to kill the flies”.
On 8/6/2025, at 12:10 PM, Surveyor observed a fly on R16’s bed and another fly at the end of the bed on the air mattress component.
On 8/7/2025, at 11:07 AM, Surveyor observed a fly flying and landing on R16's bed.
On 8/7/2025, at 12:43 PM, Surveyor observed 2 flies flying around R15 and R16’s room. R15 stated R15 is using a washcloth to swat at the flies.
3) R34 was admitted to the facility on [DATE] with diagnoses of Myasthenia Gravis muscles under voluntary control to feel weak), Depression (mood disorder that causes persistent feelings of sadness and loss of interest). R34 is currently his own person.
R34's admission Minimum Data Set (MDS) completed 7/22/25 documents R34's Brief Interview for Mental Status (BIMS) score to be 15, indicating R34 is cognitively intact for daily decision making.
On 8/11/2025, at 1:55 PM, Surveyor observed R34’s treatment being completed to R34’s right leg. Unit Manager (UM)-C and Unit Manager (UM)-E completed the treatment with Licensed Practical Nurse (LPN)-R coming in and out of the room with supplies. During the observation of the treatment being completed, a fly landed on Surveyor. LPN-R confirmed there is a fly flying around and LPN-R swatted at the fly.
On 8/13/2025, at 10:16 AM, Surveyor observed R34’s windows. The window on the right was open with a cobweb hanging from it. Surveyor observed two dead flies hanging from it.
On 8/13/2025, at 10:44 AM, Surveyor had Housekeeping Supervisor (HS)-T observe R34’s window. HS-T confirmed there is a cobweb with 2 flies hanging from R34’s slightly open window.
On 8/06/2025, at 8:20 AM, Surveyor observed a fly upon entrance into the facility.
On 8/6/2025, at 10:16 AM, Surveyor observed a fly flying around the 4 unit in the hallway. Surveyor had a fly land on Surveyor’s computer in the hallway while touring the 4 unit.
On 8/7/2025, at 8:59 AM, Surveyor observed a fly flying around the nurse's station by unit 4.
On 8/7/2025, at 12:49 PM, Surveyor observed a fly flying around room [ROOM NUMBER] and in the hallway of unit 4, and Surveyor observed a fly walking around on the floor.
On 8/7/2025, at 2:27 PM, Surveyor observed a fly in the conference room.
On 8/11/2025, at 7:59 AM, Surveyor interviewed Maintenance Director (MD)-F regarding the facility pest control. MD-F stated MD-F has not been notified of any fly issues. MD-F informed Surveyor pest control comes in 1 time a month and the facility has some UV lights in hallways with sticky pads and those are changed as needed. MD-F has not been informed of a fly issue in the kitchen. MD-F stated, “there is a fly problem yearly, it is normal”. Surveyor requested to view the logs of the monthly pest control visits.
On 8/11/2025, at 8:49 AM, Surveyor reviewed the pest control monthly visits and notes there were no pest control visits for July of 2024 or February, May, and June 2025.
On 8/11/2025, at 3:20 PM, Surveyor shared the concern with numerous flies throughout the facility with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B. Surveyor pointed out the fly in the conference room at the time of exit meeting. No further information was provided by the facility at this time.
On 8/12/2025, at 11:16 AM, Surveyor observed Certified Nursing Assistant (CNA)-HH at the nurse’s station close to 4 unit with a fly swatter and is swatting at a fly.
On 8/13/2025, at 11:18 AM, NHA-A informed Survey pest control comes to the facility monthly, but that pest control has been called to treat for flies. NHA-A also stated blue lights to attract pests were hung yesterday and the facility has ordered five extras to place around the facility.
4) R10 was admitted to the facility on [DATE].
R10’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R10 is cognitively intact.
On 8/6/25 at 9:50 AM, R10 informed Surveyor the facility has a problem with flies. R10 stated last week, R10 had killed 18 flies in 3 days. R10 stated R10’s shared bathroom frequently has an increase of flies. Surveyor noted 2 flies in R10’s room. Surveyor was swatting at a fly during interview.
5) R8 was admitted to the facility on [DATE].
On 8/6/25 at 1:07 PM, Surveyor observed R8 in the common dining area with R8’s lunch tray. Surveyor observed a fly, flying around R8’s table and observed the fly landing on R8’s food. R8 used R8’s hand to wave the fly away. At a different table, Surveyor observed 3 residents sitting together. A resident complained that a fly keeps landing on their drink.
*) R29 was admitted to the facility on [DATE].
R29’s Quarterly Minimum Data Set (MDS) assessment dated [DATE] documents R29 is cognitively intact.
On 8/6/25, at 3:23 PM, R29 informed Surveyor the facility has a problem with flies. R29 stated that R29’s room is close to an exit door which makes it worse. R29 stated R29 bought fly strips online because the flies are everywhere.
6) On 8/6/25 at 12:38 PM, Surveyor noted multiple flies while walking the 200-unit hallway. Surveyor observed a fly landing on Surveyors computer and another fly, flying around Surveyors head.
On 8/6/25 at 1:05 PM, Surveyor noted multiple flies while walking the 100-unit hallway. Surveyor counted 3 flies.
On 8/7/25 at 11:13 AM, Surveyor was in the 100-unit hallway when a fly landed on Surveyor’s hair.
*During Resident Council meeting held on 08/11/2025, at 10:30 AM, R8, R35, R49 and R78 informed Surveyor pf the resident's concerns about a large number of flies in the facility.
Surveyor asked the resident council members present if the members had any concerns about the cleanliness of the facility.
7) R78 informed Surveyor there were so many fruit flies when R78 was first admitted to the facility. R78 informed Surveyor the flies were so bad because they were everywhere, and it made it uncomfortable for R78 in her room. R78 informed Surveyor “I had to get my own ZEVO (a blue light sticky trap)” because the facility wouldn't do anything about the flies. R78 informed Surveyor staff told R78 the flies were from the previous person in the room. R78 informed Surveyor R78 had fruit flies fill R78’s ZEVO trap daily when R78 first started using the ZEVO. R78 informed Surveyor the fruit flies have decreased substantially in her room but R78 still sees a lot of big flies in the dining room. R78 informed Surveyor R78 gets big flies in R78’s room if the door is left open.
8) R8 informed Surveyor R8 has flies in R8’s room daily. R8 informed Surveyor R8 needs a fly swatter every day. R8 informed Surveyor R8 sees big flies in the dining room daily.
9) R35 informed Surveyor the R35 still has little flies and big flies daily in R35’s room, the flies never go away. R35 informed Surveyor there are always flies in the dining room.
10) R49 informed Surveyor the R49 sees sewer flies all over. R49 informed Surveyor R49 knows they are sewer flies because R49 came from an apartment with sewer flies. R49 informed Surveyor R49 had a lot of sewer flies at the apartment and a lot of sewer flies at the facility currently. R49 informed Surveyor there are a lot of flies in the dining room.
During the entire survey the survey team observed flies through-out the facility and in the dining room.
On 08/13/2025, at 9:50 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A about Surveyor’s concerns with the large number of flies in the building reported by members of the resident council. NHA-A informed Surveyor that NHA-A already has a vendor working on getting rid of the flies and are placing traps today for the flies. NHA-A stated the vendor is placing blue light nonchemical traps in several places through-out facility. NHA-A informed Surveyor the facility is committed to getting the fly problem under control.
Surveyor observed a blue light trap being placed in the dining room after leaving NHA-A’s office.
11) On 8/6/25 at 11:00 a.m. Surveyor was observing meal preparation in the kitchen. There were a few flies in the kitchen. Flies were flying around the food. Dietary staff were covering food to prevent flies from landing on it.
On 8/7/25, at 12:39 p.m., Surveyor interviewed Nursing Home Administrator (NHA)-A regarding the flies. Surveyor explained to NHA-A the observation made on 8/6/25, in the kitchen, regarding flies. NHA-A stated he understood the concern and had no additional information.
Jun 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure staff donned (put o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and review of facility policy, the facility failed to ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing a pressure ulcer dressing change for one Resident (R) 6 out of three reviewed for enhanced barrier precautions (EBP). This had the potential for cross contamination and risk for infection.
Findings include:
Review of the facility policy titled, Enhanced Barrier Precautions, last revised 02/05/25, revealed, It is the guideline of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities . an order for enhanced barrier precautions will be obtained for residents with any of the following: wounds such as pressure ulcers . Implementation of enhanced barrier precautions . h. Wound care: any skin opening requiring a dressing .
Review of the R6's Profile, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was initially admitted to the facility on [DATE] and most recently on 02/28/25 with diagnoses of paraplegia, stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle, slough or eschar may be present on some parts of the wound bed), above the right knee amputation, and heart failure.
Review of R6's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 05/28/25, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact.
Review of R6's current physician's Order, located in the EMR under the Orders tab, revealed an order to cleanse the ischium (lower and back part of the hip bone) with 1/4 strength Dakin's solution, Santyl wet to dry packed lightly into wound and cover with a foam border dressing, change twice a day and as needed (PRN).
During an observation and interview on 06/25/25 at 11:15 AM of R6's dressing change with Certified Nursing Assistant (CNA)5 and Licensed Practical Nurse (LPN)1, LPN 1 completed the treatment to R6's stage 4 pressure ulcer to his ischium as ordered. However, neither CNA5 nor LPN1 wore a gown during the dressing change. LPN1 confirmed she nor the CNA had a gown on during the dressing change. LPN1 further confirmed there was a bin outside of the resident's door with PPE and a sign on top of the bin indicating the resident was on EBP and gloves and gown were required during high contact care activities.
During an interview on 06/25/25 at 2:30 PM, the Director of Nursing (DON)/Infection Preventionist (IP) revealed it was the expectation for staff to follow EBP and to wear a gown during a dressing change to any pressure ulcer.
May 2025
7 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to assess two of 18 sampled resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, the facility failed to assess two of 18 sampled residents (Resident (R) 11 and R6) who were observed with medications at the bedside for the safe self-administration of medications. This failure could potentially lead to medications being left by staff at the residents' bedside where other residents could access them.
Findings include:
Review of a facility policy titled, Resident Self-Administration of Medication, dated 05/2025 indicated, . It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medication after the facility's interdisciplinary team has determined which medication may be self-administered safely.
1. Review of R11's Face Sheet, found in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included a left ischium wound.
Review of R11's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/03/25 and found under MDS tab of the EMR, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.
Review of R11's Physician Order, dated 04/03/25 and located under the Orders tab of the EMR, indicated clinical staff were to apply Santyl ointment to the resident's left ischium, with a wet to dry dressing with one quarter strength Dakins solution.
A review was conducted of R11's entire EMR, and there was no evidence that the facility assessed the resident's ability to safely apply the Santyl medication.
During an interview on 05/06/25 at 1:07 PM, an observation was made in R11's room, and there was a tube of Santyl on his bedside table. R11 stated the staff used it for his wound treatment and he would also apply the Santyl as needed.
During an interview on 05/06/25 at 1:15 PM, Licensed Practical Nurse (LPN) 1 verified the Santyl was left at the bedside of R11 and stated she was unaware if the resident had been assessed to be able to safely apply the Santyl.
2. Review of R6'sFace Sheet, found in EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses that included shortness of breath.
Review of R6's admission MDS, with an ARD of 02/23/25 and found under the MDS tab of the EMR, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
Review of R6's Physician Order, located under the Orders tab of the EMR, failed to indicate physician orders for the use of Albuterol (an inhaler for treatment of asthma).
A review was conducted of R6's entire EMR, and there was no evidence that the facility assessed the resident's ability to safely self-administer an inhaler.
During an interview on 05/07/25 at 10:47 AM, an Albuterol inhaler in a box was observed next to R6's bed. R6 stated she was assessed for the safe use of the inhaler to be held at her bedside.
During an interview on 05/07/25 at 12:24 PM, the Assistant Director of Nursing (ADON) entered R6's room and gathered the resident's inhaler. The resident told the ADON that she had access to the Albuterol for the past month. The ADON stated there was no safety assessment completed for R6 and the self-administration of the Albuterol. The ADON stated before a resident was to have a medication at bedside, the resident needed to be assessed for the self-administration of the medication.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure documentation of pre- and post-...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure documentation of pre- and post-dialysis assessments and failed to ensure communication occurred between the facility and the dialysis center for one of two residents (Resident (R) 17) reviewed for dialysis out of total sample of 18. This had the potential to affect the health of residents receiving dialysis.
Findings include:
Review of the facility's policy titled, Hemodialysis, revised 02/15/25, revealed, . The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a.timely medication administration [initiated, held or discontinued] by the nursing home and/or dialysis facility; b. physician/treatment orders, laboratory values, and vital signs; c. advance directive and code status; specific directive about treatment choices ; and any changes or need for further discussion with the resident/representative, and practitioners; d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered; e. Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; g. Changes and/or declines in condition unrelated to dialysis; h. The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility .
Review of R17's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R17 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis.
Review of R17's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/17/25 and located under the MDS tab of the EMR, revealed R17 received dialysis. It was recorded R17 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated intact cognition.
Review of R17's Care Plan, located under the Care Plan tab of the EMR and 10/21/23, revealed, . The resident has a diagnosis of chronic renal failure and receives hemodialysis . The Care Plan did not address communication between the dialysis center and the facility.
Review of R7's Physician Order, dated 06/04/24 and located under the Orders tab of the EMR, revealed R17 had dialysis on Mondays, Wednesdays, and Fridays. Nursing staff were directed to . Please complete Dialysis Communication Form and send to dialysis. Make a copy. If dialysis does not return form with resident call for info to complete form . In addition, orders dated 05/13/24 included daily weights on Monday, Wednesday, and Friday before dialysis, vital signs prior to sending resident to dialysis; vital signs upon returning from dialysis; and send a list of medications to the dialysis center every Monday, Wednesday, and Friday.
Review of R17's Medication Administration Records (MARs), dated 04/01/25 through 05/07/25 and located in the Orders tab of the EMR, revealed R17 refused vital signs approximately half of the scheduled pre- and post- dialysis days and refused weights before dialysis except on 04/11/25 and 04/25/25. Nursing signed off completion of the Dialysis Communication Form every dialysis day.
During an interview on 05/07/25 at 9:05 AM, Licensed Practical Nurse (LPN) 4 stated she recently finished orientation and was unsure of how the facility communicated with the dialysis centers since she had no residents who received dialysis on her wing.
During an interview on 05/07/25 at 9:10 AM, LPN5 stated nursing checked vital signs before residents went to dialysis, filled out the communication form, and sent it in the resident's dialysis binder with the resident to dialysis.
During an interview on 05/07/25 at 9:17 AM, Nurse Tech (NT) 1 reported she gave medications to R17 prior to dialysis. NT1 stated the licensed nurse who oversaw her hall prepared the Dialysis Communication Form and the binder for R17, and currently, that nurse was LPN3.
During an interview on 05/07/25 at 9:20 AM, LPN3 stated she did not do anything with R17's communication form or binder. LPN3 stated the nurse who worked that hall took care of the binder. LPN3 stated when she took care of residents on dialysis, she ensured they were sent out with their communication form, medication orders, any recent orders, and their vital signs.
During an interview on 05/07/25 at 3:05 PM, R17 reported she had just returned from dialysis. R17 stated it was hit or miss whether the facility checked her vital signs before and after dialysis. R17 stated she did not typically refuse vital signs unless it was the middle of the night. R17 stated the dialysis binder was in the bag on the back of her wheelchair, but staff had not touched it for months.
During a concurrent observation and interview on 05/07/25 at 3:10 PM, LPN6 came to R17's room to check her vital signs while the dialysis binder was reviewed and observed to not have any communication forms in it since October 2024. LPN6 reported she did not work when R17 went out to dialysis. Upon return from dialysis, LPN6 did not do anything with the dialysis binder.
During an interview on 05/07/25 at 4:05 PM, the Director of Nursing (DON) reported the expectation that nursing use the dialysis communication forms. The DON stated the forms were to include pre- and post- vital signs and weights. The DON stated the dialysis center typically obtained the weights. The DON confirmed the binder contained no communication forms since October 2024.
During an interview on 05/08/25 at 11:10 AM, the DON stated she had not located any dialysis communication forms since October 2024 for R17.
During an interview on 05/08/25 at 2:43, the Assistant Director of Nursing (ADON) stated R17 refused many vital signs and weights since dialysis monitors them. The ADON stated staff should fill out and send the communication forms so the facility was aware of pre- and post- dialysis weights done by dialysis and any order changes. The ADON reported she communicated with dialysis via phone on bigger issues such as when R17 refused labs.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R2's Face Sheet, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R2's Face Sheet, located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE].
Review of R2's Physician Orders, located under the Orders tab of the EMR and dated 10/15/24, indicated the resident had an order for Rosuvastatin five mg two tablets to be administered one time a day for hypercholesteremia (high cholesterol blood level).
Review of R2's quarterly MDS, with an ARD of 01/15/25 and located under the MDS tab of the EMR, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact.
Review of R2's MAR, located under the Orders tab of the EMR and dated 02/2025, revealed R2's Rosuvastatin 5 mg times two tablets were not documented as administered on the following dates: 02/06/25, 02/07/25, 02/08/25, 02/16/25, and 02/17/25. The MAR directed to read the associated clinical documentation for reasons medication was not administered:
a.
On 02/06/25 Rosuvastatin 5 mg two tablets were unavailable and were reordered.
b.
On 02/07/25 Rosuvastatin 5 mg two tablets were unavailable and were reordered.
c.
On 02/08/25 Rosuvastatin 5 mg two tablets, waiting on pharmacy delivery.
d.
On 02/16/25 Rosuvastatin 5 mg two tablets, waiting on delivery.
e.
On 02/17/25 Rosuvastatin 5 mg two tablets, reordered.
Review of Physician Orders, located under the Orders tab of the EMR and dated 02/28/25, indicated the resident had an order for Rosuvastatin 10 mg one tablet to be administered one time a day for hypercholesteremia.
Review of R2's MAR, located under the Orders tab of the EMR and dated 03/2025, revealed R2's Rosuvastatin 10 mg was not documented as administered on the following dates: 03/15/25, 03/16/25, 03/17/25, 03/30/25 and 03/31/25. The MAR directed to read the associated clinical documentation for reasons medication was not administered:
a.
On 03/15/25 Rosuvastatin 10 mg was unavailable.
b.
On 03/16/25 Rosuvastatin 10 mg was ordered and waiting on delivery.
c.
On 03/17/25 Rosuvastatin 10 mg was ordered and waiting on delivery.
d.
On 03/30/25 Rosuvastatin 10 mg was unavailable and ordered from pharmacy.
e.
On 03/31/25 Rosuvastatin 10 mg was not available.
During an interview on 05/08/25 at 11:05 AM, Pharmacist 2, a pharmacist with the company that the facility placed orders for medications from, stated the facility placed the following orders for Rosuvastatin on the following dates:
a.
On 01/13/25 the facility ordered a 30-day supply of Rosuvastatin, and it was delivered on the same day.
b.
On 02/08/25 the facility ordered a seven-day supply of Rosuvastatin, and it was delivered on the same date. Pharmacist 2 stated R2's insurance must have authorized a lower amount to dispense.
c.
On 02/15/25 the facility ordered a seven-day supply of Rosuvastatin but was unable to state when the medication was delivered.
d.
On 02/18/25 the facility ordered a seven-day supply of Rosuvastatin, and it was delivered on the same date.
e.
On 02/24/25 the facility ordered a seven-day supply of Rosuvastatin and was delivered early in the morning on 02/25/25. Pharmacist 2 stated the facility must have placed an order for R2's medication late in the day.
f.
On 03/06/25 the facility ordered a seven-day supply of Rosuvastatin, and it was delivered early in the morning on 03/07/25.
g.
On 03/17/25 the facility ordered a 14-day supply of Rosuvastatin, and it was delivered early in the morning on 03/18/25. Pharmacist 2 stated R2's insurance must have authorized this amount.
h.
On 03/31/25 the facility ordered R2's Rosuvastatin and an eight-day supply was authorized by the resident's insurance, and the medication were delivered on 04/02/25.
Pharmacist 2 stated it was ideal for the facility to re-order medication two to three days in advance to ensure there was coverage for the residents' medications. When Pharmacist 2 was asked if there should have been enough Rosuvastatin coverage for R2 for the month of 02/2025, she stated there should have been. Pharmacist 2 stated there should have been enough Rosuvastatin coverage for 03/15/25, 03/16/25, and 03/17/25 but not enough of Rosuvastatin for 03/30/25 and 03/31/25.
During an interview on 05/08/25 at 1:48 PM, RN2, who was also the Unit Manager for the 500 and 600 Units, stated she would get on the phone with the pharmacy regarding R2's Rosuvastatin and was told it was a change in the insurance authorization for a lower dispensing amount. RN2 stated she wanted to check the contingency box (emergency medications storage) to see if there was Rosuvastatin in it. At 2:26 PM, RN2 stated there was no Rosuvastatin in the contingency box. RN2 stated she did not remember ever seeing a 30-day supply sent from the pharmacy for R2's Rosuvastatin.
During an interview on 05/08/25 at 2:34 PM, Medication Technician (MT) 1 stated there were multiple times R2 would run out of her Rosuvastatin, and there was always a delay from the Pharmacy. MT1 stated she had reported these delays to all the nurses and her supervisor.
During an interview on 05/08/25 at 4:04 PM, the DON stated she did some training on medication availability and presented a document titled Medication Report dated 02/19/25. There was no specific medication identified on this report for R2, and the DON agreed the report was not specific enough to address the delay in R2's medications.
Based on observation, interview, record review, and facility policy review, the facility failed to have medications available to administer as ordered for three of four residents (Resident (R) 7, R18, and R2) reviewed for medication availability out of a total sample of 18. This had the potential to result in adverse health outcomes.
Findings include:
Review of the facility's policy titled, Medication Reordering, dated December 2024, revealed, . Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner. Each time a nurse is administering medications and observes [6] or less doses left of one kind, that nurse will reorder the medication, time permitting . For stat medications, a supply of medications typically used in emergency situations will be maintained in limited supply by the pharmacy in a portable, but sealed emergency box or container [may be used if applicable] .
1. Review of R7's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), pulmonary embolism (blood clot in the lung), major depressive disorder, heart failure, and asthma.
Review of R7's Orders tab and Medication Administration Records (MARs), dated 12/2024 and 01/2025 and located under the Orders tab of the EMR, revealed orders for the following medications which were documented on the 12/2024 and 01/2025 MARs by nursing with the code 4, which referred the review to other/see nurse notes:
a. Rivaroxaban 20 milligrams (mg) (blood thinner) was ordered daily from 12/21/24 to 01/25/25 and reordered on 1/25/25. It was documented as 4 on 12/30/24, 01/03/25, 01/13/25, and 01/24/25.
b. Duloxetine HCl 60mg (anti-depressant) was ordered daily from 12/21/24 to 03/05/25 and reordered on 03/05/25. It was documented as 4 from 01/24/25 through 01/27/25.
c. Azithryomycin 250mg (antibiotic) was ordered daily from 12/21/24 to 01/21/25. It was documented as 4 on 12/30/24, 01/07/25, 01/15/25, 01/16/25, 01/17/25, and 01/20/25.
d. Prednisone (oral steroid)10mg was ordered daily from 12/21/24 to 1/21/25 and was decreased to 5mg daily which started 01/21/25. It was documented as 4 on 12/30/24 and 01/03/25.
e. Fluticasone-salmeterol inhaler for COPD 1 puff twice daily was ordered on 12/21/24. It was documented as 4 for the evening doses on 12/24/24, 01/02/25, and 01/03/25.
f. Umeclidinium bromide inhaler 1 puff daily for COPD was ordered on 12/21/24. It was documented as 4 from 01/10/25 through 01/13/25 and on 01/30/25.
g. Roflumilast 500 micrograms (mcg) daily (for COPD) was ordered on 12/21/24. It was documented as 4 from 01/22/25 through 01/27/25.
Review of R7's Orders tab of the EMR revealed orders for Dupixent 300mg subcutaneous injection every 14 days for COPD from 12/21/24 until 01/12/25, reordered from 01/12/25 to 04/20/24, and reordered again on 04/20/24. It was documented on the 02/2025, 03/2025, and 04/2025 MARs by nursing as 4 on 02/09/25, 03/09/25, 03/23/25, and 04/06/25.
Review of R7's eMar - Medication Administration Notes, located under the Prog Notes tab of the EMR, revealed the following documentation:
a. The rivaroxaban was documented as reorder on 12/30/24, on order on 01/03/25, will recorder not available on 01/13/25, and pending order on 01/24/25.
b. The duloxetine was documented as not available on 01/24/25, 01/25/25, and 01/26/25. On 01/27/25, it was documented as not delivered by pharmacy.
c. The azithromycin was not available on 12/30/24, not available on 01/01/25 (but signed as given on the MAR), not available on 01/07/25, med unavailable on 01/15/25, not available on 01/16/25 and 01/17/25, and not available, contacted [pharmacy], sending tonight on 01/20/25.
d. The prednisone was documented as reorder on 12/30/24 and on order on 01/03/25.
e. The fluticasone-salmeterol inhaler was not available on 12/24/25, no rationale for 01/02/25, and on order on 01/03/25.
f. The umeclidinium bromide inhaler was documented as not available on 01/10/25, pharmacy has not sent on 01/11/25, 01/12/25, and 01/13/25, and not delivered by pharmacy yet on 01/30/25
g. The roflumilast was documented as medication not available or not available on 01/22/25, 01/23/25, 01/24/25, 01/25/25, pharmacy has not sent on 01/26/25, and not delivered by pharmacy on 01/27/25.
h. The Dupixent was documented on 02/09/25 as does not have injection available. The writer made the MD [doctor] aware. The writer called pharmacy to re-order, medication pending delivery. On 03/09/25, it was awaiting delivery. On 03/23/25, medication not available, RN called pharmacy and left message for it to be delivered ASAP. On 04/06/25, it was not available.
Review of R7's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/28/25 and located under the MDS tab of the EMR, revealed he scored a 15 out of 15 on his Brief Interview for Mental Status (BIMS), which indicated intact cognition.
During an interview on 05/06/25 at 10:20 AM, R7 stated there were times he did not receive his medications timely or at all. R7 reported he missed important medications for his COPD such as prednisone, his inhalers, and his Dupixent injections.
During an interview on 05/08/25 at 11:30 AM, Pharmacist 2 stated the pharmacy preferred that the facility order medication refills two to three days in advance to ensure the pharmacy had the medications and insurance approval. Pharmacist 2 stated that all medications needed to be requested by the facility when running low as the pharmacy did not send medications on a cycle. Pharmacist 2 stated that R7's rivaroxaban was limited by insurance to a 14-day supply, and it was sent on 12/21/24, 01/08/25, and 01/21/25, so the facility should have had it for the doses documented as unavailable. Pharmacist 2 stated a 30-day supply of the duloxetine and roflumilast were sent on 12/21/24, and the facility requested refills on 01/16/25, but the pharmacy missed that request somehow. Pharmacist 2 stated the facility faxed another request on 01/26/25, and the medications were sent. Pharmacist 2 stated the umeclidinium bromide inhaler was sent as a seven-day supply due to insurance, and it was sent on 12/21/24, 01/13/25, 01/21/25, and 2/2/25. Pharmacist 2 stated six doses of the azithromycin were sent on 12/21/24, with a note requesting an indication and/or a stop date as the order did not indicate either. Pharmacist 2 stated the facility did not clarify the order but continued to request it so six doses were sent on 12/30/24, on 01/03/25, and on 01/20/25. Pharmacist 2 stated thirty doses of prednisone 10mg were sent on 12/21/24 and thirty doses of 5mg were sent on 1/21/25 when the order changed, so the missed doses should have been available at the facility. Pharmacist 2 stated the fluticasone-salmeterol inhaler was sent as a 30-day supply on 12/21/24 and again on 02/10/25, so was available for the missed doses but likely not available for other doses as it went over 30 days between refills. Pharmacist 2 stated the Dupixent was sent as two pens (two doses) on 1/14/25 and 02/10/25, and the facility requested it a couple of times in March but insurance was not covering it, so it was not delivered until 04/08/25. Pharmacist 2 stated the facility had a contingency supply, which likely included the azithromycin but probably did not have the rivaroxaban and did not include inhalers.
During a concurrent observation and interview on 05/07/25 at 5:10 PM, Licensed Practical Nurse (LPN) 2 administered R7's medications to him. LPN2 went to a supply room to obtain one stock medication that was unavailable. LPN2 reported the facility had a Pyxis (contingency supply of medications) in a medication room. LPN2 stated in order to reorder medications, she removed stickers from the cards of medications when the medication was running low and placed the sticker on a pharmacy re-order paper. LPN2 stated medications usually arrived within a day or two and more important medications, such as antibiotics, were delivered STAT (as soon as possible) if requested and not in the Pyxis.
During an interview on 05/07/25 at 5:20 PM, LPN6 stated medications were reordered by fax or phone call. LPN6 stated the pharmacy sometimes said medication was arriving on their next delivery, but then it did not come. LPN6 stated that even STAT orders were not always timely.
During an interview on 05/08/25 at 2:45 PM, the Assistant Director of Nursing (ADON) recalled R7 had concerns about missed medications but had not realized some were unavailable and not given for multiple days in a row.
2. Review of R18's admission Record, located under the Profile tab of the EMR, revealed he was admitted to the facility on [DATE] with diagnoses which included mood disorder and depression.
Review of R18's admission MDS, with an ARD of 03/26/25 and located in the MDS tab of the EMR, revealed R18 scored a 13 out of 15 on his BIMS, which indicated intact cognition.
Review of R18's Orders tab of the EMR revealed an order for fluoxetine HCl 40mg daily for depression/mood disorder, dated 12/18/24.
During an observation on 05/08/25 at 7:46 AM, LPN9 prepared R18's morning medications and stated, The fluoxetine is on order. Let me see if it came. LPN9 looked through R18's medications and stated, No, it didn't. LPN9 documented on a pharmacy re-order form that the medication was needed, documented that the medication was not available, and administered R18's other medications to him.
During an interview on 05/08/25 at 8:15 AM, LPN9 stated she had ordered the fluoxetine the day before, and medications were delivered nightly. LPN9 stated usually the pharmacy sent a note as to why they did not send medication. LPN9 stated lots of medications had been on backorder lately.
During an interview on 05/08/25 at 9:00 AM, R18 stated he did not pay much attention to the pills he received.
During an interview on 05/08/25 at 11:30 AM, Pharmacist 2 stated the pharmacy filled R18's fluoxetine and were sending it out that night. Pharmacist 2 stated the pharmacy had a refill sticker sent the day before and sent out medications daily, but there were cut-off times and insurance hold-ups. Pharmacist 2 stated R18 last received a card of 30 doses of fluoxetine on 4/4/25. She stated, It is in the contingency supply, so they could have gotten it from there.
During an interview on 05/08/25 at 12:25 PM, Physician 1 stated he was aware of pharmacy issues, especially around the December/January time frame and felt the facility not having medications available that were needed was unacceptable. Physician 1 stated he had spoken to the nurses about his concerns.
During an interview on 05/08/25 at 12:50 PM, LPN9 stated she had contacted the pharmacy, and they needed a new prescription and were sending the fluoxetine on their nightly delivery.
During an interview on 05/08/25 at 1:45 PM, the Director of Nursing (DON) stated if medications were unavailable, staff were expected to go to the contingency supply, and if medications were not available in contingency, staff were expected to contact the pharmacy, have the medication delivered STAT, and contact the provider.
During an interview on 05/08/25 at 1:48 PM, Registered Nurse (RN) 2 stated that not having automatic cycle fills was a challenge. RN2 stated the nurses were to call and re-order when requested medications were not available.
During an interview on 05/08/25 at 2:45 PM, the ADON stated staff were supposed to be able to order medications online but were unable to do so, and so they faxed all refill requests. The ADON stated they maybe received half of the medications requested. She stated staff then called the pharmacy. She stated there were sometimes insurance issues. The ADON reported she told staff to order when there was around a week's supply left, but some medications were only sent out as a seven- or eight-day supply. She stated the contingency supply did not contain many of the needed medications. The ADON stated she updated the physician and tried to change medications when she was notified they were not available.
During an interview on 05/08/25 at 4:15 PM, the DON stated the managers spent a lot of time calling the pharmacy and tracking medications. The DON reported she expected nurses to notify the nurse managers or herself when ordered medications did not arrive.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 7) reviewed for medications was free from significant medication errors when medications were not available and/or were not administered per physician orders. This had the potential to result in adverse health outcomes.
Findings include:
Review of the facility's policy titled, Medication Error Reporting and Counseling Procedure, reviewed/revised 12/2024, revealed a significant medication error meant one which caused the resident discomfort or jeopardized his or her health and safety. The policy recorded, . The relative significance of medication errors is a matter of professional judgment. Three general guidelines in determining whether a medication error is significant or not: resident condition, drug category, and frequency of error .
Review of R7's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R7 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD), pulmonary embolism (blood clot in the lung), and asthma.
Review of R7's Orders tab and Medication Administration Records (MARs), dated 12/2024 and 01/2025 and located under the Orders tab of the EMR, revealed orders for the following medications which were documented on the 12/2024 and 01/2025 MARs by nursing with the code 4, which referred the reviewer to other/see nurse notes:
a. Rivaroxaban 20mg (blood thinner) was ordered daily from 12/21/24 to 01/25/25 and reordered on 1/25/25. It was documented as 4 on 12/30/24, 01/03/25, 01/13/25, and 01/24/25.
b. Umeclidinium bromide inhaler 1 puff daily for COPD was ordered on 12/21/24. It was documented as 4 from 01/10/25 through 01/13/25 and on 01/30/25.
c. Roflumilast 500 micrograms (mcg) daily (for COPD) was ordered on 12/21/24. It was documented as 4 from 01/22/25 through 01/27/25.
Review of R7's Orders tab of the EMR revealed orders for Dupixent 300mg subcutaneous injection every 14 days for COPD from 12/21/24 until 01/12/25, reordered from 01/12/25 to 04/20/24, and reordered again on 04/20/24. It was documented on the 02/2025, 03/2025, and 04/2025 MARs by nursing as 4 on 02/09/25, 03/09/25, 03/23/25, and 04/06/25.
Review of R7's eMar - Medication Administration Notes, located under the Prog Notes tab of the EMR, revealed the following documentation:
a. The rivaroxaban was documented as reorder on 12/30/24, on order on 01/03/25, will recorder not available on 01/13/25, and pending order on 01/24/25.
b. The umeclidinium bromide inhaler was documented as not available on 01/10/25, pharmacy has not sent on 01/11/25, 01/12/25, and 01/13/25, and not delivered by pharmacy yet on 01/30/25.
c. The roflumilast was documented as medication not available or not available on 01/22/25, 01/23/25, 01/24/25, 01/25/25, pharmacy has not sent on 01/26/25, and not delivered by pharmacy on 01/27/25.
d. The Dupixent was documented on 02/09/25 as: does not have injection available. The writer made the MD [doctor] aware. The writer called pharmacy to re-order, medication pending delivery. On 03/09/25, it was awaiting delivery. On 03/23/25, medication not available, RN called pharmacy and left message for it to be delivered ASAP. On 04/06/25, it was not available.
Review of R7's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/28/25 and located under the MDS tab of the EMR, revealed R7 scored a 15 out of 15 on his Brief Interview for Mental Status (BIMS), which indicated intact cognition.
During an interview on 05/06/25 at 10:20 AM, R7 stated there were times he did not receive his medications timely or at all. R7 reported he missed important medications for his COPD such as prednisone, his inhalers, and his Dupixent injections. He stated he had not had respiratory concerns during the time nor any blood clots.
During an interview on 05/08/25 at 11:30 AM, Pharmacist 2 stated the pharmacy preferred that the facility ordered medication refills two to three days in advance to ensure the pharmacy had the medications and insurance approval. She stated all medications needed to be requested by the facility when running low as the pharmacy did not send medications on a cycle. Pharmacist2 stated R7's rivaroxaban was limited by insurance to a 14-day supply. She stated it was sent on 12/21/24, 01/08/25, and 01/21/25, so the facility should have had it for the doses documented as unavailable. Pharmacist 2 stated a 30-day supply of the roflumilast were sent on 12/21/24, and the facility requested a refill on 01/16/25, but the pharmacy missed that request somehow. She stated the facility faxed another request on 01/26/25, and the medication was sent. Pharmacist2 stated the umeclidinium bromide inhaler was sent as a seven-day supply due to insurance, and it was sent on 12/21/24, 01/13/25, 01/21/25, and 2/2/25. She stated the Dupixent was sent as two pens (two doses) on 1/14/25 and 02/10/25. Pharmacist2 stated the facility requested it a couple of times in March but insurance was not covering it, so it was not delivered until 04/08/25. She stated the facility had a contingency supply, which probably did not have any of these medications. Pharmacist2 stated she was concerned that missing the blood thinner was a significant concern to R7. She stated the inhalers were important as well.
During an interview on 05/07/25 at 5:10 PM, Licensed Practical Nurse (LPN) reported the facility had a Pyxis (contingency supply of medications) in a medication room. LPN2 stated she faxed the pharmacy when medications were running low. LPN2 stated medications usually arrived within a day or two and more important medications were delivered STAT (as soon as possible) if requested and not in the Pyxis.
During an interview on 05/07/25 at 5:20 PM, LPN6 stated medications were reordered by fax or phone call. LPN6 stated the pharmacy sometimes said medication was arriving on their next delivery, but then it did not come. LPN6 stated that even STAT orders were not always timely.
During an interview on 05/08/25 at 2:45 PM, the Assistant Director of Nursing (ADON) recalled R7 had concerns about missed medications but had not realized some were unavailable and not given for multiple days in a row.
During an interview on 05/08/25 at 12:25 PM, Physician1 stated he was aware of pharmacy issues, especially around the December/January time frame and felt the facility not having medications available that were needed was unacceptable. He stated he had spoken to the nurses about his concerns. Physician1 stated with R7's history of COPD and risk for blood clots, he considered the missed doses of his COPD medications and blood thinner to be significant medication errors.
During an interview on 05/08/25 at 1:45 PM, the Director of Nursing (DON) stated if medications were unavailable, staff were expected to go to the contingency supply. She stated if medications were not available in contingency, staff were expected to contact the pharmacy, have the medication delivered STAT, and contact the provider.
During an interview on 05/08/25 at 4:15 PM, the DON reported she was unaware that R7 had missed COPD medications multiple days in a row. The DON stated that when any medication was not administered, especially significant medications, she expected staff to notify her and the physician and increase monitoring of symptoms for which the medications were used to treat.
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 F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility failed to ensure a Dietary Manager (DM) was designated to act as the director of food and nutrition services, when the DM position was vacant. This h...
Read full inspector narrative →
Based on interview and record review, the facility failed to ensure a Dietary Manager (DM) was designated to act as the director of food and nutrition services, when the DM position was vacant. This had the potential to affect 89 of 89 residents in the facility.
Findings include:
Review of a document provided by the facility titled job description for Food Service Manager indicated . The primary purpose of your job position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. Graduate of an accredited course in dietetic training approved by the American Dietetic Association.
Review of an employee file provided by the facility and referred to as the employee file for the former Dietary Manager indicated the former Dietary Manager ended her employment with the facility on 04/02/25.
During an interview on 05/06/25 at 9:52 AM, the current Dietary Manager stated he and the contracted company took over the facility's kitchen on 05/05/25.
During an interview on 05/06/25 at 10:16 AM, Dietary Aide (DA) 1 stated there was no full-time dietary manager, overseeing the kitchen, for approximately one month.
During an interview on 05/06/25 at 10:23 AM, [NAME] 1 stated the kitchen had been without a dietary manager for the past month. Cook1 stated there was no dietary manager to oversee the kitchen during this time.
During an interview on 05/08/25 at 12:15 PM, the Administrator stated that he had been in his position for the past three weeks and was aware of the former Dietary Manager had walked out unexpectedly. He stated the contract just went through with the company to oversee the kitchen this week.
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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on observation, menu review, interview, and facility policy review, the facility failed to ensure the menus and menu extensions were followed which included providing appropriate approved food s...
Read full inspector narrative →
Based on observation, menu review, interview, and facility policy review, the facility failed to ensure the menus and menu extensions were followed which included providing appropriate approved food substitutions and ensuring recipes were followed for 89 out of 89 residents. This failure had the potential to cause residents to lose weight.
Findings include:
Review of an undated facility policy titled, Menu indicated, . Menus will be planned to meet the nutritional needs of the residents/patients in accordance with established national guidelines .
Review of a document provided by the facility, referred to as the weekly menu for 05/06/25, indicated the residents were to be served the following meal items: baked potato, crusted fish, rice pilaf, steamed zucchini and tomatoes, a dinner roll, and bread pudding.
A tray line observation was conducted on 05/06/25 at 11:53 AM. [NAME] 1 began to serve resident meals. Kitchen staff had placed mixed fruit on resident trays at this time. [NAME] 1 stated the bread pudding was to be made the night before, and it was not available. [NAME] 2 was interviewed during this observation, and she verified that she was responsible for the preparation of the bread pudding the night before. She stated she did not have the time to make it. When asked how the residents would know of a menu substitution, [NAME] 2 stated the residents did not mind when menu items were substituted. The current Dietary Manager stated residents were to be notified in advance of any menu substitutions made.
During an interview on 05/08/25 at 12:15 PM, the Administrator stated if there were changes to the menu, the residents needed to be alerted in advance.
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
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary condi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary condition to prevent the potential spread of foodborne illness. This had the potential to affect 89 of 89 residents. Specifically, the facility failed to label, date, and store food properly.
Findings include:
Review of a facility policy titled, Food Storage: Dry Goods, dated 02/2023, indicated . All dry goods will be appropriately stored in accordance with the FDA Food Code .
Review of a facility policy titled, Food Storage: Cold Foods, dated 02/2023, indicated . All time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code . All food will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination .
During the initial tour of the kitchen on 05/06/25 at 10:30 AM with the current Dietary Manager, the following was observed:
The dry storage area held an 18-quart container which was partially filled with rice. It was labeled 03/02/25 and had an expiration date of 04/02/25.
The dry storage area held a 22-quart container which contained sugar and had a small plastic cup on the inside of the container which touched the contents. The container was not labeled and dated. The Dietary Manager confirmed the observation and stated this was a potential infection control issue and any open food was to have a date open with an expiration date.
The walk-in freezer had a partial sheet of ice in the corners and entrance of the walk-in freezer, the ceiling had iced condensation, and a stack of boxes to the right of the entrance had frost on several boxes. [NAME] 1 stated there were no temperature logs for the freezer for the month of 05/2025. Cook1 verified there were no temperature logs for the walk-in refrigerator either. The current Dietary Manager was asked for a cleaning schedule of the kitchen, and the Dietary Manager stated he was not aware of one.
Inside the walk-in refrigerator there was a plastic gallon container with fruit cocktail, partially full, with no date of when opened or an expiration date. There was a five-pound container of strawberry yogurt produced by [NAME], and there was no open or use by date. Also present in the walk-in refrigerator was a container of grated parmesan cheese, with an open date of 03/03/25 and no use by date; a large plastic container of slaw with an expiration date of 04/29/25; and a gallon container of breaded chicken breasts with no label, no open date, or a use by date. There was a metal quarter pan which contained an unknown product, covered with plastic. On the plastic cover was spilled pink substance. There were seven bags of a yellow unknown product which had no label and no use by date on a metal cookie sheet. Behind the stove were multiple disposable plates with slices of pie. [NAME] 1 stated the pies were there since the former Dietary Manager walked out of her job approximately one month ago. There were two employee jackets hanging on the rack of clean metal cooking pans and clean plate covers. Per the current Dietary Manager, this was an infection control issue. The current Dietary Manager ran a test on the facility dishwasher. The current Dietary Manager confirmed the rinse temperature was to be at 150 degrees Fahrenheit but did not reach the appropriate temperature when the dish machine was run. A request was made for the temperature logs for the dish machine, and the current Dietary Manager verified these were not completed.
During an interview on 05/08/25 at 12:15 PM, the Administrator stated that he had been three weeks and was aware that the kitchen needed some attention with sanitation.
Jan 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and policy review, the facility failed to ensure care and services were documented for four...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and policy review, the facility failed to ensure care and services were documented for four Resident (R)1, R4, R5, and R9) of 11 residents reviewed for documentation of treatments as ordered by the physician. Failure to document medication administration and treatments to residents does not ensure the treatment or medication has been completed, and could cause a delay in treatment or medication.
Findings Include:
Review of the facility's policy titled, Documentation in Medical Record dated [DATE], revealed, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.
Review of the facility's policy titled Medication Administration dated 01/24, revealed The resident's Medication Administration Record (MAR)/Treatment Administration Record (TAR), is initialed by the person administering medication, in the space provided under the date, and on the line for that specific medication dose administration and time.
1. Review of R1's undated admission Record located in the electronic medical record (EMR) under the Profile tab, indicated readmission on [DATE] with diagnoses including chronic respiratory failure with hypoxia, diabetes mellitus, and hypertension. Review of the EMR revealed that R1 expired on [DATE].
Review of R1's [DATE] MAR/TAR located in the EMR under the Orders tab, indicated the following medications and treatments were not administered per physician orders:
Coreg for beta blocker on [DATE] at 11:00PM.
Hydralazine for hypertension on [DATE] at 2:00PM, [DATE] at 8:00PM, and [DATE] at 2:00PM.
Tracheostomy cares on [DATE] day shift and [DATE] evening shift.
Bilateral heel checks on [DATE] at 8:00PM and [DATE] at 8:00PM.
Foot check: Visual check of skin condition of both feet, toes, and heels on [DATE] at 8:00PM, and [DATE] at 8:00PM.
Skin prep bilateral heels on [DATE] at 8:00PM and [DATE] at 8:00PM.
Trach size #6 type Shiley uncuffed inner cannula, change twice daily for trach cares on [DATE] at bedtime (HS), and [DATE] on day shift.
Tracheostomy cares twice daily on [DATE] on evening shift.
Humidifier compressor 50-70% three times a day on [DATE] at 10:00PM, [DATE] at 2:00PM, [DATE] at 6:00AM, and 10:00PM, on [DATE] at 2:00PM, on [DATE] at 2:00PM, on [DATE] at 10:00PM, [DATE] at 2:00PM, [DATE] at 2:00PM.
Review of R1's [DATE] TAR located in the EMR under the Orders tab, indicated the following treatments were not administered to the resident per physician orders:
Bilateral heel checks on [DATE] at 8:00PM, [DATE] at 8:00PM, [DATE] at 8:00PM, and [DATE] at 8:00PM.
Change Heat Moisture Exchanger (HME) Trach Valve daily for Tracheostomy care on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] at 8:00AM daily.
Change trach ties and inspect skin daily on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] at 8:00AM daily.
Foot check: Visual check of skin condition of both feet, toes, and heels at HS on [DATE], [DATE], [DATE], and [DATE].
Trach size #6 type Shiley uncuffed inner cannula, change daily on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] at 8:00AM.
Tracheostomy cares twice daily on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] on day shift; [DATE], [DATE], [DATE] on evening shift.
2. Review of R4's undated admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including fracture of right tibia, diabetes mellitus, chronic kidney disease, and anxiety disorder.
Review of R4's [DATE] MAR/TAR located in the EMR under the Orders tab, indicated the following medications and treatments were not administered per physician orders:
Right knee: Gently remove Adaptic (Vaseline) gauze. Cover with thin layer of Vaseline and replace Adaptic gauze and Abdominal Pads (ABD); wrap with Ace bandage every evening shift on [DATE],[DATE], [DATE], [DATE], and [DATE].
Review of R4's [DATE] MAR/TAR located in the EMR under the Orders tab, indicated the following medications and treatments were not administered to the resident per physician orders:
Rosuvastatin daily for hypercholesterolemia at 8:00PM on [DATE], [DATE], [DATE], and [DATE].
Insulin Glargine for diabetes mellitus at bedtime (10:00PM) on [DATE], [DATE], [DATE], and [DATE].
Trazodone HS for insomnia on [DATE], [DATE], and [DATE].
Apixaban twice daily for deep vein thrombosis prophylactic at 8:00PM on [DATE], [DATE], [DATE], and [DATE].
Famotidine twice daily for gastroesophageal reflux disease on [DATE] for day shift, on [DATE], and [DATE] on evening shift.
Gabapentin three times daily for nerve pain at 2:00PM on [DATE], [DATE],[DATE], [DATE], at 8:00PM on [DATE], [DATE], [DATE], and [DATE].
Review of R4's [DATE] MAR/TAR located in the EMR under the Orders tab, indicated the following medications and treatments were not administered per physician orders:
Gabapentin three times a day for fractured right tibia at 8:00AM on [DATE], at 2:00PM on [DATE], [DATE], [DATE], [DATE], and [DATE].
Right Knee: Cleanse perimeter of site, gently remove gauze. Apply Xeroform (Double Layer). May substitute with oil emulsion dressing, cover with ABD pad, and ACE bandage wrap. Re-apply leg immobilizer. Change daily and as needed (PRN) on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].
Review of R4's [DATE] MAR/TAR located in the EMR under the Orders tab, indicated the following medications and treatments were not administered per physician orders:
Glimepiride for non-insulin dependent diabetes mellitus two times a day on [DATE] at 4:00PM, and [DATE] at 8:00AM.
Gabapentin three times a day for fractured right tibia on [DATE] at 8:00PM, [DATE], [DATE], [DATE], and [DATE] at 2:00PM.
Right Knee: Cleanse perimeter of site, gently remove gauze. Apply Xeroform (Double Layer). May substitute with oil emulsion dressing, cover with ABD pad, and ACE bandage wrap. Re-apply leg immobilizer. Change daily and as needed (PRN), on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] at 8:00AM.
Tx (treatment) to right inner thigh scabbed area: Dakin's ¼ strength cleanse followed by (f/b) skin prep, f/b leave open to air change daily and as needed for wound care on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].
Nystatin powder, apply to groin and vagina topically three times a day for rash on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] at 8:00AM. On [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] at 2:00PM. On [DATE] at 8:00PM.
3. Review of R5's undated admission Record located in the EMR under the Profile tab, indicated the resident was readmitted on [DATE] with diagnoses left shoulder fracture, multiple rib fractures, schizophrenia, and hypertension.
Review of R5's [DATE] MAR/TAR located in the EMR under the Orders tab, indicated the following medications and treatments were not administered to the resident per physician orders:
Bilateral buttocks: Cleanse with ½ strength Dakin's solution. Pat dry. Skin prep peri wounds using non-sting skin prep f/b hydrocolloid dressing daily at 8:00AM on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].
Ileostomy cares every shift and as needed on day shift on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On evening shifts on [DATE], [DATE], and [DATE]. Night shift on [DATE].
4. Review of R9's undated admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE], with diagnoses including quadriplegia, ileostomy status, and pressure ulcer.
Review of R9's [DATE] MAR/TAR located in the EMR under the Orders tab, indicated the following medications and treatments were not administered to the resident per physician orders:
Left groin/perineum wound cleanse with ¼ strength Dakin's, apply skin prep to peri wound, apply calcium alginate with silver along wound bed followed by dry gauze, cover with ABD pad secure with adult brief, change daily for wound care on day shift for [DATE], [DATE], [DATE], [DATE], and [DATE].
Rinse out ostomy bag daily at 8:00AM on [DATE], [DATE], [DATE], and [DATE].
Review of R1, R4, R5, and R9's Assessments located in the EMR under the Assessment tab, and Progress Notes located in the EMR under the Progress Notes tab revealed no documentation related to why the medication and treatments were not administered on the aforementioned dates and times.
During an interview conducted with the Director of Nursing on [DATE] at 3:10PM, upon review of R1, R4, R5, and R9's MAR/TARs, the DON confirmed the missing documentation of medications and treatments on the MAR and TAR. The DON was asked what her expectations of the nursing staff regarding documentation in the MAR and TAR. The DON stated she expected the staff to document when the medication was administered, and treatments have been completed. The DON added that if the staff is unable to perform the tasks they are supposed to document the reason why.
Oct 2024
14 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure 1 (R3) of 1 Resident's resident representative was notified whe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Facility did not ensure 1 (R3) of 1 Resident's resident representative was notified when there was a need to alter treatment.
R3's POA (Power of Attorney) was not notified when occupational therapy was discontinued on 6/26/24 and physical therapy was discontinued on 7/2/24.
Findings include:
The facility's policy titled, Notification of Changes and last reviewed/revised 8/27/24 under policy documents The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.
R3 was admitted to the facility on [DATE].
R3's diagnoses includes congestive heart failure,diabetes mellitus, and end stage renal disease. R3's power of attorney for health care was activated on 7/19/23.
Surveyor reviewed R3's medical record and was unable to locate therapy progress notes to determine when R3 had previously been discharged from occupational therapy & physical therapy and whether R3's POA had been notified of R3's therapies being discontinued.
On 10/2/24, at 12:30 p.m., Surveyor met with DOR/COTA (Director of Rehab/Certified Occupational Therapy Assistant)-Q to discuss R3. DOR/COTA-Q informed Surveyor R3 has been off and on therapy. DOR/COTA-Q explained R3 is now on OT (occupational therapy) and speech therapy. DOR/COTA-Q informed Surveyor after R3 was admitted she had OT starting 5/15/24, PT (physical therapy) starting on 5/16/24, and speech therapy 5/16/24. DOR/COTA-Q informed Surveyor OT was discontinued on 6/26/24 & PT on 7/2/24. R3 received speech therapy until 8/1/24. DOR/COTA-Q informed Surveyor R3 was hospitalized and readmitted on [DATE]. DOR/COTA-Q informed Surveyor OT was started on 8/26/24, speech on 9/10/24, and PT was not started back up. Surveyor asked DOR/COTA-Q when a resident's therapy is discontinued is their POA notified of this. DOR/COTA-Q replied yes, sometimes the therapist and sometimes the DOR (Director of Therapy). Surveyor asked DOR/COTA-Q when R3's OT was discontinued on 6/26/24 & PT was discontinued on 7/2/24 is there a note documenting when R3's POA was notified of R3's therapy being discontinued. DOR/COTA-Q informed Surveyor she doesn't see a note regarding this for OT and informed Surveyor she will often hear the therapist calling but if it's not documented it doesn't mean anything. DOR/COTA-Q informed Surveyor the occupational therapist who wrote the discharge note not is not longer here. DOR/COTA-Q informed Surveyor for PT she sees the patient was discharged from PT and the patient agreed but doesn't see the POA was notified. Surveyor asked DOR/COTA-Q if she was the director when R3 was discharged from physical therapy. DOR/COTA-Q informed Surveyor [name ], Prior DOR/PT-W, is no longer here.
DOR/COTA-Q provided Surveyor with R3's occupational therapy Discharge summary dated [DATE] and physical therapy Discharge summary dated [DATE]. Surveyor was unable to locate on these discharge summaries R3's POA was notified when OT & PT was discontinued.
On 10/3/24, at 12:24 p.m., NHA (Nursing Home Administrator)-A was notified of the above. No information was provided to Surveyor as to why R3's POA was not notified when therapy was discontinued for R3.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure that 1 allegations of abuse involving 2 Residents (R10 ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure that 1 allegations of abuse involving 2 Residents (R10 and R8) of 5 allegations of abuse were reported immediately.
*On 5/16/24, Certified Nursing Assistant (CNA)-V notified Registered Nurse (RN)-S that R10 voiced an allegation that CNA-V was rough with cares. RN-S informed CNA-V that was R10's behavior. CNA-V went back and continued cares for R10 and other Residents on CNA-V's assignment. On 5/17/24, Social Services notified Nursing Home Administrator (NHA)-A of the allegation.
Findings Include:
The facility's policy Abuse, Neglect, and Exploitation implemented 9/18/23 documents:
.Policy: It the policy of this facility to provide protections for the health, welfare and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property.
V. Investigation of Alleged Abuse, Neglect and Exploitation
A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.
VI. Protection of Resident The facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.
A. Responding immediately to protect the alleged victim and integrity of the investigation
B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed
F. Providing emotional support and counseling to the Resident during and after the investigation
G. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse
VII. Reporting/Response
A. The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies(law enforcement) within specified timeframe's:
a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury
b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury
VIII. Coordination with QAPI
A. The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of Resident property, and exploitation with the QAPI program.
1. Cases of physical or sexual abuse, for example by facility staff or other Residents, will be reviewed for and receive corrective action and tracking by QAA Committee. 1
R10 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Morbid Obesity, Chronic Respiratory Failure with Hypoxia, Anemia, Paroxysmal Atrial Fibrillation, Fibromyalgia, and Depression. R10 was her own person. R10 discharged from the facility on 6/4/24.
R10's admission Minimum Data Set (MDS) completed on 5/5/24 documents R10's Brief Interview for Mental Status (BIMS) to be 15, indicating R10 was cognitively intact for daily decision making. R10's MDS also documents that R10 was independent for eating, and dependent for showers, upper and lower dressing, mobility, and transfers.
On 10/1/24, at 11:23 AM, Surveyor reviewed a self report that documents R10 reported CNA-V had been rough with cares. The Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 5/17/24 was submitted to the State Survey Agency. Surveyor reviewed CNA-V's statement which documents that CNA-V reported the allegation on the PM shift to Registered Nurse (RN)-S which was 5/16/24 around 6:30/7:00 PM. CNA-V's documented statement is that CNA-V reported R10's allegation to RN-S on 5/16/24. RN-S replied it was their behavior referring to R10 and CNA-V went back into R10's room to complete cares. CNA-V also provided ADL cares to other Residents during the shift. RN-S did not report the allegation from R10 immediately to a supervisor, Director of Nursing (DON)-B, or Nursing Home Administrator (NHA)-A.
On 10/2/24, at 2:35 PM, Surveyor shared the concern with NHA-A, Director of Nursing (DON)-B, and Director of Operations (DO)-C that R10's allegation of abuse occurred on 5/16/24, was reported by CNA-V to RN-S who did not report it immediately and was not addressed until 5/17/24. Surveyor expressed that it is unclear how or by whom NHA-A was notified of the allegation on 5/17/24.
On 10/3/24, at 12:07 PM, Surveyor was provided a grievance summary with an incident date of 5/17/24 and resolve date of 5/24/24. A post-it note was on top of the summary stating that NHA-A was notified in person by social services. Surveyor asked NHA-A at this time, if NHA-A recollects the conversation. NHA-A is not able to provide any further information at this time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R10) of 2 Residents reviewed for discharge received a comple...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R10) of 2 Residents reviewed for discharge received a complete discharge summary.
*R10 was discharged to an adult living home on 6/4/24 without a completed discharge summary and list of medications to allow for coordination of care and to effectively transition R10 to post-facility care.
Findings Include:
The facility's policy Transfer and Discharge implemented 10/26/2022, and last revised on 1/2024 documents:
14 Anticipated Transfers or Discharges -Resident -initiated discharges
a. Obtain physicians' for transfer or discharge and instructions or precautions for ongoing care.
b. A member of the interdisciplinary team(IDT) completes relevant sections of the Discharge Summary. The nurse caring for the Resident at the time of discharge is responsible for ensuring the Discharge Summary is complete and includes, but not limited to, the following:
i. A recap of the Resident's stay that includes diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
ii. A final summary of the Resident's status
iii. Reconciliation of all pre-discharge medications with the Resident's post- discharge medications(both prescribed and over the counter)
iv. A post discharge plan of care that is developed with the participation of the Resident, and the Resident's representative(s) which will assist the Resident to adjust to his/her new living environment.
c. Orientation for transfer or discharge must be provided and documented to ensure safe and orderly transfer or discharge from the facility, in a form and manner that the Resident can understand. Depending on the circumstances, this orientation may be provided by various members of the IDT.
d. Assist with transportation arrangements to the new facility and any other arrangements as needed.
e. The comprehensive, person-centered care plan shall contain the Resident's goals for admission and desired outcomes and shall be in alignment with the discharge.
f. Residents who are sent to an acute care setting for routine treatment/planned procedure must be allowed to return to the facility.
g. Supporting documentation shall included evidence of the Resident's or Resident representative's verbal or written notice of intent to leave the facility, a discharge plan, and documented discussions with the Resident and/or Resident representative.
R10 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Morbid Obesity, Chronic Respiratory Failure with Hypoxia, Anemia, Paroxysmal Atrial Fibrillation, Fibromyalgia, and Depression. R10 was her own person. R10 discharged from the facility on 6/4/24.
R10's admission Minimum Data Set (MDS) completed on 5/5/24 documents R10's Brief Interview for Mental Status (BIMS) to be 15, indicating R10 was cognitively intact for daily decision making. R10's MDS also documents that R10 was independent for eating, and dependent for showers, upper and lower dressing, mobility, and transfers.
The following focused problems were part of R10's comprehensive care plan:
-Preferred activities
-Activities of Daily Living (ADL) deficit
-Behavior problem of false accusations
-Wishes to return home
-Potential for dehydration due to diuretic use
-At risk for falls-Bowel incontinence
-History of diarrhea-Uses antidepressant
-Diuretic therapy-Anticoagulant therapy
-Mood impairment-Antibiotic therapy
-Nutritional problem
-Chronic pain-Emphysema, asthma, chronic respiratory failure
-History of Kidney Disease, stage 3
-Potential for impairment to skin integrity/moisture
-MASD (moisture associated skin damage) to bilateral buttocks-Experienced trauma
-Indwelling catheter
Surveyor notes that R10 had multiple care areas with interventions necessary for the adult living home to know in order for continuum of care to be implemented for R10 to ensure success of placement outside the facility.
On 10/1/24, at 11:23 AM, Surveyor reviewed R10's physician orders, progress notes and 'Discharge Instructions and Review of Systems for Resident' dated 6/3/24. Surveyor noted, there is no discharge order for R10 to be discharged from the facility and there is no documentation in R10's progress notes of R10 being discharged from the facility on 6/4/24, as well as no documentation of the steps taken to coordinate a successful discharge from the facility.
-R10's 'Discharge Instructions and Review of Systems' contains sections A-M.
A-Discharge Location and Date is completed
B-Discharge Summary Assessment documents vitals dated 6/3/24. It also documents that R10 is continent of bladder and incontinent of bowel, however, having an indwelling catheter is not documented for R10. Respiratory, skin evaluation, pain, vision and hearing, and ability to understand is not completed.
C-Current Physical Status which includes Eating,Hygiene, Shower/Bathing Status, Dressing, Walking, Stair, Wheelchair, Bed Mobility, and Transfers is not completed.
D-Diet Recommendations is not completed.
E-Primary Care Information with Follow-up appointments is not completed.
F-Referral for Care documents no referral has been made.
G-Advance Care Planning is completed.
H-Medications-Indicates a pharmacy the medications were called into, but then does not list R10's medications or when R10 last received a dose. It is also not documented if R10 received a current reconciled medication list or if one was given to the provider.
I-Treatment-not completed
J-Additional Instruction-not completed
K-Person receiving the instructions-there is no name documented and no signature that either R10 received instructions and/or provider.
L-BIMS and PHQ-0 (Patient Health Questionnaire) is completed.
M-Education is not completed.
On 10/2/24, at 11:27 AM, Surveyor interviewed Social Worker (SW)-FF and Social Worker (SW)-E at the same time. SW-FF and SW-E explained to Surveyor that social services and nursing completes the discharge instructions prior to a Resident leaving the facility. Nursing has to close the discharge instructions, so it is likely that nursing would be the last to be working on the discharge instructions. SW-FF and SW-E stated that nursing gets it all together and completes the discharge packet. SW-FF and SW-E informed Surveyor that there is no designated person to make sure the discharge instructions with summary/recapitulation of a Resident's stay is completed.
On 10/2/24, at 2:35 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Operations (DO)-C that there is no documentation in R10's EMR of R10's discharge from the facility. Surveyor also shared that R10's discharge instructions include multiple sections that were not completed prior to R10 discharge from the facility that includes receiving a complete discharge summary including post discharge plans/instructions, follow up care necessary and medications provided to the Resident in order to communicate necessary information to the Resident, continuing care provider, and other authorized persons at the time of the anticipated discharge. No further information was provided by the facility at this time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure residents received treatment and care in accordance with profes...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 2 (R3 & R7) of 16 residents.
* Staff did not place tubi grips on R3's bilateral lower extremities on 10/1/24 & 10/2/24.
* R7's non pressure wounds were not comprehensively assessed for 7 days. There is no order for R7's PICC (peripherally inserted central catheter), the PICC dressing, & care of PICC line. Facility staff were wrapping R7's legs with ace bandages when the physician's orders documented Coban.
Findings include:
1.) R3's diagnoses includes congestive heart failure,diabetes mellitus, and end stage renal disease.
The resident has an ADL (activity daily living) self-care performance deficit care plan initiated 5/17/24 includes an intervention of *DRESSING: The resident requires assistance by 1 staff to dress. Assist x (times) 1 with UB (upper body) and LB (lower body) dressing, Assist x1 with grooming, Tubi Grips to BLE (bilateral lower extremities), on in AM (morning), off at HS (hour sleep). Must have Hoyer Sling under/in place to W/C (wheel chair) during Dialysis Days. Initiated 5/17/24.
The physician orders with an order date of 6/4/24 documents Tubi grips to BLE on AM off HS every morning and at bedtime for edema.
The CNA (Certified Nursing Assistant) care card updated 9/27/24 under the ADL's section documents Assist x 1 with UB and LB dressing. Assist x 1 with groom, Tubi Grips to BLE, On in AM, off at HS. Must have Hoyer Sling under/in place to W/C during Dialysis Days.
On 10/1/24, from 10:56 a.m. to 10:35 a.m., Surveyor observed CNA (Certified Nursing Assistant)-G and CNA-H provide morning cares for R3, dress R3, and transfer R3 from the bed into the wheel chair. During this observation at 11:08 a.m. CNA-G removed R3's gripper socks. Surveyor checked R3's feet and did not observe any open areas. At 11:24 a.m. CNA-G & CNA-H placed pants on R3 then positioned R3 from side to side to fasten the incontinence product and pull up R3's pants. CNA-G informed R3 she has two grippy socks. Surveyor observed there is a beige & gray gripper sock. R3 asked if they were mismatched. CNA-G replied yes. R3 asked why you got me looking like this. CNA-G informed R3 its only temporary. CNA-G placed the gripper socks and crocs on R3's feet. Surveyor noted during this observation neither CNA-G or CNA-H placed tubi grips on R3 nor did CNA-G or CNA-H ask R3 about the tubi grips.
On 10/1/24, at 3:33 p.m., Surveyor observed R3 sitting in a wheelchair in the room. Surveyor observed R3's left pant leg is up. Surveyor observed R3 is still not wearing tubi grips.
On 10/1/24, at 3:34 p.m., Surveyor reviewed R3's October TAR (treatment administration record) and noted on 10/1/24 there is a check & initials for tubi grips to BLE on AM off HS every morning and at bed time for edema for the morning scheduled time. A check & initials indicate the tubi grips have been applied.
On 10/2/24, at 7:23 a.m., Surveyor observed R3 dressed for the day sitting in a wheel chair in her room. Surveyor observed R3 is wearing gray gripper socks and is not wearing tubi grips.
On 10/2/24, at 7:37 a.m., Surveyor observed CNA-H wheeling R3 out of the room and down the hallway towards the front entrance for R3's dialysis appointment. Surveyor observed R3 is not wearing tubi grips.
On 10/2/24, at 3:14 p.m., Surveyor noted R3 is still not back from dialysis and has not been wearing her tubi grips.
On 10/3/24, at 10:47 a.m., Surveyor asked RN (Registered Nurse)-K if R3 should be wearing tubi grips. RN-K replied there should be an order. RN-K then reviewed R3's physician orders and replied yup, tubi grips BLE.
On 10/3/24, at 10:51 a.m., Surveyor asked CNA-H if R3 wears tubi grips. CNA-H informed Surveyor she usually puts gray socks on her. Surveyor showed CNA-H the CNA care card with R3 listed for tubi grips and asked CNA-H if the CNA care card is what they follow. CNA-H replied yes.
On 10/3/24, at 11:15 a.m., Surveyor reviewed R3's October TAR (treatment administration record) and noted on 10/2/24 there is a check & initials for tubi grips to BLE on AM off HS every morning and at bed time for edema for the morning scheduled time. A check & initials indicate the tubi grips have been applied.
On 10/3/24, at 10:55 a.m., Surveyor informed DON (Director of Nursing)-B of the observations of R3 not wearing tubi grips during the first two days of survey as Surveyor had observed morning cares for R3 on 10/1/24 and staff did not place on the tubi grips. On 10/2/24 Surveyor observed R3 prior to going to dialysis without the tubi grips on.
On 10/3/24, at 12:24 p.m., NHA (Nursing Home Administrator)-A was informed of the above. No information was provided to Surveyor as to why R3 was not wearing tubi grips on 10/1/24 & 10/2/24.
*R7 was admitted to the facility on [DATE], to receive intravenous antibiotics due to a wound infection.
R7's admission Minimum Data Set (MDS), dated [DATE], documents R7 has a Brief Interview for Mental Status (BIMS) of 15, indicating R7 in cognitively intact. R7 did not exhibit any behaviors or rejection of care.
Surveyor reviewed R7's document titled Discharge Summary, with a service date of 06/18/2024, and documents in part,
Wound Care to BLE
1. Cleanse wound with Hibiclens and Water
2. Pat area dry with gauze
3. Apply Mepilex AG to posterior Knees
4. Fan Wrap Viscopaste gauze
5. Apply Coban 2 layer wrap to patients thighs
6. WOCN to change twice a week, Monday/Thursday . Post-discharge IV ABX: Dx: MRSA bacteremia
Rx: IV Vancomycin 1.5 g IV q18hr
Duration: continue through 06/21/2024 to complete 2 week course. -10 mL of normal saline pre-infusion and post-infusion, and 3 mL of 10 units/mL of heparin post-infusion -please remove PICC line at end of IV ABX therapy.
Surveyor reviewed R7's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated June 2024 and July 2024. Surveyor noted no orders to flush R7's Peripherally Inserted Central Catheter (PICC) with heparin, and no orders to change R7's PICC dressing. Surveyor noted multiple progress notes indicating R5 was using ace bandage wraps and the Facility did not have Coban available.
Wound assessment
Surveyor reviewed R7's document, titled Admission/Readmission/Routine Heat-to-toe Evaluation, dated 06/18/2024, and documents in part, . Coban wraps to BLE done twice weekly at hospital and d/t tomorrow, would like them to be done tomorrow vs assessing today.
Surveyor reviewed the document titled, Weekly Wound Assessment- champion, dated 06/25/2024 and signed 07/01/2024 by DON-B, documents the first comprehensive wound assessment for R7 was 7 days after being admitted to the Facility.
PICC Dressing change-
Per the Center for Disease Control document titled, Summary of Recommendations from the Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011), dated 02/28/2028, documents in part,
6. Catheter Site Dressing Regimens . 1. Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. 3.
Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. 6. Replace dressings used on short-term CVC sites every 2 days for gauze dressings. 7. Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing.
Surveyor reviewed R7's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated June 2024 and July 2024. Surveyor noted no orders to change R7's PICC dressing.
Surveyor noted a progress note, indicating PICC site was cleaned, and dressing changed on 06/21/2024. No further documentation of PICC dressing changes.
R7 had PICC removed on 06/22/2024 while in the Facility, but PICC was reinserted while in the Facility on 06/28/2024, R7 was discharged from the Facility on 07/25/2024.
Heparin Flush-
The Facility's policy, titled Vascular Access Devises and Infusion Therapy Procedures Maintaining Patency of Peripheral and Central Vascular Access Devices, date 08/2021, documents in part, 12. Variations from recommended flush are based on physician orders.
Surveyor reviewed R7's Medication Administration Record (MAR) and Treatment Administration Record (TAR), dated June 2024 and July 2024. Surveyor noted no orders to flush R7's Peripherally Inserted Central Catheter (PICC) with heparin.
On 10/04/2024, at 03:07 PM, Surveyor received a document from NHA-A via confidential email. The document provided by NHA-A documents in part, . the risk of using Heparin outweighs the benefits. signed by MD-U, dated 10/04/2024.
Coban-
Surveyor reviewed R7's orders and noted an order documenting, Coban wraps to BLE twice weekly one time a day every Wed, Sat with a start date of 06/19/2024 and end date of 06/20/2024. Surveyor noted this was marked completed in R7's June 2024 Treatment Administration Record (TAR).
Surveyor noted an order documenting, Per Dr. [NAME] wounds should be dressed with COBANZ MATERIAL instead of ACE wraps. Wrap feet with COBANZ first the escalate up the leg to prevent LE edema every shift with a start date of 06/28/2024 and end date 08/07/2024. Surveyor noted in R7's June and July TAR was marked as completed every shift (except not documented on 07/18/2024 evening shift and 07/19/2024 day shift).
Surveyor noted a progress note on 06/23/2024, at 06:33 AM documents in part, . Has ace wrap to rt. leg. Has excoriated lt. leg .
Surveyor noted a progress note, dated 06/23/2024, at 02:40 PM, documents in part, Situation: Resident c/o pain, burning and clear discharge from bilateral legs not relieved with analgesic given. Wants to go to ER.
Surveyor noted a progress note, dated 06/23/2024, at 10:10 PM, documents in part, Resident returns from hospital ER, RN received report from [NAME], RN. Resident has had bilateral legs wrapped with xeroform, kerlix, and ace bandages. VSS obtained, 128/74, 18 respirations, 76 heart rate, 97% room air upon arrival to our facility. He reports he is in no pain at this time. will continue to monitor.
Surveyor noted on 06/24/2024, a progress note by NP-AA, documents resident was seen and examined today in his room at Burlington's rehabilitation center for follow-up on Leg wounds that are weeping. Resident is alert awake oriented x 4 sitting up on his comfortably with no acute distress no chest pain no shortness of breath stable vital signs, his pain level is 7-9 out of 10. On exam patient is wearing Ace wraps to bilateral legs from his knees down to his ankles.
Surveyor noted a progress note on 06/29/2024, documents, Note Text: Per Dr. [NAME] wounds should be dressed with COBANZ MATERIAL instead of ACE wraps. Wrap feet with COBANZ first and escalate up the leg to prevent LE edema
every shift no Coban available in facility, wrapped w/ kerlix f/b tubi grips.
Surveyor noted a progress note by NP-AA, dated 07/02/2024, documents in part, . resident was seen and examined today in his room at Burlington's rehabilitation center for follow-up on Leg wounds that are weeping. Resident is alert awake oriented x 4 sitting up on his comfortably with no acute distress no chest pain no shortness of breath stable vital signs, his pain level is 7-9 out of 10. On exam patient is wearing Ace wraps to bilateral legs from his knees down to his ankles.
Surveyor noted a progress note, dated 07/07/2024, documents, Per Dr. [NAME] wounds should be dressed with COBANZ MATERIAL instead of ACE wraps. Wrap feet with COBANZ first and escalate up the leg to prevent LE edema every shift
COBANZ unavailable.
Surveyor noted a progress note on 07/08/2024, by RN-K, documents Resident had ordered supplies from Amazon for his leg treatment. RN did treatment per order using these supplies. Coban wrap to be monitored for any circulation issues.
Surveyor noted a progress not on 07/11/2024, by NP-AA documents in part, . resident was seen and examined today in his room at Burlington's rehabilitation center for follow-up on Leg wounds that are weeping. Resident is alert awake oriented x 4 sitting up on his comfortably with no acute distress no chest pain no shortness of breath stable vital signs, his pain level is 7-9 out of 10. On exam patient is wearing Ace wraps to bilateral legs from his knees down to his ankles.
Surveyor noted a progress note on 07/13/2024, documents, Per Dr. [NAME] wounds should be dressed with COBANZ MATERIAL instead of ACE wraps. Wrap feet with COBANZ first and escalate up the leg to prevent LE edema
every shift. Cobanz not available. Res. has legs wrapped in kerlix.
Surveyor noted a progress note dated 07/15/2024 by NP-AA, documents in part, . resident was seen and examined today in his room at Burlington's rehabilitation center for follow-up on Leg wounds that are weeping. Resident is alert awake oriented x 4 sitting up on his comfortably with no acute distress no chest pain no shortness of breath stable vital signs, his pain level is 7-9 out of 10. On exam patient is wearing Ace wraps to bilateral legs from his knees down to his ankles.
Surveyor noted a progress note dated 07/22/2024 by NP-AA, documents in part, . Continue with wound care, follow-up with Dr. [NAME], per Dr. [NAME] and medical director follow-up with infectious diseases.
Surveyor noted a progress note, dated 07/23/2024 documents, Clarification/Late entry for 7/23/2024; Wound care to BLE dressings completed, However, Resident declined to have Coban wraps applied, stating I don't need them right now, the swelling to my legs went down and I've been keeping my legs elevated MD updated, NNO sat this time.
On 10/02/2024, at 03:07 PM, Surveyor interviewed RN-K regarding his progress note for R7's Coban. RN-K informed Surveyor that at the time the Facility did not have Coban, and the R7 ordered his own. RN-K informed Surveyor that he notified Medical Records/Central Supply-J to order Coban. RN-K informed Surveyor that the supply gets to the Facility quick.
On 10/02/2024, at 01:25 PM, Surveyor interviewed Medical Records/Central Supply-J. Medical Records/Central Supply-J informed Surveyor that usually order requests are done verbally, no logs are kept of order requests. Medical Records/Central Supply-J informed Surveyor that the order for Coban arrived to the facility on [DATE]. Medical Records/Central Supply-J informed Surveyor that the week prior to the Coban arriving, 1 pack of Coban arrived due to error when ordering.
On 10/02.2024, at 03:12 PM, UM-F informed Surveyor that UM-F bought Coban for R7 and informed R7 not to buy his own. UM-F informed Surveyor that the Coban was sent with R7 upon discharge.
On 10/02/2024, at 03:55 PM, Surveyor received a printout of Coban in an online Walmart cart with an estimated total of $18.38. Surveyor was also given a copy of document titled FREE CKG W/PLATINUM CARD indicating a charge of $18.34 on July 20,2024.
On 10/03/2024, at 09:29 AM, Surveyor interviewed DON-B. DON-B informed Surveyor the expectation is to follow policy regarding PICC line dressing changes and flushes. DON-B informed Surveyor that PICC line dressing should be changed every 7 days or as needed, and the site should be monitored every shift. DON-B informed Surveyor that flushing a PICC would include Saline flushes before and after, as well as a Heparin flush after. DON-B informed Surveyor that if a concern is made by a resident to a nurse, the expectation is the nurse would further investigate the concern and DON-B would expect to be notified. DON-B informed Surveyor that no concerns were brought to her attention aside from the issue with the Coban.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents received adequate assistance with devi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents received adequate assistance with devices to prevent accidents for 1 (R5) of 1 resident observed for accidents.
R5 required assistance of 2 staff to be transferred using a Hoyer lift. Facility staff were observed walking away from R5 during the transfer process to address other issues leaving R5 suspended in the sling and creating a potential unsafe transfer.
Findings include:
R5's most recent admission to the Facility was on 05/16/2022. R5's annual Minimum Data Set (MDS), dated [DATE], documents R5 has a Brief Interview for Mental Status (BIMS) of 15 with a primary medical condition category of Traumatic Spinal Cord Dysfunction. R5 has functional limitations in bilateral upper and lower extremities, and is dependent with transfers from bed to chair.
Surveyor reviewed R5's care plan and noted R5 requires the assist of 2 staff for transfer with a Hoyer. Full body sling / Xlarge. No Ambulation.
On 10/01/2024, at 11:06 AM, Surveyor observed Hospice RN-CC ask RN-L for assistance transferring R5 from the bed to the wheelchair using a Hoyer lift. RN-L went into R5's room with Hospice RN-CC, the door to R5's room was left open. Surveyor observed from the hall. Surveyor observed RN-L controlling the Hoyer lift controls to maneuver the Hoyer. While R5 was attached to the Hoyer lift, in the air, a phone began ringing on the medication cart in the hallway outside of R5's room. Surveyor observed RN-L walk away to turn the ringer off on the phone. RN-L then went back into R5's room. R5 was then positioned in the air, over the wheelchair, RN-L and Hospice RN-CC attempted to lower R5 into the wheelchair a few times. On the last attempt to lower R5 to the wheelchair, Surveyor observed the front wheels of the wheelchair coming off the ground. Surveyor heard RN-L tell Hospice RN-CC he is going to fall. RN-L instructed Hospice RN-CC to assist R5 to position R5 better in the wheelchair. RN-L then indicated needing more help transferring R5 into the wheelchair. RN-L left R5's room to go get a certified nursing assistant (CNA), at the time RN-L left R5's room, R5 was suspended in the air with the Hoyer lift, with the wheelchair underneath R5. Hospice RN-CC stayed with R5 while RN-L left to get assistance. Hospice RN-CC informed Surveyor that Hospice RN-CC brought an XL sling today for R5's Hoyer transfers due to R5 having the wrong size sling, stating it was too small. R5 was suspended in the air for approximately 6 minutes until RN-L returned with Certified Occupational Therapy Aide (COTA)-Q and CNA-DD, they all went into R5's room and closed the door. Surveyor later observed R5 in his wheelchair with no concerns.
On 10/03/2024 at 12:30 PM, Surveyor notified NHA-A of above findings.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure 1 (R3) of 1 resident was provided with appropriat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure 1 (R3) of 1 resident was provided with appropriate food items for a renal/LCS (low concentrated sweets) diet as prescribed by the physician.
R3 was served french fries and a tomato slice on 10/1/24.
Findings include:
The Renal Diet/Liberal Renal Diets/Renal LCS (low concentrated sweets) from [Name] Food Service not dated under description documents The renal/liberal rental diets regulate sodium, potassium, and fluid intake. The renal diet also regulates protein. These diets are primarily prescribed to patients with renal (kidney) disease. There are many stages of renal disease ranging from Acute Renal Failure to End-stage Renal Disease. However, a protein-restricted diet is generally only used for patients with acute or chronic renal failure who are not on dialysis. It is is important to follow the appropriate individualized guidelines set by a physician and registered dietitian nutritionist knowledgeable in treating patients with kidney disease. The Renal/LCS diet combines the Renal diet and LCS diets.
Under restricted foods for Vegetables documents High potassium/sodium vegetables such as baked beans, beets, potatoes, tomatoes, sweet potatoes.
R3's diagnoses includes chronic kidney disease with heart failure and end stage renal disease. R3 receives hemodialysis three times weekly.
The physician orders include with an order date of 9/26/24 Renal, LCS diet Regular texture, regular/thin consistency.
On 10/1/24, at 12:16 p.m., Surveyor observed R3 sitting in a wheel chair in her room talking on the telephone. Surveyor observed there is an over bed table across R3 and R3 has not been served lunch.
On 10/1/24, at 12:29 p.m., Surveyor observed the food truck being delivered to R3's unit.
On 10/1/24, at 12:37 p.m., Surveyor informed CNA (Certified Nursing Assistant)-G Surveyor would like to see R3's lunch tray when they remove the tray from the food truck.
On 10/1/24, at 12:38 p.m., CNA-G showed Surveyor R3's lunch meal which consisted of a chicken sandwich on a bun, french fries, pea salad, lettuce with a tomato, mayonnaise packet and green jello. R3's meal ticket listed Renal LCS, texture regular fluid thin. Surveyor noted R3 should not have received french fries & the tomato slice which is high in potassium.
On 10/1/24, at 1:13 p.m., Surveyor telephone R3's POA (power of attorney). Surveyor asked R3's POA if there are any food concerns with R3. R3's POA informed Surveyor her mom doesn't like the food and they give her mom foods that are high in potassium such as potatoes and bananas.
On 10/2/24, at 10:46 a.m., Surveyor interviewed RD (Registered Dietitian)-P. Surveyor asked RD-P if a resident is on a renal, LCS diet what does this mean. RD-P explained a renal diet is low potassium, low phosphorus, and LCS limits excessive sugar stating it's a pretty liberal diabetic diet. Surveyor asked for the renal diet is there any foods a resident should not receive. RD-P replied tomatoes, chocolate, bananas, potatoes, and soda drink. RD-P replied these are the main things to avoid. I would say those are the main trouble makers for a renal diet. Surveyor asked RD-P how the kitchen staff knows a resident is on a renal diet. RD-P explained when a resident comes in nursing gives the diet order to FSD (Food Service Director)-O, the diet order is put into menu matrix and is printed out on all the tickets. RD-P informed Surveyor if he makes any changes he notifies FSD-O. Surveyor inquired how the cooks would know a resident is on a renal diet. RD-P informed Surveyor the diet ticket would say renal diet and the cooks should be educated on the basic of a renal diet. Surveyor asked RD-P if he has had any communication with the dialysis dietitian. RD-P replied absolutely. RD-P informed Surveyor R3 was having high labs mainly potassium & phosphorus but the last labs were within normal limits. Surveyor informed RD-P of the food items R3 received for lunch on 10/1/24. RD-P replied that's not exactly compliant. RD-P stated he needs to go into the kitchen and do some education on a renal diet as they have new cooks.
On 10/2/24, at 10:58 a.m., Surveyor asked FSD-O how the dietary staff know what diet a resident has ordered. FSD-O informed Surveyor nursing gives them a diet slip and she puts it on their diet cards. Surveyor asked how do the cooks know what foods they should not give a resident who is on a renal diet. FSD-O informed Surveyor they have a book in the kitchen that lists the foods the resident should not have like tomatoes, oranges, bananas, orange juice mostly. Surveyor asked FSD-O if a resident on a renal diet can the resident receive potatoes. FSD-O replied no can't get it. Surveyor informed FSD-O of the food items R3 received for lunch on 10/1/24. FSD-O informed Surveyor she'll have to check into that.
On 10/3/24, at 12:24 p.m., NHA (Nursing Home Administrator)-A was informed of the above. No information was provided as to why R3 received food items which should not have been served on a renal diet.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not provide the necessary respiratory care and services for ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not provide the necessary respiratory care and services for 1 (R3) of 1 residents with a tracheostomy.
The facility did not change R3's HME (heat moisture exchanger) trach valve daily according to physician orders.
Findings include:
R3 was admitted to the facility on [DATE].
R3's diagnoses include chronic respiratory failure, morbid obesity, and paralysis of vocal cords and larynx.
The physician orders include with an order date of 5/17/24 Change HME trach valve daily one time a day for tracheostomy care. An HME trach valve traps the moisture and heat from exhaled gas allowing it to be recycled on inspiration and also helps keep large particles out of the lung such as food particles.
Surveyor reviewed R3's May 2024, June 2024, July 2024, August 2024, September 2024 & October 2024 MAR (medication administration record) and noted licensed staff are checking & initialing the HME trach valve is being changed daily with a scheduled time of 0800 (8:00 a.m.) when R3 is in the facility.
On 10/1/24, at 9:44 a.m., LPN (Licensed Practical Nurse)-M informed Surveyor R3's ready and she will get the supplies ready. LPN-M had a suction catheter kit, T sponge, and inner cannula 6.5 mm (millimeter). LPN-M placed the appropriate PPE (personal protective equipment) on and entered R3's room. From 9:50 a.m. to 9:59 a.m. Surveyor observed LPN-M suction R3's trach, change the T sponge and inner cannula. Surveyor did not observe LPN-M change R3's HME trach valve.
On 10/2/24, at 1:05 p.m., Surveyor asked LPN-M if she could show Surveyor the HME trach valve. LPN-M informed Surveyor she doesn't know what that is and will have to ask first name of DON (Director of Nursing)-B. Surveyor then accompanied LPN-M to the medication room to look for the HME trach valve. LPN-M stated it may be something different than what they call it. I need to Google it. LPN-M stated maybe it's in the box referring to a box with trach supplies. LPN-M was unable to locate the HME trach valve.
On 10/2/24, at 1:11 p.m., Surveyor asked MR/CS (Medical Records/Central Supply)-J what she is responsible for ordering. MR/CS-J informed Surveyor wound care treatments, tube feeding, over the counter medications, Foley catheters, trach supplies, cups for med pass, and all personal care supplies such as shampoo & toothpaste. Surveyor asked MR/CS-J if the facility has HME trach valves. MR/CS-J replied I don't think I every ordered them then stated wait I put an order in because [first name of] UM (Unit Manager)-I asked me to order them but then R3 went to the hospital. Surveyor asked MR/CS-J if the HME trach valves came in the building. MR/CS-J replied no. Surveyor then accompanied MR/CS-J down to the central supply room in the basement to observe trach supplies. Surveyor noted there are inner cannula's, trach ties, suction catheter kits, canisters, trach masks. MR/CS-J informed Surveyor upstairs there are tubing and she just put an order in for humidifier bags and Y connectors.
On 10/2/24, at 1:27 p.m., LPN-M asked Surveyor if Surveyor was able to find out what the HME trach valve is. Surveyor informed LPN-M the facility has never had this in the building. LPN-M informed Surveyor she had checked the HME trach valve as being changed and will have to change it.
On 10/3/24, at 8:02 a.m., Surveyor interviewed DON (Director of Nursing)-B regarding R3's HME trach valve. DON-B informed Surveyor after R3 was admitted she let MR/CS-J what needs to be ordered. DON-B stated I have no answer other than it was not ordered, referring to the HME trach valve. DON-B also stated nor did the nurses communicate, again referring to the HME trach valve. Surveyor informed DON-B the licensed nurses have been checking and initialing the HME trach valve is being changed daily. DON-B informed Surveyor when R3 was admitted RT (respiratory therapy) set up the equipment, education was provided to the nurses and MR/CS-J was sent a list of supplies that needed to be ordered.
On 10/3/24, at 12:24 p.m., NHA (Nursing Home Administrator)-A was notified of the above. No information was provided to Surveyor as to why the facility did not provide the HME trach valve according to physician orders for R3.
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 F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not ensure each Resident's drug regimen was free from unnecessary drugs for 1 (R6) of 5 Residents reviewed for antibiotic use.
*R6 began having Urinary Tract Infection (UTI) symptoms on 7/16/24. R6 had a urinalysis (UA) and culture lab test collected by the facility staff on 7/17/24 and Rocephin (an antibiotic medication) was ordered to start on 7/18/24. R6 requested to go to the emergency room (ER) on 7/17/24 due to R6's UTI symptoms. The ER doctor prescribed Bactrim (an antibiotic medication) to start on 7/18/2024. On 7/19/24, R6 received Rocephin and Bactrim for R6's UTI symptoms. On 7/20/24, R6's urinary culture results came back and Macrobid (an antibiotic medication) was ordered to start on 7/20/2024 by the on-call Medical Doctor (MD). On 7/20/24, R6 received Rocephin, Bactrim and Macrobid for R6's symptoms of UTI. On 7/21/24, R6 requested to return to the ER and was prescribed Fosfomycin (an antibiotic drug). On 7/21/24, R6's doctor, MD-U identified that R6 was on 4 different antibiotics and Rocephin and Bactrim were discontinued on 7/22/24. R6 continued Macrobid and Fosfomycin as prescribed until the UTI symptoms had resolved.
Findings include:
The facility policy entitled, Antibiotic Stewardship Program, dated 12/23/22, documents, in part: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use .
Antibiotic use protocols: Nursing staff shall assess residents who are suspected to have an infection . Laboratory testing shall be in accordance with current standards of practice .
Monitoring antibiotic use: Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made . Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. Antibiotic orders obtained from consulting, specialty or emergency providers shall be reviewed for appropriateness.
On 10/2/2024 at 9:10 AM, Director of Nursing informed Surveyor that the facility follows McGeer's criteria to determine the use of antibiotics for UTI symptoms. The facility McGeer's documentation included the following:
UTIs-For Residents without an Indwelling Catheter. BOTH criteria 1 and 2 must be present
1. At least 1 of the following sign or symptom subcriteria:
a. Acute dysuria or acute pain, swelling or tenderness of the testes, epididymis or prostate.
b. Fever OR leukocytosis AND at least ONE of the following localizing urinary tract subcriteria:
- Acute costovertebral angle (mid/center back) pain or tenderness.
- Suprapubic pain.
- Gross hematuria.
- New or marked increase in incontinence.
- New or marked increase in urgency.
- New or marked increase in frequency.
c. In the absence of fever or leukocytosis, then TWO or more of the following localizing urinary tract subcriteria:
-Suprapubic pain
-Gross hematuria
-New or marked increase in incontinence.
-New or marked increase in urgency.
-New or marked increase in frequency.
2. One of the following microbiologic subcriteria:
a. At least 10 to the 5th cfu (colony forming units)/ml (milliliter), or no more than 2 species of microorganisms in a voided urine sample.
b. At least 10 to the 2nd cfu/ml of any number of organisms of in a specimen collected by in-and-out catheter.
R6 was admitted to the facility on [DATE] with diagnosis that include Type 2 Diabetes, Chronic Heart Failure, Morbid obesity, and Chronic pain.
R6's admission Minimum Data Set (MDS) Assessment, dated 7/21/24, documents R6 is cognitively intact. R6 is dependent on staff for personal hygiene and for transfers. R6 is always incontinent of urine.
R6's progress note, dated 7/16/24 at 2:46 PM, documents, in part: . Resident has burning, itching and pain when urinating. New order for UA with reflex .
R6's progress note, dated 7/17/24 at 2:16 PM, documents, in part: . UA collected from resident 7/17/24 and was found to have an UTI after resident [complained of] burning when urinating, pain in vaginal area and itching. On 7/16/24 an attempt to collect UA was done but unsuccessful. Resident had new order for . 1 gram Rocephin [Intramuscular (IM)] for 7 days from [Nurse Practitioner (NP)]. Resident at [7 PM] requested to be sent out to [Emergency Room] . Resident was then taken to [name of area hospital ER] on stretcher .
R6's MD order with a start date of 7/18/24, documents: Ceftriaxone Sodium (Rocephin)-inject 1 gram intramuscularly one time a day for pain for 7 days.
R6's progress note, dated 7/18/24 at 12:11 PM, documents, in part: Resident returned from ER visit new orders for Bactrim DS 1 tablet in the evening [for] 7 days .
R6's MD order with a start date of 7/18/24, documents: Sulfamethoxazole-Trimethoprim (Bactrim) 800-160mg. Give 1 tablet by mouth two times a day for UTI until 7/25/24.
R6's Medication Administration Record (MAR) documents that R6 did not receive Rocephin on 7/18/24. R6 received a PM dose of Bactrim on 7/18/24.
R6's Infection Report form, dated 7/18/2024, documents R6 with the following symptoms: Suprapubic pain, New or marked increase in incontinence, New or marked increase in urgency and New or marked increase in frequency. Surveyor noted R6 met the criteria for Number one of McGeer's criteria. Surveyor noted that nothing was marked in section 2 indicating that R6 did not meet McGeer's criteria for starting antibiotics.
R6's MAR documents R6 received an AM dose of Rocephin and an AM and PM dose of Bactrim on 7/19/24.
R6's progress note, dated 7/20/24 at 3:19 PM, documents, in part: . Resident's UA results came back, results sent to on-call [doctor]. Resident started on Macrobid 100 mg twice a day for seven days.
Surveyor noted that there was no documentation of a discussion about the other antibiotics R6 was receiving when the on-call doctor was notified of the UA culture results on 7/20/24.
R6's MD order with a start date of 7/20/24, documents: Macrobid 100mg. Give 1 capsule orally two times a day for UTI for 7 days.
R6's Infection Report form, dated 7/20/2024, documents R6 with the following symptoms: Suprapubic pain, New or marked increase in incontinence, New or marked increase in urgency and New or marked increase in frequency. Surveyor noted R6 met the criteria for Number one of McGeer's criteria. Surveyor noted that nothing was marked in section 2 indicating that R6 did not meet McGeer's criteria for starting antibiotics. On the Infection Report form, a note written and signed by Unit Manager-I, documents: provided education with antibiotic stewardship to resident with MD. Culture less than 100,000. MD aware. Continue antibiotic per residents [signs and symptoms]
R6's MAR documents that R6 received an AM dose of Rocephin, an AM and PM dose of Bactrim and a PM dose of Macrobid on 7/20/24.
Surveyor noted R6 received 3 different antibiotics on the same day for R6's symptoms of UTI.
R6's progress note, dated 7/21/24 at 4:16 AM, documents: [R6] asked if [R6] could be sent to [name of hospital] for severe vaginal pain.
R6's progress note, dated 7/21/24 at 3:50 PM, documents: Resident arrived back to facility at 12:30 PM . one new order Fosfomycin (an antibiotic medication) 3 [gram] packet two doses Tuesday morning and Thursday morning.
R6's MD order with a start date of 7/23/24 documents: Fosfomycin Tromethamine. Give 3 grams by mouth one time a day every [Tuesday], [Thursday] for UTI until 7/25/24.
R6's MAR documents R6 received a PM dose of Bactrim and a PM dose of Macrobid on 7/21/24. Surveyor noted that no AM doses of antibiotics were given to R6 on 7/21/24 because R6 was out of the facility in the ER.
R6's progress note signed by MD-U, dated 7/21/24 at midnight, documents, in part: . At this time [R6] is on 4 active antibiotics with no culture and sensitivity report. Will [discontinue] Bactrim DS and Ceftriaxone (Rocephin). Awaiting Culture and sensitivity report and will adjust accordingly . Addendum detail: Urine culture and sensitivity report showed sensitivity to [Macrobid]. Will continue as prescribed and will DC Bactrim DS and Ceftriaxone (Rocephin).
Surveyor noted that Rocephin and Bactrim DS were discontinued on 7/22/24. R6 continued to take Macrobid and Fosfomycin as prescribed until the end of treatment.
On 10/2/24 at 7:55 AM, Surveyor interviewed Registered Nurse (RN)-L. Surveyor asked what standard of practice the facility uses for infections. RN-L stated the facility uses McGeer's criteria. Surveyor asked what steps are taken when a resident starts having symptoms of UTI. RN-L stated that there is an infection packet that is started. The nurse will fill out the documentation and give it to Unit Manager-I. The infection packet includes the McGeer's criteria section, any lab work that is being completed and a section to include any new orders. Surveyor asked what steps are taken if a resident returns from the ER with a new antibiotic order. RN-L stated that the nurse will enter the order and fax the order to pharmacy. Surveyor asked if it is normal for a resident to be on 3 different antibiotics for symptoms of a UTI. RN-L stated that it is not normal. RN-L indicated that RN-L would call the resident's physician if RN-L noted a resident taking 3 different antibiotics for symptoms of a UTI.
On 10/2/24 at 8:01 AM, Surveyor interviewed RN-S. Surveyor asked what steps RN-S would take if RN-S identified that a resident was taking 3 different antibiotics for symptoms of a UTI. RN-S stated she would do some follow up and possibly contact the resident's primary doctor.
On 10/2/24 at 9:10 AM, Surveyor interviewed Director of Nursing (DON)-B. Surveyor reviewed the timeline of R6's antibiotic usage with DON-B. DON-B stated that there were multiple teams involved in prescribing R6's antibiotics. The facility provider, the ER doctors and the facility's on-call MD all contributed to R6's antibiotics order. Surveyor shared the continued concern that R6 was on 3 different antibiotics at the same time and R6 did not meet McGeer's criteria for infection. DON-B indicated DON-B understood the concern but stated that R6 also insisted on receiving the antibiotics for R6's infection. DON-B stated that Unit Manager-I had additional information to review with Surveyor.
On 10/2/24 at 10:09 AM, Surveyor interviewed Unit Manager-I. Unit Manager-I reviewed the timeline of R6's antibiotics with Surveyor. Unit Manager-I stated that Unit Manager-I and the resident's MD spoke to R6 about the antibiotics not meeting the facilities criteria and Unit Manager-I educated R6 about the risk vs benefits of receiving antibiotics. Surveyor shared the continued concern that R6 was on 3 different antibiotics at the same time and R6 did not meet McGeer's criteria for infection.
On 10/2/24 at 12:05 PM, Surveyor interviewed NP-T who works in the same medical group as MD-U. Surveyor asked when NP-T would put a resident on antibiotics for a UTI. NP-T stated NP-T would speak to the nurse and CNA first. Then NP-T would interview the resident for the signs and symptoms. NP-T would review the resident's medical history and then start deciding on the course of action. NP-T stated NP-T would do standard diagnostic tests first and determine what antibiotic to give based on the Culture and Sensitivity results from the urinalysis. Surveyor asked if it was standard for a resident to receive 3 different antibiotics for symptoms of a UTI infection. NP-T stated that in her multiple years of practice, NP-T has never prescribed 3 antibiotics for a UTI infection. NP-T stated that giving 3 antibiotics at one time could potentially harm the kidneys or liver based upon the age of the resident.
On 10/2/24 at 12:18 PM, Surveyor informed Nursing Home Administrator and Director of operations-C of the concern that R6 was on 3 different antibiotics at the same time and R6 did not meet McGeer's criteria for infection. Director of Operations-C stated that they understood.
On 10/2/24 at 3:05 PM, DON-B returned to Surveyor. DON-B indicated that 7/20/24 was a Saturday and that is part of the reason that the ON-Call MD got involved with ordering the additional antibiotics, Macrobid. Surveyor asked if DON-B would expect the nurse calling the On-call MD with the culture results to review the other antibiotics currently being taken by R6 with the MD. DON-B stated that it would be something DON-B would do but that DON-B can not speak for that nurse.
On 10/4/24, Surveyor received an additional note from the facility signed by MD-U. The note documented, in part: . Due to non-adherence to medical advices, medications, immobility and poor hygiene, [R6] had recurrent UTIs. [R6] always claimed she knew which antibiotic she should be on and due to the presence of multiple medical teams-that included in house team, on-call team, and ER team that resulted in multiple treatments that overlapped each other at certain points.
No further information was provided as to why the Facility did not ensure R6's drug regimen was free from unnecessary drugs.
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
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility did not ensure its medication error rates are not 5 percent or greater. The facility medication error rate was 20%.
*R14 received crush...
Read full inspector narrative →
Based on observation, interview, and record review the facility did not ensure its medication error rates are not 5 percent or greater. The facility medication error rate was 20%.
*R14 received crushed Depakote (delayed release) and administered 8AM scheduled medications, including Carbidopa-levodopa, at 10:04 AM.
*R8 received 8AM scheduled Gabapentin and Tramadol medications at 10:26 AM.
*On 10/1/24 R3 did not receive Complex B-100 extended release with biotin & folic acid per physician orders and did not receive the correct dosage of Carvedilol.
Findings include:
The Facility Policy titled, Medication Administration dated 01/24, documents in part, . Medication Preparation: . 5. b. Long-acting, extended release or enteric-coated dosage forms should generally not be crushed; an alternative should be sought. Medications Administration: . 14. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center.
On 10/01/2024, at 09:56 AM, Surveyor observed RN-L prepare R14's medications which included, Carbidopa-levodopa and Depakote (delayed release). At 10:02 AM Surveyor observed RN-L crush all R14's medications and mix them with apple sauce. At 10:04 AM Surveyor observed RN-L administer the crushed medications in apple sauce then administered to R14.
Surveyor reviewed R14's Medication Administration Record (MAR) and noted R14 receives Depakote oral tablet delayed release 125 milligrams (mg) twice a day. According to The Federal Drug Administration (FDA) document titled, HIGHLIGHTS OF PRESCRIBING INFORMATION, last revised 05/2020, documents in part, Depakote is administered orally in divided doses. Depakote should be swallowed whole and should not be crushed or chewed (2.1, 2.2). Surveyor noted no documentation indicating R14's Depakote delayed release was reviewed and deemed safe to be crushed. R14's Depakote is also scheduled to be given at 8AM and 8PM.
Surveyor reviewed R14's MAR and noted R14's Carbidopa-Levodopa oral tablet, 25-100mg is to be given 3 times per day at 8AM, noon and 5PM.
On 10/01/2024, at 10:26 AM, Surveyor observed LPN-M prepare and administer R8's medications to R8.
Surveyor reviewed R8's MAR and noted R8's Gabapentin 300mg is scheduled to be given 2 times per day, at 8AM and 8PM. Surveyor also noted, R8's Tramadol 50mg is scheduled to be given 3 times per day, at 8AM, 2PM and 8PM.
On 10/02/2024, at 10:11 AM, Surveyor interviewed DON-B who indicated medications are to be given within a time frame of 1 hour before or 1 hour after scheduled time. DON-B indicated that if a medication is given outside of that time frame, the doctor should be notified. DON-B indicated that if there is an exception for this rule, it would be documented in a progress note in the resident's chart.
On 10/02/2024, at 10:22 AM, Surveyor interviewed Unit Manager-I. Unit Manager-I informed Surveyor that medications are to be administered 1 hour before or 1 hour after scheduled times, unless it is a as needed (PRN) medication. Unit Manager-I informed Surveyor that the system will automatically document the time medication was given, which can not be changed, but that time will not show up in the MAR. Unit Manager-I informed Surveyor that she would need to look into how exactly someone would know the exact time a medication was given and where that would be documented. Unit Manager-I informed Surveyor the expectation of administering a medication outside of the scheduled timeframe is to notify the doctor, document in a progress note and report to the next shift nurse.
Surveyor noted doctor notifications were not made and documented for R8 and R14 until after Surveyor brought concern to the Facility's attention.
* On 10/1/24, at 9:00 a.m., Surveyor observed LPN (Licensed Practical Nurse)-M prepare R3's medication which consisted of acidophilus 1 capsule, Eliquis 5 mg (milligrams) one tablet, Carvedilol 12.5 mg one tablet, B complex with B12 one tablet, Hydralazine HCI 100 mg one tablet, 5% Lidocaine patch, Metronidazole 500 mg one tablet, and Pantoprazole Sodium DR (delayed release) 40 mg one tablet. LPN-M informed Surveyor she will be holding the poly powder due to R3's C diff (Clostridium difficile).
At 9:05 a.m. Surveyor verified with LPN-M there are 7 tablets/capsule in the medication cup and one patch. LPN-M then crushed R3's oral medication with the exception of the acidophilus capsule and Pantoprazole sodium DR tablet. LPN-M placed the crushed medication, opened the acidophilus capsule and Pantoprazole sodium DR tablet in applesauce. LPN-M placed on the appropriate PPE (personal protective equipment) and entered R3's room.
At 9:11 a.m. LPN-M administered R3's oral medication, removed the Lidocaine patch from R3's right hip and applied the Lidocaine patch on R3's right hip.
On 10/1/24, at 3:18 p.m., Surveyor reviewed R3's physician orders and noted an order with an order date of 8/20/24 for Complex B-100 Oral Tablet Extended Release (B-Complex w/ (with) Biotin & Folic Acid).
On 10/3/24, at 7:37 a.m., Surveyor asked RN (Registered Nurse)-K to show Surveyor the bottle of B complex with B12 that is in the medication cart. Surveyor informed RN-K R3's physician order is Complex B-100 Oral Tablet Extended Release (B-Complex w/ (with) Biotin & Folic Acid) and the B complex with B12 in the medication cart is not what the physician ordered. RN-K informed Surveyor unless it is sent by the pharmacy this is the only one I've seen in here.
On 10/3/24, at 7:43 a.m., Surveyor informed DON (Director of Nursing)-B of R3 not receiving Complex B-100 Oral Tablet Extended Release (B-Complex w/Biotin & Folic Acid) according to physician orders. DON-B informed Surveyors she went through R3's chart and it's kind of a nightmare.
On 10/3/24, at 8:22 a.m., Surveyor asked DON-B why the hospital discharge summary with medication changes for R3's Carvedilol was not picked up by the Facility and the incorrect dosage has been administered to R3. DON-B replied you are correct it's in there. Surveyor informed DON-B during the medication observation with R3 & LPN-M, LPN-M administered Carvedilol 12.5 mg when 25 mg should have been administered. Cross reference F760.
This observation resulted in two medication errors for R3.
On 10/3/24, at 12:24 p.m., NHA (Nursing Home Administrator)-A was informed of R3's two medication errors.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R3) of 1 residents were free of significant medication error...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 1 (R3) of 1 residents were free of significant medication errors.
R3 was readmitted to the facility on [DATE] with discharge medications to include Carvedilol 25 mg every 12 hours. The facility did not change the dosage when R3 was readmitted and continued the previous dose of 12.5 mg. R3 received the incorrect dosage from 8/20/24 until 10/3/24 when DON (Director of Nursing)-B spoke with R3's physician on the telephone. R3 received the incorrect dose of Carvedilol 69 times during August and September 2024.
Findings include:
R3 was readmitted to the facility on [DATE].
Diagnoses includes bilateral lower extremity edema, hypertension, and congestive heat failure.
Under hospital course for date of discharge 8/20/24 under the section PCP (primary care physician) to Follow up:
documents:
-Maintain care of tracheostomy and re-evaluate need for continued use.
-re-evaluate need for Keppra.
-maintain COVID-19 precautions
-Medication changes:
-complete 10 day course of PO (by mouth) Vancomycin 125 mg (milligrams) QID (four times daily)
- increase Carvedilol to 25mg BID (twice daily).
The hospital expected medications list at discharge as of 8/20/24 documents Carvedilol (Coreg) 25 mg tablet. Take 1 tablet every 12 hours oral. Start date is documented as 8/20/24.
The after visit summary for discharge date of 8/20/24 for discharge medications under CONTINUE taking these medications which have CHANGED documents Carvedilol 25 mg tablet. Commonly known as Coreg. What changed: medication strength, how much to take. Under details documents Take 1 tablet by mouth every 12 hours.
The nurses note dated 8/20/24 at 17:02 (5:02 p.m.) by RN (Registered Nurse)-S documents Resident, a Type 2 diabetic, returned from [Name] Medical Center. She is alert/oriented to time, place and person. She is in no respiratory distress. She has no anxiety at this time. VSS (vital signs stable). BP (blood pressure) is 142/76, Resp (respirations) is 16, pulse is 93, temp (temperature) is 97.8. She is 98% O2 (oxygen) on room air at this time. Her lungs are clear to auscultation, no wheezes or rhonci. Her tracheostomy tube, and right side central line are in place. Her primary discharge diagnosis, from [hospital name], is C diff Colitis and COVID 19. She is pleasantly communicating with RN. Standard precautions place on her door entry. Will continue to monitor.
The physician orders dated 8/20/24 documents Carvedilol oral tablet 12.5 mg. Give 12.5 mg by mouth every 12 hours for beta blocker. This order was discontinued on 8/29/24.
The physician orders dated 8/29/24 documents Carvedilol oral tablet 12.5 mg. Give 12.5 mg by mouth every 12 hours for beta blocker. Hold if BP (blood pressure) is less than 110/70 or heart rate is less than 70.
Surveyor reviewed R3's August 2024 & September 2024, MAR (medication administration record). Surveyor noted R3 received the incorrect dose of Carvedilol on 8/20 at 8:00 p.m., 8/21, 8/22, 8/23, 8/24, 8/25, 8/26, 8/27, 8/28, 8/29, 8/30, & 8/31 at 0800 (8:00 a.m.) and 2000 (8:00 p.m.)
Surveyor noted R3 received the incorrect dosage of Carvedilol on 9/1, 9/2, & 9/3 at 8:00 a.m. & 8:00 p.m., 9/4 & 9/5 at 8:00 a.m., 9/6, 9/7, & 9/8 at 8:00 a.m. & 8:00 p.m., 9/9 at 8:00 a.m., 9/10 at 8:00 a.m. & 8:00 p.m., 9/11 at 8:00 p.m., 9/12 & 9/13 at 8:00 a.m. & 8:00 p.m., 9/14 at 8:00 p.m., 9/15 at 8:00 a.m. & 8:00 p.m., 9/16 at 8:00 a.m., 9/17 at 8:00 a.m., 9/18 at 8:00 a.m., 9/19 at 8:00 a.m. & 8:00 p.m., 9/20 at 8:00 a.m., 9/21 & 9/22 at 8:00 a.m. & 8:00 p.m., 9/23 at 8:00 a.m., 9/24 at 8:00 p.m., 9/26, 9/27, 9/28, & 9/29 at 8:00 a.m. & 8:00 p.m., & 9/30 at 8:00 a.m.
R3 received the incorrect dose of Carvedilol 69 times during August and September 2024.
On 10/2/24, at 7:36 a.m., Surveyor asked LPN (Licensed Practical Nurse)-M when a resident is admitted who reviews the hospital records for their medication. LPN-M informed Surveyor usually UM (Unit Manager)-F or UM-I and does the orders.
On 10/2/24, at 1:32 p.m., Surveyor asked UM-I who reviews the hospital records when a resident is admitted . UM-I informed Surveyor the nurse on the floor will do the medication and put the orders in. UM-F does chart orders if they have a GT (gastrostomy tube), wound orders, etc. UM-I explained another nurse verifies the medication orders. Surveyor asked UM-I when R3 was readmitted on [DATE] was she involved with verifying the orders. UM-I informed Surveyor she doesn't know because R3 has been in and out so many times Surveyor showed UM-I the hospital records with the change in dosage for Carvedilol and this dose was not picked up. UM-I informed Surveyor she will have to look into this and get back to Surveyor.
On 10/2/24, at 2:36 p.m., during the end of the day Surveyor informed NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B, and Director of Operations-C Surveyor interviewed UM-I regarding R3's Carvedilol 25 mg not being transcribed correctly when R3 was readmitted to the facility on [DATE] resulting in R3 receiving the incorrect dose. UM-I informed Surveyor she will look into this & get back to Surveyor but as of this time has not.
On 10/3/24, at 8:22 a.m., Surveyor asked DON-B why the hospital discharge summary with medication changes for R3's Carvedilol was not picked up by the Facility and the incorrect dosage has been administered to R3. DON-B replied you are correct it's in there. DON-B informed Surveyor she did a medication error variance yesterday for this. DON-B informed Surveyor she text R3's physician yesterday requesting the physician contact her. DON-B informed Surveyor she spoke with the physician today and the physician said it was okay to keep the 12.5 mg dose. Surveyor asked DON-B about the facility's system for admission/readmission orders. DON-B informed Surveyor the floor nurse picks up the orders and reviews the medication orders with a second nurse for a second check. DON-B indicated then an admission audit is done by the managers. DON-B stated it was missed.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of ...
Read full inspector narrative →
Based on observation, interview, and record review the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 2 Residents.
* Appropriate hand hygiene was not observed during trach & incontinence cares for R3 who is on contact isolation for C diff (Clostridioides difficile).
Findings include:
The facility's policy titled, Management of C. (Clostridioides) Difficile Infection and not dated under policy documents This facility implements facility-wide strategies for the prevention and spread of Clostridioides difficile (C. difficile) infections. Under #5. General principles related to contact precautions for C. difficile: b. documents Hand hygiene shall be performed by hand washing with soap and water in accordance with facility policy for hand hygiene.
The facility's policy titled Hand Hygiene and date implemented 12/23/22 under policy documents All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility.
Under Policy Explanation and Compliance Guidelines #2 documents Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. #6 Additional considerations a. documents The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.
The Hand Hygiene Table for Exposure to Clostridioides difficile is suspected or likely (i.e. isolation room for C. diff) is checked for soap and water.
R3's quarterly MDS (minimum data set) with an assessment reference date of 9/6/24 assesses R3 as dependent for toileting hygiene and frequently incontinent of urine and bowel. R3 is checked for suctioning and tracheostomy care while a resident.
On 10/1/24, at 9:48 a.m., Surveyor observed LPN (Licensed Practical Nurse)-M place a gown & gloves on and entered R3's room with trach care supplies. LPN-M removed items from R3's over bed table, placed a towel on the over bed table and placed the trach care supplies on the towel. LPN-M removed her gloves, did not perform hand hygiene, opened the suction catheter kit, and placed gloves on. LPN-M poured water into the container, connected the suction to the tubing and asked R3 to take the box off. LPN-M asked R3 if she was ready, suctioned R3 and then suctioned R3 for a second time asking R3 if she was okay. LPN-M removed her gloves and placed gloves on. LPN-M did not perform any hand hygiene. LPN-M unfastened the trach ties, removed the T dressing, washed around R3's trach site, and placed a new T drainage sponge dressing on. LPN-M fastened the trach ties, removed her gloves and placed new gloves on. LPN-M did not perform any hand hygiene. LPN-M informed R3 she was going to change her cannula stating then you will be good to go. LPN-M removed the cannula, removed her gloves and placed new gloves on. LPN-M did not perform any hand hygiene. LPN-M placed the new cannula in and asked R3 to place the box on. LPN-M removed her PPE and left R3's room.
On 10/1/24, at 10:55 a.m., Surveyor observed CNA (Certified Nursing Assistant)-G and CNA-H place a gown & gloves on and entered R3's room. CNA-G informed R3 they were going to get her washed up. CNA-H lowered the head of the bed down and removed the blanket from R3, and then covered R3 with a bath blanket. R3's gown was removed and CNA-G asked R3 if she could wash her face, handing R3 a wash cloth. CNA-G & CNA-H washed R3's upper body and then covered R3's upper body. CNA-G informed R3 they were going to wash R3's lower half. CNA-G washed R3's legs & feet and then washed R3's frontal perineal area. CNA-G removed her gloves, opened a drawer & removed out an incontinence product and placed gloves on. CNA-G did not perform any hand hygiene. R3 was assisted with positioning on the left side. CNA-G washed R3's buttocks & rectal area and then asked R3 if she was going number two. R3 replied no. CNA-G stated to R3 I think you are. Surveyor observed BM (bowel movement) on the wash cloth. CNA-G rewashed R3's rectal area. CNA-G informed R3 she needs a treatment on her bottom and placed the call light on. CNA-G informed R3 she was going to place the brief under her, stating you'll need to stay on your side until the nurse comes in. CNA-G emptied the water basins, removed her gloves, cleansed her hands with hand sanitizer and placed gloves on. CNA-G did not wash her hands with soap and water. CNA-G asked R3 what clothing she wanted to wear and removed a shirt & pants from the closet.
At 11:21 a.m. LPN-M, wearing PPE, entered R3's room and placed cream on R3's open area. After applying the cream, LPN-M removed her PPE, cleansed her hands, and left R3's room.
At 11:24 a.m. CNA-G and CNA-H placed pants on and fastened the incontinence product by positioning R3 from side to side. CNA-G & CNA-H placed gripper socks on, a brown bra, and a shirt on R3. CNA-G & CNA-H transferred R3 from the bed into the wheelchair using a gait belt and walker. After R3's bed was made, CNA-G and CNA-H removed their gloves and cleansed their hands.
On 10/3/24, at 8:15 a.m., Surveyor asked DON (Director of Nursing)-B if a resident is on contact isolation for C Diff after incontinence care can staff use hand sanitizer or should they wash their hands with soap & water. DON-B informed Surveyor it's soap & water. Surveyor informed DON-B of the observations with LPN-M not performing hand hygiene after removing her gloves & placing new gloves on. Surveyor also informed DON-B of the observation R3 and CNA-G & CNA-H.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 5 (R11, R15, R16, R3, and R7) of 12 Residents reviewed receive...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 5 (R11, R15, R16, R3, and R7) of 12 Residents reviewed received a prompt resolution to grievances.
*On 5/17/24, it is documented R11 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. The facility did not have any documentation the concerns/grievance was investigated promptly and resolved.
*On 5/17/24, it is documented R15 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. The facility did not have any documentation the concerns/grievance was investigated promptly and resolved.
*On 5/17/24, it is documented R16 answered yes to the question 'Do you have any concerns?' There is no evidence if the concerns were confirmed. The facility did not have any documentation the concerns/grievance was investigated promptly and resolved.
*On 7/11/24, R3's representative filed a grievance with the facility and there is no evidence if the grievance was confirmed or not or if R3's representative was informed of the corrective actions taken by the facility and resolution. The facility did not have any documentation this grievance was investigated promptly and resolved.
*Documentation refers to R7 having multiple concerns and there is no evidence if the concern/grievance was confirmed or not or if R7 was informed of the corrective actions taken by the facility and resolution. The facility did not have any documentation these concerns/grievances were investigated promptly and resolved.
Findings Include:
The facility's policy Grievance Guideline dated 10/3/22 and last revised on 5/31/2023 documents:
.Purpose: To provide a process to voice grievances(such as those about treatment, care, management of funds, lost clothing, or violation of rights) and respond with prompt efforts to resolve while keeping the Resident and/or Resident representative appropriately apprised of progress toward resolution.
-As necessary, taking immediate action to prevent further potential violations of any Resident right while the alleged violation is being investigated. -Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the Resident grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the Resident concern(s), a statement as to whether the grievance was 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.
-Taking appropriate corrective action in accordance with State law if the alleged violation of the Resident's rights is confirmed by the facility of if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these Residents' rights within its area of responsibility.
-Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Response
Any employee of this facility who receives a complaint shall immediately attempt to resolve the complaint within their role and authority. If a complaint cannot be immediately resolved the employee shall escalate that complaint to their supervisor and the facility Grievance Official. Grievances will be recorded and logged through Grievance Portal or written Grievance Form.
Upon receipt of a grievance or concerns, the Grievance Official will review the grievance, determine immediately if the grievance meets a reportable complaint consistent with the facility Abuse Prevention Policy. The Grievance Official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown sources and/or misappropriation of Resident property by anyone to the Administrator as required by State Law.
The Grievance Official will initiate the appropriate notification and investigation processes per individual circumstance and facility guidelines. The investigation will consist of at least the following:
-A review of the completed complaint report
-An interview with the person or persons reporting the grievance-Interviews with any witnesses to the concern
-A review of the medical record if indicated
-A search of Resident room(with Resident permission)
-Interview with staff members having contact with the Resident during the relevant periods or shifts of the alleged incident-Interview with the Resident roommate, family members and visitors
-Completion of a root cause analysis of all circumstances surrounding the concern
As necessary, the Grievance Official and the facility leadership will take immediate action prevent further potential continuations of any additional and like Resident concerns while the grievance is being investigated.
Resolution
The Grievance Official and/or designee will complete a response within 5 days of receipt to the Resident and/or Resident representative which includes:
-Date of grievance
-Summary of grievance
-Investigations steps
-Findings
-Resolution outcome and actions taken with date decision was determined
The Grievance Officer and/or designee will maintain a log of all grievances for a period of (3) years including:
-Date of grievance Tracking number or identification
-Type of grievance
-Location/Department
-Person assigned to investigate
-Date of resolution-Actions taken .
1.) R11 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, Alzheimer's Disease, Major Depressive Disorder, and Generalized Anxiety Disorder. R11 has an activated Health Care Power of Attorney (HCPOA).
R11's Quarterly Minimum Data Set (MDS) completed on 8/8/24 documents R11's Brief Interview for Mental Status(BIMS) score of 6, indicating R11 demonstrates severely impaired skills for daily decision making. No mood or behavior issues were documented on R11's MDS.
2) R15 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Type 2 Diabetes Mellitus, Chronic Kidney Disease, Stage 4 and Vascular Dementia.
R15's Quarterly Minimum Data Set (MDS) completed on 8/31/24 documents R15's Brief Interview for Mental Status(BIMS) score of 15, indicating R15 is cognitively intact for daily decision making. No mood or behavior issues were documented on R15's MDS.
3) R16 was admitted to the facility on [DATE] with diagnoses of Morbid Obesity, Chronic Kidney Disease, Stage 3, Pulmonary Hypertension, Major Depressive Disorder, and Anxiety Disorder. R16 is her own person.
R16's Quarterly Minimum Data Set (MDS) completed on 8/24/24 documents R16's Brief Interview for Mental Status(BIMS) score of 15, indicating R16 is cognitively intact for daily decision making. No mood or behavior issues were documented on R16's MDS.
On 10/1/24, at 11:23 AM, Surveyor reviewed a 5/17/24 self report involving an allegation of a Certified Nursing Assistant (CNA) being rough with cares involving Resident(10). In review, Surveyor notes there is documentation of interviews conducted with R11, R15, and R16 all of whom answered 'Yes' to the question 'Do you have any concerns?' Surveyor reviewed the grievance log provided by the facility and was unable to locate documentation that a concern/grievance had been documented with resolution for R11, R15, and R16.
On 10/2/24, at 11:27 AM, Surveyor interviewed Social Worker (SW)-E regarding the grievance procedure. Surveyor discussed R11, R15, and R16's interviews where all 3 Residents indicated they had concerns. SW-E confirmed based on the grievance process, there should be documentation of R11, R15, and R16's concerns. Surveyor indicated, there is no documentation on the facility grievance log of what R11, R15, or R16's concerns may have been. SW-E stated SW-E will need to look for the grievances and get back to Surveyor.
On 10/2/24, at 2:35 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Director of Operations (DO)-C the concern that R11, R15, and R16 expressed in an interview dated 5/17/24 that all 3 Residents had concerns. Surveyor shared that there is no documentation of steps taken to investigate R11, R15, and R16's concerns/grievance, a summary of pertinent findings, conclusion, statements as to whether the grievance was confirmed or not confirmed, corrective actions taken by the facility, and the date the written decision was issued. NHA-A, DON-B, and DO-C acknowledged the concern of no documentation that R11, R15, and R16's concerns were addressed. No further information was provided by the facility at this time.
4.) R7's admission Minimum Data Set (MDS), dated [DATE], documents R7 has a Brief Interview for Mental Status (BIMS) of 15, indicating R7 in cognitively intact. R7 did not exhibit any behaviors or rejection of care.
Surveyor reviewed progress notes from R7's Electronic Health Record (EHR) and noted the following:
-a progress note dated 07/02/2024, documents Resident compliant with all cares and medications. His PICC line remains intact, and he has had no A/R (allergic reaction) to antibiotic. will continue to monitor.
-a progress note dated 07/09/2024, documents Resident compliant with cares and medications.
Surveyor noted a progress note dated 07/11/2024, Resident complaint with cares and medications.
Surveyor noted a progress note dated 07/16/2024, Resident compliant with cares and medications.
Surveyor noted a progress note dated 07/23/2024, resident complaint with medications and cares.
Surveyor noted, no documentation as to what exactly R7's complaints were, or if they were addressed.
R7 was discharged from the Facility on 07/25/2024.
On 10/03/2024, at 09:29 AM, Surveyor interviewed Director of Nursing DON-B. DON-B informed Surveyor that if a concern is made by a resident to a nurse, the expectation is the nurse would further investigate the concern and DON-B would expect to be notified. DON-B informed Surveyor that no concerns were brought to her attention aside from the issue with R7's Coban wrap.
On 10/03/2024, at 12:30 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A. NHA-A informed Surveyor NHA-A spoke with R7 regarding concerns with service. NHA-A states no formal grievance was completed, communication with R7 regarding concerns were verbal.
5.) R3's diagnoses includes congestive heart failure, diabetes mellitus, and end stage renal disease. R3's power of attorney for health care was activated on 7/19/23.
On 10/1/24, at 1:01 p.m., Surveyor reviewed the facility's grievance summaries which is the grievance log. Surveyor noted there is a grievance summary for R3 with an incident & reported date of 7/11/24. The category documents care concern. Resolved Date - Resolved by documents 7/12/24. The resolved note documents [first name of] CNA (Certified Nursing Assistant)-X was given a teachable moment. Under grievance details documents [R3's first name] expressed concern regarding CNA being lazy. Under Summary of Investigation and Summary of findings documents [R3's first name] feels safe in the community. doesn't feel [CNA-X's first name] is abusive or neglectful. Just lazy. Under summary of actions taken documents [CNA-X's first name] was given a teachable moment.
On 10/1/24, at 2:37 p.m., during the end of the day meeting Surveyor asked NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B for the complete grievance for R3 dated 7/11/24.
On 10/2/24, at approximately 2:00 p.m., Surveyor noted the facility had provided Surveyor with R3's grievance summaries for incident date of 7/11/24. This was the same grievance summaries Surveyor had reviewed the previous day.
On 10/2/24, at 2:36 p.m., during the end of the day meeting Surveyor informed NHA-A, DON-B and Director of Operations-C Surveyor still needed R3's complete grievance for 7/11/24.
On 10/3/24, at 11:15 a.m., Surveyor reviewed R3's grievance investigation provided by the facility. Surveyor was provided with the same grievance summaries as previously provided, in addition there is CNA-X's employee teachable moment, and 15 resident interviews dated 7/12/24 with the questions do you feel safe here at (name of facility)? and do you have any concerns? There is no information as to what being lazy means or whether facility staff asked R3 what lazy means and the steps taken to investigate this grievance. There is not a summary of the findings other than R3 feels safe in the community, doesn't feel CNA-X is abusive or neglectful just lazy. There is no documentation as to whether the grievance is confirmed or not and the date of the written decision was provided to R3.
On 10/3/24, at 11:37 a.m., Surveyor spoke with NHA-A and Director of Operations-C. Surveyor asked if there is anymore information for R3's grievance dated 7/11/24. NHA-A informed Surveyor CNA-X is a good aide. Director of Operations-C informed Surveyor they will have to look if they have additional information and then looked in her computer pulling up the grievance summaries. Surveyor informed Director of Operations-C this is the facility's grievance log. Surveyor then asked NHA-A if R3 voiced the concern or the POA (power of attorney) as they both have the same name. NHA-A informed Surveyor she thought it was the resident. Surveyor informed NHA-A & Director of Operations-C the investigation does not document what is being lazy mean and whether the facility asked about this. There is no documentation as to whether the grievance was confirmed and the date when the written decision was provided to R3. Director of Operations-C informed Surveyor there's not a thorough investigation. Surveyor asked NHA-A & Director of Operations-C if there is any additional information to let Surveyor know. Surveyor was not provided with any additional information regarding R3's grievance dated 7/11/24.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R10 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Morbid Obesity, Chronic Respiratory Failure with Hy...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R10 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Morbid Obesity, Chronic Respiratory Failure with Hypoxia, Anemia, Paroxysmal Atrial Fibrillation, Fibromyalgia, and Depression. R10 was her own person. R10 discharged from the facility on 6/4/24.
R10's admission Minimum Data Set (MDS) completed on 5/5/24 documents R10's Brief Interview for Mental Status (BIMS) to be 15, indicating R10 was cognitively intact for daily decision making. R10's MDS also documents that R10 was independent for eating, and dependent for showers, upper and lower dressing, mobility, and transfers.
On 10/1/24, at 11:23 AM, Surveyor reviewed a self report that documents R10 reported CNA-V had been rough with cares. The Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 5/17/24 was submitted to the State Survey Agency. Surveyor reviewed CNA-V's statement which documents that CNA-V reported the allegation on the PM shift to Registered Nurse (RN)-S which was 5/16/24 around 6:30/7:00 PM. CNA-V's documented statement is that CNA-V reported R10's allegation to RN-S on 5/16/24. RN-S replied it was their behavior referring to R10 and CNA-V went back into R10's room to complete cares. CNA-V also provided cares to other Residents during the shift. RN-S did not report the allegation from R10 immediately to a supervisor, Director of Nursing (DON)-B, or Nursing Home Administrator (NHA)-A.
The Misconduct Incident Report dated 5/24/24 submitted to the State Survey Agency contains a statement from CNA-V. There are no other documented statements from other staff members. There is no statement from RN-S. No statements from other staff members who worked the shift with CNA-V. Surveyor notes that CNA-V's assignment for 5/16/24 was Unit 5 and 6. All 6 of the provided Resident statements resided on units other than unit 5 and 6 so CNA-V would not have taken care of those Residents on the PM shift.
On 10/2/24, at 2:35 PM, Surveyor shared the concern with NHA-A, DON-B, and Director of Operations (DO)-C that R10's allegation of abuse was not thoroughly investigated.
On 10/3/24, at 12:07 PM, Surveyor was provided by NHA-A a text message print out from RN-S to central supply documenting the following: On May 16, CNA-V is stating that I refused to help her with R10. This is a false/untrue accusation Sent from iPhone. No additional explanation or information was provided.
Based on interview and record review, the facility did not ensure an allegation of abuse for 2 of 5 investigations reviewed, included steps that were taken by the facility to ensure safety of the facility residents.
* Visitor-HH alleged facility housekeeper-N was sexual inappropriate to the visitor when visiting a resident in the facility. The facility did not complete a thorough investigation of the allegation/actions of housekeeper-N by ensuring current facility residents were interviewed to determine if they had concerns or similar allegations regarding housekeeper-N.
*R10 made an allegation of rough care that was reported to a registered nurse. This was not thoroughly investigated by the facility.
This deficient practice had the potential to affect 73 of 73 residents in the facility.
Findings include:
On 10/2/24, the facility's Abuse, Neglect and Exploitation policy and procedure implemented on 9/18/23 and notes the following in regards to reporting requirements:
.Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property.
V. Investigation of Alleged Abuse, Neglect and Exploitation
A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.
3. Investigating different types of alleged violations
4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations
5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause
6. Providing complete and thorough documentation of the investigation
VI. Protection of Resident The facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.
A. Responding immediately to protect the alleged victim and integrity of the investigation.
B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed.
F. Providing emotional support and counseling to the Resident during and after the investigation.
G. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.
VII. Reporting/Response
5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to the following:
a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes are needed to prevent further occurrences.
b. Defining how care provision will be changed and/or improved to protect Residents receiving services.
VIII. Coordination with QAPI (Quality Assurance Performance Improvement)
A. The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of Resident property, and exploitation with the QAPI program.
1. Cases of physical or sexual abuse, for example by facility staff or other Residents, will be reviewed for and receive corrective action and tracking by QAA Committee. This coordinated effort results in the QAA Committee determining:
a. If a thorough investigation is conducted
b. Whether the Resident is protected
1.) On 7/19/24 Visitor-HH reported to the facility an allegation of possible sexual assault involving housekeeper-N to visitor-HH. At that time the facility suspended housekeeper-N and the police were called and also initiated an investigation into the allegation. Housekeeper-N no longer is employed by the facility.
On 10/3/24 at 11:33 AM, Detective-R was interviewed and indicated housekeeper-N admitted to inappropriate sexual behavior towards visitor-HH at the time and the facility was notified right away about what housekeeper-N admitted to.
On 10/2/24, the Facility's investigation into the sexual assault allegations against housekeeper-N were reviewed and included interviews from 7 staff and 7 residents out of a census of 73 residents. Surveyor noted there was no summary of the results of the investigation were documented. Surveyor noted the investigation was not thorough as housekeeper-N had ben an employee since 2022 and the facility did not determine if residents beyond visitor-HH may have been subjected to housekeeper-N's sexually inappropriate behavior.
On 10/3/24 at 12:36 PM, Director of Operations-C was interviewed and indicated that the facility did not do a thorough investigation into R4's allegations and should have.
The above findings were shared with the Nursing Home Administrator-A and Director of Nursing-B on 10/2/24. Additional information was requested if available, but none was provided as to why a thorough investigation was not completed after the allegation of sexual abuse was made against housekeeper-N.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not provide pharmaceutical services to assure accurate dispe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not provide pharmaceutical services to assure accurate dispensing and administering medications to meet the needs of each resident. This has the potential to affect R3, R7, 17 residents who reside on the 400 unit & R17.
* R3's Bisacodyl (Dulcolax) 10 mg (milligram) suppository was transcribed incorrectly on 8/20/24 when R3 was readmitted from the hospital.
*The Facility did not provide R7 with the ordered Coban wraps, per the physician's order.
* Medications were left on top of medication cart unattended.
* R17's glucose monitor was not labeled to identify it was R17's glucose monitoring device.
1.) R3 was readmitted to the facility on [DATE] with diagnosis which includes C Diff (clotridoides difficile).
The after visit summary for date of discharge of 8/20/24 for discharge medications under continue taking these medications which have not changed includes Bisacodyl 10 mg (milligrams) suppository. Commonly known as: Dulcolax. Under details documents Place 10 mg rectally daily as needed for Constipation.
R3's Bisacodyl 10 mg suppository was transcribed incorrectly on 8/20/24 to Insert 10 mg rectally every 24 hours for constipation. R3's Bisacodyl 10 mg suppository should have been transcribed as needed and not scheduled every 24 hours.
Surveyor reviewed R3's August MAR (medication administration record) and noted R3 received the Bisacodyl suppository on 8/23/24. According to R3's bowel records on 8/23/24 R3 had 3 episodes of loose/watery stools.
Surveyor reviewed R3's September MAR and noted R3 received the Bisacodyl suppository on 9/4/24 & 9/6/24. According to R3's bowel records R3 had one episode of loose/watery stools on 9/4/24 and on 9/6/24.
On 10/3/24, at 7:54 a.m., Surveyor informed DON (Director of Nursing)-B Surveyor didn't understand why R3's Bisacodyl 10 mg suppository was transcribed to be administered every 24 hours when R3 was admitted on [DATE] with a diagnosis of C Diff and was having loose stools. DON-B replied me too and explained to Surveyor it was brought to her attention by R3's daughter who is the POA (Power of Attorney). DON-B informed Surveyor R3's daughter had emailed her asking why her mom was receiving a suppository. DON-B informed Surveyor this was brought to her attention on 9/9/24 and the scheduled suppository was discontinued on 9/7/24 and changed to PRN (as needed). DON-B informed Surveyor she spoke with the nurse who wrote the order, RN (Registered Nurse)-L. RN-L couldn't remember why she wrote the order. DON-B informed Surveyor she spoke with Nurse Tech-BB who gave the suppository during the period when R3 was having diarrhea. Nurse Tech-BB informed her she was following physician orders. Surveyor asked DON-B if she provided anyone with education following this incident. DON-B informed Surveyor she gave education to RN-L and Nurse Tech-BB. Surveyor asked DON-B if R3's Bisacodyl suppository order should have been PRN. DON-B replied should of been PRN.
On 10/3/24, at 12:24 p.m., NHA (Nursing Home Administrator)-A was informed of the above.
Coban
*)R7 was admitted to the facility on [DATE], to receive intravenous antibiotics due to a wound infection.
Surveyor reviewed R7's document titled Discharge Summary, with a service date of 06/18/2024, and documents in part,
Wound Care to BLE
1. Cleanse wound with Hibiclens and Water
2. Pat area dry with gauze
3. Apply Mepilex AG to posterior Knees
4. Fan Wrap Viscopaste gauze
5. Apply Coban 2 layer wrap to patients thighs
6. WOCN to change twice a week, Monday/Thursday
Surveyor reviewed R7's document, titled Admission/Readmission/Routine Heat-to-toe Evaluation, dated 06/18/2024, and documents in part, . Coban wraps to BLE done twice weekly at hospital and d/t tomorrow, would like them to be done tomorrow vs assessing today.
Surveyor reviewed R7's orders and noted an order documenting, Coban wraps to BLE twice weekly one time a day every Wed, Sat with a start date of 06/19/2024 and end date of 06/20/2024. Surveyor noted this was marked completed in R7's June 2024 Treatment Administration Record (TAR).
Surveyor noted an order for R7 documenting, Per Dr. [NAME] wounds should be dressed with COBANZ MATERIAL instead of ACE wraps. Wrap feet with COBANZ first the escalate up the leg to prevent LE edema every shift with a start date of 06/28/2024 and end date 08/07/2024. Surveyor noted, in R7's June and July TAR, was marked as completed every shift (except not documented on 07/18/2024 evening shift and 07/19/2024 day shift).
Surveyor noted a progress note on 06/23/2024, at 06:33 AM documents in part, . Has ace wrap to rt. leg. Has excoriated lt. leg .
Surveyor noted a progress note, dated 06/23/2024, at 02:40 PM, documents in part, Situation: Resident c/o pain, burning and clear discharge from bilateral legs not relieved with analgesic given. Wants to go to ER.
Surveyor noted a progress note, dated 06/23/2024, at 10:10 PM, documents in part, Resident returns from hospital ER, . Resident has had bilateral legs wrapped with xeroform, kerlix, and ace bandages. VSS obtained, 128/74, 18 respirations, 76 heart rate, 97% room air upon arrival to our facility. He reports he is in no pain at this time. will continue to monitor.
Surveyor noted a progress note on 06/24/2024, by NP-AA, documents resident was seen and examined today in his room at Burlington's rehabilitation center for follow-up on Leg wounds that are weeping. Resident is alert awake oriented x 4 sitting up on his comfortably with no acute distress no chest pain no shortness of breath stable vital signs, his pain level is 7-9 out of 10. On exam patient is wearing Ace wraps to bilateral legs from his knees down to his ankles.
Surveyor noted a progress note on 06/29/2024, documents, Note Text: Per Dr. [NAME] wounds should be dressed with COBANZ MATERIAL instead of ACE wraps. Wrap feet with COBANZ first and escalate up the leg to prevent LE edema every shift no Coban available in facility, wrapped w/ kerlix f/b tubi grips.
Surveyor noted a progress note by NP-AA, dated 07/02/2024, documents in part, . resident was seen and examined today in his room at Burlington's rehabilitation center for follow-up on Leg wounds that are weeping. Resident is alert awake oriented x 4 sitting up on his comfortably with no acute distress no chest pain no shortness of breath stable vital signs, his pain level is 7-9 out of 10. On exam patient is wearing Ace wraps to bilateral legs from his knees down to his ankles.
Surveyor noted a progress note, dated 07/07/2024, documents, Per Dr. [NAME] wounds should be dressed with COBANZ MATERIAL instead of ACE wraps. Wrap feet with COBANZ first and escalate up the leg to prevent LE edema every shift
COBANZ unavailable.
Surveyor noted a progress note on 07/08/2024, by RN-K, documents Resident had ordered supplies from Amazon for his leg treatment. RN did treatment per order using these supplies. Coban wrap to be monitored for any circulation issues.
Surveyor noted a progress not on 07/11/2024, by NP-AA documents in part, . resident was seen and examined today in his room at Burlington's rehabilitation center for follow-up on Leg wounds that are weeping. Resident is alert awake oriented x 4 sitting up on his comfortably with no acute distress no chest pain no shortness of breath stable vital signs, his pain level is 7-9 out of 10. On exam patient is wearing Ace wraps to bilateral legs from his knees down to his ankles.
Surveyor noted a progress note on 07/13/2024, documents, Per Dr. [NAME] wounds should be dressed with COBANZ MATERIAL instead of ACE wraps. Wrap feet with COBANZ first and escalate up the leg to prevent LE edema every shift. Cobanz not available. Res. has legs wrapped in kerlix.
Surveyor noted a progress note dated 07/15/2024 by NP-AA, documents in part, . resident was seen and examined today in his room at Burlington's rehabilitation center for follow-up on Leg wounds that are weeping. Resident is alert awake oriented x 4 sitting up on his comfortably with no acute distress no chest pain no shortness of breath stable vital signs, his pain level is 7-9 out of 10. On exam patient is wearing Ace wraps to bilateral legs from his knees down to his ankles.
Surveyor noted a progress note dated 07/22/2024 by NP-AA, documents in part, . Continue with wound care, follow-up with Dr. [NAME], per Dr. [NAME] and medical director follow-up with infectious diseases.
Surveyor noted a progress note, dated 07/23/2024 documents, Clarification/Late entry for 7/23/2024; Wound care to BLE dressings completed, However, Resident declined to have Coban wraps applied, stating I don't need them right now, the swelling to my legs went down and I've been keeping my legs elevated MD updated, NNO sat this time.
On 10/02/2024, at 03:07 PM, Surveyor interviewed RN-K regarding his progress note for R7's Coban. RN-K informed Surveyor that at the time the Facility did not have Coban, and the R7 ordered his own. RN-K informed Surveyor that RN-K notified Medical Records/Central Supply-J to order Coban. RN-K informed Surveyor that the supply gets to the Facility quick one ordered.
On 10/02/2024, at 01:25 PM, Surveyor interviewed Medical Records/Central Supply-J. Medical Records/Central Supply-J informed Surveyor that usually order requests are done verbally, no logs are kept of order requests. Medical Records/Central Supply-J informed Surveyor that the order for Coban arrived to the facility on [DATE]. Medical Records/Central Supply-J informed Surveyor that the week prior to the Coban arriving, 1 pack of Coban arrived due to error when ordering.
On 10/02.2024, at 03:12 PM, UM-F informed Surveyor that UM-F bought Coban for R7 and informed R7 not to buy his own. UM-F informed Surveyor that the Coban was sent with R7 upon discharge.
On 10/02/2024, at 03:55 PM, Surveyor received a printout of Coban in an online Walmart cart with an estimated total of $18.38. Surveyor was also given a copy of document titled FREE CKG W/PLATINUM CARD indicating a charge of $18.34 on July 20,2024.
On 10/03/2024, at 09:29 AM, Surveyor interviewed DON-B. DON-B informed Surveyor the expectation is to follow policy regarding PICC line dressing changes and flushes. DON-B informed Surveyor that PICC line dressing should be changed every 7 days or as needed, and the site should be monitored every shift. DON-B informed Surveyor that flushing a PICC would include Saline flushes before and after, as well as a Heparin flush after.
*)R17 Glucose monitor
On 10/01/2024, at 08:53 AM, Surveyor observed LPN-Z obtain a blood sugar from R17. Surveyor noted the glucose monitor LPN-Z was using, was not labeled. Surveyor inquired to LPN-Z if residents have their own glucose monitors. LPN-Z informed Surveyor that residents do all have their own glucose monitors. Surveyor asked LPN-Z to show Surveyor how staff know which monitor belongs to which resident. LPN-Z began looking through the medication cart for R17's bag. LPN-Z informed Surveyor she could not find the bag for R17's glucose monitor, and informed Surveyor that the glucose monitor she used is 1 of the 2 stock glucose monitors in the medication cart. Surveyor noted neither of the other glucose monitors were labeled as stock monitors and noted other bags containing glucose monitors with resident names.
Medication left on Medication Cart
On 10/01/2024, at 09:25 AM, Surveyor observed RN-L walk away from medication cart, leaving stock medications on top of the medication cart within reach of other residents and staff walking by.
On 10/01/2024, at 10:00 AM, Surveyor observed RN-L leave R14's medications on top of medication cart within reach of other staff/residents and walk away from medication cart to administer medications.
Jun 2024
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
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure 1 of 3 residents (R1) reviewed for potential se...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure 1 of 3 residents (R1) reviewed for potential sexual abuse was provided medically related social services to assist R1 in attaining or maintaining their mental and psychosocial health.
* On 5/18/24, R1 was approached by her spouse to have sexual relations while R1 resided at the facility. The facility was made aware of R1's spouse's intentions to have sexual relations with R1 prior to 5/18/24 but took no steps on 5/18/24 to ensure that R1 could consent to having sexual relations.
Findings include:
R1 was admitted to the facility on [DATE] with a diagnosis that included Left Hand Contracture, Bipolar Disorder, Anxiety Disorder, Schizophrenia, Unspecified Dementia without Behavioral Disturbance, Mood Disturbance and Anxiety.
R1's Annual MDS (Minimum Data Set) dated 3/15/24 documents a BIMS (Brief Interview for Mental Status) score of 00, indicating that R1 is severely cognitively impaired.
Section E (Behavior) documents that R1 experiences hallucinations, delusions and experiences verbal behavioral symptoms directed towards others.
Section GG0115 (Functional Limitation in Range of Motions) documents that R1 has impairment on both sides of her upper and lower extremities.
R1's Behavior care plan dated as initiated 11/4/23 documents, Focus: The resident has a behavior problem calling out due to cognitive impairment, bipolar, anxiety, schizophrenia. Resident suffers from PTSD (post traumatic stress disorder) due to losing a patient while a nurse.
R1's Intimacy and Sexual Preferences care plan dated as initiated 4/14/24 documents, Focus: Resident is married and comfortable showing affection with husband by holding hands, kissing and sexual relations. Interventions: Intimacy and Sexual Assessment to be completed on admission. Will be updated as needed with change in condition; Social worker will be available to meet with resident regarding choices.
R1's nursing note dated 5/3/24 at 3:29 PM documents, Social Services Note Text: POA (power of attorney) contacted writer to make aware he will be in tomorrow. POA would like privacy for sexual relations with wife.
R1's nursing note dated 5/15/24 at 5:22 PM documents, Note Text: Unwitnessed Fall: Nonapparent injury. Resident observed by kitchen staff face down in front of her chair in the dining hall, nursing staff notified immediately. Resident was assessed, AOx3, denies any pain, very good spirits, no complaints. Assessed, no injury found. Hoyer sling used to help resident back to bed. Reassessed with a scrap found on her left eyebrow. Resident confused which is her baseline. Unable to explain what happened. Room well-lit. Floor dry and uncluttered.
R1's Fall Risk Evaluation dated 5/15/24 documents, Memory and Recall Ability: In the last 7 days: recalls three out of four of the following: current season, that he/she is in a nursing home, location of room, staff names/faces. Answer: Sometimes.
R1's nursing note dated 5/16/24 at 3:43 PM documents, Nurses Note Text: At 08:15 (AM) CNA (Certified Nursing Assistant) informed RN (registered nurse) that resident was on the floor in the dining room. Resident was noted to be laying on side on foot rest of chair. RN assessed resident, resident denied pain . Neuro checks negative, no injuries noted. Resident transferred back into chair via Hoyer, resident was relocated and monitored until notable decrease of fidgeting behavior.
R1's Fall Risk Evaluation dated 5/15/24 documents, Memory and Recall Ability: In the last 7 days: recalls three out of four of the following: current season, that he/she is in a nursing home, location of room, staff names/faces. Answer: Sometimes.
R1's nursing noted dated 5/18/24 at 2:59 PM documents, Note Text: Husband here this AM, complains that his wife is not ready for him at 9 am, and where is the sign for the door, writer unaware of what he actually means. Writer is assuming not ready for taking to dining room or outside. Social worker explains to writer if this sign is on door it means do not go in room that they are performing sexual acts. Husband comes out of room a few hours later states to writer I'm done now you can clean her up now and I will be back next Saturday. I go in room to check on patient she is on her left side balled up in a ball in fetal position and will not speak to me. this patient seems to be A/O x 2.
At the time, Surveyor was unable to locate any documentation in R1's medical record that documented that facility staff assessed R1's mental status and ability to consent to sexual relations on 5/18/24.
On 6/6/24 at 12:05 PM, Surveyor observed R1 sitting in a Broda chair. Surveyor attempted to speak with R1 but R1 did not answer Surveyor's attempts to initiate conversation.
On 6/6/24 at 12:17 PM, Surveyor informed DON (Director of Nursing)-B and SW (Social Worker)-D of the above findings. Surveyor asked SW-D if she had assessed R1's ability to consent to sexual relations with her husband on 5/18/24, as R1 is confused at times.
SW-D informed Surveyor that she had spoken to R1 the morning of 5/18/24 and that she thought she had documented the interaction in R1's medical record. Surveyor informed SW-D that Surveyor could not locate any assessment in R1's medical record that documented R1 was able to consent to sexual relations and that documented R1 was alert and orientated enough to make such decision. SW-D informed Surveyor that she spoke with R1 but did not complete a formal assessment on R1.
Surveyor informed DON-B and SW-D that fall documentation on 5/15/24 and 5/16/24 (see above) documented R1 was confused as a baseline. Surveyor also noted that R1's nursing noted dated 5/18/24 documents that R1 was AO (alert and orientated) x 2 after she had engaged in intimate time with her husband.
Surveyor asked SW-D why she had not completed an assessment of R1's ability to consent to sexual relations prior to R1's husband's arrival on 5/18/24 and why R1 was documented as being AOX 2 on 5/18/24 by nursing staff.
SW-D informed Surveyor that she could not explain why she did not formally assess R1 and could provide no explanation why nursing staff would document that R1 was AO X 2 on 5/18/24.
SW-D informed Surveyor that she spoke with R1 the morning of 5/18/24 and was told by R1 she wanted her husband's penis. SW-D informed Surveyor that because of this, she assumed R1 was able to consent to sexual relations with her husband.
SW-D informed Surveyor that she would go back into R1's medical record and document this conversation.
R1's nursing note dated 5/18/24 at 8:05 AM but written on 6/6//24 documents, Social Services Late Entry:
Note Text: Writer met with resident in dining room, resident was eating breakfast. Resident stated her husband is coming today. Writer asked resident if she was comfortable having sexual relations with her husband. Resident replied, I want his dick. Writer left resident to eating her breakfast.
On 6/6/24 at 3:15 PM, Surveyor informed NHA (Nursing Home Administrator)-A and DON-B of the above findings. No additional information was provided as to why the facility failed to provided medically related social services to assist R1 in consenting to sexual relations.
May 2024
16 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and a comprehensive record review, the facility did not ensure that a resident with pressure in...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and a comprehensive record review, the facility did not ensure that a resident with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new injuries from developing for 1 of 3 (R13) residents reviewed for pressure injuries.
R13 developed a facility acquired Suspected Deep Tissue Injury (SDTI) on the left heel. Subsequent staging of the pressure injury included staging of the pressure injury as unstageable and a stage 3. While on survey, Surveyor had observations of R13's care plan interventions not implemented, including offloading of R13's heel.
Findings include:
R13 admitted to the facility on [DATE]. R13's face sheet documents diagnoses that include Paraplegia, Chronic Obstructive Pulmonary Disease, neuromuscular dysfunction of bladder, heart failure, chronic Atrial Fibrillation, pressure ulcer of sacral region stage 4, major depressive disorder, unspecified open wound left foot, colostomy, autonomic dysreflexia, hypertension, and acquired absence of right leg above knee. R13's History and Physical dated 12/25/22 includes diagnoses of Peripheral Vascular Disease, severe protein calorie malnutrition, and osteomyelitis.
The facility policy titled Pressure Injury Prevention Guidelines and dated as implemented on 2/14/23 documents:
.To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present.
1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics).
2. The goal and preferences of the resident and/or authorized representative will be included in the plan of care.
3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them.
Preventative Skin Care:
1. Inspect skin while providing care, paying close attention to bony prominences.
3. Avoid positioning the resident on an area of redness whenever possible.
Repositioning:
1. Reposition all residents at risk of, or with existing pressure injuries, unless contraindicated due to medical condition. Utilize small shifts in repositioning, if otherwise contraindicated.
2. Routine repositioning schedule: Every 2-3 hours, using both side-lying and back positions. Reposition when in bed and out of bed.
Repositioning techniques:
a. Avoid positioning the resident on bony prominence's/turning surfaces with existing pressure injuries, including stage 1.
f. Ensure that heels are floated off the surface of the bed, using pillows or devices that elevate and offload the heel in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon.
g. When in chair, provide adequate seat tile to prevent sliding forward. Ensure the feet are properly supported.
Pressure Re-Distribution Devices:
1. Support surfaces do not eliminate the need for turning and repositioning.
2. Pillows and wedges may be utilized to maintain proper positioning.
3. Apply heel suspension devices according to the manufacturer's instructions:
a. For prevention, stage 1 or stage 2: Use pillows or heel suspension devices. If using heel protectors, will still need to utilize pillows for floatation.
b. For stage 3, 4, unstageable or deep tissue injury: Place foot and leg into a heel suspension boot that elevates the heel from the surface of the bed, completely offloading the pressure injury. Check the skin each shift and PRN (as needed) for signs of redness or skin breakdown related to the boot.
R13's Annual Minimum Data Set, dated [DATE] documents:
Functional Limitation in Range of Motion: Lower extremity (hip, knee, ankle, foot) - impairment on 1 side. Mobility: Roll left and right - substantial/maximal assistance. Is this resident at risk of developing pressure ulcers? Yes. Does this resident have one or more unhealed pressure ulcer(s) at Stage 1 or higher? Yes. Brief Interview for Mental Status score: 15, indicating no cognitive impairment.
Rejection of Care - Presence & Frequency: Did the resident reject evaluation or care (e.g., bloodwork, taking medications, ADL assistance) that is necessary to achieve the resident's goals for health and well-being? Behavior not exhibited.
Surveyor was able to view R13's care plan in Point Click Care (PCC) but was unable to view all revisions. The facility provided a printed copy of R13's care plan.
Self-care deficit r/t (related to) decreased mobility, generalized weakness - initiated 6/8/21. Interventions include Bed Mobility: Assist of 1. Uses trapeze over bed and enabler bars x 2.
Resident has Potential for impaired skin integrity r/t: Altered nutritional status, assist needed with turning and/or repositioning, decreased mobility, dry skin, History of pressure injuries - 10/24/23. Interventions include:
Cushion in wheelchair - 2/10/23
Encourage side to side positioning- 12/11/23
Float heels while in bed - 10/24/2023
Assist to reposition side to side approximately q 2-3 hours and prn - 10/24/23
Elevate feet while in wheelchair - 11/7/23
Wheelchair cushion - 10/24/23
Weekly skin assessment - 10/24/23
Resident has Impaired Skin integrity. Pressure Injury Sacrum, Heel, Ischium initiated 6/9/21, revised 5/9/24. Interventions include:
Float heels - 6/9/21
Soft boots on in bed - 6/9/21
Specialty air mattress - 6/9/21
(Resolved) encourage to turn and reposition every 2-3 hours - 6/9/21
(Resolved) ensure ROHO cushion is inflated and fill if not - 6/30/21
Resident may be up as he prefers, encourage to lay down after 2 hours - 4/18/22
Ensure proper footwear while up in chair - 8/4/22
Foot buddy to wheelchair - 7/11/23
Heel lift cushion placed between foot board and patient's feet. Foot board extension - 8/29/23
Soft boot Left foot on in bed at all times; float heels - 10/24/23
Shoes/slippers on to left foot when up - 10/24/23
Encourage side to side positioning (resident needs encouragement as resident often refuses)- 1/19/24
R13's June 2023 TAR (Treatment Administration Record) documents: Check skin and edema weekly with shower day Wednesday AM shift. Foot checks every HS (hour of sleep) one time a day - 6/21/23.
Surveyor asked for a list of residents with pressure injuries. R13's name was on the list which documented: Sacrum stage IV (4) POA (present on admission), Right ischium FA (facility acquired), Left heel FA.
Surveyor review of R13's medical record revealed the following pressure injuries:
Sacrum stage 4 POA 6/8/21, Left plantar FA SDTI (suspected deep tissue injury) identified 6/21/23. R13 underwent a transmetatarsal amputation of his toes. R13 subsequently developed a FA Left plantar SDTI identified on 10/24/23, FA Right lateral and right medial gluteal fold stage 4's identified on 11/7/23 and a FA Left heel SDTI identified 1/9/24.
On 5/8/24 at 9:40 AM, Surveyor noted R13 was not in his room, the nurse reported he was getting a shower.
On 5/8/24 at 10:25 AM, Surveyor observed R13 was back in his room, lying in bed which had an air mattress. Surveyor spoke with R13. R13 reported he gets out of bed for a couple hours a day which is all he is allowed because of a big sore on his butt. R13 reported he has had the pressure sore for at least 3 years, prior to admission to the facility. R13 reported the wound is slowly getting better, the facility is doing a good job, but it takes a long time to heal. Surveyor observed R13 had a right leg amputation. Surveyor observed R13's left heel resting directly on the mattress, not offloaded. Surveyor observed a mepilex dressing on his left heel. Surveyor asked R13 if he wears anything on his foot for protection when in bed. R13 stated, No, but they usually put my leg on a pillow.
R13 was observed not wearing a heel suspension boot according to facility policy (for stage 3, 4, unstageable, or deep tissue injury) and his heel was not offloaded according to his care plan. Surveyor noted R13's care plan interventions of a heel lift cushion placed between foot board and patient's feet, soft boot left foot on in bed at all times, and float heels when in bed were not observed as implemented.
On 5/9/24 at 9:00 AM, Surveyor observed R13 lying in bed on his back, watching TV. The head of bed was elevated 30 degrees. Surveyor observed R13's left heel wrapped with Kerlix gauze dated 5/9. Surveyor observed R13's left heel resting directly on the mattress, not offloaded.
Surveyor asked R13 how he thought his wounds developed. R13 stated, Well, I'm paralyzed from the waist down, so I'm not really able to move much. Surveyor noted grab bars on both sides of the bed and a trapeze. Surveyor asked R13 if he was able to use the trapeze. R13 stated, Yeah, I can grab it to boost myself up a little. Surveyor asked R13 if he can turn and reposition himself with the grab bars. R13 stated, No, I'm not strong enough to turn myself all the way over on my side. Surveyor asked if staff offers to turn and reposition him. R13 stated, No, I don't know why. Surveyor asked R13 if he asks to be turned and repositioned. R13 stated, No, but I probably should. Surveyor asked R13 if he is able to move his leg or lift his leg off the bed. R13 reported he cannot lift his leg off the bed.
R13 was observed not wearing a heel suspension boot according to facility policy (for stage 3, 4, unstageable, or deep tissue injury) and his heel was not offloaded according to the care plan. Surveyor noted R13's care plan interventions of a heel lift cushion placed between foot board and patient's feet, soft boot left foot on in bed at all times, and float heels were not observed as implemented.
On 5/9/24 at 11:00 AM, Surveyor observed R13 lying in bed on his back watching TV. Surveyor noted the bed was tilted downward on an angle with his head higher than his legs. Surveyor observed R13's left heel resting directly on the mattress, not offloaded. Surveyor observed several dried dark stains on the sheet in the area where R13's left heel would rest, indicating the heel was previously resting on the mattress.
R13 was not wearing a heel suspension boot according to facility policy (for stage 3, 4, unstageable, or deep tissue injury) and his heel was not offloaded according to his care plan. Surveyor noted R13's care plan interventions of a heel lift cushion placed between foot board and patient's feet, soft boot left foot on in bed at all times, and float heels were not observed as implemented.
On 5/9/24 at 12:54 PM, Surveyor observed R13 sitting up in his wheelchair watching TV. R13 was wearing a gripper sock on his left foot. Surveyor noted a blue pad covering R13's wheelchair footrests. R13's heel was resting directly on the blue pad. There was no pillow under his leg and his heel was not offloaded. R13's care plan intervention to elevate feet while in wheelchair was not observed as implemented.
On 5/13/24 at 9:14 AM, Surveyor observed R13 lying in bed on his back with the head of bed elevated, watching TV. Surveyor observed R13's left heel offloaded on a pillow. Surveyor observed a Mepilex dressing peeling halfway off the heel. Surveyor observed dark drainage on the dressing which was dated 5/12. Surveyor noted dried dark stains on the sheet in area where R13's heel previously rested, indicating the heel had previously been resting directed on the mattress.
Review of R13's medical record documented:
The facility's initial wound assessment dated [DATE] documents: Left lateral foot pressure 2.5 x 2.6 x 0.2 cm (centimeters) unstageable. 100% eschar. Resident exhibits two or more conditions that increase the likelihood of the development of an unavoidable wound? NO.
R13's pressure injuries to be followed by Wound Doctor-I. The left foot plantar pressure injury subsequently healed.
Surveyor was advised Wound Doctor-I stopped working for the facility in December 2023, and wounds were then followed by Director of Nursing (DON)-B.
On 5/14/24 at 11:01 AM, Surveyor met with RN (Registered Nurse) Consultant-C. She reported having spent the whole weekend reviewing R13's medical record which revealed R13 admitted in 2021 with a right gluteal fold stage 3 pressure injury and vascular wound left lateral foot. IV (intravenous) antibiotics were ordered for osteomyelitis of the left foot and ankle. The gluteal fold did progress to a stage 4 and did eventually heal. In August 2021, the left gluteal opened related to wound vac tape, and eventually healed. Surveyor reviewed Wound Doctor-I's documentation regarding R13's current gluteal pressure injuries. Surveyor asked why the wounds were staged as stage 4. RN Consultant-C reported Wound Doctor-I had been following R13 for years, at another facility prior to admission. Wound Doctor-I advised once a wound is staged, like a stage 4, if it heals and re-opens at any time, it is then still staged at a stage 4. DON-B (present in room) stated, I guess I can understand that logic, but his assessment and documentation indicates stage 3, but that's why he classified it as stage 4.
The facility's weekly skin assessment dated [DATE] documents: Sacrum, right thigh (rear,) Left heel - tx (treatment) continues. Surveyor noted there was no documentation of an assessment or measurements of a left heel wound and no treatment implemented on 1/3/24. The left heel SDTI was not documented as identified until 1/9/24.
On 1/9/24, R13 developed a Facility Acquired SDTI on his left heel. The initial wound assessment documents: Left heel pressure 2.0 x 2.0 x 0 cm. Suspected Deep Tissue Injury. Area has 2 small discolored areas inside of it. Resident exhibits two or more conditions that increase the likelihood of the development of an unavoidable wound? Yes. Resident exhibits the following conditions (check all that apply) - Diabetes, Severe PVD.
Surveyor reviewed R13's medical record, including the face sheet, hospital discharge summary, and History and Physical. Surveyor located no diagnosis of Diabetes in R13's medical record. R13's prior assessment of the left lateral foot pressure injury dated 6/21/23 of resident exhibits two or more conditions that increase the likelihood of the development of an unavoidable wound documented No.
Subsequent documentation and weekly measurements of the left heel:
1/16/24 3 x 2 x UTD (unable to determine) SDTI
1/23/24 2.8 x 2.0 x 0 SDTI
1/30/24 2 x 2 x 0 SDTI. Area has become 1 area but is not open
2/6/24 3.8 x 2 x UTD unstageable. DTI reabsorbed
2/13/24 2.5 x 1.5 unstageable. 100% eschar.
2/20/24 2 x 1 x 0 SDTI 100% eschar
2/27/24 4 x 1 unstageable 100% eschar
3/5/24 4 x 1 SDTI 100% eschar
3/12/24 2 x 2.2 unstageable, 100% eschar
3/19/24 2 x 1.5 SDTI 100% slough
3/26/24 2 x 1 SDTI 100% slough
4/2/24 1.8 x 1.8 unstageable 100% slough
4/9/24 1.5 x 1.8 unstageable 100% eschar
4/16/24 2 x 3 unstageable 100% slough
4/23/24 3 x 3.5 unstageable - no percentages documented
4/30/24 4 x 2.5 stage 3 75% granulation, 25% slough
5/7/24 2.4 x 3.5 unstageable 75% granulation, 25% slough
Surveyor noted inconsistent and/or inaccurate documentation of staging and wound characteristics. Documentation varies from week to week, indicating SDTI 100% eschar, then unstageable 100% eschar, then SDTI 100% slough. A SDTI would not include slough. When the wound progressed to stage 3 with 75% granulation and 25% slough, which indicates only 25% of the wound is obscured with slough, no depth is measured or documented.
On 5/14/24 at 9:10 AM, Surveyor spoke with RN (Registered Nurse)/MDS (Minimum Data Set) Coordinator-D who reported she was the prior DON (Director of Nursing.) Surveyor advised of observations of R13's heels not offloaded while on survey. RN/MDS Coordinator-D rolled her eyes and stated OK, that's a problem.
On 5/14/24 at 10:41 AM, Surveyor observed R13's wound care with Assistant Director of Nursing (ADON)-J. Surveyor noted several dark stains on R13's sheet in area where his heel would rest, indicating the heel was previously resting directly on the mattress.
Surveyor noted no wound or discoloration to the left foot plantar area. R13's left heel revealed a stage 3 pressure injury approximate size of a half dollar. The center of the wound was necrotic surrounded by a rim of slough, surrounded by maceration. R13's entire heel was reddened. There was no active drainage or odor noted.
On 5/14/24 at 11:30 AM, Surveyor advised DON-B of the concern that R13 admitted to the facility with pressure injuries and a long history of wounds, including RLE amputation. Weekly skin checks were implemented, however, although R13 had current pressure injuries and was at increased risk, daily foot checks were not implemented until after R13 developed a facility acquired pressure injury on his foot. Surveyor advised of multiple observations R13's care plan interventions, including offloading of heels, which were observed to not be implemented while on survey.
On 5/14/24, during the daily exit meeting with the facility, DON-B voiced she did not agree with recommended citation for R13's heel pressure injury. DON-B reported the reason the heel wound was staged as stage 3 is because it was an SDTI and, there is no way to know how deep it would be, it could go as deep as the bone, therefore stage 3 would actually indicate healing. Surveyor advised DON-B Surveyor would be happy to review any additional information the facility chooses to provide.
RN Consultant-C then reported the facility has evidence from the doctor that the pressure injury was unavoidable. This was the first time the facility alleged the pressure injury was unavoidable. Surveyor had asked previously if there was any documentation as such, and was not provided any information. Surveyor reminded the facility of multiple observations on survey of care plan interventions not implemented and R13's heel not offloaded.
After Surveyors left the facility, the facility provided a form titled Community Acquired Pressure Injury Investigation Form. The form did not document anything about R13's FA left heel pressure injury or that it was specific to said pressure injury. At the bottom of the form was a typed statement with a check mark: Based on this review, it is unavoidable. Unavoidable, per NPUAP means that the individual developed a pressure injury even though the community had evaluated the individual's clinical condition and pressure risk factors, defined and implemented interventions that are consistent with the individual's needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions and revised the approach as appropriate. If unavoidable, has the physician documented this? (Check mark next to yes).
Surveyor noted the form was dated 2/23/24 and signed by a physician (not Wound Doctor-I.) Surveyor located no evidence or other documentation by a physician that indicated the pressure injury was unavoidable.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that 2 (R47 &R322) of 7 facility reported incidents investigat...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that 2 (R47 &R322) of 7 facility reported incidents investigations reviewed were reported to the State Survey Agency, within 5 working days of the incidents, after the initial reporting and with the results of the investigations of each alleged violation.
Findings include:
The facility's policy with no date and titled Abuse, Neglect and Exploitation documents:
A. The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes .
B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.
1. R47 was readmitted to the facility on [DATE] with a diagnosis that included of Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
R47's MDS (Add Date and type) documents a BIMS (Brief Interview for Mental Status) score of 0, indicating that R47 is severely cognitively impaired.
Section E0100 (Potential Indicators of Psychosis) documents that R47 experiences hallucinations and delusions.
Section GG0115 (Functional limitation in range of motion) no impairment to lower and upper extremities.
The facility's self-report submitted to the State Agency dated 4/5/24 documents:
It was reported to the Administrator of a possible resident to resident altercation during a scheduled activity; Factual findings revealed: Through a detailed investigation, including resident statements, both residents were attending an activity in the activity room with activity staff present. Resident A was being very vocal that triggered resident b to become agitated. She kicked at him and made contact with his wheelchair. Resident B swung back as a reaction. Neither resident was physically or emotionally harmed due to the interaction.
Staff statement:
Today at the beginning of our 10 am activity, R47 told resident to shut up as she was talking loudly. She then yelled back at him and kicked the side of his chair. At this point, resident was pulling R47 back and staff was pulling away to de-escalate the situation. Both residents were cussing and yelling. While being separated, R47 made contact with the leg of resident.
The facility's follow up report was submitted on 4/15/24. Surveyor noted that the subsequent investigation was not reported to state agency within 5 working days after the initial report.
On 5/9/24 at 1:35 PM, Surveyor informed Nursing Home Administrator (NHA-A) of the above findings. Surveyor asked NHA-A why the facility had not submitted the above self-report to the state agency within 5 working days after the initial reporting on 4/5/24.
NHA- A informed Surveyor that she was unsure why the facility did not report to the state agency within 5 working days of the initial reporting on 4/5/24 but that she would review the self-report and let Surveyor know.
On 5/14/24 at 8:32 AM, NHA- A informed Surveyor that the facility attempted to follow the resident-to-resident altercation flow chart and was confused as to if the actions that were reported were willful or not. NHA-A informed Surveyor that the facility should have reported to the state agency within 5 working days of the initial report of 4/5/24. NHA-A informed Surveyor that going forward the facility would follow the reporting guidelines for investigations.
No additional information as to why the facility did not report to the State Agency, within 5 working days of the incidents, after the initial reporting and with the results of the investigations of each alleged violation. 2.) On 5/8/24 at 12:25 PM, Surveyor reviewed a Facility self-report with a report submitted date of 3/20/24. The Facility's self-report described an allegation of staff for potential misappropriation of $60 from R322 that occurred on 3/11/24.
On 5/8/24 at 3:15 PM, Surveyor conducted interview with NHA-A. Surveyor asked what staff members at the facility would be responsible for submitting self-reports of abuse, neglect or misappropriation allegations to the state agency. NHA-A responded that Facility's administration would be responsible for submission of self-reports. Surveyor noted the facility's self-report was submitted to the state agency on 3/20/24 at 1:18 PM.
On 5/9/24 at 3:22 PM, Surveyor asked NHA-A about the self-report regarding R322's allegations of potential misappropriation of $60 and why it was not submitted within 5 days as required by the State Agency. NHA-A responded that there had been a misunderstanding as NHA-A was previously working in a different state that had different reporting requirements. NHA-A reported that they have since acclimated themselves to the state agency's reporting requirements.
On 5/9/24 at 3:30 PM, Surveyor shared concerns with NHA-A that R322's allegation of suspected misappropriation that occurred on 3/11/24 was not reported to the state agency until 3/20/24 at 1:18 PM. No additional information was provided by the facility at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not incorporate the recommendations from the Preadmission Screen and Resident Review (PASARR) Level 2 determination and evaluation report into a Resident's assessment, care planning, and transitions of care for 1 (R52) of 1 Resident reviewed with PASARR level 2 recommendations.
*R52's PASARR dated 7/21/21 determination states R52 needs specialized services to address R52's developmental disability needs.
Findings Include:
Policy Review: Specialized Rehabilitative Services ( date implemented- blank, Date reviewed- blank, Date revised- blank)
Policy: The facility shall provide or obtain services from an outside resource for specialized rehabilitative services if required by the resident's comprehensive assessment and care plan to assist them to attain, maintain or restore their highest practicable level of physical mental functional and psycho- social well- being, as well as ensure that residents with Mental Disorder ( MD), Intellectual Disability ( ID) or related conditions receive services as determined by their Preadmission Screening and Resident Review (PASARR).
Policy Explanation and Compliance Guidelines: ( includes)
1. Specialized rehabilitative services include but are not limited to the following:
a. Physical therapy
b. Speech-language pathology
c. Occupational therapy
d. Respiratory therapy
e. Specialized services for mental illness or intellectual disability ( those services to be provided by the State in accordance with the PASARR report)
2. Specialized rehabilitative services will be provided under the written order of a physician by qualified personnel.
4. The care plan for individuals receiving specialized rehabilitative services will be monitored and revised as indicated by a licensed professional.
R52 was originally admitted to the facility on [DATE] with diagnosis that included Cerebral palsy, Asthma, Blindness Right Eye, Major Depressive Disorder, Bipolar Disorder, Developmental Disorder, Anxiety and Seizures.
On 7/21/21, the Level 2 Preadmission Screen and Resident Review (PASARR) was completed by a Qualified Intellectual Disabilities Professional (QIDP). The determination was that R52 is appropriate for placement in a nursing home and has both an intellectual/ developmental disability needs. It was determined that R52 needs specialized services to address his/ her developmental disability needs. The decision was based primarily on the following: R52 needs specialized services. The focus of the Specialized Services is to maintain or improve his current level of functioning. SPRS should include a thorough assessment of his unique capabilities, functional limitations, and behaviors, if any, by a QIDP. He requires full assistance with monitoring his own health status and administering medications. He requires assistance with activities of daily living. He is lacking independent living skills. Staff should encourage his involvement in activities of daily living and allow extra time when learning new skills.
A review of R52 individual plan of care indicates that R52 requires Specialized Services. Resident has Impaired Mobility r/t (related to) Cerebral Palsy. Decreased Range of Motion due to contractures Date Initiated: 07/30/2021. Created by: (Licensed Practical Nurse)
Revision on: 11/03/2023
o Resident will have ADL needs met with Staff assistance
Date Initiated: 08/02/2021
Created on: 08/02/2021
o Bed mobility/Repositioning:
Total assist for all ADL completion. Mod assist of 1 to roll-log roll technique.
Date Initiated: 07/30/2021
o R52 continues needing Specialized Services. All of his posters have been updated on his door and wall. I love going down the hallway and listening to his
Christmas music and hearing staff sing along with him. R52 will remember everyone's voices and say their name each time upon saying Hello. Smart guy! And
very happy when staff sings his favorite music with him. The [NAME] was a perfect addition to his room!
Date Initiated: 09/30/2022
o R52 continues needing specialized services. He is a happy guy who sings a lot of music!! He has the [NAME] in his room that he loves!! He knows how to use it now
and can verbalize [NAME] to play whatever music he wants. His favorite is Christmas music. When knocking on the door to announce who is coming in, all you have to do
is say Hi R52 and he knows exactly who is coming in just by their voice. Smart guy. He has been accepted to a group home and will be leaving in the next week or
two.
Date Initiated: 12/29/2021
Surveyor conducted a review of the most recent full MDS, annual, dated 8/25/23. The MDS indicates that R52 has the following in place:
PASARR level 1- yes
PASARR level 2- serious mental illness- yes
PASARR level 2 conditions- Intellectual Disability- NO
PASARR level 2 conditions- other related conditions- no
On 05/13/24 at 12:50 p.m., Surveyor made an observation of R52's room. Surveyor did not observe any posters in R52's room. There was a sign by closet stating to keep head of bed elevated at 30 degrees at all times. In addition, there was a sign on closet door- do not use R52's supplies for other residents. These are his own personal supplies. Surveyor did observe an [NAME] device on the end table .
On 05/14/24 at 08:25 a.m., Surveyor interviewed Director of Social Services (DSS)- H DSS- H stated that she had worked at the facility for approximately 1 year. DSS-H stated that she has not worked with Residents who are in need of Specialized Services before. There is a total of 3 residents who receive specialized services in the facility.
DSS- H stated that she was involved in making the plan of care and the use of sensory items such as stuffed animals. Surveyor asked if DDS- H has reviewed R52's needs for Specialized Services. DSS- H stated that the team will re-evaluate as needed. If R52 becomes more behavioral, may need to make changes. The music and stuffed animals help with behaviors. DSS- H I understand that the music plan is more to treat the behaviors. I'm not aware of what to add to care plan for the Specialized Services. Surveyor went over the plan of care and asked about the intervention of posters being placed in R52's room. DSS-H stated ,I'm not even sure what they were or what they said or used for. Surveyor shared observations of R52's room and there were no posters on the walls. DSS- H stated that she will need to have help moving forward to write the plan of care for Specialized Service needs for R52.
As of the time of exit, the facility did not provide additional evidence that they had developed a plan for R52 to address his needs for specialized services. The facility was unable to state why they have not reevaluated R52's needs for Specialized Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility did not ensure a complete baseline care plan was developed and a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility did not ensure a complete baseline care plan was developed and addressed all of the resident's needs within 48 hours of admission for 1 (R371) of 2 sampled residents for new admission.
R371's baseline care plan did not address R371's enabler bar usage on the baseline plan of care.
Findings include:
The facility policy titled, Baseline Care Plan, with implementation date, February 2023, states in part:
Policy Explanation and Compliance Guidelines:
1. The baseline care plan will:
a. Be developed within 48 hours of a resident's admission.
b.Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:
i.Initial goals based on admission orders.
ii.Physician orders .
2
b. Interventions shall be initiated that address the resident's current needs including:
i. Any health and safety concerns to prevent decline or injury .
ii. Any identified needs for supervision .
iii. Any special needs such as IV therapy, dialysis, or wound care.
c. Once established, goals and interventions shall be documented in the designated format .
R371 was admitted to the facility on [DATE] from the hospital with a primary diagnosis of paraplegia, complete; and other diagnoses which include, in part, morbid obesity, chronic respiratory failure, local infection of the skin and subcutaneous tissue, fibromyalgia, and osteoarthritis.
R371's admission Minimum Data Set (MDS) with an assessment reference date of 5/5/24 indicated R371 had a Brief Interview for Mental Status score of 15 (fully intact memory). R371 is able to make decisions for themselves. R371's MDS showed that upper extremities have no impairment and lower extremities have impairment on both sides. R371 uses a wheelchair for mobility.
R371 has a physician order for enabler bars to assist with self positioning dated 4/29/2024.
On 05/08/24 at 09:49 AM, Surveyor notes observing enabler bars on R371's bed.
R371's baseline care plan with admission date 4/29/2024 has no mention of the enabler bars under the Focus, Goal or Interventions sections.
On 5/9/2024 a Screening Tool form was completed by Evolve Therapy Services with a note stating Patient does have ability to utilize assist bar on bed to improve bed mobility.
Surveyor notes this was completed on the same day that the assessment information was requested from the facility, 10 days after physician order and admission. Surveyor noted that R371 did not have a baseline care plan upon admission.
On 05/13/24 at 03:19 PM, Surveyor informed Nursing Home Administrator-A and Regional Nurse-C of the above concerns
On 05/14/24 at 10:30 AM, Surveyor spoke with Regional Nurse-C who agreed that enabler bars should have been placed on the baseline care plan for R371.
No additional information was provided as to why the facility did not ensure a complete baseline care plan was developed and addressed within 48 hours of admission for R371.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure 1 (R32) of 1 Resident reviewed for communicati...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure 1 (R32) of 1 Resident reviewed for communication with the use of hearing aides, received proper treatment and assistive device to maintain R32's hearing abilities.
Findings Include:
R32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Hypo-osmolality and Hyponatremia, and Gastro-Esophageal Reflux Disease. R32 has an activated health care power of attorney(HCPOA).
R32's Significant Change Minimum Data Set(MDS) dated [DATE] documents R32's Brief Interview for Mental Status(BIMS) score to be a 0 indicating R32 demonstrates severely impaired skills for daily decision making. R32 has no behaviors documented. R32's Patient Health Questionnaire(PHQ-9) score is 8 indicating mild depression. R32 has no range of motion(ROM) impairment on upper extremities, and does have ROM impairment on bilateral lower extremities. R32's MDS documents R32 is dependent for dressing, mobility and transfers. R32's MDS documents that R32 has moderate difficulty for hearing and does not have hearing aides. R32 usually understands and usually is understood.
R32's Certified Nursing Assistant(CNA) care card does not document that R32 has bilateral hearing aides.
R32 has the following care plan in place for having difficulty with hearing:
The resident has a communication problem r/t progressive neurological disease and hard of hearing 5/8/23
· Resident will be able to make basic needs known on a daily basis through the review date. Encourage resident to see audiologist on next visit, she has previously declined the service. 5/8/23
· Anticipate and meet needs. [CNA] 5/8/23
· Encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express. 5/8/23
· Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. 5/8/23
· Refer to Audiology for hearing consult as ordered 5/8/23
R32 also has a care plan documenting that R32 has impaired cognitive function/dementia or impaired thought processes due to diagnosis 11/14/23 with the following intervention:
-Identify yourself at each interaction. Face R32 when speaking and make eye contact. Reduce any distraction-turn off television, radio, close door. R32 understands consistent, simple, directive sentences. Provide R32 with necessary cues. 11/14/23
Surveyor notes there is no documentation in R32's electronic medical record(EMR) that R32 has refused to have the hearing aides put in on a daily basis.
On 5/8/24 at 9:27 AM, Surveyor observed R32 in bed and did not have R32's bilateral hearing aides in.
On 5/9/24 at 8:27 AM, Surveyor observed R32 watching television and R32 informed Surveyor that R32 did not have any hearing aides in.
On 5/9/24 at 12:58 PM, Surveyor notes that R32's television is very loud, and R32 is having difficulty hearing Surveyor. R32 informed Surveyor that R32 has not been wearing hearing aides for a long time.
On 5/13/24 at 8:55 AM, R32 informed Surveyor that R32 does not know if R32 has hearing aides. Surveyor observed the hearing aide charger on R32's bedside table.
R32 was seen by the audiologist on 7/17/23. The audiologist documented that speech had to be loud for R32 to hear audiologist. With the hearing loss, R32 will miss all of conversational speech and that R32 has severe sesorineural hearing loss in both ears.
On 9/7/23, documentation from the audiologist stated that the new hearing aides fit well, included 1 charger, cleaning tool and user manuals. Audiologist documented that television volume went from 36 without hearing aides to 5 with the hearing aides. It is also documented to store the hearing aides on the charger at night, keep charger plugged into wall outlet, wipe down hearing aides daily with a dry cloth and for R32 to wear daily.
On 4/17/2024, the audiologist documented that R32's hearing aides fit well and for the nurse to store the hearing aides in the charger at night. The audiologist documents that R32 requires assistance with insertion and removal of hearing aides daily. To store the hearing aides on the charger at night and keep charger plugged into wall outlet.
On 4/17/2024 Social Worker(SW-R) documented that R32 was seen by Audiology. Change wax filter monthly or PRN; R32 requires assistance with insertion and removal of hearing aids daily. Store hearing aids on charger at night, and keep charger plugged into wall outlet. Hearing Aids worn daily.
On 5/13/24 at 3:20 PM, Surveyor shared the concern with Administrator(NHA-A) and RN Consultant(RNC-C) that R32 has not been wearing R32's hearing aides during the survey process. No further information was provided by the facility at this time.
On 5/14/24 at 9:23 AM, Surveyor interviewed RN-E in regards to R32's hearing aides. RN-E informed Surveyor that R32 should have hearing aides, but stated, something must have happened to them because they are not in the medication cart.
On 5/14/24 at 1:53 PM, NHA-A and RNC-C were informed by Surveyor that R32's hearing aides could not be located by RN-E.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not always ensure that , based on a comprehensive assessment, prov...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not always ensure that , based on a comprehensive assessment, provided the appropriate treatment and services to restore continence , to the extent possible, for 1 out of 2 residents ( R19) reviewed for bowel and bladder incontinence.
This is evidenced by:
Policy Review: Incontinence Date implemented: ( blank), Date Reviewed/ Revised ( blank).
Policy: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services.
Policy Explanation and Compliance Guidelines: ( includes)
1. The facility must ensure that residents who are continent of bladder and bowel upon admission receive appropriate treatment, services, and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.
4. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.
R19 was admitted to the facility on [DATE] with diagnosis that included type 2 diabetes, Morbid Obesity, Chronic Obstructive Pulmonary Disease, Spinal Stenosis, Anxiety Disorder, Hypertension, and Major Depressive Disorder.
A review of the admission assessment dated [DATE] documents: Clinical Summary: Resident (R19) arrived to facility via wheelchair. Resident was admitted to hospital for generalized weakness and diagnosed with PE to lower left lobe. Full code, split to right wrist but refuses to wear, regular diet, thin liquids, room air, glasses, upper and lower dentures, incontinent of bowel and bladder, last BM (bowel movement) 3/12/2024, transfers pivot with gait belt and walker, excoriation under breast and abdomen, open area to left shin, AxO (Alert and Orientated) x4, lives at home with caregivers assisting during the day.
The Admission/ Readmission/ Routine Head to Toe evaluation, dated 3/14/24, indicates that R19 is continent of bowel. The last bowel movement was noted on 3/13/24, Frequency of bowel movements is every other day. No indication that a plan of care is to be developed. The assessment also states that R19 is incontinent of bladder and has been incontinent longer than 1 month, less than 1 year. Goal is to have R19 be / remain free form skin breakdown due to incontinence and brief use through the review date.
A review of the physician's order's for R19 dated 3/14/24 documented: : Record bowel movements every shift.
A review of the admission/ full MDS ( minimum data set), dated 3/20/24 indicates that R19 has a BIMS score of 13 ( cognitively intact).
*Section H0200 Urinary Toileting Program:
A. Has a trial of a toileting program (e.g., scheduled toileting, prompted voiding, or bladder training) been attempted on admission/ entry or reentry since urinary incontinence was noted at facility. Answer- No.
*Section H0300- always incontinent of urine
*Section H0400- always incontinent of bowel
*Section H0500 Bowel Toileting Program
Is a toileting program currently being used to manage the resident's bowel continence? ? Answer- no
*Section H0600 Bowel Patterns: Constipation Present- answer no.
Surveyor conducted a review of the CAA ( care area assessment) for Urinary Incontinence and Indwelling Catheter. Analysis of findings: Resident ( R19) is always incontinent of bladder. Needs assist with toilet transfer and toileting hygiene. Type of incontinence is not indicated. Care Plan considerations: Avoid complications. Will be addressed in the care plan.
On 4/10/24, the facility completed a Bowel evaluation - full assessment. Does the resident have a history of Bowel Incontinence? - yes. Was the resident continent of bowel on admission?- No. Resident is frequently incontinent since admission. Resident can communicate need to defecate. Mental Status- alert and orientated. Last Bowel Movement is- unknown. Bowel Status- incontinent. Resident is not appropriate for training due to - resident is totally incontinent
Surveyor conducted a review of the plan of care for R19. The plan states :
The resident ( R19) has mixed bladder incontinence r/t decreased mobility, nerve damage. Date initiated: 3/14/24. Revision : 3/30/24.
oThe resident will remain free from skin breakdown due to incontinence and brief use through the review date. +
oClean peri-area with each incontinence episode.
oMonitor/document for s/sx UTI (Urinary Tract Infection): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.
Further review of the plan of care for R19 does not show that a plan was developed for R19's bowel incontinence.
R19's nursing notes document:
4/17/2024 1:59 p.m. Nurses Note Text: MD (medical doctor) and resident consulted regarding resident bowel patterns, resident noted to go days without BM. MD suggests increasing senna, resident is not agreeable to change. Resident states at home she typically had 1 bm a week, states she has been complaint with taking 1 senna but does not want any more. MD aware of resident refusal for change.
4/19/2024 9:00 p.m., Nurses Note Text: 24-hour report board. Resident is being monitored D/T (due to) No BM Q4 (every four days) days, refused a suppository again. Will pass onto next shift nurse. No issues with resident at this time. No pain noted. Resident is safe and continue to observe.
4/26/2024 2:34 p.m., Nurses Note Text: Pt continues to be monitored for no bowel movement within 3 days. Pt alert and oriented x4, able to make all needs known. Active BS x4. Abd (abdomen) soft, non-tender. Pt continues to refuse stool softeners. Will continue to monitor closely.
On 05/13/24 at 03:28 p.m., Surveyor interviewed RN Consultant-C regarding R19's comprehensive assessment for bowel and bladder incontinence. Consultant RN-C stated that there should be patterning for bowel and bladder for R19, and she will provide a copy of this information.
On 5/14/24 at 8:00 a.m., Surveyor conducted a review of the information provided by RN Consultant-C for R19. The 3-day bowel and bladder tracker, dated 3/14/24 - 3/18/24 documented findings at time of toileting, wet or dry. The tracker did not indicate if R19 was incontinent of bowel or bladder. RN- Consultant-C also provided a document stating that the facility will be starting a 3-day assessment for prompted toileting schedule starting 5/13/24.
The facility's assessment of R19's bowels indicated that although R19 is incontinent of bowel, R19 can communicate the need to defecate. Surveyor noted that the facility did not comprehensively assess R19's bowel incontinence to help maintain or restore as much bowel continence as possible. The facility also did not comprehensively assess R19's urinary incontinence by trying to determine the type of incontinence and to develop a pattern. The facility did not provide services to try to maintain or restore as much bladder incontinence as possible for R19.
No additional information was provided as of the time of exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility did not ensure a Resident with a gastrostomy tube received the a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the Facility did not ensure a Resident with a gastrostomy tube received the appropriate care and services for 1 (R60) of 3 Residents with gastrostomy tubes.
*R60's water flush bag and tube feeding was not labeled for two days during the survey process. R60's tube feeding pump had not been calibrated to ensure proper flow rate.
Findings Include:
Surveyor reviewed the facility's undated Care and Treatment of Feeding Tubes policy and procedure and notes the following:
10. Direction for staff regarding how to manage and monitor the rate of flow will be provided:
a. Use of gravity flow
b. Use of a pump
c. Periodic evaluation of the amount of feeding being administrated for consistency with practitioner's orders
d. Calibration of enteral feeding pumps to ensure that pump settings accurately provide the rate and volume consistent with the Resident's care plan.
e. Periodic maintenance of feeding pumps consistent with manufacturer's instructions to ensure proper mechanical functioning.
12. The Resident's plan of care will direct staff regarding proper positioning of the Resident consistent with the Resident's individual needs.
R60 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction due to Unspecified Occlusion, Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Left Dominant Side, Type 2 Diabetes Mellitus, End Stage Renal Disease, and Major Depressive Disorder. R60 has an activated Health Care Power of Attorney (HCPOA).
R60's Quarterly Minimum Data Set (MDS) dated [DATE] documents R60's Brief Interview for Mental Status (BIMS) score to be a 13, indicating R60 is cognitively intact for decision making. R60 has no mood issues and R60 can have verbal behaviors 1-3 days. R60 has range of motion (ROM) impairment on 1 side of both upper and lower extremities. R60 is dependent for upper and lower dressing and transfers. R60 requires substantial to max assist for mobility. R60's MDS documents that R60 is receiving tube feeding.
Surveyor reviewed R60's comprehensive care plan for tube feeding/nutrition related care plans:
The resident requires tube feeding r/t dysphagia 12/11/23
·The resident will maintain adequate nutritional and hydration status aeb weight stable, no s/sx of malnutrition or dehydration through review date. 12/11/23
·The resident needs the HOB elevated 45 degrees during and thirty minutes after tube feed.
[CNA,LPN,RN] 12/11/23
·Monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubation, Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration.
[LPN,RN] 12/11/23
·Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated.
[LPN,RN] 12/11/23
·Provide local care to G-Tube site as ordered and monitor for s/sx of infection.
[LPN,RN] 12/11/23
·RD to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed.
[LPN,RN] 12/11/23
Surveyor reviewed R60's current physician orders and notes the following:
-140 ml peg flush every 2 hours every shift, Monday, Wednesday, Friday effective 8/30/23
-Check residual from PEG tube every 4 hours. Return aspirate. If >300 ml hold tube feeding and recheck residual in 1 hours. If residual <300 ml resume tube feeding at previous rate three times a day effective 12/19/23
-Oral Feeding: Pureed Diet; Nectar Liquids. Only feed when alert/awake. Sit upright when feeding. effective 8/15/23
-Head of bed elevated 45 degrees at all times every shift for tube feedings effective 8/12/23
-Nepro 1.8@45 ml/hour continues with 120 ml flush every 2 hours every shift every Tues, Thurs, Sat, Sun effective 11/18/23
-Nepro 1.8@70 ml/hr x 12 hours (1900-0700) with 145 ml FWF (free water flush) every shift every Mon, Wed, Fri effective 4/24/24
R60's Nutritional Evaluation dated 5/8/24 documents that R60 is on a renal, puree, nectar diet and tube feeding in April was changed to Nepro 1.8@70 ml/hours 12 hours with 145 ml FWF every 2 hours x 24 hours. The evaluation stated R60 has had goo intake and has not had a significant weight loss in the past 3 months.
Surveyor had the following observations during the survey process:
On 5/9/24 at 8:33 AM, Surveyor observed R60's tube feeding is not dated or initialed. R60's flush bag is dated 5/8/24.
On 5/9/24 at 1:41 PM, Surveyor observed R60's tube feeding is not dated or initialed.
On 5/13/24 at 8:48 AM, Surveyor observed R60's tube feeding and flush is not dated or initialed.
On 5/13/24 at 11:19 AM, Surveyor observed R60's tube feeding and flush is not dated or initialed.
On 5/13/24 at 1:01 PM Surveyor spoke to Registered Dietitian (RD-S) who stated that R60 eats 3 meals a day, and R60 has been switched to night tube feedings. R60 has had no issues with dehydration. RD-S stated the goal is to transition R60 off of the tube feeding in order to discharge to the community. The night tube feeding has been switched on April 22, 2023. RD-S confirmed that the tube feeding and flush should be dated and initialed. RD-S is not sure who calibrates the tube feeding pump.
On 5/13/24 at 3:20 PM, Surveyor shared the concern with Administrator (NHA-A) and RN Consultant (RNC-C) that R60's tube feed and flush has not been dated or initialed during the survey process. RNC-C stated the expectation is that when the tube feed and flush is hung both should be dated and initialed. No further information was provided by the facility at this time.
On 5/14/24 at 7:30 AM, RNC-C shared that the pump should be calibrated every 2 years and confirmed this has not been done. RNC-C stated that it is getting calibrated today.
On 5/14/24 at 9:23 AM, Registered Nurse (RN-E) confirmed that tube feeding and flushes are supposed to be dated and initialed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not provide dialysis services consistent with professional standards of p...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility did not provide dialysis services consistent with professional standards of practice for 1 (R321) of 1 Residents reviewed for dialysis.
* R321 receives dialysis three times per week. R321's dialysis center communication records are not being completed by Facility nurses.
Findings include:
1. R321 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, diabetes mellitus and encephalopathy. R321 is dependent upon renal dialysis and attends dialysis three times per week.
On 5/9/24, Surveyor reviewed R321's medical record, including physician's orders and comprehensive care plans. Surveyor was unable to locate any dialysis communication forms for R321 in R321's medical record.
On 5/9/24 at 12:45 PM, Surveyor requested R321's dialysis communication forms that are to be completed on R321's dialysis days.
On 5/9/24 at 2:25 PM, Nurse Consultant-C approached Surveyor for interview. Nurse Consultant-C told Surveyor that the facility had not been sending any Dialysis communication forms to dialysis centers on days residents receive dialysis. Nurse Consultant-C provided Surveyor with a PIP (Performance Improvement Plan) related to the facility's failure to communicate with dialysis centers for residents receiving dialysis care.
On 5/9/24 at 2:45 PM, Surveyor shared concerns with Nursing Home Administrator (NHA)-A related to lack of dialysis communication records completed by facility on R321's dialysis days.
No additional information was provided as to why the facility did not provide dialysis services consistent with professional standards of practice for R321.
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
Based on interview and record review the pharmacist recommendations made during the monthly record review were not reported to the attending physician and were not acted upon for 1 of 5 (R37) resident...
Read full inspector narrative →
Based on interview and record review the pharmacist recommendations made during the monthly record review were not reported to the attending physician and were not acted upon for 1 of 5 (R37) residents reviewed for unnecessary medications.
R37's pharmacy recommendations were not acted upon by the physician.
Findings include:
The facility policy titled Medication Regimin Review (not dated) documents (in part) .
.The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart.
1. Medication Regimen Review (MRR), or Drug Regimen Review, is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes:
a. Review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication erros, or other irregularities.
4. The pharmacist shall document, either manually or electronically, that each medication regimen review has been completed.
5. The pharmacist shall communicate any irregularities to the facility in the following ways:
a. Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs.
b. Written communication to the attending physician, the facily's Medical Director, and the Director of Nursing.
7. Timelines and responsibilities for MRR:
a. The consultant pharmacist shall schedule at least one monthly visit to the facility, and shall allow for sufficient time to complete all required activities.
b. The pharmacist shall communicate any recommendations and identified irregularities via written communication within 10 working days of the review.
f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.
On 5/14/24 at 7:30 AM, the facility provided Surveyor the Pharmacy recommendation printed 4/19/24 which documented: Current order Meloxicam 15 mg (milligrams) TID (three times daily) increased from 15 mg qd (daily) on 9/20/23 in hospital. Manufacturer max dose is 15 mg/day. Manufacturer states not recommended for mod/severe renal impairment. Recommendation: Please evaluate current therapy and indicate below the appropriate option for this resident.
( ) A benefit/risk analysis of current therapy warrants continuation at the present dose above manufacturer max dose.
( ) Reduce dose to Meloxicam 15 mg qd per manufacturer guidelines.
( ) Please consider increase in Pantoprazole from 40 mg every other day to daily.
Surveyor noted no check marks or orders to indicate the physician response.
R37 has current physician orders for Meloxicam 15 mg give 1 tablet by mouth three times a day for pain.
On 5/14/24 at 8:09 AM, Surveyor asked Director of Nursing (DON)-B who was responsible to ensure physician follow up on pharmacy recommendations. DON-B reported the recommendations are faxed to the doctor. We had to call yesterday to ask for it. He marked to reduce the dose, but the resident does not agree, so he's going to discuss it with the NP (Nurse Practitioner). Surveyor asked, so there was no follow up on the recommendation until yesterday? DON-B stated: Apparently not.
On 5/14/24 at 8:43 AM, RN (Registered Nurse) Consultant-C advised Surveyor there was a new pharmacist last month who did not know she needed to send the recommendations to the physician and thought they just get sent out automatically, that's why there was no follow up. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on interviews and record review the facility did not ensure that residents are free of any significant medication errors for 2 of 2 (R3 and R37) residents reviewed.
Morning medications are not ...
Read full inspector narrative →
Based on interviews and record review the facility did not ensure that residents are free of any significant medication errors for 2 of 2 (R3 and R37) residents reviewed.
Morning medications are not administered within timeframe specified and are often administered after 11 AM along with noon medications.
The facility policy titled Medication Administration (not dated) documents (in part) .
.10. Ensure that the six rights of medication administration are followed:
a. Right resident
b. Right drug
c. Right dosage
d. Right route
e. Right time
f. Right documentation
12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time.
b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician.
On 5/8/24 at 9:43 AM, during initial interview, R3 reported the Assistant Director of Nursing (ADON) is an idiot because she has only 1 nurse for wings 1 and 2. R3 stated: Sometimes I don't get my 8 AM (morning) meds (medications) until 2 PM (afternoon) and sometimes I don't get my noon meds at all.
On 5/8/24 at 2:31 PM, during initial interview with R37 reported there is only 1 nurse for 2 wings. R37 reported he often gets his 8 AM medication around noon. R37 reported he is supposed to get pain meds every 4 hours, but never gets them on time because there's only 1 nurse and she's too busy. R37 stated: Everyone is complaining, including the nurses. People are calling in all the time because they're sick of it.
On 5/9/24 at 11:30 AM, Surveyor spoke with Licensed Practical Nurse (LPN)-F who reported he is an agency/contract nurse that has worked for the facility since February 2024. LPN-F reported he works the front units 1 and 2. Surveyor asked LPN-F since he has worked for the facility, has he always been assigned to both units. LPN-F stated No, there used to be 1 nurse on each side, but (Director of Nursing-B) made a lot of changes with staffing recently. LPN-F confirmed he is responsible for passing meds to all residents on both sides 1 and 2, which is 28 residents. Surveyor asked LPN-F if he is able to pass the 8 AM meds in the allotted time. LPN-F stated: Well, it depends on the day, if there's a fall or change in condition or emergency. On a good day, with nothing else happening, I finish about 11 AM. Surveyor asked what time he starts passing meds in the morning. LPN-F reported 7 AM. Surveyor asked: When you say you finish at 11 AM, do you mean you finish the passing the 8 AM morning meds at 11 AM? LPN-F replied yes. Surveyor asked: So depending on which resident you start with, some residents won't get their 8 AM meds until 11 AM or later. LPN-F stated: Yes. It's a lot of residents and a lot of meds, I do what I can.
Surveyor review of the facility schedule from 4/30/24 to 5/7/24 confirmed only 1 nurse scheduled on units 1 and 2. Of note, Surveyor review of the schedule on 5/13/24 and 5/14/24 while Surveyors were in the building and survey was in process, the schedule listed 2 nurses on units 1 and 2.
On 5/13/24 at 2:19 PM, Surveyor spoke with DON-B. Surveyor asked: When meds are ordered for example, for anxiety or pain BID (twice daily), TID (three times daily) or QID (four times daily) how does the facility determine the times they are administered. DON-B reported the doctor sometimes determines the times based on the residents need or targeted times for behaviors. Surveyor asked what if the times are not specified. DON-B stated: Then, for like anxiety or pain, we will schedule times so they receive a continued amount of medication throughout the day. Like Morphine ER BID - we'd do 12 hours apart so they get a continuous dose of the medication. Surveyor asked: What about anti-anxiety meds ordered TID. DON-B stated: The same, we'd separate it to every 8 hours so they get a continuous dose throughout the day. Surveyor confirmed: So TID would be every 8 hours and BID would be every 12 hours unless the doctor specifies times. DON-B stated: Basically.
Surveyor review of R3's Medication Administration Record (MAR) included the following:
Risperdal 1 mg (milligram) - Give 1 tablet by mouth one time a day for psychosis. Takes 1 mg in AM and 2 mg in HS (hour of sleep). Times: 8 AM and 8 PM.
Acetaminophen 500 mg - Give 2 tablets by mouth two times a day for pain. Times: 8 AM and 5 PM.
Hiprex Tablet (Methenamine Hippurate) - Give 1 gram by mouth two times a day for Prophylaxis UTI (urinary tract infection) with meals indefinitely. Times: 8 AM and 4 PM.
Lyrica Capsule 50 mg - Give 50 mg by mouth two times a day for Pain. Times: 8 AM and 5 PM.
Savella Tablet 100 mg - Give 1 tablet by mouth two times a day for pain. Times: 8 AM and 8 PM.
Baclofen Tablet 10 mg - Give 0.5 tablet by mouth three times a day for spasms related to spastic quadriplegic Cerebral Palsy. Times: 8 AM, 12 PM and 4 PM.
According to interview with both R3 and LPN-F, 8 AM meds are often not given until 11 AM or later, thus R3 would not benefit from the effect of the medications throughout the day. For example, R3's Baclofen which is to be given at 8 AM and 12 PM for spasms, could potentially be administered at the same time or within an hour of each dose.
Surveyor review of R37's MAR included the following:
Bupropion HCl (Hydrochloride) 100 mg - Give 1 tablet by mouth two times a day related to major depressive disorder. Times: 8 AM and 5 PM.
Morphine Sulfate ER (extended release) 30 mg - Give 30 mg by mouth two times a day for pain. Times: 8 AM and 8 PM.
Gabapentin Capsule 300 mg - Give 1 capsule by mouth three times a day for neuropathy.
Times: 8 AM, 2 PM and 8 PM.
Hydroxyzine HCl 25 mg - Give 25 mg by mouth three times a day related to anxiety disorder.
Times: Midnight, 8 AM and 4 PM.
Klonopin 1 mg (Clonazepam) - Give 1 mg by mouth three times a day for anxiety disorder and insomnia. Times: 12:30 AM, 8:30 AM and 4:30 PM.
Meloxicam 15 mg - Give 1 tablet by mouth three times a day for pain. Times: 8 AM, 2 PM and 8 PM.
Methocarbamol 500 mg - Give 2 tablet by mouth three times a day for Spasms. Times: 8 AM, 2 PM and 8 PM.
Baclofen 20 mg - Give 1 tablet by mouth four times a day related to paraplegia. Times: 8 AM, 2 PM 6 PM and 10 PM.
Oxycodone HCl 20 mg - Give 1 tablet by mouth every 4 hours for pain. Times: Midnight, 4 AM, 8 AM, 12 PM, 4 PM and 8 PM.
According to interview with both R37 and LPN-F, 8 AM meds are often not given until 11 AM or later, thus R37 would not benefit from the effect of the medications throughout the day. For example, R37's Morphine extended release for pain is ordered 12 hours apart, Gabapentin, Meloxicam, Methocarbamol, Baclofen for pain and/or spasms are ordered at 8 AM and 2 PM, could potentially be administered at the same time or within a 2 hours of each dose. In addition, Oxycodone for pain, which is ordered to be given at 8 AM and 12 PM could potentially be administered at the same time.
On 5/14/24 at 9:30 AM, Nursing Home Administrator (NHA)-A was advised of the above concerns. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure 3 of 3 medication carts had insulin vials dated wi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility did not ensure 3 of 3 medication carts had insulin vials dated with the open date and insulin pens that have expired after being open removed from the medication cart. This affected 4 residents (R35, R30, R56 and R29)
On [DATE] Surveyor observed medication carts from 200, 300, and 400 hall.
The 200 hall had insulin vials opened and not dated.
The 300 hall had an insulin pen that expired after it was opened on [DATE].
The 400 hall had an insulin pen that expired after it was opened on [DATE].
Findings include:
On [DATE] at 8:55 a.m. Surveyor observed the 200 hall medication cart. Surveyor observed R30 humalog insulin vial opened but not dated. Surveyor also observed R35 lispro insulin vial opened but not dated. Surveyor showed RN(Registered Nurse)-G the insulin vials open and not dated and asked what is the facility's policy regarding insulin vials. RN-G stated once an insulin vial is opened it is dated with the date it was opened and only good for 28 days.
On [DATE] at 9:08 a.m. Surveyor observed the 300 hall medication cart. Surveyor observed R56 lispro insulin pen dated with an open date of [DATE] in the cart. Surveyor showed the insulin pen to LPN(licensed practical nurse)-F and asked after the lispro insulin pen is open how long can it be kept in use. LPN F stated that was a good question and stated he wasn't sure how long.
On [DATE] at 9:11 a.m. Surveyor observed the 400 hall medication cart. Surveyor observed R29 lispro insulin pen with an open date of [DATE] in the cart. Surveyor showed the insulin pen to RN-E and RN-E stated she will get rid of it.
Humalog, the makers of the lispro pen, indicate once the pen is opened it can be stored at room temperature for no more than 28 days and then must be discarded.
On [DATE] at 12:42 p.m. Surveyor interviewed DON (director of nursing)-B. Surveyor explained the observations regarding the insulin vials opened and not dated and the lispro pens opened and left in the cart past the 28 days. DON-B confirmed that the insulin vials need to be dated when opened and the lispro insulin pens need to be discarded after 28 days after it has been opened.
No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure hospice services providing end of life were coordinated for 1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility did not ensure hospice services providing end of life were coordinated for 1 (R32) of 3 sampled Residents receiving hospice services.
*R32 was admitted on hospice on 4/8/24. R32's hospice binder did not have a physician certification of terminal illness, physician orders, documentation of visits, schedule of hospice visits with hospice team listed, and the facility did not designate a specific individual of the facility's interdisciplinary team to act as a liaison between the facility and the hospice provider.
Findings Include:
Surveyor reviewed the facility's Hospice Program policy and procedure and notes the following applicable:
.Policy Interpretation and Implementation
9. In general, it is the responsibility of the hospice to manage the Resident's care as it relates to the terminal illness and related conditions, including:
a. Determining appropriate hospice plan of care
b. Changing the level of services provided when it is deemed appropriate
c. Providing medical direction, nursing and clinical management of the terminal illness
d. Providing spiritual, bereavement and/or psychosocial counseling and social services as needed
e. Providing medical supplies, durable medical equipment, and medications necessary for the palliation of pain and symptoms
10. In general, it is the responsibility of the facility to meet the Resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual Resident's needs.
d. Communicating with the hospice provider(and documenting such communication) to ensure that the needs of the Resident are addressed and met 24 hours per day.
12. Our facility has designated _____________________________ Name_____________________________ Title to coordinate care provided to the Resident by our facility staff and the hospice staff. He or she is responsible for the following:
a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for Residents receiving these services
b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the Resident and family.
d. Obtaining the following information from the hospice
1. The most recent hospice plan of care specific to each Resident
2. Hospice election form
3. Physician certification and recertification of the terminal illness specific to each Resident
4. Names and contact information for personnel involved in hospice care of each Resident
5. Instructions on how to access the hospice's 24-hour on-call system
6. Hospice medication information specific to each Resident
7. Hospice physician and attending physician(if any) orders specific to each Resident
13. Coordinated care plans for Residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility(including the responsible provider and discipline assigned to specific tasks) in order to maintain the Resident's highest practicable physical, mental and psychosocial well-being.
Surveyor also reviewed the Hospice-Nursing Facility Services Agreement effective on the 20th day of March, 2023 between Hospice and the Facility:
2. Responsibilities of Facility
(e) Coordination of Care
i. General-Facility shall participate in any meetings, when requested by Hospice, for the coordination of services provided to Hospice Patients.
ii. Design of Hospice Plan of Care-In accordance with applicable federal and state laws and regulations, facility shall coordinate with hospice in developing a hospice plan of care for each hospice patient that is consistent with the hospice philosophy and is responsive to the unique needs of each hospice patient and his or her expressed desire for hospice care.
v. Designated Facility Member-Facility shall designate a member of facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to each hospice patient provided by facility and hospice. Facility's designated interdisciplinary team member shall be responsible for:
1. Collaborating with hospice representatives and coordinating facility's participation in hospice's care planning process for hospice patients
2. Obtaining patient-specific information from hospice as required by applicable laws and regulations
3. Responsibilities of Hospice
(e) Provision of Information At a minimum, hospice shall provide the following information to the facility's designated interdisciplinary team member for each hospice patient residing at facility:
(1) Hospice plan of care, medications and orders-The most recent hospice plan of care, medication information and physician orders specific to each hospice patient residing at facility
(2) Election Form-The hospice election form and any advance directives
(3) Certifications-Physician certifications and recertifications of terminal illness
(4) Contact Information
(5) On Call System .
R32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Hypo-osmolality and Hyponatremia, and Gastro-Esophageal Reflux Disease. R32 has an activated health care power of attorney(HCPOA).
R32's Significant Change Minimum Data Set(MDS) dated [DATE] documents R32's Brief Interview for Mental Status(BIMS) score to be a 0 indicating R32 demonstrates severely impaired skills for daily decision making. R32 has no behaviors documented. R32's Patient Health Questionnaire(PHQ-9) score is 8 indicating mild depression. R32 has no range of motion(ROM) impairment on upper extremities, and does have ROM impairment on bilateral lower extremities. R32's MDS documents R32 is dependent for dressing, mobility and transfers.
Surveyor reviewed R32's certified nursing assistant(CNA) care card which does not document that R32 receives hospice services.
R32 has the following facility hospice care plan:
The resident is receiving hospice services 4/8/24
· The resident's comfort will be maintained through the review date. 4/8/24
· Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate.
[LPN,RN] 4/8/24
· Assess resident coping strategies and respect resident wishes.
[LPN,RN] 4/8/24
· Consult with physician and Social Services to have Hospice care for resident in the facility
[LPN,RN] 4/8/24
· Encourage resident to express feelings, listen with non-judgmental acceptance, compassion.
[LPN,RN] 4/8/24
· Encourage support system of family and friends 4/8/24
On 5/9/24 at 2:17 PM, Surveyor completed a record review of R32's hospice binder located at the nurse's station. Surveyor notes there is a hospice care plan in place as of 5/2/24. There is a list of staff on the outside of the binder and the phone number of hospice and details of when to contact. A Hospice Election of Benefit Statement signed 4/8/24 by R32's activated HCPOA.
The following items were not located in R32's hospice binder:
1. Physician certification of terminal illness
2. Schedule of when designated hospice care providers coming in to care for/visit R32
3. Any physician orders
4. Any documentation or communication from each hospice visit
On 5/13/24 at 8:57 AM, Surveyor asked R32 how things were going with the care provided by hospice. R32 responded, I don't know, are they supposed to see me?.
On 5/13/24 at 3:20 PM, Surveyor shared the concern with Administrator(NHA-A) and RN Consultant(RNC-C) that R32's hospice binder did not contain the required documentation that should have been obtained from hospice by the facility. Surveyor also shared there is no documentation of communication between the facility and hospice representatives to collaborate in providing care to/for R32. No further information was provided by the facility at this time.
On 5/14/24 at 7:30 AM, RNC-C informed Surveyor that social services is auditing all hospice binders to make sure all required information and documentation is in the binder. Surveyor asked RNC-C who is the designated liaison from the facility responsible for the coordination of care between the facility and hospice. RNC-C does not know.
On 5/14/24 at 1:53 PM, NHA-A informed Surveyor that R32's hospice provider was in the facility and updating R32's hospice documentation.
No additional information was provided as to why the facility did not ensure hospice services providing end of life were coordinated for R32.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility did not implement effective infection prevention measures. This included observation of a nurse touching medications with bare hands du...
Read full inspector narrative →
Based on observation, interview, and record review, the facility did not implement effective infection prevention measures. This included observation of a nurse touching medications with bare hands during medication pass on two occasions. Observation of two residents having their catheter bag on the floor multiple times during the survey affecting 2 of 4 residents sampled with catheter bags.
* The facility did not ensure R371 and R372's catheter bags were maintained in a sanitary manner.
Findings include:
The facility policy titled, Indwelling Catheter Use and Removal, with no implementation or revision date, states in part:
Compliance Guidelines:
.4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures .
.7.e. Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the bladder .
Surveyor notes no further infection prevention guidelines in policy.
1) .On 05/08/24 at 09:44 AM Surveyor interviewed R371 and learned they have had a catheter since 2019. Bag was hanging on bed frame with no privacy cover over.
On 05/09/24 at 01:30 PM Surveyor observed R371 in their room. R371 was in bed and the catheter bag was laying on the floor.
On 05/13/24 at 03:19 PM during the end of day meeting with Nursing Home Administrator (NHA)-A and Regional Nurse-C Surveyor shared concerns regarding observation of R371's catheter bag laying on the floor while in bed.
On 05/14/24 at 07:56 AM Surveyor observed catheter bag laying directly on the floor again and asked Director of Nursing (DON)-B to come take a look at something. DON-B saw the problem and commented that the bag was directly on the floor.
On 05/14/24 at 10:31 AM DON-B approached Surveyor and stated that the reason the bags have been touching or on the floor is that the beds have nowhere to hang them, they will need to find a solution. Surveyor notes having seen bag hanging from bed frame on separate observations.
2.) On 05/08/24 at 09:21 AM Surveyor observed R372 in bed sleeping, catheter bag laying on the floor.
On 05/08/24 at 09:54 AM Surveyor checked back and R372 was still sleeping and the catheter bag remained on the floor.
On 05/08/24 at 09:57 AM Surveyor spoke with the agency registered nurse in the hallway and was told that R372 has a groin abscess and a foley is in use because of abscess.
On 05/09/24 at 08:41 AM and 1:30 PM Surveyor observed the catheter bag off floor, hanging from bed frame.
On 05/13/24 at 03:19 PM during the end of day meeting with Nursing Home Administrator (NHA)-A and Regional Nurse-C Surveyor shared concerns regarding observations of R372's catheter bag laying on the floor while in bed.
On 05/14/24 at 07:56 AM Surveyor observed catheter bag hanging on bedframe, bottom of bag touching the floor and asked Director of Nursing (DON)-B to come take a look at something. DON-B saw the problem and commented that the bag was touching the floor.
On 05/14/24 at 10:31 AM DON-B approached Surveyor and stated that the reason the bags have been touching or on the floor is that the beds have nowhere to hang them, they will need to find a solution. Surveyor notes having seen bag hanging from bed frame on separate observations.
No additional information was provided.
3.) The facility's medication administration policy (undated) indicate:
Policy explanation and compliance guidelines: .
14. Remove medication from source, taking care not to touch medication with bare hand.
On 5/14/24 at 8:00 a.m. Surveyor observed LNP (licensed practical nurse)-F administer medication to R64. LPN-F proceeded to dispense the pills out of the medication bubble pack into his bare hands then place the pills into a medication cup. LPN-F proceeded to dispense the medication in this manner for 4 different pills.
On 5/14/24 at 8:06 a.m. Surveyor observed LPN-F administer medication to R42. LPN-F proceeded to dispense the pills out of the medication bubble pack into his bare hands then place the pills into a medication cup. LPN-F proceeded to dispense the medication in this manner for 6 different pills.
On 5/14/24 at 8:14 a.m. Surveyor interviewed LPN-F. Surveyor asked LPN-F if there was a reason why he dispensed R64 and R42 medications into his hands then place them in the medication cup. LPN-F told Surveyor he should have dispensed the medication in the medication cup.
On 5/14/24 at 12:42 p.m. Surveyor interviewed DON-B. Surveyor explained the observation of LPN-F dispensing medications into his hands then placing them in the medication cup. DON-B stated there have been many inservices regarding infection control procedures during medication pass. DON-B stated she understood the concern and had no addition information.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 6 (R2, R12, R33, R35, R39, & R46) of 13 Residents reviewed...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 6 (R2, R12, R33, R35, R39, & R46) of 13 Residents reviewed for a room change within the facility, were provided with prior written notice, including reason for the room change.
*R2 transferred to another room on 4/12/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer. There is no documentation that R2's guardian was provided written notice.
*R12 transferred to another room on 2/28/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer.
There is no documentation that R12's guardian was provided written notice.
*R33 transferred to another room on 4/9/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer.
*R35 transferred to another room on 4/30/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer.
*R39 transferred to another room on 4/10/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer.
There is no documentation that R39's activated Health Care Power of Attorney(HCPOA) was provided written notice.
*R46 transferred to another room on 4/15/24 and did not receive prior written notice, was not given a choice or rooms, and did not meet potential roommate prior to the transfer.
There is no documentation that R46's unactivated HCPOA was provided written notice.
Findings Include:
Surveyor reviewed the facility's Change of Room or Roommate policy and procedure dated 3/7/23 and notes the following:
.Policy Explanation and Compliance Guidelines:
4. Prior to making a room change or roommate assignment, all person involved in the change/assignment, such as Residents and their representatives, will be given advance notice of such a change as is possible.
5. The notice of a change in room or roommate will be provided in writing, in a language and manner the Resident and representative understands and will include the reason(s) why the move or change is required.
6. The social service staff can assist the Resident to adjust to the new room or roommate by:
a. Informing the Resident and family as soon as possible of the room or roommate change.
b. Involving the Resident in the decision and selection of a room or roommate when possible.
c. Allowing the Resident to ask questions about the move.
d. Showing the Resident where the room is located.
e. Introducing the Resident to his/her new roommate and sharing information about the new roommate while maintaining confidentiality regarding medical information in order to help the Resident become acquainted.
f. Introducing the Resident to employees who will be providing care.
g. Explaining to the Resident why the change is necessary; reassuring the Resident his/her personal possessions will be safeguarded.
7. The Social Service designee or Licensed Nurse should inform the Resident's sponsor/family in advance of a change in the Resident's room or roommate.
8. A Resident has the right to refuse a transfer to another room within the facility.
On 5/9/24 at 11:05 AM, Surveyor met with a group of Residents for the group interview to complete the Resident Council task during the surveyor process. R2 and R35 informed Surveyor that R2 and R35 had been transferred to another room without giving permission, was not given prior knowledge of the transfer, was not given choices of potential options for a new room, and was not provided opportunity to meet any potential new roommate. R2 and R35 informed Surveyor that a lot of room changes had been completed in the past couple of months.
On 5/13/24 at 11:09 AM, Surveyor requested a list of Resident room changes from Social Services Director(SSD-H). Surveyor completed an electronic medical record(EMR) audit and notes the following Residents had a room change and did not receive advance written notice, and there is no documentation that the Residents/representative gave consent.
1) R2 was admitted to the facility on [DATE] with diagnoses of Multiple Sclerosis, Type 2 Diabetes Mellitus, Hemiplegia, Affecting Right Dominant Side, Chronic Kidney Disease, Mild Intellectual Disabilities, Major Depressive Disorder, and Dementia. R2 has a legal guardian.
R2's Quarterly Minimum Data Set(MDS) dated [DATE] documents R2's Brief Interview for Mental Status(BIMS) score to be a 15, indicating R2 is cognitively intact for daily decision making.
On 5/9/24 at 11:05 AM, R2 informed Surveyor that R2 did not give permission to transfer to another room. R2 stated R2 did not want to move. R2 informed Surveyor that they walked in R2's room and stated R2 is transferring to another room, and R2 moved that same day to a new room.
R2's EMR documents R2 transferred rooms on 4/12/24.
R2's EMR contains no documentation that R2/representative was provided advance written notification of the room change, the reason for the room change, the opportunity to choose from a selection of roommates, and that R2 was provided the opportunity to meet any new potential roommates. Surveyor notes there is no documentation that R2/representative gave consent for the room transfer. Surveyor also notes there is no follow-up documentation to indicate how R2 was adjusting to the room transfer.
On 4/12/2024 LPN-Q documents in R2's EMR: Tolerating room change well.
2) R12 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following Cerebrovascular Disease Affecting Left Non-Dominant Side, Epilepsy, Major Depressive Disorder, and Delusional Disorders. R12 has a legal guardian.
R12's Quarterly Minimum Data Set(MDS) dated [DATE] documents R12's Brief Interview for Mental Status(BIMS) score to be a 1, indicating R12 is severely impaired for daily decision making.
R12 is non-interviewable.
R12's EMR documents R12 transferred rooms on 2/28/24.
R12's EMR contains no documentation that R12/representative was provided advance written notification of the room change, the reason for the room change, the opportunity to choose from a selection of roommates, and that R12 was provided the opportunity to meet any new potential roommates. Surveyor notes there is no documentation that R12/representative gave consent for the room transfer. Surveyor also notes there is no follow-up documentation to indicate how R12 was adjusting to the room transfer.
3) R33 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Human Immunodeficiency Virus, Unspecified Cirrhosis of Liver, Restlessness and Agitation, and Anxiety Disorder. R33 is his own person. R33's primary language is Spanish.
R33's Quarterly Minimum Data Set(MDS) dated [DATE] documents R33's Brief Interview for Mental Status(BIMS) score to be a 15, indicating R33 is cognitively intact for daily decision making.
R33 was not available for interview.
R33's EMR documents R33 transferred rooms on 4/9/24.
R33's EMR contains no documentation that R33 was provided advance written notification of the room change in a language R33 could understand, the reason for the room change, the opportunity to choose from a selection of roommates, and that R33 was provided the opportunity to meet any new potential roommates.
On 4/10/24 Registered Nurse(RN-O) documented in R33's EMR: Monitoring due to 4/9/24 room change. No issues noted. Seems okay with room change.
4) R35 was admitted to the facility on [DATE] with diagnoses of Chronic Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Venous Insufficiency, Major Depressive Disorder, and Anxiety Disorder. R35 is his own person.
R35's Quarterly Minimum Data Set(MDS) dated [DATE] documents R35's Brief Interview for Mental Status(BIMS) score to be a 15, indicating R35 is cognitively intact for daily decision making.
On 5/9/24 at 11:05 AM, R35 informed Surveyor that they came and told me I was moving with no knowledge. R35 informed Surveyor that R35 did not give permission to transfer rooms. R35 stated they just said you are moving. R35 stated that R35 had to transfer rooms that same day. R35 states R35 now has to share a bathroom.
R35's EMR documents R35 transferred rooms on 4/30/24.
R35's EMR contains no documentation that R35 was provided advance written notification of the room change, the reason for the room change, the opportunity to choose from a selection of roommates, and that R35 was provided the opportunity to meet any new potential roommates.
On 5/1/2024 Licensed Practical Nurse documented in R35's EMR: Moved from wing 6 and is adjusting.
5) R39 was admitted to the facility on [DATE] with diagnoses of Chronic Pulmonary Embolism, Bipolar Disorder, Anxiety Disorder, Dementia, and Schizophrenia. R39 has an activated HCPOA.
R39's Annual Minimum Data Set(MDS) dated [DATE] documents R33's Brief Interview for Mental Status(BIMS) score to be a 0, indicating R39 is severely impaired for daily decision making.
R39 is non interviewable.
R39's EMR documents R39 transferred rooms on 4/10/24.
R39's EMR contains no documentation that R39 was provided advance written notification of the room change, the reason for the room change, the opportunity to choose from a selection of roommates, and that R39 was provided the opportunity to meet any new potential roommates.
On 4/11/2024 RN-O documents in R39's EMR: R39 seems okay with 4/10/24 room change to wing 4
6) R46 was admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm of Unspecified Ovary, Bipolar Disorder, and Schizophrenia. R46 is currently her own person.
R46's Quarterly Minimum Data Set(MDS) dated [DATE] documents R46's Brief Interview for Mental Status(BIMS) score to be a 11, indicating R46 is moderately impaired for daily decision making.
R46 is non interviewable.
R46's EMR documents R46 transferred rooms on 4/15/24.
R46's EMR contains no documentation that R46 was provided advance written notification of the room change, the reason for the room change, the opportunity to choose from a selection of roommates, and that R46 was provided the opportunity to meet any new potential roommates.
On 4/19/2024, LPN-Q documented in R46's EMR: R46 is being monitored for room change. room change well. Resident is safe and continue to observe.
On 5/13/24 at 11:09 AM, Surveyor interviewed SSD-H in regards to the room transfers . SSD-H stated the facility got verbal consent from the Residents for the room transfers and the expectation would be that it should be documented in the Residents' progress notes. SSD-H stated the reason for all the room transfers was to move the more independent Residents in the front of the facility so that is what people saw when you first walked into the facility. SSD-H stated the facility moved all the dependent Residents with hoyers to the back of the facility. SSD-H informed Surveyor that Residents were moved due a dignity issue. SSD-H stated there is no written form that the Resident/representative is provided prior to the room transfers and that the Resident/representative consent to the room transfer would be documented in the Residents' EMR. SSD-H recalls giving advance notice for the room transfers but the facility could not guarantee the day of the room transfer that the room decided on would be the actual room the Resident transferred to.
On 5/13/24 at 3:20 PM, Surveyor shared the concern with Administrator(NHA-A) and RN Consultant(RNC-C) the concern that R2, R12, R33, R35, R39, & R46 were transferred to another room and were not provided advance written notice with an explanation of why the room transfer is required. Surveyor also shared there is no documentation that R2, R12, R33, R35, R39, & R46/representative gave consent for the room transfer.
No further information was provided by the facility at this time.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) R371 was admitted to the facility on [DATE] from the hospital with a primary diagnosis of paraplegia, complete; and other di...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) R371 was admitted to the facility on [DATE] from the hospital with a primary diagnosis of paraplegia, complete; and other diagnoses which include, in part, morbid obesity, chronic respiratory failure, local infection of the skin and subcutaneous tissue, fibromyalgia, and osteoarthritis.
R371's admission Minimum Data Set (MDS) with an assessment reference date of 5/5/24 indicated R371 had a Brief Interview for Mental Status score of 15 (fully intact memory). R371 is able to make decisions for themselves. R371's MDS showed that upper extremities have no impairment and lower extremities have impairment on both sides. R371 uses a wheelchair for mobility.
R371 has a physician order for enabler bars to assist with self positioning dated 4/29/2024.
On 05/08/24 at 09:49 AM Surveyor notes observing enabler bars on R371's bed.
On 5/9/2024 at 10:32 AM Surveyor reviewed a Screening Tool form completed by Evolve Therapy Services with a note stating Patient does have ability to utilize assist bar on bed to improve bed mobility. Surveyor notes this was completed on the same day that the assessment information was requested from the facility, 10 days after physician order and admission.
On 05/13/24 at 08:29 AM Surveyor reviewed the signed Consent for Use of Assistive Devices/Physical Restraints form provided by the Facility. The form was signed by R371 on 5/12/2024. Surveyor notes that this is after the date (5/9/2024) this was requested from Facility by Surveyor.
On 05/13/24 at 03:19 PM Surveyor informed Nursing Home Administrator-A and Regional Nurse-C of the above concerns. No further information was provided.
6.) R44 was admitted to the facility on [DATE]. R44 has a primary diagnosis of type 2 diabetes mellitus; and other diagnoses which include, in part, chronic kidney disease and dementia.
R44's Quarterly Minimum Data Set (MDS) with an assessment reference date of 4/27/24 indicated R44 had a Brief Interview for Mental Status score of 00 (severe cognitive impairment). R44 is not able to make decisions for themselves. R44's MDS showed that upper extremities and lower extremities have no impairment on both sides. R44 uses a wheelchair for mobility.
R44 has a physician order for 1/4 side rails x2 to assist with self positioning dated 2/13/2023.
On 05/08/24 at 02:02 PM Surveyor notes observing side rails on R44's bed.
On 05/13/24 at 08:29 AM Surveyor reviewed the signed Consent for Use of Assistive Devices/Physical Restraints form provided by the Facility. The form was signed by R44 on 5/12/2024. Surveyor notes that this is after the date (5/9/2024) this was requested from Facility by Surveyor. Surveyor notes that R44 has an activated health care power or attorney and is not able to make decisions for self.
On 05/13/24 at 03:19 PM Surveyor informed Nursing Home Administrator-A and Regional Nurse-C of the above concern. No further information was provided.
7.) R12 was admitted to the facility on [DATE] with a primary diagnosis of stroke.
R12's Quarterly Minimum Data Set (MDS) with an assessment reference date of 5/1/24 indicated R12 had a Brief Interview for Mental Status score of 01 (severe cognitive impairment). R12 is not able to make decisions for themselves. R12's MDS showed that upper extremities and lower extremities have impairment on both sides.
R12 has a physician order for 1/2 side rail x1 to aid in positioning dated 5/15/2023.
On 05/08/24 at 01:43 PM Surveyor notes observing side rail on R12's bed.
On 05/13/24 at 08:29 AM Surveyor reviewed the signed Consent for Use of Assistive Devices/Physical Restraints form provided by the Facility. The form shows telephone consent was given by R12's Power of Attorney on 5/12/2024. Surveyor notes that this is after the date (5/9/2024) this was requested from Facility by Surveyor.
On 05/13/24 at 03:19 PM Surveyor informed Nursing Home Administrator-A and Regional Nurse-C of the above concern. No further information was provided.
Based on observation, interview, and record review the facility did not have evidence that it attempted appropriate alternatives prior to installation of bed rails, did not have evidence it assessed residents at risk of entrapment from bed rails prior to installation, did not have evidence the risks and benefits of bed rails were discussed with the Resident and/or resident representatives and that informed consent was obtained prior to installation for 7 (R32, R36, R60, R371, R44, R12, and R52) of 7 Residents reviewed for repositioning bars.
*R32 has a physician order dated 3/14/23 for bilateral quarter side rails. R32 did not have an assesment completed and consent discussing risks and benefits signed prior to installation.
*R33 has a physician order dated 5/16/23 for bilateral 1/2 side rails. R60 did not have an assesment completed and consent discussing risks and benefits signed prior to installation.
*R60 has a physician order dated 8/21/23 for bilateral enabler bars. R32 did not have an assesment completed and consent discussing risks and benefits signed prior to installation.
*R371 had no comprehensive assessment prior to use of enabler bars and had no signed consent for enabler bars.
*R44 had no signed consent for enabler bars.
*R12 had no signed consent for enabler bars.
*R52's care plan indicates padded 1/4 side rails added on 2/13/23, consent from representative explaining risks and benefits was not obtained until 5/13/24.
Findings Include:
Surveyor reviewed the undated facility's Proper Use of Bed Rails policy and procedure and notes the following applicable:
.Policy:
It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails.
Resident Assessment
1. As part of the Resident's comprehensive assessment, components will be considered when determining the Resident's needs, and whether or not the use of bed rails meets the needs.
2. The Resident assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the Resident's assessed needs.
3. The Resident assessment must also assess the Resident's risk from using bed rails.
4. The Resident assessment should assess the Resident's risks of entrapment between the mattress and bed rail or in the bed rail itself.
5. The facility will assess to determine if the bed rail meets the definition of a restraint. A bed rail is considered to be a restraint if the bed rail keeps a Resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently. If it is determined to be a restraint, the facility will follow their procedures related to physical restraints.
Informed Consent
6. Informed consent from the Resident or Resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. This information should be presented in an understandable manner, and consent given voluntarily, free from coercion.
7. The information that the facility should provide to the Resident, or Resident representative includes, but is not limited to:
a. What assessed medical needs would be addressed by the use of bed rails
b. The Resident's benefits from the use of bed rails and the likelihood of these benefits
c. The Resident's risks from the use of bed rails and how these risks will be mitigated
d. Alternatives attempted that failed to meet the Resident's needs and alternatives considered but not attempted because they were considered to be inappropriate.
8. Upon receiving informed consent, the facility will obtain a physician's order for the use of the specified bed rail and medical diagnosis, condition, symptom, or functional reason for the use of the bed rail.
Appropriate Alternatives
9. The facility will attempt to use appropriate alternatives prior to installing or using bed rails.
10. Alternatives that are attempted should be appropriate for the Resident, safe and address the medical conditions, symptoms or behavioral patterns for which a bed rail was considered.
11. If no appropriate alternatives are identified, the medical record should include evidence of the following:
a. Purpose for which the bed rail was intended and evidence that alternatives were tried and were not successful
b. Assessment of the Resident, the bed, the mattress, and rail for entrapment risk
c. Risks and benefits were reviewed with the Resident representative, and informed consent was given before installation or use
Ongoing Monitoring and Supervision
15. The facility will continue to provide necessary treatment and care to the Resident who has bed rails in accordance with professional standards of practices and the Resident's choices. This should be evidenced in the Resident's records, including their care plan, including, but not limited to, the following information:
a. The type of specific direct monitoring and supervision provided during the use of the bed rails, including the documentation of the monitoring
b. The identification of how needs will be met during use of the bed rails, such as for re-positioning, hydration, meals, use of the bathroom and hygiene
c. Ongoing assessment to assure that the bed rail is used to meet the Resident's needs
d. Ongoing evaluation of risks
e. The identification of who may determine when the bed rail will be discontinued
f. The identification and interventions to address any residual effects of the bed rail
16. Responsibilities of ongoing monitoring and supervision are specified as follows:
a. Direct care staff will be responsible for care and treatment in accordance with plan of care.
b. A nurse assigned to the Resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, or a change in the type of of bed/mattress/rail
c. The interdisciplinary team will make decisions regarding when the bed rail will be used or discontinued, or when to revise the care plan to address any residual effects of the bed rail .
On 5/13/24, Director of Nursing(DON-B) provided documentation of an audit dated 5/2/24 that had been initiated to define what Residents had enabler bars or quarter rails. DON-B also provided documentation of correction education dated 5/9/24 which included the following:
-Any Resident that has enabler bars/side rails must have a safety evaluation completed
-Therapy should be notified to screen/eval for bed mobility
-Any Resident with a Enabler Bar/Side Rail must have a Consent for Use of Assistive Devices/Physical Restraints form completed explaining the Risk and Benefits of the device used
The Consent for Use of Assistive Devices/Physical Restraints documents the following:
The use of assistive devices/physical restraints presents benefits to the Residents as well as potential negative outcomes. In accordance with the facility policy, an assessment will be performed to determine the least restrictive device/physical restraint, deemed appropriate related to the Resident's medical condition and to attain or maintain the highest practicable level of physical and psychosocial well-being. A physician order will be obtained, and a personalized care plan/service will be developed.
The form includes a list of potential benefits and potential negative outcomes.
1) R32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Type 2 Diabetes Mellitus, Hypo-osmolality and Hyponatremia, and Gastro-Esophageal Reflux Disease. R32 has an activated health care power of attorney(HCPOA).
R32's Significant Change Minimum Data Set(MDS) dated [DATE] documents R32's Brief Interview for Mental Status(BIMS) score to be a 0 indicating R32 demonstrates severely impaired skills for daily decision making. R32 has no behaviors documented. R32's Patient Health Questionnaire(PHQ-9) score is 8 indicating mild depression. R32 has no range of motion(ROM) impairment on upper extremities, and does have ROM impairment on bilateral lower extremities. R32's MDS documents R32 is dependent for dressing, mobility and transfers.
R32's Certified Nursing Assistant(CNA) card documents that R32 has enabler bars times 2 with positioning and bed mobility.
R32's physician orders document that R32 has had 1/4 side rails times 2 for positioning effective 3/14/23.
Surveyor reviewed R32's comprehensive care plan and notes the following about R32's 1/4 side rails:
R32 has Impaired Mobility due to weakness, metabolic encephalopathy Initiated 1/13/22
Interventions Include:
·Bed mobility/Repositioning: Assist 2 and 1/4 side rail x2 1/13/22
·Therapy to screen/eval for needs 1/13/22
·Transfers with assist of 2 and HOYER. Full body sling / Large sling 1/16/22
·Update MD prn 1/13/22
On 5/8/24 at 9:25 AM, Surveyor observed R32 in bed, head of bed elevated and quarter side rails on both sides of R32's bed.
On 5/9/24 at 1:00 PM, Surveyor observed R32 in bed with quarter side rails on both sides of R32's bed. R32 informed Surveyor that R32 uses them to turn over.
On 5/9/24 at 1:40 PM. Surveyor is unable to locate R32's side rail assessment or consent in R32's electronic medical record(EMR). At this time, Surveyor requested additional information in regards to a side rail assessment and consent for R32's quarter side rails.
On 5/13/24 at 8:06 AM, the facility provided Surveyor with a side rail assessment dated [DATE] and a verbal consent obtained from R32's representative dated 5/12/24.
2) R33 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Human Immunodeficiency Virus, Unspecified Cirrhosis of Liver, Restlessness and Agitation, and Anxiety Disorder. R33 is his own person. R33's primary language is Spanish.
R33's Quarterly Minimum Data Set(MDS) dated [DATE] documents R33's Brief Interview for Mental Status(BIMS) score to be a 15, indicating R33 is cognitively intact for daily decision making. R33's MDS also documents that R33 has range of motion impairment on both upper and lower extremities on both sides. The MDS documents that R33 is dependent for upper and lower body dressing, mobility, and transfers.
R33's Certified Nursing Assistant(CNA) card documents that R32 has enabler bars times 2 with positioning and bed mobility.
R33's physician orders document that R33 has had 1/2 side rails times 2 to aide in positioning effective 5/16/23.
Surveyor reviewed R33's comprehensive care plan and notes the following about R32's 1/4 side rails:
Self care deficit r/t generalized weakness, impaired cognition, quadriplegia Initiated 4/8/20
Interventions Include:
·L LE PROM, AARM R LR 10-15 reps, 1-2 sets daily 7/6/20
·ASSIST OF 1 WITH ADLs 4/8/20
·Assist of 1 with bed mobility and 1/2 side rails x 2 4/8/20
·Assist of 2 transfer with Hoyer. Full body sling / Xlarge. No Ambulation, High back W/C with mobility. 4/8/20
·Bathing: A1 4/8/20
·Dressing: Assist x1 with UB and LB dressing and grooming 4/8/20
·Eating: tray table appropriate height to keep hand from sliding, tray close to him, scoop/divider plate, vertical fork and spoon, cup with handle/lid/straw if having difficulty, dicem under plate/bowl, no small bowls 4/8/20
·High back w/c, chair slightly reclined, should not be upright, foot drop shoes on while in W/C and foot rests on. 4/8/20
·Soft touch call light, pinned to bed near right hip 4/8/20
·Toileting: Assist x2 using Hoyer Lift to and from bed and W/C with toileting, Assist x1 with hygiene 4/8/20
On 5/8/24 at 9:43 AM, Surveyor observed 1/2 siderails on both sides of R33's bed. Head of bed elevated more that 45. Bed in regular position.
On 5/9/24 at 1:39 PM, Surveyor is unable to locate a side rail assessment and consent for R33 in R33's EMR. At this time, Surveyor requested additional information in regards to a side rail assessment and consent for R33's 1/2 side rails.
On 5/13/24 at 8:06 AM, Surveyor received R33's side rail assessment dated [DATE] and a consent form with no date.
3) R60 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction due to Unspecified Occlusion, Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease Affecting Left Dominant Side, Type 2 Diabetes Mellitus, End Stage Renal Disease, and Major Depressive Disorder. R60 has an activated Health Care Power of Attorney(HCPOA).
R60's Quarterly Minimum Data Set(MDS) dated [DATE] documents R60's Brief Interview for Mental Status(BIMS) score to be a 13, indicating R60 is cognitively intact for decision making. R60 has no mood issues and R60 can have verbal behaviors 1-3 days. R60 has range of motion(ROM) impairment on 1 side of both upper and lower extremities. R60 is dependent for upper and lower dressing and transfers. R60 requires substantial to max assist for mobility.
Surveyor requested R60's Certified Nursing Assistant(CNA) card but the facility did not provide.
R60's physician orders document that R60 has had enabler bars times 2 for assist with self positioning effective 8/21/23.
Surveyor reviewed R60's comprehensive care plan and notes the following about R60's enabler bars:
Self care deficit r/t CVA with deficits - left-sided weakness Initiated 7/2/23
Interventions put into place on 7/2/23:
·Assist x1
·Dressing: Assist x1 with UB and LB dressing and grooming
·enabler bars x 2 to enable independent repositioning/assist with repositioning. Assist x2 with bed mobility
·Encourage resident to complete as many ADL's for self as is able
·Personal Hygiene - A1
·set up for meals: set up/ can feed self need encouragement
·Toileting: has colostomy, can use urinal with assist - urinates rarely due to dialysis
·Transfers with Hoyer Assist of 2 Large/ Full Body. No Ambulation, Assist with W/C mobility,
On 5/9/24 at 8:30 AM, Surveyor observed R60 in bed, eating breakfast with enabler bars on both sides of the bed.
On 5/9/24 at 1:04 PM, R60 informed Surveyor that R60 uses the enabler bars for repositioning.
On 5/9/24 at 1:47 PM, Surveyor was unable to locate an enabler bar assessment or consent in R60's EMR. At this time, Surveyor requested additional information in regards to a side rail assessment and consent for R60's enabler bars.
On 5/13/24 at 8:06 AM, Surveyor received R60's enabler bar assessment and consent both dated 5/9/24.
On 5/13/24 at 9:54 AM, Director of Nursing(DON-B) informed Surveyor that an audit was completed on 5/2/24 to identify what Residents had side rails or enabler bars. DON-B stated an education on side rails and enabler bars was completed on 5/9/24.
On 5/13/24 at 3:20 PM, Surveyor shared the concern with Administrator(NHA-A) and RN Consultant(RNC-C) the concern that R32, R33, and R60 did not have a side rail/enabler bar assessment completed prior to placing on the bed and there was no consent signed prior to placement which explained the risks/benefits of the devices. No further information was provided by the facility at this time.
On 5/14/24 at 9:23 AM, Registered Nurse(RN-E) confirmed that R32, R33, and R60 use their bars on the bed to help turn and reposition.
4.) R52 was re-admitted to the facility on [DATE] with diagnosis that included Cerebral palsy, asthma, blindness right eye, major depressive disorder, bipolar disorder, developmental disorder, anxiety, seizures. R52 was originally admitted to the facility on [DATE].
Surveyor conducted a review of R52's plan of care that indicates R52 has the potential for falls, accidents and incidents due to immobility, impaired cognition, unaware of safety needs. Interventions included padded side rail to prevent bruising to extremities from swatting/ hitting when anxious. The need for padded side rail was added on 8/10/23.
The plan of care also states that R52 has self- care deficit due to cognitive deficits, disease process/ progression due to his cerebral palsy, blind in both eyes. Interventions include that R52 needs the assist of 1 for bed mobility. Also the use of 1/4 side rails to aide in positioning was added to the plan of care on 2/13/23.
The admission/ readmission/ routine head to toe evaluation, dated 3/2/24, description quarterly' states that R52 uses an enabler/ assistive device that assists in the improvement in the resident's functional status. This is not considered a restraint for R52. The physician order reflecting the device, medical symptoms, and timeframe to be used is completed along with the consent and enabler/ assistive device care plan.
On 5/13/24 at 3:15 p.m., Surveyor requested to review information for the use of the enabler bars for R52. This was to include the consent for the use and comprehensive assessment. Additionally, Surveyor shared observations of R52's enabler bars that were connected to the right and left side of the bed. The bars had foam taped to the bars with duct tape . There were many areas in which the duct tape was torn and the foam was not fastened to the enabler bar.
On 5/14/24 at 8:00 a.m., Surveyor was provided with a copy of the consent form for the use of enabler bars for R52, dated 5/13/24. The consent was received via telephone from R52's Guardian. RN- Consultant- C stated that therapy will be evaluating R 52's enabler bars and will be replacing then with something that is padded. The foam was used originally because R52 had some bruising believed to be from the enabler bars.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on record review, observation and interview the facility did not distribute and serve food in a manner that prevents foodborne illness to 74 out of 74 (census 76, 2 NPO) residents who receive th...
Read full inspector narrative →
Based on record review, observation and interview the facility did not distribute and serve food in a manner that prevents foodborne illness to 74 out of 74 (census 76, 2 NPO) residents who receive their meals from the main serving kitchen.
*Cook-K was observed grabbing ready to eat food with gloved hands, after touching non-sanitized food surfaces, and placing the ready to eat food on plates for residents to eat.
*Dietary Aide-M was observed touching nose with gloved hands while transferring yogurt from large container to individual service containers.
Findings include:
The facility policy titled, Food Safety-Food Handling with revision date, 7/20/2019, states in part:
Purpose
To ensure food handling practices are consistent with USDA Food Code guidelines. To comply with federal and state regulations governing food safety and prevention of foodborne illness and to comply with state and local ordinances governing food safety.
Policy
1. Food handling practices shall be completed in a manner to protect food safety and avoid cross contamination.
2. Safe food practices shall be consistent with the USDA Food Code and shall include the following: .
c. proper handwashing and correct use of gloves;
d. proper handling of dishes and equipment; .
The facility policy titled, Food Safety Requirements with revision date, 1/2024, states in part:
Policy:
.Food will be stored, prepared, distributed and served in accordance with professional standards for food service safety.
Policy Explanation and Compliance Guidelines:
1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following:
.d. Distribution and service of food to the resident, including transportation, set up, and assistance.
.f. Employee hygienic practices .
Example 1
On 05/09/24 at 12:00 PM Surveyor observed Cook-K wearing gloves on both hands, grab the metal food cart, open door then touch the top of the cart and plate lids. Using same dirty gloves, did not wash hands, grabs ready to eat biscuit and places it on plate for resident to eat.
On 05/09/24 at 12:01 PM Surveyor observed Cook-K wearing same gloves on both hands, grab the metal food cart, and grab plate lids. Using same dirty gloves, did not wash hands, grabs ready to eat biscuit and places it on plate for resident to eat.
On 05/09/24 at 12:02 PM Surveyor observed Cook-K wearing same gloves on both hands, grab the metal food cart, open door then touch the top of the cart and plate lids. Using same dirty gloves, did not wash hands, with right and left gloved hands grabs two ready to eat biscuits and places on plates for residents to eat.
On 05/09/24 at 12:03 PM Surveyor observed [NAME] wearing same gloves on both hands, grab the metal food cart. Using same dirty gloves, did not wash hands, grabs ready to eat biscuit and places it on plate for resident to eat.
On 05/09/24 at 12:03 PM Surveyor observed Cook-K wearing same gloves on both hands, touching food lids, using same dirty gloves, did not wash hands, with right and left gloved hands grabs two ready to eat biscuits and places on plates for residents to eat.
On 05/09/24 at 12:03 PM Surveyor asked Food Service Director-N if all food served for the entire facility comes from this steam table and it was confirmed that all food served comes from this steam table.
On 05/09/24 at 12:06 PM Surveyor observed Cook-K wearing same gloves on both hands, grab a new metal food cart and using same dirty gloves, did not wash hands, with right gloved hand grabs ready to eat biscuit and places it on plate for resident to eat.
On 05/09/24 at 12:08 PM Surveyor observes as Cook-K continues using same gloves, grabs ready to eat biscuit with right dirty gloved hand and places on plate for resident to eat, did not wash hands or put on new gloves.
On 05/09/24 at 12:10 PM Surveyor observed Cook-K wearing same gloves on both hands, grab the metal food cart door, wipe nose with right gloved hand and using same dirty gloves, did not wash hands, with right and left gloved hands grabs two ready to eat biscuits and places them on plates for residents to eat.
On 05/09/24 at 12:12 PM Surveyor observed Cook-K wearing same gloves on both hands, grab a metal food cart door and using same gloves, did not wash hands, with right dirty gloved hand grabs ready to eat biscuit and places on plate for resident to eat.
On 05/09/24 at 12:14 PM Surveyor observed Cook-K continue using same gloves, grabs ready to eat biscuit with right dirty gloved hand and places on plate for resident to eat, did not wash hands or put on new gloves.
On 05/09/24 at 12:16 PM Surveyor observes as Cook-K continues using same gloves, grabs ready to eat biscuit with right dirty gloved hand and places on plate for resident to eat, did not wash hands or put on new gloves.
On 05/09/24 at 12:19 PM Surveyor observed Cook-K remove gloves.
On 05/09/24 at 12:20 PM Surveyor observed Cook-K put on new gloves, but did not wash hands.
On 05/09/24 at 12:21 PM Surveyor observed Cook-K remove gloves and wash hands before carrying plates of ready to eat food to dining room.
Surveyor noted that Cook-K did not wash hands or change gloves after touching non-sanitized food surfaces and prior to touching ready to eat food.
Dietary Aide-M Observations
On 05/09/24 at 11:55 AM Surveyor observed Dietary Aide-M scooping yogurt from a larger container into small plastic containers, Dietary Aide-M was wearing gloves on both hands. Surveyor observed Dietary Aide-M wiping nose with gloves while scooping the yogurt then continue scooping, did not remove gloves or wash hands.
On 05/09/24 at 11:56 AM Surveyor observed Dietary Aide-M wipe nose again without changing gloves or washing hands.
Surveyor noted that Dietary Aide-M did not wash hands or change gloves after touching nose.
On 05/14/24 at 09:18 AM Surveyor interviewed Food Service Director-N regarding staffing. It was stated that staffing in kitchen is usually made up of 2 dietary aides and 1 [NAME] for both morning and second shift. Food Service Director-N stated no staffing issues observed or identified on survey.
On 05/14/24 at 09:23 AM Surveyor informed Food Service Director-N of observations with Dietary Aide-M and Cook-K touching/handling ready to eat food with gloves after wiping nose and touching non-sanitized food surfaces. When asked if they should be washing hands or using utensils to handle ready to eat food, states staff is expected to use tongs and utensils to handle ready to eat food, should be washing hands and changing gloves. Surveyor asked how many people are served out of the kitchen steam table, Food Service Director-N states all in census minus 2 who are NPO. States going forward will work to ensure that staff are using utensils to handle ready to eat food.
No further information was provided as to why the facility did not ensure that food was distributed and served in accordance with professional standards for food service safety.
Nov 2023
5 deficiencies
2 IJ
CRITICAL
(J)
📢 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
Deficiency F0740
(Tag F0740)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R4 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Chronic Kid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) R4 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Chronic Kidney Disease, Stage 3, Type 2 Diabetes Mellitus, Anxiety Disorder and Major Depressive Disorder. R4 is his own person.
Surveyor reviewed R4's Quarterly Minimum Data Set (MDS) dated [DATE] documents R4's Brief Interview for Mental Status (BIMS) score to be a 15 which indicates that R4 is cognitively intact for daily decision making. R4's Patient Health Questionnaire(PHQ-9) score of 5 indicates that R4 has mild depression present and R4's MDS does not document any behaviors. R4's MDS documents that R4 requires limited assistance for bed mobility, transfers, dressing, and toileting and has range of motion impairment on both upper and lower of 1 side. R4 is mobile with an electric wheelchair.
Surveyor reviewed R4's comprehensive care plan and notes the following applicable:
1. R4 has a history of substance use disorder due to use of/addiction to illegal drugs. R4's drug of choice is/was marijuana; use of/addiction to alcohol-Initiated 5/2/23
There are only 2 updated interventions implemented since 5/2/23
-In house AA offered-Initiated 8/11/23
-R4 was presented with behavior contract, R4 refused to sign-Initiated 9/15/23
2. R4 has potential to demonstrate verbally/physically abusive behaviors due to poor impulse control, history of verbal altercation with peer-Initiated 11/18/23
There is 1 updated intervention since 11/18/23
-30 day notice given but refused to sign-Created 10/13/23
3. R4 has a behavior problem. R4 told another Resident R4 wanted to make a bomb-Created 10/13/23
Interventions put into place on 10/13/23
-Ask R4 to let staff search items delivered to facility or brought into facility upon return while off grounds. R4 agreed.
-Notify local police department of R4's threats to self or others
-R4 issued 30 day discharge notice
4. I am/have experienced trauma in my life. R4 recently had a friend/Resident that was close move to another facility-Initiated 9/11/23
-R4 enjoys visiting and reminiscing about spouse, family provided 1:1 visits by offering time voice R4's feelings to offer validation and provide support and encouragement-Created 9/11/23
5. R4's Intimacy and Sexual Preferences-currently in a relationship with a female Resident in facility, thoughts of being in a relationship, is hand holding, giving and receiving gifts, hugging, kissing, showing that R4 cares, and someone to talk with-Created 4/14/23, Revised 5/23/23
-Intimacy and Sexual Assessment to be completed on admission. Will be updated quarterly, annually and with any significant change of condition-Initiated 4/14/23
-Involve Resident/family/guardian/POA as indicated-Initiated 4/14/23
-R4 is not to visit female that R4 has relationship in her room and she is not to be in R4's room-Initiated 8/24/23
-R4 does also agree to visit with girlfriend outside of room in a public setting-Revised 8/24/23
-Social Worker will be available to meet with R4 regarding choices-Initiated 4/14/23
6. R4 displays socially inappropriate behaviors related to R4 calls 911 inappropriately for care services-Initiated 5/15/23
-Meet with R4 when feeling anxious-Initiated 5/15/23
-R4 is not allowed on Wing 4-Created 10/9/23
R4's Social Services Evaluation completed 1/4/21 documents R4 has a long history of alcohol and substance abuse along with being treated by a psychiatrist for anxiety and depression many years ago.
R4 has 2 Trauma Informed Care Assessments
12/25/22-Happened to R4 is checked for any other unwanted sexual experiences-it is documented at the end of the evaluation that a female Resident went into R4's room and attempted to inappropriately touch R4. R4 notified staff and police were called. Female was removed from R4's room immediately and placed in her room.
6/18/23-Happened to R4 is checked for physical assault, assault with a weapon-it is documented at the end of the evaluation that R4 was hit and scratched by peer in the facility.
R4 has 1 Recommendations for Addressing Resident Relationships Intimacy and Sexuality completed 4/12/23. The answers R4 provided indicate that R4 is comfortable with receiving or giving affection such as kissing, hug, soothing touch. It indicates that a care plan was initiated.
R4 has 2 Substance Abuse Evaluations
8/10/23-Asks 3 questions
1. Family history of substance abuse-circled for illegal drugs
2. Personal history of substance abuse-circled for illegal drugs
3. No history of Psychological disease
Surveyor notes there is a scoring total but it is blank and there is no interpretation guide. The evaluation is not signed by whom completed it.
9/8/23-R4 currently or have a history of illegal drug use, currently/history of association with substance using peers, and family currently/history of substance use putting R4 at High Risk for substance use.
Surveyor notes that documentation provided indicates R4 has only been reviewed by the behavior interdisciplinary team (IDT) one time since admission on [DATE]. No behaviors are noted and medication adjustments made.
On 9/15/23, R4 was given a Behavior Contract that R4 refused to sign. R4's Behavior Contract is not specific as to what behaviors R4 is displaying that would warrant a behavior contract. The behavior contract mentions the use of illegal substances in a general term, but not specific to R4. The behavior contract is not person-centered and does not explain specific steps to decrease or stop any behaviors of R4.
Surveyor reviewed R4's current physician orders, Medication (MARS) and Treatment Administration Record (TARS) for October and notes the following:
1.The facility was monitoring conducting substance abuse monitoring:Visually check on R4's whereabouts and monitor for suspicious behaviors and/or signs and symptoms of alcohol/illicit drug use and drug overdose every shift. Start date of 8/11/23
2. 15 minute checks for suspected abuse every shift from 10/12/23-10/16/23
Surveyor notes there is no physician order to hold medications if suspected of alcohol or illicit drug use.
3. Monitor for self isolation, increased withdrawing, tearfulness, voicing feelings of sadness, decreased appetite, change in social behavior. Document Y if having depressive symptoms or N if no symptoms. Update Social Services every shift if increase in symptoms-Start date of 4/14/23
Surveyor notes this is completely blank with no Y or N documented for any day of October.
On 10/30/23 at 9:34 AM, Surveyor completed a record review of R4's progress notes located in R4's EMR. Surveyor reviewed progress notes from 8/1/23 to current date. Surveyor notes there are very few entries of any behavior issues with R4. There is no documentation indicating why the behavior contract was issued on 9/15/23.
-On 9/25/23, it is documented by Social Services Director (SSD-C) that a room search was completed and 2 cans of beer was found in R4's room along with a package of delta 8 which was purchased at the local gas station.
-On 10/2/23, it is documented that SSD-C attempted to speak with R4 regarding bringing alcohol into the facility.
- On 10/3/23 Licensed Practical Nurse (LPN-E) documented I was told that R4 is not allowed to be on wing 4 because R4 was found in bed with R32. Surveyor notes there was no thorough investigation of this alleged incident.
-On 10/4/23, it documented by Social Worker (SW-D) that SW-D informed R4, R4 could not be on another's Resident's wing.
From 10/4/23-10/12/23, it is documented that R4 has had no behaviors.
On 10/12/23, another Resident (R5) called the police accusing R4 of making a bomb and had plans to blow up the facility. The police department came to the facility and investigated #23-010442. The police investigated and found the allegations to not be credible and there is no evidence that R4 is a threat to the facility. It also noted, in the search of R4's room, the police document that no other illegal contraband was found.
On 10/12/23 at 6:37 PM, SSD-C issued a 30 day discharge notice to R4. It is not documented the specific reason why the 30 day discharge was issued in R4's EMR. The following is documented by SSD-C in regards to R4's 30 day: writer went over the document with R4, answered any questions or concern R4 had, R4 understood document but refused to sign. Copy given to R4 and document was emailed over to ombudsman. Caseworkers were also notified. No additional questions or concerns.
Surveyor was provided 15 minute checks that started 10/12/23 until 10/16/23 for R4 and documents the reason as suspected substance abuse. There is no documentation that R4 was suspected of substance abuse on 10/12/23. There is documentation that R4 is being monitored for possible threat to others. Surveyor notes the discrepancy for the reason why R4 is on 15 minute checks.
Surveyor notes there are no documented behaviors from 10/12/23-11/2/23 in R4's progress notes.
On 10/30/23 at 9:30 AM, Surveyor introduced self to R4 and asked questions to get to know R4. R4 stated that art is my happy place. R4 also stated that R4 has felt bad about being accused of making a bomb, something that was not true. They did me wrong.
Surveyor notes there is no care plan revision in regards to how R4 feels due to this accusation, and no new Trauma Informed Care Assessment was completed after the 10/12/23. incident.
On 10/30/23 at 10:12 AM, Surveyor interviewed Social Worker (SW-D) in regards to R4. SW-D informed Surveyor that R4 has never displayed any harmful behaviors. R4 only has quirks. SW-D was surprised by the accusation that R4 may have been making a bomb.
On 10/30/23 at 10:40 AM, Surveyor interviewed SSD-C in regards to R4. SSD-C stated a 30 day involuntary discharge notice was given to R4 because of past alcohol issues and safety of others, but was not able to elaborate as to why R4 was given the notice for alcohol issues when other Residents also have the same issue.
On 10/31/23 at 11:55 AM, Surveyor interviewed both SSD-C and SW-D at the same time. SSD-C and SW-D both stated that R4 does not consume alcohol. Both SSD-C and SW-D confirmed that R4's behavior contract dated 9/15/23 has not been updated and should be to reflect R4's current behavior status with interventions. SW-D stated that R4 follows the rules to the best of R4's ability. SW-D meets with R4 daily but has not documented the 1:1 interactions. SW-D stated it has not been confirmed that R4 was bringing in alcohol for other Residents. SW-D stated R4 has had no behavior issues. Both SSD-C and SW-D understand that the expectation would be that with any new behaviors, the behavior contract and care plan should be be updated.
On 10/31/23 at 3:10 PM, Surveyor shared the concern with Regional Director of Op (RDO-G), Administrator (NHA-A), Interim Director of Nursing(DON-B), and Clinical Specialist(CS-I) that R4's behavior contract and care plan have not been updated to reflect person-centered interventions with specific behaviors. Surveyor shared the concern that trauma and substance abuse assessments have been completed, but interpreting the results and implementing a person centered care plan with interventions has not been completed by the facility. Surveyor also shared the concern that R4's physician orders have not been updated to reflect medications should be held with suspected use of alcohol. No further information was provided by the facility at this time.
On 11/1/23 at 7:43 AM, CS-I informed Surveyor that Social Services met with R4 after Surveyor shared the concern and updated the behavior contract. CS-I stated that a comprehensive assessment of behaviors will be completed and social services will work on interpreting the substance abuse evaluation by asking questions 1 time a month, and as needed if exhibiting behaviors.
On 11/1/23 at 12:23 PM, Surveyor again spoke to both SSD-C and SW-D at the same time. SW-D stated that the substance abuse evaluation completed 8/11/23 for R4 was a paper compliance and department heads were instructed to complete on all Residents and the department heads may not have known the Residents. Both SW-D and SSD-C stated they were instructed by the previous administration to give standard behavior contracts to Residents that all stated the same. SW-D stated it was a pre-made template and was only tweaked to reflect each Residents' personal preferences.
On 11/2/23 at 9:19 AM, SSD-C stated that the expectation is that a social services evaluation is done on admission. The trauma assessments should be done on admission and as needed. The intimacy evaluation should be done on admission, quarterly, annually, and as needed. SSD-C agreed the intimacy evaluation does assess if a Resident is cognitively able to make decisions in regards to intimacy and sexual relationships.
3) R5 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabestes Mellitus, Chronic Obstructive Pulmonary Disease, Secondary Malignant Neoplasm of Live and Intrahepatic Bile Duct, Essential Hypertension, Schizophrenia, and Anxiety Disorder. R5 is his own person.
Surveyor reviewed R5's Quarterly Minimum Data Set (MDS) dated [DATE] which documents R5's Brief Interview for Mental Status (BIMS) score to be 15 indicating R5 is cogntively intact for daily decision making. R5's MDS also documents that R5 has no mood issues and has demonstrated verbal behaviors and rejection of care for 1-3 days. R5 requires limited assistance for transfers and toileting and supervision for bed mobility and dressing. R5 uses an electric wheelchair for locomotion.
Surveyor reviewed R5's comprehensive care plan and notes the following applicable:
1. R5 has a history of substance use disorder due to use of/addiction to illegal drugs. R5's drug of choice is/was Marijuana-Initiated 5/2/23
There are only 2 updated interventions implemented since 5/2/23
-In house AA offered-Initiated 8/11/23
-Increased routine monitoring, observing signs/symptoms of use/possession of illegal substances and signs/symptoms of overdose-Created 9/6/23
Of note, there is the following interventions that are significant to R5
- To account for any traumas in past that may influence R5's substance use and help avoid triggers-Initiated 5/2/23
-Report changes in mood and any suspected use of substance abuse to physician-Initiated 5/2/23
2. R5 displays socially inappropriate behaviors related to mental illness. This problem is manifested by possessing several knives in R5's room that R5 would give to staff. R5 claimed R5 needed for protection. R5 also displays socially inappropriate behavior with staff-makes sexual comments-Initated 4/18/22
Surveyor notes there are no interventions addressing R5's need to feel protection and keep knives in room. There is no intervention to address a possible past trauma involving the the need for protection.
3. R5 has mood problem due to diagnosis of schizophrenia-Initated 11/10/21
There have been no updated interventions since 11/10/21
4. R5, Intimacy and Sexual Preferences, R5 is heterosexual, comfortable giving and receiving affection, R5 showed R5 cared by hug, kiss, talking-Initated 4/14/23
-Intimacy and Sexual Assessment to be completed on admission. Will be updated quarterly, annually and with any significant change of condition-Initiated 4/14/23
-Involve Resident/family/guardian/POA as indicated-Initiated 4/14/23
-Social Worker will be available to meet with R5 regarding choices-Initiated 4/14/23
R5's Social Services Review, Version 2 dated 1/31/22 documents a PHQ-9 score of 10 indicating moderate depression. The facility was unable to provide a Social Services Evaluation completed at time of admission, 10/29/21.
On 10/13/23, a Trauma Informed Care Evaluation was completed documenting that R5 witnessed a natural disaster, assault with a weapon (being shot, stabbed, threatened with knife, gun bomb) has happened to R5, involved in combat, life threatening illness or injury and another traumatic event. Surveyor notes R5's care plan was not updated as a result of this significant trauma evaluation.
R5's Social Services Evaluation completed 10/17/23, documents R5 has current use of alcohol. The evaluation also documents that R5 has witnessed a natural disaster, assault with a weapon(being shot, stabbed, threatened with knife, gun bomb) has happened to R5, involved in combat, life threatening illness or injury and another traumatic event. Surveyor notes R5's care plan was not updated as a result of this significant trauma evaluation.
R5 does not have an evaluation for Addressing Resident Relationships Intimacy and Sexuality. However, R5 has a care plan that was initiated.
R5 has 2 Substance Abuse Evaluations
8/10/23-Asks 3 questions
1. Family history of substance abuse-circled for illegal drugs, alcohol, and prescription drugs
2. Personal history of substance abuse-circled for illegal drugs, alcohol, and prescription drugs
3. No history of Psychological disease
Surveyor notes there is a scoring total but it is blank and there is no interpretation guide. The evaluations is not signed by who completed it.
9/5/23-R5 currently/have a history of illegal drug and alcohol use, currently/history of association with substance using peers, and currently/history of misusing prescription drugs putting R5 at High Risk for substance use.
Documentation dated 7/17/23 indicates R5 was reviewed by the behavior IDT which states R5 is stable and no adjustments are being made.
On 10/9/23, R5 was given a Behavior Contract that R5 refused to sign. R5's Behavior Contract is not specific as to what behaviors R5 is displaying that would warrant a behavior contract. The behavior contract mentions the use of illegal substances in a general term, but not specific to R5. The behavior contract is not person-centered and does not explain specific steps to decrease or stop any behaviors of R5.
Surveyor reviewed R5's current physician orders, Medication (MARS) and Treatment Administration Record (TARS) for October and notes the following:
1.The facility was monitoring conducting substance abuse monitoring:Visually check on R5's whereabouts and monitor for suspicious behaviors and/or signs and symptoms of alcohol/illicit drug use and drug overdose every shift. Start date of 8/11/23
Surveyor notes there is no physician order to hold medications if suspected of alcohol or illicit drug use.
On 10/30/23 at 9:25 AM, Surveyor completed a record review of R5's progress notes located in R5's EMR. Surveyor reviewed progress notes from 8/1/23 to current date.
On 10/12/23, R5 called the police accusing another Resident (R4) of making a bomb and had plans to blow up the facility The police department came to the facility and investigated #23-010442. The police investigated and found the allegations to not be credible and there is no evidence that R4 is a threat to the facility.
On 10/12/23 at 12:50 PM, SSD-C met with R5 regarding the call R5 made to the police in regards to the bomb. Upon leaving, SSD-C observed 2 empty bottles of [NAME] in R5's trash can. R5 informed SSD-C, the big one was R5's and the smaller one another Residents.
Surveyor notes that there is no updated care plan intervention to address R5's trauma evaluation answers of being in combat and threatened with a weapon which may have been a trigger for something R4 said in regards to a bomb. Surveyor also notes that the documentation of finding empty liquor bottles in R5's trash can, did not trigger an updated care plan intervention or substance abuse evaluation.
On 10/30/23 at 10:12 AM, Surveyor interviewed SW-D in regards to R5. SW-D stated that R5 gets very confused at times and paranoid. SW-D stated that R5 was distressed only on the day of the alleged bomb issue, but has been fine since.
On 10/30/23 at 10:40 AM, Surveyor interviewed SSD-C in regards to R5. SSD-C stated that R5 is an occasional drinker. SSD-C stated that R5 is a veteran. SSD-C confirmed that 2 bottles of liquor had been found in R5's trash can, but has not been given a 30 day involuntary discharge notice of discharge for alcohol issues.
On 10/30/23 at 11:50 AM, SSD-C informed Surveyor that SSD-C did not update R5's care plan after the trauma assessment was completed on 10/13/23 and informed Surveyor that SSD-C should have, based on the answers R5 provided.
On 10/30/23 at 12:11 PM, Surveyor spoke with R5 who confirmed that R5 feels safe in the facility and is not in any current distress. Surveyor observed a large bottle of liquor in R5's trash can at this time.
On 10/31/23 at 11:55 AM, Surveyor interviewed SSD-C and SW-D together. SSD-C and SW-D confirmed that R5 is known to smoke an illegal substance. When the 2 bottles of liquor were found in R5's trash can, neither SSD-C or SW-D updated R5's behavior contract or care plan. Both SSD-C and SW-D understand that the expectation would be that with any new behaviors, the behavior contract and care plan should be be updated. Surveyor made SSD-C and SW-D aware that Surveyor had observed a large liquor bottle in R5's trash can.
On 10/31/23 at 12:31 PM, SW-D informed Surveyor that SW-D reviewed with administration and R5's behavior contract dated 10/9/23 had been given to R5 in error and that R5 can drink responsibly and the behavior contract is going to be updated and a physician order is going to be obtained that R5 can have 1 drink per day.
On 10/31/23 at 3:10 PM, Surveyor shared the concern with Regional Director of Op(RDO-G), Administrator(NHA-A), Interim Director of Nursing(DON-B), and Clinical Specialist(CS-I) that R5's behavior contract and care plan have not been updated to reflect person-centered interventions with specific behaviors. Surveyor shared the concern that trauma and substance abuse assessments have been completed, but interpreting the results and implementing a person centered care plan with interventions has not been completed by the facility. Surveyor also shared the concern that R5's physician orders have not been updated to reflect medications should be held with suspected alcohol use. No further information was provided by the facility at this time.
On 11/1/23 at 7:43 AM, CS-I informed Surveyor that Social Services met with R5 after Surveyor shared the concern and updated the behavior contract. CS-I stated that a comprehensive assessment of behaviors will be completed and social services will work on interpreting the substance abuse evaluation by asking questions 1 time a month, and as needed if exhibiting behaviors. CS-I also informed Surveyor that CS-I is aware that R5 has been smoking marijuana out by the back fence and has discussed this with R5 in the past.
On 11/1/23 at 7:54 AM, SW-D informed Surveyor that administration did not realize that R5 has had marijuana use.
On 11/1/23 at 12:23 PM, Surveyor again spoke to both SSD-C and SW-D at the same time. SW-D stated that the substance abuse evaluation completed 8/11/23 for R5 was a paper compliance and department heads were instructed to complete on all Residents and the department heads may not have know the Residents. Both SW-D and SSD-C stated they were instructed by the previous administration to give standard behavior contracts to Residents that all stated the same. SW-D stated it was a pre-made template and was only tweaked to reflect each Residents' personal preferences.
On 11/2/23 at 9:19 AM, SSD-C stated that the expectation is that a social services evaluation is done on admission. The trauma assessments should be done on admission and as needed. The intimacy evaluation should be done on admission, quarterly, annually, and as needed. SSD-C agreed the intimacy evaluation does assess if a Resident is cognitively able to make decisions in regards to intimacy and sexual relationships.
4) R32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Alcoholic Hepatic Failure, Alcohol Induced Chronic Pancreatitis, Wernicke's Encephalopathy, Major Depressive Disorder, and Alcohol Use, Unspecified with Alcohol-Induced Anxiety Disorder. R32 currently has an activated Health Care Power of Attorney(HCPOA) in place.
Surveyor reviewed R32's Quarterly Minimum Data Set(MDS) dated [DATE] which documents R32's Brief Interview for Mental Status(BIMS) score to be a 9, indicating R32 demonstrates moderately impaired skills for daily decision making. R32's Patient Health Questionnaire(PHQ-9) score is 11, indicating moderate depression. There are no behaviors for R32 documented on the MDS. The MDS documents R32 requires extensive assistance for bed mobility, transfers, and toileting.
Surveyor reviewed R32's comprehensive care and notes the following applicable:
1. R32 has a history of substance abuse/chemical dependency related to depression/anger, mental health, poor impulses. R32's substance choice is alcohol-Initiated 8/11/23
There are new updated interventions since 8/11/23
2. 6/19/2023 a focused problem was initiated for R32's intimacy and sexual preferences but stated R32 was unable to answer questions due to cognitive deficits
Interventions put into place on 6/19/23 include the following:
-Intimacy and Sexual Assessment to be completed on admission. Will be updated quarterly, annually and with any significant change of condition.
-Involve Resident/family/POA/guardian as indicated
-Social Worker will be available to meet with R32 regarding choices
R32's Social Services Evaluation dated 6/27/23 documents that R32's short and long term memory is intact but demonstrates severely impaired skills for daily decision making. The evaluation documents a history of alcohol or drug abuse.
Surveyor reviewed R32's Trauma Informed Care Evaluation dated 6/27/23 and notes R32 was able to answer the questions on this evaluation. R32 answered yes it happened to R32 for natural disaster, transportation, exposure to toxic substances, physical assault, assault with a weapon, and sexual assault.
A new Trauma Informed Care Evaluation or an updated Intimacy and Sexual Assessment was not completed after a 10/2/23 allegation of abuse involving R32. Surveyor notes both evaluations were not completed on a quarterly basis.
R32 has 2 Substance Abuse Evaluations
8/10/23-Asks 3 questions
1. Family history of substance abuse-circled no for illegal drugs, prescription drugs, or alcohol
2. Personal history of substance abuse-circled for illegal drugs, prescription drugs, and alcohol
3. Psychological disease-depression
Surveyor notes there is a scoring total but it is blank and there is no interpretation guide. The evaluations is not signed by who completed it.
9/8/23-R32 currently/history of illegal drug use, substance abuse and misusing prescription drugs putting R32 at High Risk for substance use.
Surveyor notes that the facility has not reviewed R32 by the behavior interdisciplinary team(IDT) since admission on [DATE].
Surveyor reviewed R32's current physician orders, Medication (MARS) and Treatment Administration Record (TARS) for October and notes the following:
1. The facility was monitoring conducting substance abuse monitoring:Visually check on R32's whereabouts and monitor for suspicious behaviors and/or signs and symptoms of alcohol/illicit drug use and drug overdose every shift. Start date of 8/11/23
2. Monitor for self isolation, increased withdrawing, tearfulness, voicing feelings of sadness, decreased appetite, change in social behavior. Document Y if having depressive symptoms or N if no symptoms. Update Social Services every shift if increase in symptoms-Start date of 6/17/23
Surveyor notes this is completely blank with no Y or N documented for any day of October.
3. Monitor for alcohol use every shift-Start date of 10/14/23
4. Hold all meds if R32 appears under the influence of alcohol-Start date of 10/2/23
On 10/31/23 at 12:40 PM, Surveyor completed a record review of R32's progress notes located in R32's EMR. Surveyor reviewed progress notes from 8/1/23 to current date. There are no documented behaviors from 6/17/23 to 10/2/23. The following is documented in regards to R32:
-SW-D documents on 10/2/23 that HCPOA removed 3 small bottles of vodka from R32's room. HCPOA gave permission to search R32's room for more and found and removed 2 additional small bottles of vodka. HCPOA would like R32 to have minimal contact with R4.
-SW-D documents on 10/5/23 that SW-D was made aware that R32 contacted a friend requesting they bring vodka to R32
R32 remains on the 24 board for monitoring of alcohol use and documentation indicates there has been no other issues
In record review of a different resident's daily progress notes (R4's) located in R4's electronic medical record (EMR), Surveyor located a progress note written by licensed practical nurse (LPN-E) on 10/3/23 that stated: I was told that R4 is not allowed to be on wing 4 because R4 was found in bed with R32. Surveyor notes there was no thorough investigation of this alleged incident.
On 10/31/23 at 11:55 AM, SSD-C confirmed that R32 does not have a behavior contract related to alcohol use. SSD-C stated that R32 receives psychotherapy. Both SSD-C and SW-D understand that the expectation would be that with any new behaviors, the care plan should be be updated.
On 11/1/23 at 7:43 AM, Clinical Specialist(CS-I) informed Surveyor that a comprehensive assessment of behaviors will be completed and social services will work on interpreting the substance abuse evaluation by asking questions 1 time a month, and as needed if exhibiting behaviors.
On 11/1/23 at 12:23 PM, Surveyor again spoke to both SSD-C and SW-D at the same time. SW-D stated that the substance abuse evaluation completed 8/11/23 for R32 was a paper compliance and department heads were instructed to complete on all Residents and the department heads may not have know the Residents.
On 11/2/23 at 9:19 AM, SSD-C stated that the expectation is that a social services evaluation is done on admission. The trauma assessments should be done on admission and as needed. The intimacy evaluation should be done on admission, quarterly, annually, and as needed. SSD-C agreed the intimacy evaluation does not assess if a Resident is cognitively able to make decisions in regards to intimacy and sexual relationships.
On 11/1/23 at 3:43 PM, Surveyor shared the concern with Administrator(NHA-A), Interim Director of Nursing(DON-B), CS-I, and Registered Nurse Consultant(RNC-H) that R32 has a long history of alcohol abuse, remains at high risk and the care plan has not been updated to reflect person-centered interventions. Surveyor shared the concern that trauma and substance abuse assessments have been completed, but interpreting the results and implementing a person centered care plan with interventions has not been completed by the facility and that an Initimacy and Relationship evaluation had not been completed on a quarterly basis or with the 10/2/23 incident. No further information was provided by the facility at this time.
On 11/2/23 at 10:17 AM, Surveyor received a written response to Surveyor's concerns related to R4, R5, and R32. Surveyor carefully read through the information provided which did not change the outcome of the identified deficiency practice. R4, R5, and R32's trauma and substance abuse assessements were completed without interpreting the results and implementing person centered care planned interventions. Behavior contracts were not update to reflect person centered interventions with specific behaviors and physician orders did not reflect medications should be held with suspected use of alcohol for R4 and R5.
This is an uncorrected deficiency from Survey Event: VLJH11
Based on interview and record review the facility did not ensure 4 (R2, R4, R5, & R32) of 4 residents received necessary behavioral health care to attain their highest practicable mental health well-being.
* R2
CRITICAL
(J)
📢 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
Deficiency F0841
(Tag F0841)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to utilize the services of the Facility's Medical Director to ensure 1...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to utilize the services of the Facility's Medical Director to ensure 1 (R2) of 1 Residents received the appropriate behavioral health services, including ensuring R2 received medications and health services as assessed.
R2 had been receiving Clonazepam since being admitted in 2020. In May of 2023, the facility became aware that the psychiatric nurse practitioner (psych NP) that was seeing R2 and actively prescribing R2's antianxiety medication would no longer see R2. The psych nurse practitioner did not help refer R2 to an alternate provider and the psychiatrist supervising the psych nurse practitioner did not step in to assess R2 or help refer R2 to an alternate provider. The facility's medical director did not communicate with the behavioral practitioners to facilitate services for R2.
On 7/24/23 R2's Clonazepam was discontinued. The Facility did not utilize the services of the medical director to ensure R2 had a qualified mental health practitioner to continue to see R2 to address R2's behavioral/mental healthcare needs including coordination of prescribing medications (Clonazepam). This medication was not reordered until 8 days later.
On 9/1/23 R2's Clonazepam ran out with the last dose being received at 2:00 a.m. and then was discontinued on 9/12/23. R2's previous history of orders for this medication was to receive Clonazepam 1 mg three times daily. Clonazepam is a medication that cannot be abruptly discontinued. Shortly after receiving this last dose, R2 started demonstrating withdrawal symptoms from not receiving the medication. Facility staff noted and documented R2 was experiencing withdrawal and was actively asking for medications due to anxiety. There was no active facilitation and coordination of care and addressing R2's behavioral and mental health care needs during this time by the medical director.
R2 turned to illicit drugs to self-medicate including methamphetamine and was found to be in possession of other illicit drugs including fentanyl. On multiple dates R2 was found to be hallucinating and engaging in other behaviors not typical for R2.
On 10/11/23 R2 was found to be experiencing an overdose requiring 911 transport, admission to the intensive care unit and intubation. R2 returned to the facility and still does not have the services of a behavioral/mental health professional or services from a qualified individual to address R2's substance abuse issues.
The failure of the facility to utilize the medical director to coordinate medical care when R2's Clonazepam was abruptly stopped & did not intervene with other medical practitioners to facilitate R2's medical care created a finding of immediate jeopardy that began on 7/24/23. Surveyor notified NHA (Nursing Home Administrator)-A, Assistant Administrator-L, Interim DON (Director of Nursing)-B, and RN (Registered Nurse) Consultant-H of the immediate jeopardy on 11/2/23 at 4:47 p.m.
The immediate jeopardy was not removed at the time of the facility exit.
Findings include:
The Duties and Responsibilities of the Medical Director signed on 5/20/22 under Duties and Responsibilities: The Essential Functions documents 1. Provide medical direction and support to the Managers and Governing Body.
1.1 Participate in meetings with the administration and/or professional staff to discuss and resolve clinical or administrative issues and specific resident care concerns.
2. Provide on-going guidance in developing, establishing, and implementing polices and procedures to enhance and promote the quality of life and care for residents. This involves collaborating with the facility regarding the policies and protocols that guide clinical decision making to help assure that they address the needs of the residents.
2.1 Examples of resident care policies include, but are not limited to:
2.1.1 admission policies and care practices that address the types of residents that may be admitted and retained based upon the ability of the facility to provide the services and care to meet their needs.
2.1.7 Mechanisms for communicating and resolving issues related to medical care;
3. Coordinate medical care and treatment through the facility's quality assessment and assurance committee and quality assurance program. This includes, but is not limited to, assisting the facility:
3.4 Address and resolve concerns and issues between the physicians, health care practitioners and facility staff.
R2 was originally admitted to the facility on [DATE] with a readmission date of 10/19/23. Diagnoses includes paraplegia, anxiety disorder, other psychoactive substance abuse, depressive disorder, diabetes mellitus and hypertension.
Psych NP-N note dated 5/1/23 under narrative documents Staff report pt (patient) willing to be seen by psych practitioner again after patient recently terminated psych services. Pt stated, I need you to prescribe my Clonazepam until I can find another provider. Pt became upset when this practitioner stated she would provide only a one month supply which will allow him time to secure another provider. Under treatment recommendations no change is checked with documentation of no change, pt reports he is looking for another provider for psychiatric medications, will cover one month supply Clonazepam to allow pt time to secure new provider. For follow up appointment documents PRN (as needed). Also checked is due to history of past failed GDR (gradual dose reduction) on going baseline sx (symptoms) reduction of psych meds is clinically contraindicated.
R2 did not receive psych services after 5/1/23.
Psych NP-N did not help refer R2 to an alternate provider and the Psychiatrist supervising Psych NP-N did not step in to assess R2 or help refer to another provider. The Facility did not utilize the medical director to ensure R2 had a qualified mental health practitioner to continue to see R2 to address R2's behavioral & mental healthcare needs.
Surveyor reviewed R2's July eMAR (electronic medication administration record) and noted a start date of 10/9/22 for Clonazepam tablet 0.5 mg (milligrams) Give 0.5 mg by mouth three times a day for anxiety. R2's Clonazepam was discontinued on 7/24/23.
The nurses note dated 7/24/23 documents Resident Clonazepam has been d/c (discontinued) by NP. Resident was to have appointment with outside provider that he missed. Resident no longer wanted to see psych NP [Name] at facility. [Psych NP first name] covered his medication until the 18th when he was supposed to see his new doctor. NP [Name] will no longer prescribe the Clonazepam. This was explained to the resident, and he stated that he understands. Resident is in process of making another appointment for MD outside of facility.
The Facility did ensure the medical director became involved with assessing R2's healthcare needs or assisting with R2 locating an alternative provider for behavioral health services and mental health services for R2.
R2 did not receive Clonazepam 0.5 three times a day from 7/24/23 until 8/1/23.
The nurses note dated 8/1/23 documents Writer spoke to NP [Name] regarding resident Clonazepam. Resident is not able to get into the new psych MD until September. Resident will be restarted on Clonazepam and the script will be filled for 60 days until resident sees his new psych NP. Resident is his own person and declines family update.
Surveyor noted the following eMAR (electronic medication administration record) notes for Clonazepam oral tablet 0.5 mg (milligram) Give 1 tablet by mouth three times a day for anxiety:
9/1/23 at 1:13 p.m. documents do not have, reported to nurse manager, nurse manager stated that the unit manager would be taking care of this.
9/2/23 at 3:30 a.m. documents needs to be reordered none in cart.
9/2/23 at 1:07 p.m. documents an order.
9/3/23 at 2:23 a.m. documents none in cart.
9/4/23 at 1:04 p.m. documents on order.
9/4/23 at 2:36 a.m. documents none in the cart.
9/5/23 at 1:35 a.m. documents not available on order. Called pharmacy and they stated they put note out to [Psych NP (nurse practitioner) name] for approval to fill script. Will update am (morning) shift to reach out.
9/5/23 at 1:39 a.m. documents on order.
9/5/23 at 8:08 p.m. documents on order awaiting new rx (prescription).
9/6/23 at 2:42 a.m. documents none in the cart.
9/6/23 at 1:00 p.m. documents on order.
9/6/23 at 8:01 p.m. documents on order.
9/7/23 at 1:57 a.m. documents none available.
9/7/23 at 1:11 p.m. documents Medication is on order.
9/7/23 at 7:14 p.m. documents on order.
9/8/23 at 1:09 p.m. documents Drug not available.
9/8/23 at 8:25 p.m. documents on order.
9/9/23 at 8:00 p.m. documents on order.
9/10/23 at 1:27 p.m. documents on order.
9/10/23 at 8:08 p.m. documents on order.
9/11/23 at 1:50 a.m. documents not available on order.
9/11/23 at 2:31 p.m. documents requested script from psych NP.
9/12/23 at 2:15 a.m. documents on reorder.
9/12/23 at 1:08 p.m. documents not available.
The nurses note dated 9/12/23 documents NP ordered resident's Clonazepam to be discontinued. Resident fired psych NP and is still pending to see new provider. [Name] NP agreed with decision of psych NP to discontinue Clonazepam until resident sees his new provider. Resident is his own person and declines family update.
Surveyor reviewed September 2023 MAR (medication administration record) and noted Clonazepam 0.5 mg is initialed as being administered on 9/1/23 at 0200 (2:00 a.m.) & 2000 (8:00 p.m.), 9/2/23 & 9/3/23 at 2000, 9/9/23 at 1400 (2:00 p.m.), 9/10/23 at 0200 (2:00 a.m.), and 9/11/23 at 2000 (8:00 p.m.).
On 11/2/23 at 8:37 a.m. Surveyor informed Interim DON-B Surveyor had reviewed R2's September 2023 MAR for Clonazepam and noted there are times from 9/1/23 to 9/12/23 when the MAR was initialed as the medication being administered. Surveyor inquired if Clonazepam is in contingency. Interim DON-B informed Surveyor it is but they would have to call pharmacy & get a code but pharmacy would only give the code if they had a script. Interim DON-B informed Surveyor she didn't believe during this time they had a script and would check. Interim DON-B later informed Surveyor they did not have a script and the only time R2 received Clonazepam during this time was the first dose (2:00 a.m.) on 9/1/23. Interim DON-B informed Surveyor she is going to speak with the nurses and find out why they initialed the medication as being administered.
According to https://medlineplus.gov/druginfo/meds/a682279.html for Clonazepam documents Clonazepam may cause a physical dependence (a condition in which unpleasant physical symptoms occur if a medication is suddenly stopped or taken in smaller doses), especially if you take it for several days to several weeks. Do not stop taking this medication or take fewer doses without talking to your doctor. Stopping Clonazepam suddenly can worsen your condition and cause withdrawal symptoms that may last for several weeks to more than 12 months. Your doctor probably will decrease your Clonazepam dose gradually. Call your doctor or get emergency medical treatment if you experience any of the following symptoms: unusual movements; ringing in your ears; anxiety; memory problems; difficulty concentrating; sleep problems; seizures; shaking; muscle twitching; changes in mental health; depression; burning or prickling feeling in your hands, arms, legs or feet; seeing or hearing things that others do not see or hear; thoughts of harming or killing yourself or others; over excitement; or losing touch with reality.
The nurses note dated 9/23/23 at 2:00 a.m. documents Writer entered resident's (R2) room at 0200 (2:00 a.m.) to administer medication, resident (R2) was sitting on his buttock on the floor with his legs extended out in front of him and his back leaning against the bed, resident was wearing a long sleeve shirt and shorts, resident had tennis shoes on, walker was right in front of resident, writer noted that resident was very anxious the more questions that were asked, writer also noted resident was jittery, resident states he's been having panic attacks on and off the past few weeks because he has not had his Clonazepam, Resident states he did not fall, resident states he sat himself on to the floor to stretch his legs out because he has been having cramps in his legs, Resident upset at writer when writer notified resident that being found on the floor is considered an unwitnessed fall and I have to update the MD of the fall, resident refused writer to assess vital signs and assess for injuries, resident denied injury or pain from sitting on the floor, but does claim to have his normal everyday pain, writer updated NP [Name], ADON [Name], and DON [Name], resident responsible for self and denies family update.
The nurses note dated 9/23/23 at 5:00 a.m. documents Writer entered resident's (R2) room for neuro assessment, resident standing with walker in the middle of his room, writer noted resident was diaphoretic and shaky, writer asked resident to have a seat so that I may obtain his vitals, resident was agreeable and sat in his recliner, writer took resident blood pressure with automatic unit, residents BP (blood pressure) was very high (155/124) so writer notified resident that I needed to obtain residents BP manually, resident became agitated with writer and stated that I am making him anxious, writer updated co-nurse the RN to see if resident would allow her to obtain his vitals, resident refused and said all he want to do is go have a cigarette at the fence line on the residents smoking patio and that he would allow us to obtain his vitals after, writer reapproached resident approximately 15 to 20 minutes later and resident began yelling at writer that I gave him no time to smoke a cigarette, writer explained to resident that I needed to verify his blood pressure due to the last reading was so high and my concerns with waiting any longer, resident began screaming at writer about having panic attacks and I am making him more anxious, resident refusing to allow writer to obtain VS, writer updated NP [Name], ADON [Name] and DON [Name].
The nurses note dated 9/23/23 at 7:26 a.m. documents Author arrived at 6:30 and was informed resident was having an issue. Resident was found on the floor. Resident states he was having muscle cramps and was on the floor to stretch. Fall report initiated. Resident shivering and sweating. Hypertensive and tachycardic. Resident describing cramping in his hands and feet that may be r/t (related to) hyperventilation. Pupils are constricted but reactive; note that resident takes prescribed scheduled narcotic pain relief every three hours. RN suspects the resident may be going through withdrawals. Resident normally takes TID (three times daily) Clonazepam but has not had it for weeks as he seeks a provider to replace one the sic (that) retired. Resident aggressively denies taking any non prescribed substances and invites a search of his room if staff does not believe him. Resident anxious, fidgeting, shivering and talking extremely fast without allowing staff to respond. All staff would very much like to see resident go to the hospital in hopes that something could be given to relax resident. Resident has just returned from a short stay at [Hospital Name] and is agitated with the care he was given while hospitalized . At this time resident is refusing transport to the hospital. Resident is pleading with staff to be left alone for a couple hours. Author has a good rapport with this resident; resident agrees at this time to go to the hospital if the episode does not pass within the next couple hours. Staff to monitor. NP to be updated.
The nurses note dated 9/23/23 at 12:57 p.m. documents RN spoke with resident, and he is willing to comply with urine drug screen at this time. Test scheduled for Monday.
The nurses note dated 9/23/23 at 10:25 p.m. documents Resident continues on ABT (antibiotic) for tooth extraction. No A/R (adverse reactions). Resident has been sweating, restless, hallucinating, with delusions this shift. Resident seen by Director of Nursing (DON) [Name] for assessment. Noted was hallucinating, restlessness with arms and legs were constantly moving. Requested urine from resident and he refused. 911 was called for altered mental status. 911 arrived and assessed resident whom then refused to go to the ER for further evaluation, as he is his own person. Hydroxyzine 25 mg was administered po (by mouth) x 1 for anxiety as per order NP [Name].
The nurses note dated 9/24/23 at 4:07 a.m. documents Resident remains on ABT for tooth abscess/extraction, no AR noted, resident has been sitting on his floor this entire shift, resident talking to himself and moving personal articles around, when staff was checking on resident he asked staff to leave because he was having private conversation with his shampoo bottle, resident has food all over the floor and personal items all on the floor, when staff asked to assist resident he refused any assistance, resident slept on this floor for a short time, staff monitoring resident every 15 minutes this shift, resident refusing vital signs.
The nurses note dated 9/24/23 at 10:41 p.m. documents Resident on 1 hour checks due to change in condition. Resident slurring his words, has thrown things everywhere around his room, verbally aggressive. Continue to monitor. Medications held.
The nurses note dated 9/25/23 at 5:46 a.m. documents Resident continues with AMS (altered mental status), resident did allow writer to obtain VS, VSS this shift, resident pupils dilated (approximately 5 mm (millimeter)) and sluggish, resident alert and communicating, some speech understood by writer and some speech in incomprehensible, resident talking with jaw clenched, resident asked for narcotic for pain, writer informed resident that due to AMS I am holding all medications at this time, writer offered resident to go to the ER and resident refused, writer performed assessment with CNA as witness to residents behavior, will continue to monitor.
The social service late entry note dated 9/25/23 documents Writer Crisis was called and informed of resident current state, hallucination, weight loss and major change in behavior.
The nurses note dated 9/25/23 at 2:03 p.m. documents Resident continues to have AMS this shift. Resident speech continues to be understandable at times but most times it is a lot of gibberish. Writer turned on residents light in room to assess him and resident was screaming and putting the cover over and off his face continuously. Resident was diaphoretic drenching in sweat and the blanket was soaked as well. Resident was found in the shower room running the water over him with his clothes on. Writer helped resident with shower. Resident was yelling with the water touching him was put back into bed after shower and resident has been sleep since. Staff was able to clean room with resident sleep and staff found a bottle of butane and ETOH (alcohol) in room. Resident resting at this time. Will continue to monitor.
The nurses note dated 9/25/23 at 3:00 p.m. documents Writer went into residents room this AM to discuss recent behaviors. Upon entering the room resident was sitting on the floor on a blanket and had a pillow next to him with an additional blanket wrapped around him tightly. He had no shirt on and shorts on the bottom. He has a large bruise on the top of his right hand and scattered bruises all over bilateral legs. He also had scabs on the right leg that he was picking at. Writer asked resident how he was feeling he said ok and then started talking about his brother and looking over at the window. He had wrappers, cat food all over the floor. The garbage was knocked over. Typically resident is very clean and organized with everything in place and orderly. Writer asked to obtain vitals. He agreed. BP 127/78, heart rate 82, O2 (oxygen) 98 on room air, temperature 97.8. Resident is very diaphoretic and is not making sense with speech but is answering more appropriately. Writer asked to obtain a drug screen lab draw and CBC (complete blood count) to check for infection from his previous tooth extraction which he is currently on antibiotics for. He agreed. Labs drawn, CBC results sent to NP. NNO (no new orders). Resident agreed to let CNA (Certified Nursing Assistant) and writer clean up his room. Upon cleaning we found a bottle of butane as well as a large vodka bottle. Staff took this from his room with his permission. Soon after cleaning staff found resident in shower room spraying himself with shower head fully clothed. Staff assisted him in taking off his clothes, finish his shower and getting clean clothes on. After shower resident went and laid in bed and took around a two hour nap. Later in the afternoon around 3pm writer and social worker went to check back in with resident and he was again on the floor trying to climb underneath his bed. He stated that he needed to get warm. Writer provided him with more blankets and asked him to please get off of floor and move back to the bed where it would be more comfortable. Resident refused. Writer asked resident if he would be willing to get sent out to ER for evaluation so that we could get him feeling better, he refused. Social worker contact crisis to come out and evaluate resident. He has been refusing meals and lost close to 40 lbs (pounds) in two months. Continues to be extremely anxious and keeps looking at window saying he is waiting for his brother and friends. Resident is currently on hourly checks. Resident is his own person and declines family update. NP is aware of situation. Writer will be reaching out to psych NP and [Psychologist Name] to see in what ways we are able to further assist resident.
The social service note dated 9/25/23 documents [Name] county crisis came out to eval resident. Updates given to her regarding resident. She went to meet with resident, continues to talk non-sense told writer and worker to get out of the room before his friends come back from a holiday party. Crisis told writer that resident at this time, is safe they cannot chapter him or do much at this time. Stated if resident becomes combative towards himself, staff or peers to call 911 and then crisis will follow up if needed. IDT updated and aware.
The lab report collected on 9/25/23 and verified on 9/28/23 is positive for barbiturates and methamphetamine.
The nurses note dated 9/26/23 at 12:52 p.m. documents Resident's drug screen back positive for barbiturates in which he does not have a prescription for. NP updated. NNO (no new order). Resident is his own person and declines family update. Resident is being put on 15 minute checks d/t recent hallucinations, erratic behavior and positive UA drug screen.
The social service note dated 9/26/23 documents Resident is on 15 minute checks for behaviors. Behavior contract to be established and signed when resident is coherent.
The nurses note dated 9/28/23 at 6:22 a.m. includes documentation of .staff member came to writer and stated resident was very diaphoretic in his room, and his pupils were very large and that the resident was talking very fast and kept moving his arms and legs around like he couldn't sit still, resident stated that he doesn't want writer to come check on him for his 15 minute checks, he only wanted the CNA to check on him, writer informed the CNA to notify writer if resident is in need of my assistance at anytime during checks, writer updated NP [Name], ADON [Name] and DON [Name] on residents current behavior.
The nurses note dated 9/28/23 at 1:52 p.m. documents Lab results sent to NP for CBC. NOR (new order received) to obtain a repeat CBC 10/2/23. Writer went into resident room this AM to follow up on how things are going and to discuss the hallucinations that were again occurring over night shift. NP [Name] went into room with writer to talk with resident. Upon entering room resident was sitting on the edge of his bed. When NP asked if he could scoot back further onto the bed resident got angry quick and snapped back that he is [AGE] years old and knows how to sit on a bed. We explained to him why he is on 15 minutes and asked if he remembers the conversation he had with writer 2 days previously about being on the 15 minute checks and understanding why. He dismissed that conversation and did not want to talk about it. Resident very upset about not receiving pain medication over night or this morning from nurses due to having suspected drug use from his own source. It was explained to him yet again why the pain medication is being held. Writer contacted [Physician's Name] who prescribes residents Oxycodone to see what his thoughts were on decreasing medication and a more effective pain regimen. Writer was instructed to have our NP give [Physician's Name] a call so they can discuss a plan of action. Awaiting a response to that meeting between the two providers. [Name] NP from psych was also emailed asking if she can take [R2's first name] back as a resident as he has many factors occurring recently that he needs addressed. She stated that she needs to be in contact with her boss and will get back to me early next week. Resident did refuse to go to his CT scan this morning. Initially resident was refusing his antibiotics for his tooth abscess. Resident did end up accepting antibiotic from writer after two attempts. Writer asked if there was anyone she could call for resident to talk to since he was so upset and anxious with staff here. Residents aunt and him have a very good relationship. He declined to call her. Resident has been resting in bed today throughout first shift.
The nurses note dated 9/28/23 at 2:41 p.m. documents Meds. withheld this shift due to res. behaviors. Speech noted to be fast and garbled, difficult to understand at times. Refused assessment but pupils noted to be dilated and skin appears moist. Told writer not to do 15 min. (minute) checks. Did answer when writer knocked on door. Refused writer to open door to check on him.
The nurses note dated 9/29/23 at 3:49 p.m. documents resident lab results received, resident tested positive for methamphetamine, [Name] DON and [Name] NP updated.
The Facility investigated R2's illegal drug use. Facility staff determined the root cause dated 9/29/23 as [R2's first name] was possibly self-medicating because he did not have a Rx (prescription) for the Clonazepam.
The Facility did not utilize the medical director after R2's Clonazepam was abruptly stopped & R2 started to self medicate with illegal drug to assist with locating a qualified mental health practitioner to address R2's behavioral and mental health needs.
The nurses note dated 10/3/23 at 10:30 p.m. documents Held resident's HS medications, as resident was difficult to arouse, bilateral legs moving rapidly, and staff notice he was slurring his words or was just staring at you with no response.
The eMAR note dated 10/4/23 at 2:31 a.m. documents 15 min checks being completed he is in his room sleeping he has not come out of his room none the previous shifts 10/3/23 each check he seems very drowsy nodding, his room is unkept he has things everywhere which is unusual for him he usually has a very clean room, he was found sitting on the floor said he just got down there to sit he didn't fall, he has some slurred speech as well.
The nurses note dated 10/4/23 at 2:39 p.m. documents Resident has been very jittery this shift. Upon arrival pupils were dilated. Writer held everything but his ABT and antiviral's. Resident has been in room all shift. He was stating he was cleaning a 3x but it was more of a mess. Resident confused this shift. He dropped his breakfast plate on the floor. Writer asked him to move in center of bed a 3x this shift. Resident compliant. Resident has stated that he is ok and has no concerns. Resident has not c/o (complained of) pain this shift and has not been out to smoke.
The nurses note dated 10/4/23 at 4:13 p.m. documents Writer asked resident if we could draw labs due to current anxious behaviors, staying in room and throwing things all over room that have started up again. Resident had previously tested positive for methamphetamine so we are trying to monitor use. Resident declined. NP updated. Resident is his own person and declines family update.
The nurses note dated 10/5/23 at 12:28 p.m. documents Resident alert and oriented x4 this shift. No signs of paranoia. Resident jittery. Room continues to be messy and resident states that he starts to clean but becomes anxious and starts to drop stuff. Resident denied assistance to help clean. Resident meds given this shift per NP [Name]. NP stated that [Name of Medical Director-F] is still waiting to speak with [Physician's name] that prescribes his narcotics. No confusion noted this shift pain rate 10/10 oxy given. Resident continues to be 15 min checks due to abnormal drug panel. No signs of illicit drug use this shift. No VS (vital signs) taken this shift as writer did not want to upset resident due to him asking for a pain pill and writer wanted to wait until NP assessed resident. Resident did not go out to smoke this shift. Resident laying in bed at this time awaiting lunch. Will continue to monitor.
The lab report collected on 10/5/23 and verified on 10/7/23 is positive for amphetamines and opiates. There is handwritten notation next to opiates which documents prescribed oxycodone.
The nurses note dated 10/11/23 at 6:57 a.m. documents Resident was noted to have normal behavior most of the shift, resident went to smoke x1 this shift and was supervised the whole time, towards the end of the shift resident began to behave abnormally, writer and [Name] (Administrator) went to assess resident in his room and noted resident to be anxious, fidgety, speaking rapidly with jaw clenching, writer assessed residents pupils and they were noted to be 4mm in size with a sluggish response, resident denied using any substance when asked, 15 minute checks were completed this shift.
The nurses note dated 10/11/23 at 2:12 p.m. documents Resident has not left room all shift. Upon arrival Administrator and DON assessing resident. Writer noticed resident sweating profusely. Writer could not understand resident, his speech was not coherent. Resident was jittery and could not stop moving. Writer asked resident to get in the middle of the bed because he was on the edge resident compliant. Resident did not eat breakfast and a few bites of lunch. Resident stated he was in pain and writer got him Tylenol. Meds held except antivirals and Tylenol due to AMS. NP [Name] updated. Resident continues 15 min checks due abnormal drug screen. By end of shift resident was more understandable in speech but he was talking about things that had nothing to do with anything. Resident refused for staff to take vitals this shift. Will continue to monitor.
The nurses note dated 10/11/23 at 10:02 p.m. documents Entered resident's room at 1945 (7:45 p.m.), resident legs between heater and head off the side of the side of bed. Attempted to assess LOC (level of consciousness), resident sleeping very soundly. Requested assistance of wing 1 nurse, she and CNA [Name] moved resident's legs from side of bed by heater and resident moved his head. He was speaking noncoherently and moving bilateral upper and lower extremities rapidly, which I was unable to do vital signs. Resident agreed to be assessed by 911. Resident left with wing 1 nurse in attendance. 911 was called at 1950 (7:50 p.m.) and police officer arrived at 1955 (7:55 p.m.). Resident was assessed by EMT's (emergency medical technicians) and gave medication to resident for anxiety. EMS left with resident via stretcher at 2040 (8:40 p.m.). NP [Name] notified, [Name] DON notified and [Name] Admin. was notified.
R2 was hospitalized from [DATE] to 10/19/23.
The hospital discharge summary for admission date of 10/11/23 and discharge date of 10/19/23 under final discharge diagnoses documents methamphetamine overdose, acute hypoxic respiratory failure due to above, AKI (acute kidney injury) resolved, Rhabdomyolysis, resolved, mood disorder/anxiety, chronic pain.
Under hospital course for admission narrative documents This is a [AGE] year-old male c[TRUNCATED]
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is an uncorrected deficiency from survey event: VLJH12.
Based on interview and record review, the facility did not ensure t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is an uncorrected deficiency from survey event: VLJH12.
Based on interview and record review, the facility did not ensure that 1 of 1 allegations of abuse involving R32 was reported immediately to the State Survey Agency.
On 10/2/23, it is documented that a male Resident who was monitored to not be on R32's wing was found in R32's bed.
Findings Include:
Surveyor reviewed the facility's Abuse, Neglect and Exploitation policy and procedure implemented 9/18/23 and notes the following in regards to reporting requirements:
.Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property.
III Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of Resident property, and exploitation that achieves:
A. Establishing a safe environment that supports, to the extent possible. a Resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the Resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.
V. Investigation of Alleged Abuse, Neglect and Exploitation
A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.
VI. Protection of Resident The facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.
A. Responding immediately to protect the alleged victim and integrity of the investigation
B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed
F. Providing emotional support and counseling to the Resident during and after the investigation
G. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse
VII. Reporting/Response
A. The facility will have written procedures that include:
1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies(law enforcement) within specified timeframe's:
a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in bodily injury
b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury
VIII. Coordination with QAPI
A. The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of Resident property, and exploitation with the QAPI program.
1. Cases of physical or sexual abuse, for example by facility staff or other Residents, will be reviewed for and receive corrective action and tracking by QAA Committee.
R32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Alcoholic Hepatic Failure, Alcohol Induced Chronic Pancreatitis, Wernicke's Encephalopathy, Major Depressive Disorder, and Alcohol Use, Unspecified with Alcohol-Induced Anxiety Disorder. R32 currently has an activated Health Care Power of Attorney (HCPOA) in place.
Surveyor reviewed R32's Quarterly Minimum Data Set (MDS) dated [DATE] which documents R32's Brief Interview for Mental Status (BIMS) score to be a 9, indicating R32 demonstrates moderately impaired skills for daily decision making. R32's Patient Health Questionnaire (PHQ-9) score is 11, indicating moderate depression. There are no behaviors for R32 documented on the MDS. The MDS documents R32 requires extensive assistance for bed mobility, transfers, and toileting.
Surveyor reviewed R32's comprehensive care plan and noted that on 6/19/2023, a focused problem was initiated for R32's intimacy and sexual preferences but stated R32 was unable to answer questions due to cognitive deficits.
Interventions put into place on 6/19/23 include the following:
-Intimacy and Sexual Assessment to be completed on admission. Will be updated quarterly, annually, and with any significant change of condition.
-Involve Resident/family/POA/guardian as indicated
-Social Worker will be available to meet with R32 regarding choices
Surveyor reviewed R32's Trauma Informed Care Evaluation dated 6/27/23 and noted R32 was able to answer the questions on this evaluation. R32 answered yes it happened to R32 for natural disaster, transportation, exposure to toxic substances, physical assault, assault with a weapon, and sexual assault.
A new Trauma Informed Care Evaluation or an updated Intimacy and Sexual Assessment was not completed after the 10/2/23 allegation of abuse involving R32. Surveyor noted neither evaluation was completed on a quarterly basis.
On 10/2/23, Social Worker (SW-D) documented in R32's electronic medical record (EMR) that Health Care Power of Attorney (HCPOA) would like R32 to have minimal contact with R4.
In record review of R4's daily progress notes located in R4's EMR, Surveyor read a progress note written by Licensed Practical Nurse (LPN-E) on 10/3/23 that stated the following: I was told that R4 is not allowed to be on wing 4 because R4 was found in bed with R32.
On 10/3/23, it is documented by Social Worker (SW-D) that SW-D met with R4 to inform him he was not to be on wing 4.
On 10/4/23, it is documented that R4 was found in bed with R32. R4 is not allowed on wing 4 due to R4 possibly buying alcohol for R32.
On 10/31/23 at 9:37 AM, Surveyor requested any self-reports and/or investigations submitted by the facility to the State Agency involving R32.
On 10/31/23 at 11:31 AM, Surveyor interviewed LPN-E in regards to the abuse allegation with R32 and R4. LPN-E states that a Certified Nursing Assistant (CNA) informed LPN-E that the social worker had found R4 in R32's bed . Similar to the situation with the lady on 6 that left.
LPN-E stated that management should have told LPN-E that R4 is not allowed on R32's unit and why. LPN-E stated the information about R4 not allowed on R32's unit should have been documented on the 24-hour board and it was not. LPN-E stated LPN-E got a call the next day from Director of Nursing (DON-B) who asked why I wrote that in reference to LPN-E writing a note on the 24 hour board that R4 was found in R32's bed.
DON-B informed me at that time, it was because R4 was banned from going on wing 4 for possibly bringing in alcohol to R32. LPN-E stated that was not even documented on the 24 hour board. I didn't know what to believe.
Surveyor attempted to reach the CNA for interview on 2 separate occasions but did not receive a phone call back.
Surveyor reviewed the facility's 24 hour report board and confirmed on 10/3/23, LPN-E added for R4 not allowed on wing 4 found in (R32 bed). On 10/4/23, it is added on the 24 hour report board that R4 is being monitored for bringing alcohol in to R32.
On 10/31/23 at 11:55 AM, Surveyor interviewed Social Services Director (SSD-C) and SW-D at the same time. Neither SSD-C or SW-D confirm that they found R4 in R32's bed. SW-D asked R32 at the time if R4 had been in the room, and R32 responded no. SW-D further stated that SW-D did not ask any other questions of R32.
On 10/31/23 at 12:12 PM, Surveyor was provided R32's 24 hour report documentation which documents R32 was being monitored for alcohol use on 10/2/23.
On 10/31/23 at 12:20 PM, Surveyor interviewed Interim Director of Nursing (DON-B) in regard to R32's abuse. DON-B stated that the incident was similar to R4 and involvement with another female resident who is no longer at the facility. DON-B stated DON-B did call LPN-E to get more information.
On 10/31/23 at 3:10 PM, Surveyor was informed by Regional Director of Op (RDO-G) that there were no self reports submitted to the State Agency or investigations in regard to R32.
On 11/1/23 at 8:23 AM, Surveyor spoke with DON-B (who was a unit manager at the time) in regard to the abuse allegation involving R32. DON-B stated DON-B had been reviewing the 24 hour report boards and noted the documentation of LPN-E that R4 had been found in bed with R32. DON-B stated DON-B informed the DON and Administrator at the time. DON-B asked for guidance from administration. DON-B was asked to get a statement from R32 and speak with LPN-E. DON-B is unaware of any investigation that was initiated at this time involving R32.
On 11/1/23 at 3:43 PM, Surveyor shared with DON-B, Administrator (NHA-A), Registered Nurse Consultant (RNC-H), and Clinical Specialist (CS-I) the concern that there was an allegation of abuse involving R32 which was not reported to the State Agency within the required 2 hour regulation. All in attendance agree not reporting this allegation involving R32 is a concern. No further information was provided at this time by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is an uncorrected deficiency from survey event: VLJH12
Based on record review and staff interview, the facility did not ens...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is an uncorrected deficiency from survey event: VLJH12
Based on record review and staff interview, the facility did not ensure an allegation involving potential sexual abuse was thoroughly investigated for 1 of 1 Resident (R32) reviewed for allegations of abuse.
Findings Include:
Surveyor reviewed the facility's Abuse, Neglect and Exploitation policy and procedure implemented on 9/18/23 and notes the following in regards to reporting requirements:
.Policy: It is the policy of this facility to provide protections for the health, welfare, and rights of each Resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of Resident property.
III Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of Resident property, and exploitation that achieves:
A. Establishing a safe environment that supports, to the extent possible. a Resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the Resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship.
V. Investigation of Alleged Abuse, Neglect and Exploitation
A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur.
3. Investigating different types of alleged violations
4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations
5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause
6. Providing complete and thorough documentation of the investigation
VI. Protection of Resident The facility will make efforts to ensure all Residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation.
A. Responding immediately to protect the alleged victim and integrity of the investigation
B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed
F. Providing emotional support and counseling to the Resident during and after the investigation
G. Revision of the Resident's care plan if the Resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse
VII. Reporting/Response
5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to the following:
a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of Resident property or exploitation occurred, and what changes are needed to prevent further occurrences.
b. Defining how care provision will be changed and/or improved to protect Residents receiving services
VIII. Coordination with QAPI (Quality Assurance Performance Improvement)
A. The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of Resident property, and exploitation with the QAPI program.
1. Cases of physical or sexual abuse, for example by facility staff or other Residents, will be reviewed for and receive corrective action and tracking by QAA Committee. This coordinated effort results in the QAA Committee determining:
a. If a thorough investigation is conducted
b. Whether the Resident is protected
R32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Alcoholic Hepatic Failure, Alcohol Induced Chronic Pancreatitis, Wernicke's Encephalopathy, Major Depressive Disorder, and Alcohol Use, Unspecified with Alcohol-Induced Anxiety Disorder. R32 currently has an activated Health Care Power of Attorney (HCPOA) in place.
Surveyor reviewed R32's Quarterly Minimum Data Set (MDS) dated [DATE] which documents R32's Brief Interview for Mental Status (BIMS) score to be a 9, indicating R32 demonstrates moderately impaired skills for daily decision making. R32's Patient Health Questionnaire (PHQ-9) score is 11, indicating moderate depression. There are no behaviors for R32 documented on the MDS. The MDS documents R32 requires extensive assistance for bed mobility, transfers, and toileting.
Surveyor reviewed R32's comprehensive care and notes that on 6/19/2023 a focused problem was initiated for R32's intimacy and sexual preferences but stated R32 was unable to answer questions due to cognitive deficits
Interventions put into place on 6/19/23 include the following:
-Intimacy and Sexual Assessment to be completed on admission. Will be updated quarterly, annually and with any significant change of condition.
-Involve Resident/family/POA/guardian as indicated
-Social Worker will be available to meet with R32 regarding choices
Surveyor reviewed R32's Trauma Informed Care Evaluation dated 6/27/23 and notes R32 was able to answer the questions on this evaluation. R32 answered yes it happened to R32 for natural disaster, transportation, exposure to toxic substances, physical assault, assault with a weapon, and sexual assault.
A new Trauma Informed Care Evaluation or an updated Intimacy and Sexual Assessment was not completed after the 10/2/23 allegation of abuse involving R32. Surveyor notes both evaluations were not completed on a quarterly basis.
On 10/2/23, Social Worker (SW-D) documented in R32's electronic medical record (EMR) that HCPOA would like R32 to have minimal contact with R4.
In record review of R4's daily progress notes located in R4's electronic medical record (EMR), Surveyor located a progress note written by licensed practical nurse (LPN-E) on 10/3/23 that stated the following: I was told that R4 is not allowed to be on wing 4 because R4 was found in bed with R32.
On 10/3/23 it is documented, by Social Worker (SW-D) that SW-D met with R4 to inform R4 he was not to be on wing 4.
On 10/4/23 it is documented that R4 was not found in bed with R32, R4 is not allowed on wing 4 due to R4 possibly buying alcohol for R32.
On 10/31/23 at 9:37 AM, Surveyor requested any self-reports and/or investigations submitted by the facility to the State Agency involving R32.
On 10/31/23 at 11:31 AM, Surveyor interviewed LPN-E in regards to the abuse allegation with R32 and R4. LPN-E states that a Certified Nursing Assistant (CNA) informed LPN-E that the social worker had found R4 in R32's bed . Similar to the situation with the lady on 6 that left. LPN-E stated that management should have told LPN-E that R4 was not allowed on R32's unit and why. LPN-E stated the information about R4 not allowed on R32's unit should have been documented on the 24-hour board and it was not. LPN-E stated LPN-E got a call the next day from Director of Nursing(DON-B) who asked why I wrote that in reference to LPN-E writing a note on the 24-hour board that R4 was found in R32's bed. DON-B informed me at that time, it was because R4 was banned for going on wing 4 for possible bringing in alcohol to R32. LPN-E stated that was not even documented on the 24 board. I didn't know what to believe.
Surveyor attempted to reach the CNA in order to interview on 2 separate occasions but did not receive a phone call back.
Surveyor reviewed the facility's 24 report board and confirmed on 10/3/23, LPN-E added for R4not allowed on wing 4 found in (R32 bed). On 10/4/23, it is added on the 24 hour report board that R4 is being monitored for bringing alcohol in not in R32's bed.
On 10/31/23 at 11:55 AM, Surveyor interviewed Social Services Director (SSD-C) and SW-D at the same time. Neither SSD-C or SW-D confirm that they found R4 in R32's bed. SW-D asked R32 at the time if R4 had been in the room, and R32 responded no. Neither SSD-C or SW-D stated they were involved in any abuse investigation involving R32.
On 10/31/23 at 12:12 PM, Surveyor was provided R32's 24- hour report documentation which documents R32 was being monitored for alcohol use on 10/2/23.
On 10/31/23 at 12:20 PM, Surveyor interviewed Interim Director of Nursing (DON-B) in regards to R32's abuse. DON-B stated that the incident was similar to R4 and involvement with another female Resident who is no longer at the facility. DON-B stated DON-B did call LPN-E to get more information.
On 10/31/23 at 3:10 PM, Surveyor was informed by Regional Director of Op (RDO-G) that there were no self reports submitted to the State Agency or investigations in regards to R32.
On 11/1/23 at 8:23 AM, Surveyor spoke with DON-B (was a unit manager at the time) in regards to the abuse allegation involving R32. DON-B stated DON-B had been reviewing the 24 hour report boards and noted the documentation of LPN-E that R4 had been found in bed with R32. DON-B stated DON-B informed the DON and Administrator at the time. DON-B asked for guidance. DON-B was asked to get a statement from R32 and speak with LPN-E. DON-B is unaware of any investigation that was initiated at this time involving R32. DON-B confirmed that DON-B was not asked to get written statements from staff in regards to R32's abuse allegation
On 11/1/23 at 3:43 PM, Surveyor shared with DON-B, Administrator(NHA-A), Registered Nurse Consultant (RNC-H), and Clinical Specialist (CS-I) the concern that there was an allegation of abuse involving R32 that was not thoroughly investigated. Surveyor explained that not completing a thorough investigation and immediately put effective measures into place resulted in R32 and other Residents to be potentially abused. All in attendance agree not thoroughly investigating this allegation involving R32 is a concern. No further information was provided at this time by the facility.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure 2 (R4 and R2) of 2 Residents who received a facility initiated...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure 2 (R4 and R2) of 2 Residents who received a facility initiated 30 day notice of involuntary discharge received a notice that contained the required contents.
*R4 received a 30 day notice of discharge on [DATE] which included the incorrect phone number for the Division of Quality Assurance (DQA) Southeastern Regional Office and the notice contains the incorrect address to contact the ombudsman for assistance with filing an appeal. R4's 30 day notice also did not include a reason for the discharge and the location of where R4 is to be discharged . R4's electronic medical record did not contain documentation as to the reasons why R4 is to be discharged .
*R2 received two 30 day notices of discharge on [DATE] and 10/20/23 which included the incorrect phone number of the Division of Quality Assurance (DQA) Southeastern Regional Office and the 30 day notice incorrectly advises R2 to contact the ombudsman which contains the incorrect address for the ombudsman for assistance with filing an appeal. R2's two 30 day notices also did not include a reason for the discharge and the location of where R2 is to be discharged . R2's electronic medical record did not contain documentation as to the reasons why R2 is to be discharged .
Findings Include:
Surveyor reviewed the facility's Transfer and Discharge policy and procedure implemented 10/26/2022 and notes the following applicable:
.Policy: Its is the policy of this facility to permit each Resident to remain in the facility, and not initiate transfer or discharge for the Resident from the facility, except in limited circumstances.
Policy Explanation and Compliance Guidelines:
4. The facility's transfer/discharge notice will be provided to the Resident and the Resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:
a. The specific reason and basis for transfer or discharge.
b. The effective date of transfer or discharge.
c. The specific location to which the Resident is to be transferred or discharged .
d. An explanation of the right to appeal the transfer or discharge to the State.
e. The name, address(mailing and email) and telephone number of the State entity which receives such appeal hearing requests.
f. Information on how to obtain an appeal form.
g. Information on obtaining assistance in completing and submitting the appeal hearing request.
h. The name, address(mailing and email), and telephone number of the representative of the Office of the State Long-Term Care Ombudsman.
i. For nursing facility Residents with intellectual and developmental disabilities or with mental illness, the notice will include the name, mailing, and email addresses and phone number of the state agency responsible for the protection and advocacy of these populations.
5. Generally, the notice must be provided at least 30 days prior to a facility-initiated transfer or discharge of the Resident.
7. The facility will maintain evidence that the notice was sent to the Ombudsman.
8. If the information in the notice changes prior effecting the transfer or discharge, the Social Services Director must update the recipients of the notice as soon as practicable once the updated information becomes available. For significant changes, such as change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30 day advance notification.
11. Non-Emergency Transfers or Discharges -initiated by the facility, return not anticipated.
a. Document the reasons for the transfer or discharge in the Resident's medical record, and in the case of necessity for the Resident's welfare and the Resident's needs cannot be met in the facility, document the specific reason Resident needs that cannot be met, facility attempts to meet the Resident needs, and the services available at the receiving facility to meet the needs. Document any danger to the health or safety of the Resident or other individuals that failure to transfer or discharge would pose.
b. Provide transfer/discharge notice to the Resident/representative and Ombudsman as indicated.
e. Orientation for transfer or discharge will be provided and documented to ensure a safe and orderly transfer or discharge from the facility, in a form and manner that the Resident can understand. Depending on the circumstances, this orientation may be provided by various members of the facility.
1) R4 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Heart Failure, Chronic Kidney Disease, Stage 3, Type 2 Diabetes Mellitus, Anxiety Disorder, and Major Depressive Disorder. R4 is his own person.
Surveyor reviewed R4's Quarterly Minimum Data Set (MDS) dated [DATE] which documents R4's Brief Interview for Mental Status (BIMS) score to be a 15 which indicates that R4 is cognitively intact for daily decision making. R4's Patient Health Questionnaire (PHQ-9) score of 5 indicates that R4 has mild depression present and R4's MDS does not document any behaviors. R4's MDS documents that R4 requires limited assistance for bed mobility, transfers, dressing, and toileting, and has range of motion impairment on both upper and lower of 1 side. R4 is mobile with an electric wheelchair.
Surveyor reviewed R4's comprehensive care plan and noted there is a discharge planning care plan to return to the community initiated 12/31/20, revised 1/4/21, but does not address interventions specific to being issued a 30 day involuntary discharge notice.
Surveyor notes there is a Behavior Contract dated 9/15/23 with R4's name on it. R4's Behavior Contract is not specific as to what behaviors R4 is displaying that would warrant a behavior contract. The behavior contract mentions the use of illegal substances in a general term, but not specific to R4.
On 10/30/23 at 9:34 AM, Surveyor completed a record review of R4's progress notes located in R4's EMR. Surveyor reviewed progress notes from 8/1/23 to current date. Surveyor notes there are very few entries of any behavior issues with R4. There is no documentation indicating why the behavior contract was issued on 9/15/23.
-On 9/25/23, it is documented by Social Services Director (SSD-C) that a room search was completed and 2 cans of beer were found in R4's room along with a package of delta 8 which was purchased at the local gas station.
-On 10/2/23, it is documented that SSD-C attempted to speak with R4 regarding bringing alcohol into the facility.
-On 10/4/23, it documented by Social Worker (SW-D) that SW-D informed R4, R4 could not be on another's Resident's wing.
From 10/4/23-10/12/23, it is documented that R4 has no behaviors.
On 10/12/23 at 6:37 PM, SSD-C issued a 30 day discharge notice to R4. It is not documented the specific reason why the 30 day discharge was issued in R4's EMR. The following is documented by SSD-C in regards to R4's 30 day: writer went over the document with R4, answered any questions or concern R4 had, R4 understood document but refused to sign. Copy given to R4 and document was emailed over to Ombudsman. Caseworkers were also notified. No additional questions or concerns.
Surveyor reviewed R4's 30 day discharge involuntary discharge notice dated 10/12/23 and notes the following:
R4's 30 day discharge of involuntary discharge included the incorrect phone number of the Division of Quality Assurance (DQA) Southeastern Regional Office, the notice contains the wrong address to contact the Ombudsman for assistance with filing an appeal. R4's 30 day notice also did not include a reason for the discharge and the location of where R4 is to be discharged . R4's electronic medical record did not contain documentation as to the reasons why R4 is to be discharged .
On 10/12/23, another Resident (R5) called the police accusing R4 of making a bomb and had plans to blow up the facility. The police department came to the facility and investigated #23-010442. The police investigated and found the allegations to not be credible and there is no evidence that R4 is a threat to the facility. It also noted, in the search of R4's room, the police document that no other illegal contraband was found.
Surveyor notes there are no documented behaviors in R4's EMR from 10/12/23 to day of the survey process and through the survey process, 10/30/23-11/2/23.
On 10/30/23 at 10:12 AM, SW-D informed Surveyor that R4 has had no harmful behaviors ever. R4 only has quirks. SW-D was surprised by the accusation in regards to R4 from R5. SW-D believes the 30 day discharge notice was issued to R4 in regards to R4 bringing alcohol into the facility. SW-D informed Surveyor that R4 is not a drinker.
On 10/30/23 at 10:40 AM, SSD-C states SSD-C explained the 30 day discharge notice to R4 but wanted nothing to do with it. SSD-C states SSD-C explained R4 his rights and was choosing to not appeal. SSD-C is aware there is no specific discharge location and knows the facility cannot kick out R4. SSD-C states the 30 day discharge notice was given to R4 for alcohol use. SSD-C confirmed that other Residents in the facility have been found with alcohol and have not been given a 30 day discharge notice.
On 10/30/23 at 1:12 PM, Surveyor interviewed R4 in regard to the 30 day involuntary discharge notice. R4 stated that SSD-C went over the 30 day involuntary discharge notice and has the right to appeal until 11/8/23. R4 does not understand R4's appeal rights. Surveyor notes R4's notice documents that R4 has 7 days to appeal which would be 10/18/23.
11/8/23 is the date of the planned discharge meeting with an anticipated date of discharge 11/12/23. R4 informed Surveyor that SSD-C did not inform R4 the specific reason for the need to discharge R4. R4 stated, I assumed it was because of the bomb issue. R4 stated that R4 does not drink, brought in alcohol one time for a Resident (R32), R4 did not know R32 had problem with alcohol. R4 stated the facility came down hard on R4 for that, but never did it again. R4 is not aware of any current behavior contract.
On 10/31/23 at 11:55 AM, Surveyor interviewed SW-D again in regard to R4. SW-D stated R4 does not consume alcohol. SW-D stated that R4 follows the rules of the facility to the best of R4's ability. SW-D confirmed there are no behavior problems with R4. SW-D informed Surveyor it was never confirmed by the facility that R4 brought in alcohol for R32.
On 10/31/23 at 3:10 PM, Surveyor expressed concerns to Administrator (NHA-A), Interim Director of Nursing (DON-B), Regional Director of Operations (RDO-G), and Clinical Specialist (CS-I) that R4's 30 day involuntary discharge notice included the incorrect phone number of the Division of Quality Assurance (DQA) Southeastern Regional Office, the notice contains the wrong address to contact the ombudsman for assistance with filing an appeal. R4's 30 day notice also did not include a reason for the discharge and the location of where R4 is to be discharged . R4's electronic medical record did not contain documentation as to the reasons why R4 is to be discharged . No further information was provided by the facility at this time.
On 11/1/23, Surveyor informed NHA-A, DON-B, CS-I, and Registered Nurse Consultant(RNC-H) that if the facility intended on pursuing a 30 day involuntary discharge for R4, that due to significant changes like no specific reason as to why safety of individuals is endangered due to R4, and there is no specific destination, that a new notice must be provided to R4 which resets the discharge date in order to provide 30 day advance notification. The facility acknowledges and understands.
2) R2 was originally admitted to the facility on [DATE] with a readmission date of 10/19/23. Diagnoses includes paraplegia, anxiety disorder, other psychoactive substance abuse, depressive disorder, diabetes mellitus, and hypertension.
R2 does not have an activated power of attorney for healthcare.
The resident requires assistance with discharge planning care plan created 2/5/20 and initiated & revised on 10/19/23 documents the following interventions:
* Assist resident with adjustments to the residential setting so that he has a sense of control that is maintained throughout. Created 2/5/20 and initiated & revised 10/19/23.
* Consult with the physician, therapy, and other disciplines regarding progress toward discharge goals. Make arrangements for appropriate placement and update. Created 2/5/20 and initiated & revised 10/19/23.
* When discharging o [sic] (to) the community, provide for continuity of care after discharge. Provide medication list and information on scheduled appointments and on-going treatments. Provide information on reaching physician(s) involved in residents care. Created 2/5/20 and initiated & revised 10/19/23.
The resident requires discharge planning care plan created 2/5/20 and initiated & revised 10/19/23 documents the following interventions:
* Complete home visit and make recommendations as needed. Created 2/5/20 and initiated & revised 10/19/23.
* Invite resident/family/case managers to discharge planning care conference. Created 2/5/20 and initiated & revised 10/19/23.
* Meet with resident as needed during the discharge planning process. Created 2/5/20 and initiated & revised 10/19/23.
* Refer resident for PT, OT, ST (physical therapy, occupational therapy, speech therapy) or nursing services as ordered by the MD (medical doctor). Created 2/5/20 and initiated & revised 10/19/23.
* Review medication list, administration times, treatments, and upcoming appointments with resident prior to discharge to ensure accuracy. Created 2/5/20 and initiated & revised 10/19/23.
* Secure recommended DME (durable medical equipment) with MD orders. Created 2/5/20 and initiated & revised 10/19/23.
The late entry nurses note dated 10/6/23 documents, This writer and admin (Administrator) were notified that laundry had found a small baggie of white powdery substance was found in the laundry cart with wing 2 laundry. Police were called, they arrived at facility and took the bag with them. Due to this resident recently testing positive for methamphetamines and being on a behavior contract, we asked if we could search his room. Resident gave permission. Staff found a glass pipe in room. Police were called again and came and took the pipe. This writer and unit manager (who is now Interim DON) - B spoke with resident and asked about the pipe that was found in his room. Resident denied knowing anything about a pipe and that he doesn't use illegal drugs. Asked resident if he knows of anyone else that would use the pipe and maybe hide it in his room, resident again denied knowing anything. Due to his use of illegal drugs, resident was given a 30 day notice of discharge. His right to appeal was explained to him and he willingly signed the 30 day notice of discharge. Resident also denied knowing anything about the baggie of white powdery substance found in the laundry. MD (medical doctor) and NP (nurse practitioner) were updated on all of the above. Copy of 30 day notice of discharge was emailed to Ombudsman.
R2's Discharge Notice dated 10/6/23 under the reason for your being discharged is that: is checked for The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; The health of individuals in the facility would otherwise be endangered; Surveyor noted the facility did not specify what R2's clinical or behavior status is which would endanger other residents residing in the facility.
The location to which you will be moving is: documents Address to be determined within the 30 days.
Contact for the regional office for DQA (Division of Quality Assurance) does not have the correct telephone number.
The 10/6/23 nurses notes documents a copy of the 30 day notice of discharge was emailed to the Ombudsman.
R2 was hospitalized from [DATE] to 10/19/23.
R2's Discharge Notice dated 10/20/23 under the reason for your being discharged is that: is checked for The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; The health of individuals in the facility would otherwise be endangered; Surveyor noted the facility did not specify what R2's clinical or behavior status is which would endanger other residents residing in the facility.
The location to which you will be moving is: documents Address to be determined within the 30 days.
Contact for the regional office for DQA (Division of Quality Assurance) does not have the correct telephone number.
On 11/1/23 at 9:49 a.m., Surveyor spoke with R2. Surveyor asked R2 if he knew why the facility gave him a 30 day discharge notice. R2 replied yes. Surveyor asked R2 what was the reason the facility gave him the discharge notice. R2 replied I would rather not say. Surveyor inquired if the facility spoke to him about his appeal rights. R2 informed Surveyor they said he has the right to appeal and told him if he needed to know he could ask them.
On 11/1/23 at 12:23 p.m., Surveyor met with SSD (Social Service Director)-C and SW (Social Worker)-D to discuss R2's discharge notices dated 10/6/23 & 10/20/23. SW-D informed Surveyor she was told she had to reissue the discharge notice on 10/20/23 when a resident goes to the hospital and comes back. Surveyor informed SSD-C & SW-D neither discharge notice specifies what danger R2 is. SW-D informed Surveyor she will have to get back to Surveyor on this. Surveyor asked why the address is to be determined. SW-D replied because we didn't have a location. Surveyor informed SSD-C & SW-D the 30 day discharge notice needs to have a location where R2 is being discharged . Surveyor also informed SSD-C & SW-D name of contact for DQA phone number is incorrect.
On 11/2/23 at 11:09 a.m., another member of the survey team spoke with R2. During this conversation, R2 informed the Surveyor he got a discharge notice and can't be gone by the date. R2 stated he has no where to live. R2 stated he worries about it everyday and has a lot of anxiety. Surveyor noted R2 became teary eyed while speaking with Surveyor.
Sept 2023
10 deficiencies
3 IJ (1 affecting multiple)
CRITICAL
(J)
📢 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 1 resident
Based on interview and record review the facility failed to protect 1 of 6 residents (R10) right to be free from sexual and mental abuse by Dietary Aide (DA)-O. (DA)-O failed to maintain caregiver bou...
Read full inspector narrative →
Based on interview and record review the facility failed to protect 1 of 6 residents (R10) right to be free from sexual and mental abuse by Dietary Aide (DA)-O. (DA)-O failed to maintain caregiver boundaries by engaging in a personal/sexual relationship with R10.
DA-O became overly involved with R10 which included spending inappropriate amounts of time while off duty with R10, directing staff that she was providing 1:1 supervision and cares of R10, such as doing dressing changes, allowing R10 to call her for support when R10 wanted to get high, allowing R10 to watch movies at her home, assisting R10 with detoxing by providing R10 with narcotics (such as Heroin and/or Fentanyl). The facility was aware of the relationship and dynamics that were developing between DA-O and R10. On 6/28/23 the facility questioned DA-O about this relationship but did not take the steps to protect R10 from abuse from a caregiver as DA-O would be defined in her capacity as an employee of the facility. DA-O conveyed in her statements to the facility and interview that she implied to R10 and others, DA-O was the only one that could help R10, creating a situation of authority over R10. R10 was noted to overdose on Fentanyl on 8/8/23 after DA-O was observed providing unofficial (determined as needed by DA-O and not assessed as needed by the facility) 1:1 supervision of R10. DA-O admitted having a sexual relationship with R10 to the police/detective.
The facility's failure to ensure staff maintained caregiver boundaries with R10 created a finding of immediate jeopardy that began on 6/28/23. Surveyor notified NHA-A and Director of Nursing (DON)-B of the Immediate Jeopardy on 8/22/23 at 3:07 PM.
The immediate jeopardy was removed on 8/11/23, however; the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor their removal plan.
This is evidenced by:
Wisconsin Statute Chapter 50.065 (1) (ag) 1. Caregiver means any of the following:
a. A person who is, or is expected to be, an employee or contractor of an entity, who is or is expected to be under the control of an entity, as defined by the department rule, and who has, or is expected to have, regular, direct contact with clients of the entity .
The Wisconsin Administrative Code Chapter Division of Health Services (DHS) 13.03 (3) (a) Caregiver means a person who is all of the following:
1. A person who has received regulatory approval from an agency or is employed by or under contract with an entity.
2. A person who has access to the entity's clients.
3. A person who is under the entity's control.
According to the State Operations Manual:
F600 Freedom from Abuse, Neglect and Exploitation.
Under Guidance 483.12 (a) (1); Allegations of Staff to Resident Sexual Abuse: Nursing home staff are entrusted with the responsibility to protect and care for the residents of that facility. Nursing home staff are expected to recognize that engaging in a sexual relationship with a resident, even an apparently willingly engaged and consensual relationship, is not consistent with the staff member's role as a caregiver and will be considered an abuse of power. Also, for some health care professionals, it is prohibited by licensure or certification requirements for professionals to have a relationship with a resident (or patient.)
According to Observing Professional Boundaries for Caregivers developed by UW Oshkosh Center for Community Development, Engagement and Training and Wisconsin Department of Heath Services, Division of Quality Assurance, February 2016:
Professional boundaries are guidelines for maintaining a positive and helpful relationship with your residents. Understanding boundaries helps caregivers avoid stress and misconduct, recognize boundary crossings and provide the best possible care. The caregiver has a powerful role in the relationship between caregiver and client. This power comes from: 1. Control over the services provided to the client and 2. Access to private knowledge about the client . Maintaining professional boundaries helps the caregiver maintain a helpful or therapeutic relationship with the client.
Crossing Boundaries:
Type of Boundary Crossing:
Sharing Personal Information
Not seeing behavior as symptomatic,
Over-involvement: signs may include spending inappropriate amounts of time with a particular client, visiting the client when off duty, thinking you are the only caregiver who can meet the client's needs.
Romantic or Sexual Relationships: A caregiver is never permitted to have a romantic or sexual relationship with a client. Sexual contact with a client is against the law in Wisconsin because residents of many facilities are not viewed as being able to give consent under the law.
Secrets: Secrets between you and a client are different than client confidentiality . Personal secrets compromise boundaries and can result in abuse or neglect of a client.
https://wss.ccdet.uwosh.edu/stc/CAREGIVER/_WebRedesign/Documents/Keys/ObsProfBoundariesCgvrs-ParticipantGuide.pdf
Prior to 8/9/23, the facility's Employee Handbook and facility education did not address professional boundaries of staff and did not indicate staff to resident sexual relationships were prohibited.
R10 was admitted to the facility 9/27/22 with diagnoses that included Metabolic Encephalopathy, Lower Extremity Wounds, Sepsis, Opioid Dependency, Diabetes Mellitus 2 and Psychoactive Substance Abuse.
Surveyor reviewed R10's Minimum Data Set (MDS) Assessment with an assessment reference date of 7/7/23. Documented under Cognition was a brief interview mental status (BIMS) score of 15 which indicated cognitively intact.
Surveyor reviewed employee documents for staff member DA-O. DA-O was hired on 10/11/21 as a Temporary Certified Nursing Assistant (CNA) under the Covid 19 waiver, then in September of 2022 switched positions to a Hospitality Aide. In December 2022 DA-O switched positions to a Dietary Aide.
According to the facility, Dietary Aide (DA)-O was involved in a relationship with another Resident (R1) prior to R1 being admitted into the facility and DA-O being employed at the facility. The facility allowed for this relationship to continue despite both having affiliations with the facility.
Nursing Home Administrator (NHA)-A created special rules for DA-O's relationship/friendship with R1.
On 6/22/23 R1 and R10 had an altercation in the facility. An investigation was completed including interviews, interventions and follow-up. There is no mention of DA-O in the report.
On 6/28/23 NHA-A interviewed DA-O about R10 and R1. Documented was:
Discussion with [DA-O] regarding [R10] and [R1]
6-28-23
Present:
[Food Services Director (FSD)-Q]
[NHA-A]
I [NHA-A] entered [FSD-Q's] office and asked to speak with [DA-O], [FSD-Q] went to get [DA-O].
[NHA-A]: What is going on with you and [R10]?
[DA-O]: What do you mean?
[NHA-A]: You seem to be hanging around [R10] much more than you used to, and you do not seem to be paying attention to [R1] anymore.
[DA-O]: Yes, I am
[NHA-A]: Are you with [R1] anymore?
[DA-O]: No, he is an [expletive]. I tried to help him, and he continues to drink and act like an [expletive] to everyone.
[NHA-A]: Are you and [R10] dating?
[DA-O]: (laughed) Oh no! I am just trying to help him
[NHA-A]: Help him with what?
[DA-O]: Get clean, off of drugs so he can go be with his wife.
[NHA-A]: What do you do to help him?
[DA-O]: When he is frustrated and angry we talk, he opens up to me a lot. When he feels he wants to get high he calls me and we talk, I talk him down.
[NHA-A]: That is a huge responsibility [DA-O], have you asked him to see a professional to help him?
[DA-O]: tried but he doesn't trust anyone but me.
[NHA-A]: I need to discuss with you hanging around [R10] in front of [R1], this is a very big issue as I am sure you know. You were very large support for [R1] and in a relationship prior to [R1] coming to [facility] and now you dumped him to be with [R10], who we all know [R1] and [R10] do not get along. This is causing many altercations between [R1] and [R10].
[DA-O]: Yea, I know. I don't mean to make [R1] mad but [R10] wants my help, and he listens to me.
[NHA-A]: I want to make it clear that you are not to have any contact with [R10] while you are on the clock working in the kitchen, the same rules apply when you were with [R1].
[DA-O]: It is not like that, I am just talking with [R10] to help him, he wants to get better and be with his wife.
There were no other interviews with staff and residents into the allegation of abuse between DA-O and R10. (Cross reference F610).
During this interview on 6/28/23, NHA-A became aware that DA-O was taking on responsibilities beyond DA-O's qualifications and position within the facility. NH-A became aware R10 was calling DA-O to talk to DA-O when upset and opening up to DA-O when wanting to get high. NH-A became aware of DA-O's attempts to help R10 get clean and off drugs. NH-A acknowledged to DA-O as taking on a huge responsibility and asked if DA-O asked R10 to seek professional help. DA-O informed NH-A that R10 did not trust anyone other than DA-O.
NHA-A, FSD-Q and DA-O should have recognized from this interview, DA-O's relationship with R10 was beyond professional boundaries and should have intervened with R10's need for professional intervention in regard to his substance abuse disorder. DA-O continued to develop an abusive relationship with R10 creating a situation of mental anguish for R10 by fostering feelings of fright and anxiety related to their drug addiction and overall well-being by encouraging R10 to not trust anyone but DA-O. This progressed to sexual abuse as a caregiver.
On 7/2/23 R1 and R10 had another altercation in the facility. An investigation was completed including interviews, interventions and follow-up. There is no mention of DA-O in the investigative report even though NHA-A stated in the 6/28/23 interview with DA-O that she (DA-O) was the reason for the resident to resident incidents.
On 7/22/23 Certified Nursing Assistant (CNA)-J observed DA-O in R10's room. CNA-J wrote a statement that documented:
On Saturday July 22, 2023, I walked by [R10's] room and witnessed [DA-O] in the bathroom with the resident. I notified [SW-L].
On 7/22/23 SW-L wrote a statement about DA-O in R10's room. Documented was:
I, [SW-L], was doing rounds around 10:40 AM. I witnessed [DA-O] in [R10's] bathroom with [R10]. I asked if everything was OK and [R10] replied yes. [DA-O] then walked out of the bathroom.
On 7/25/23 DA-O wrote a statement about the event on 7/22/23. Documented was:
On the day in question, I came in at 6 AM to bring Dietary Aide [DA-BB] to work. When I came in I saw [R10] and we conversed (sic) a little while.
I then went and ran some errands and came back. When I came back [R10] told me he was about to go wash his leg and rewrap it. He said he wanted me to see how good they healed. When I got to [R10's] room he was in the bathroom washing his leg so I walked in and stood in the doorway of his bathroom as he showed me how good his legs looked. All doors remained open.
Then [SW-L] walked in and asked him if he was OK. He replied yes at this time I was gathering some items he asked me to get for when he was done and was going to rewrap them. We at that point realized [R10] needed more rolled gauze so I walked down to the nurses' station and asked [Licensed Practical Nurse (LPN)-S] for some . When [LPN-S] came back up I took the roll of gauze to [R10] and asked him if he needed anything else before I walked away. He said no so I left and went and clocked in and started doing my job.
NHA-A prepared the following summary about above the event on 7/22/23.
Documented was:
Investigation on complaint
7-22-23
On 7-24-23 [SW-L] brought to my attention that [DA-O] was in [R10's] bathroom.
This occurred at approx. 10:30 a.m.
[R10] had the door open to the bathroom; [DA-O] was bending over helping with his bandage.
[SW-L] stated that [DA-O] shortly went to the kitchen to work.
The administrator looked up [DA-O's] work hours for 7-22-23.
She clocked in at 11:00 (AM) and clocked out at 7:05 PM
[DA-O] was not in working hours when she was with [R10].
There were no other interviews completed with staff and residents (such as frequency of DA-O visiting with R10, what DA-O was doing for R10 etc.) and no investigation into the relationship between DA-O and R10.
On 8/21/23 at 9:57 AM Surveyor interviewed SW-L. Surveyor asked if anyone had reported anything inappropriate between R10 and DA-O to her. SW-L stated on 7/22/23 CNA-J came to her office and stated that a kitchen staff member was in R10's room. SW-L stated she went to R10's room and DA-O and R10 were in his bathroom. SW-L stated DA-O was hunched over his legs with a white towel in her hand. SW-L stated she asked DA-O what she was doing. SW-L stated DA-O responded just wiping his legs. SW-L stated she wrote a statement and had CNA-J write a statement.
On 8/17/23 at 3:43 PM Surveyor interviewed FSD-Q. Surveyor asked if she knew about the relationship between DA-O and R10. FSD-Q stated she knew that she (DA-O) was spending a lot of time with him after her shifts. Surveyor asked if she heard anything inappropriate between the two of them. FSD-Q stated a couple of CNAs, who she does not remember their names, told her DA-O should not be in R10's room. Surveyor asked when this was reported to her. FSD-Q stated 2 to 3 weeks before the last overdose [of R10] on 8/8/23. Surveyor asked what she did with the information. FSD-Q stated she asked DA-O what was going on and DA-O stated nothing, she was just helping R10 with his bandage changes to his legs. Surveyor asked if she reported this to anyone. FSD-Q stated the CNAs had already reported it to SW-L [noting the incident on 7/22/23].
Surveyor noted FSD-Q became aware DA-O was assisting R10 with his bandage changes to R10's legs. This was beyond DA-O's position responsibilities and DA-O had no qualifications to be performing dressing changes on R10's legs or cares. Surveyor noted FSD-Q was aware of DA-O spending a lot of time with R10 after her shifts and did not recognize DA-O's behaviors as crossing caregiver boundaries which can lead to abuse. FSD-Q did not report this to anyone as FSD-Q stated the CNAs had already reported it to SW-L.
R10's Progress Notes dated 8/7/2023 at 9:49 PM by Licensed Practical Nurse-U documents Resident did sober up somewhat but meds were held because of earlier under the influence. Narcan was given for one dose to right nostril. Sleeping with a chaperone at the bedside.
On 8/21/23 at 9:49 AM Surveyor interviewed LPN-U. Surveyor asked who the chaperone was. LPN-U stated the chaperone was DA-O. LPN-U stated she approached DA-O and asked her what she was doing there. LPN-U shared DA-O stated the facility asked her to do a 1:1 with R10 and she was just there to watch him.
On 8/17/23 at 10:41 AM Surveyor interviewed CNA-N who was working 8/7/23 through 8/8/23 on night shift on R10's unit. Surveyor asked if she saw DA-O in R10's room. CNA-N stated yes, she was doing a 1:1 supervision. CNA-N stated she did not know why though, because she (DA-O) is not a CNA anymore. Surveyor asked if the door was open. CNA-N stated no, it was closed.
On 8/17/23 at 12:33 PM Surveyor interviewed LPN-R who was working 8/7/23 through 8/8/23 on night shift on R10's unit. Surveyor asked if she saw DA-O in R10's room. LPN-R stated yes, she talked to her and DA-O told her she was doing a 1:1 supervision because of the overdose on 8/7/23. Surveyor asked if the door was open. LPN-R stated throughout the night the door was both open and closed.
Surveyor asked if she saw anything inappropriate. LPN-R stated DA-O was massaging his (R10's) feet and legs around 11:30 PM on 8/7/23. Surveyor asked if she was aware if they were in a relationship. LPN-R stated she had heard that and had seen them together after her [DA-O's] shifts were over.
Documented in Progress Notes on 8/8/23 at 2:44 PM by DON-B was This writer was contacted by nurse on duty at facility around 5:35 this AM stating that resident was unresponsive. This writer told nurse to administer Narcan due to resident's history of OD (overdose) and drug abuse and call 911. Upon arrival to facility at 5:45AM this writer went to resident's room where police and paramedics were already with resident and staff. EMT [emergency medical transport] tried to get resident to arouse and answer questions but resident was not able to answer any questions, he was moaning and spitting everywhere. At approximately 6:20 (am) resident was taken to local ER by ambulance. A staff member reported to this writer around 9:40 (am) that resident called her and stated he needed a ride back to facility because he had been discharged . The staff member was identified as DA-O.
On 8/8/23, NHA-A interviewed DA-O with Detective-V after the R10's overdose.
The facility was concerned DA-O was giving R10 drugs since she was with him (R10) for both the overdoses on 8/7/23 and 8/8/23.
Documented by NHA-A was:
Interview between [Police] and [DA-O]
August 8, 2023
Interviewer: [Detective-V]
[Detective-V]: Introduced herself to [DA-O].
[Detective-V]: How do you know [R10]?
[DA-O]: He is a resident here
[Detective-V]: What kind of relationship do you have with [R10]?
[DA-O]: We don't have sex it is not like that
[Detective-V]: I was not referring to that I just asked what kind of relationship with [R10] do you have
[DA-O]: We are friends that is it. We talk about his wife.
[Detective-V]: This morning you told my officer to look in [R10]s wallet because there may be drugs in it, how did you know that?
[DA-O]: I didn't know that
[Detective-V]: Then why did you tell the officer to look in his wallet?
[DA-O]: He is always protective of his wallet, he sleeps with it.
[Detective-V]: What position do you do?
[DA-O]: I work in the kitchen, I am a dietary aide
[Detective-V]: How do you know he sleeps with his wallet?
[DA-O]: He usually has a lot of money in his wallet and he is very protective of his money, I assumed he slept with it.
[Detective-V]: I was told that you helped [R10] Detox from drugs, how did you do that
[DA-O]: Yes, I did. I was his support, I would just talk to him about his wife and that he wants to get out of here.
[Detective-V]: Did you provide anything else?
[DA-O]: No, we would just talk about him getting clean and getting out of here and be with his wife.
[Detective-V]: Do you have a relationship with [R10] outside of the facility?
[DA-O]: No
[NHA-A]: Has [R10] ever been to your house?
[DA-O]: No
[NHA-A]: It has been reported by staff that [R10] was seen at your house, has [R10] been to your house?
[DA-O]: Puts her head down and stated, yes, I made a bad decision and had him come over.
[Detective-V]: What did you and [R10] do when he was in your house?
[DA-O]: We just watched movies.
[Detective-V]: Is that the only time he has been at your house?
[DA-O]: Yes
[Detective-V]: Is there anything else you need to tell me before we end?
[DA-O]: No, that is pretty much it
[Detective-V]: Ok, I need you to know I found three phones in [R10's] room, we will be getting a search warrant for them, I will be dumping these phones, so if there is anything you need to tell me or you are not telling me it will show up on the phone.
Let me ask again, is there anything you need to tell me that may be on the phones?
[DA-O]: No, I cannot think of anything.
Included in the report was the follow-up phone call made to the facility by Detective-V. Documented by NHA-A was:
Discussion with [Detective-V]
August 9, 2023 [at 9:15 AM]
On August 9, 2023, [Detective-V] called and stated that [DA-O] came into the police station to speak with her.
[Detective-V] stated that [DA-O] admitted to lying to the [Detective-V] at the interview the day before.
[DA-O] stated that she has sex with resident [R10].
She also confessed that she has given [R10] Illegal drugs, Fentanyl while in the facility.
[Detective-V] stated that she called me immediately due to the danger of [DA-O] bringing in illegal drugs into the facility and giving them to a resident .
On 8/15/23 at 10:40 AM Surveyor interviewed DA-O. Surveyor asked if she was having a sexual relationship with R10. DA-O stated yes. Surveyor asked if she had ever had training on having relationships with residents. DA-O stated she was told that as long as both people are their own person, it is consensual, and the resident is not coerced it is fine. Surveyor asked if she told anyone at the facility about the relationship. DA-O stated no. Surveyor asked how the facility knew about the relationship. DA-O stated she spent a lot of time there after her shift and people talk. Surveyor asked about the night of 8/7/23 through 8/8/23. DA-O stated she spent the night with R10 but the door was kept open. DA-O stated she did not trust the staff on the floor to take care of him overnight since his overdose on 8/7/23. Surveyor asked when R10 was at her house. DA-O stated she thought it was sometime in July and it was only that once. Surveyor asked if she told anyone about R10 being at her house. DA-O stated no. Surveyor asked if she had ever given R10 illegal drugs. DA-O stated yes, a little bit of heroin over the course of 30 days to help him detox and get off drugs.
Surveyor reviewed the facility's undated Policy and Procedure Abuse and Neglect Reporting and Investigating portion of the Employee Handbook Documented was .4. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. Any non-consensual of any type with a resident . The procedure did not state staff to resident sexual relationships were not permitted.
After the incident on 8/8/23 and information received on 8/9/23 from Detective-V, the facility completed a Quality Assurance and Performance Improvement (QAPI) Plan and a Root Cause Analysis. The facility determined that DA-O crossed therapeutic thresholds and ended up in an inappropriate relationship with R10 because she thought she was helping him detox from an illegal substance. They determined the root cause to be that the employee thought she was helping the resident.
After this, the facility developed a new policy, Workplace Relationships, with an implementation date of 8/9/23. Documented on the new policy was:
Policy: Work-place relationships are a mandatory disclosure to the Administrator. The Administrator will review on a case-by-case basis if the relationship poses violation to our code of ethics policy, including and not-limiting to a relationship between an employee and a resident.
Definition: Ethical standards in the workplace acknowledging human values such as respect, responsibility, integrity, and the personal behavioral standards a person holds.
Purpose: To re-enforce the code of ethics in the employee handbook. Consensual and serious relationships disclosed to the Administrator will require a signed disclosure by both parties.
Personal relationships (including romantic and/or sexual) between individuals in inherently unequal positions, where one party has real or perceived authority over the other in their professional roles, may be inappropriate in the workplace and are strongly discouraged.
Employee may not be defined as the direct report over the other.
Employees must always possess professional conduct so as not to affect job performance for either party, public displays of affection are prohibited.
Employee may not be assigned as caregiver during hours of work, unless approved by the Administrator and written within the Residents' care plan.
Employee must refrain from the Resident area during work hours unless on authorized breaks or during their assigned meal period.
Reporting of a relationship to the Administrator needs to occur prior to employment. If the Relationship is established within the employment period, then the employee must come forward within 24 hours of the established relationship.
Witnessing a relationship is also reportable to the Administrator, when an employee identifies a relationship with a co-worker or resident that is defined as romantic and or sexual, bringing it to the attention of the Administrator.
Acknowledgement of Work-place relationship
DATE
[Name and Title of Employee 1 to be filled in]
[Name and Title of Employee 2 to be filled in]
o Acknowledgement that the relationship is consensual.
o Acknowledgement that the relationship was never a term of employment.
o Acknowledgement that the (Employee/Resident) relationship, although an employee of the facility will abide by family/visitor rights, unless authorized by the Administrator. I.e., staying in the facility during non-visiting hours.
o Agreement public displays of affection are forbidden in the workplace.
o Agreement that the relationship will not affect job performance.
o Agreement that transfers and promotions may be affected by policies that prohibit employees to work in the same department or prohibit supervisor/subordinate relationships.
[signature lines]
Cc: employee file(s) and or resident care plan
Surveyor noted this policy includes that any relationship needs to be reported prior to employment and that witnessing a relationship is reportable to the NHA and when a relationship develops between a coworker or a resident, that is reportable to the NHA as well. The policy does not define whether the relationship is between staff and staff or staff and a resident. The policy acknowledges if the relationship is consensual, (employee/resident relationship,) they will abide by the family visitor rights, for example, staying in the facility after business hours and the relationship will not affect job performance. The policy does state that personal relationships can provide a real or perceived position of authority and may be inappropriate in the workplace and are strongly discouraged. This policy also states, If the relationship is established within the employment period, then the employee must come forward within 24 hours of the established relationship.
On 8/21/23 at 12:18 PM Surveyor interviewed NHA-A and DON-B. Surveyor asked about the employee handbook and why it does not specify that staff are not permitted to have sexual relationships with residents, nor does it address staff boundaries. NHA-A stated Corporate creates those policies. Surveyor asked why the new policy does not address that employees are not permitted to have sexual relationships with residents and does not specify staff or residents on the form. NHA-A stated she will investigate this. Surveyor asked when NHA-A was aware of the relationship between DA-O and R10. NHA-A stated 8/9/23 when Detective-V told her. Surveyor asked about the incidents/events on 6/28/23, 7/22/23 and the knowledge that R10 had been to DA-O's house. Surveyor asked why these incidents were not investigated further with interviews with other staff, residents, and with R10.
NHA-A stated that these were just rumors and she cannot look into all rumors. Surveyor asked how does she know they are just rumors and not facts if she does not investigate? NHA-A stated I guess I can't. Surveyor asked about the altercations between R1 and R10. NHA-A stated they stemmed from fighting over DA-O. Surveyor noted this is not documented anywhere in the investigation. Surveyor asked what were the rules that were in place for DA-O and R1 and subsequently R10. NHA-A stated DA-O could only visit after work hours, never during; all meetings would be in a common area or in the room with the door open. Surveyor asked when she was made aware that DA-O stayed the night 8/7/23 through 8/8/23. NHA-A stated not until 8/8/23 in the morning. Surveyor asked if DA-O staying overnight in R10's room was appropriate. NHA-A stated no. Surveyor asked if she ever had a conversation with DA-O about not having a relationship with R10. NHA-A stated no. Surveyor asked if NHA-A thought the sexual relationship between DA-O and R10 was OK. NHA-A stated no.
Surveyor also reviewed an additional Work-Place Relationships policy dated 8/9/23. This policy addresses Romantic Relationships which states, Romantic or sexual relationships, consenting or otherwise, between an employee and a facility resident is strictly prohibited and will lead to the immediate termination of the employee's employment
Surveyor noted although this policy prohibits a romantic or sexual relationship with residents the facility has developed 2 policies both dated 8/9/23 pertaining to Work-Place Relationships. One policy states . The Administrator will review on a case-by-case basis if the relationship poses violation to our code of ethics policy, including and not-limiting to a relationship between an employee and a resident with the requirement to come forward within 24 hours of the established relationship. The second policy references a romantic or sexual relationship between and employee and a facility resident as strictly prohibited leading to the immediate termination of employment.
Neither policy addresses crossing professional/caregiver boundaries which is an abuse of power a staff member has over a resident. This can lead to abuse, including resident to resident abuse such as the altercations between R1 and R10 as a result of their relationships with DA-O.
The facility's failure to investigate and recognize that DA-O was crossing caregiver boundaries and to prevent abuse including sexual abuse of R10 created a a finding of immediate jeopardy.
The immediate jeopardy was removed on 8/11/23 when the facility completed the following:
RESIDENTS DIRECTLY INVOLVED:
1.) [R10] no longer resides in the facility. However, facility did complete the following steps upon his return to the facility on 8/10/2023;
a. 1:1 staff supervision in place upon his return to facility. Staff trained on specific guidelines for his care and monitoring.
b. Resident was educated on expectation and new supervision guidelines of 1:1 prior to his return.
ACTIONS FOR POTENTIALLY AFFECTED RESIDENTS:
1) Police were notified and interviewed on 8/8/2023
2) Identified resident received medical care outside of the facility on 8/8/2023
3) Interview with the resident and administrator on 8/8/2023 at the outside facility
4) Police interviewed identified staff member on 8/8/2023
5) Staff member was removed from the facility on 8/8/2023 and suspended pending investigation on 8/9/2023. Staff member no longer employed at facility at this time.
SYSTEMIC ACTIONS:
1) Systemic changes to include;
a. Residents and staff were interviewed regarding exploitation and relationships with staff starting 8/8/2023.
b. Residents without the ability to speak or communicate were monitored for any changes in condition to include mood or behaviors without known root cause or changes in normal mood or behavior on 8/9/2023. (Any resident with changes had an investigation for root cause)
c. Workplace Relationship Policy that addressed employee/resident romantic or sexual relationships, consensual or not, are strictly prohibited, reviewed, revised and trained on 8/9/2023. Addendum to policy completed on 8/23/2023 to include the responsibility to protect and care for the residents and potential abuse of power when policy is violated, training on professional boundaries to include post-test for competency. Ad Hoc QAPI held on 8/23/2023 with Medical Director/Designee for review of policy update.
d. Resident Council held on 8/10/2023 with Administrator; topics discussed around resident relationships and substance abuse guidelines. Additional Resident Council to be held on 8/24/2023 to include review of revised Wor[TRUNCATED]
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) The facility policy entitled Elopements and Wandering Residents implemented on 2/20/2023 states: This facility ensures that ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) The facility policy entitled Elopements and Wandering Residents implemented on 2/20/2023 states: This facility ensures that residents who exhibit wandering behavior and/or are at a risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk.
Policy Explanation and Compliance Guidelines: .
3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.
4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering:
a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan (IDT) team.
b. The IDT team will evaluate the unique factors to contributing to risk in order to develop a person-centered care plan.
c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff.
d. Adequate supervision will be provided to help prevent accidents or elopements.
e. Charge nurses and unit managers will monitor the implementation if interventions, response to interventions, and document accordingly.
f. The effectiveness of interventions will be evaluated, and changes, will be made as needed. Any changes or new interventions will be communicated to relevant staff.
6. Procedure Post-Elopement: .
e. Staff will be educated on the reasons for elopement and possible strategies for avoiding such behavior.
g. Documentation in the medical record will include findings from nursing home and social service assessments, physician/family notification, care plan discussions, and consultant notes as applicable.
The facility policy entitled One-to-one Supervision initiated on 1/2/2023 states: Purpose: to provide guidance for the IDT team on the approach to safely reduce monitoring for those who are provided a one-to-one (1:1) supervision.
Guideline:
1:1 supervision requires that a resident is never out of line of site from designated staff at all times:
- The resident is always accompanied by the staff member (including bathing, showering, shaving, and toileting).
All residents on 1:1 status will be evaluated at least every shift by a licensed nurse.
Monitoring will additionally include:
- Everyday review by the IDT team
- The 1:1 will be added to the orders, and the charge nurse will sign off each shift
- The resident will be on Alert charting every shift for the duration of 1:1 supervision.
- Information from the resident observations will be documented.
1:1 Supervision is only discontinued after the resident has been assessed by the IDT team and the physician/ extender as no longer requiring this level of supervision secondary to the comprehensive assessment. The resident will remain on Alert' charting- charting every shift= for the three days following discontinuation of the 1:1 supervision.
Procedure:
- Assess individual resident risk, including the need for supervision.
- Evaluate and analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce hazards/ risks as much as possible.
- Implement interventions, including adequate supervision consistent with needs, goals, care plan and professional standards to eliminate the risk.
- Monitor the effectiveness of the interventions and modify the care plan as necessary.
R8 was admitted to the facility on [DATE] and has diagnoses that include Wernicke's Encephalopathy, major depressive disorder, blindness in right and left eyes, Parkinson's disease, anxiety disorder, middle cerebral artery syndrome, cerebral infarction, and hemiplegia/ hemiparesis affecting the right dominant side.
R8's quarterly minimum data set (MDS) dated [DATE] indicated R8 had severely impaired cognition with a brief interview for mental status (BIMS) score of 00 and the facility assessed R8 was independent with most activities of daily living (ADL's) and only required supervision with hygiene and limited assist with bathing. The facility assessed R8 to be an independent smoker on 6/23/2023. R8 was assessed on 5/31/2023 to be no to low risk for elopement with an elopement risk evaluation score of 12.
On 7/14/2023 at 8:47 AM in the progress notes nursing charted nursing was informed by another resident that R8 left out of the gate by the smoking doors. Nursing followed and called the unit manager when caught up to R8. Nursing stayed with R8 until the social worker caught up to R8 and nursing staff and escorted R8 back to the facility.
On 7/14/2023 at 9:42 AM a wander guard was placed on R8's right ankle,
R8'S Elopement risk care plan was initiated on 7/14/2023 with the following interventions:
- (R8) placed on hourly checks for visual placement of wander guard and desire to exit building.
- Smoking assessment, trauma, pain, skin, and elopement assessments complete.
- Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books.
- Identify pattern of elopement: Is exit seeking purposeful aimless, or escapist? Is (R8) looking for someone or something?
- Notify supervisor, director of nursing (DON), and administrator immediately of any successful exits from the building. Follow facility elopement protocol.
- Wander guard placed on R8's right ankle. WANDER ALERT
- 1:1 during the day/night, fifteen minute checks when in (R8's) bedroom (initiated 7/15/2023)
- Wander guard applied to walker (initiated 7/17/2023)
- Wander guard removed from right ankle, wander guard remains on walker (initiated 7/18/2023)
- Fifteen minute checks (initiated 7/24/2023)
- (R8) changed to 30 minute checks (initiated 8/1/2023)
- (R8) checks changed to hourly (initiated 8/7/2023)
R8's smoking care plan was revised on 7/14/2023 for R8 to be a supervised smoker. R8 was assessed on 7/14/2023 to be at risk for elopement with an elopement risk evaluation score of 36.
On 7/17/2023 at 6:44 AM in the progress notes nursing charted R8 was let outside by another resident while the certified nursing assistant (CNA) and night shift nurse were attending to a fall. The CNA coming on for day shift went to watch R8 and bring R8 inside the facility. R8 became verbally aggressive with staff. R8 was swearing and attempting to take R8's wander guard off. R8 feels R8 should not have a wander guard on and states R8 can do whatever R8 wants. R8 calmed down when the MDS coordinator (MDS)-K was able to convince R8 to go out on patio to smoke.
Surveyor noted there was no investigation by facility staff regarding incident on 7/17/2023 when R8 was found outside without staff supervision.
On 8/15/2023 at 12:46 PM Surveyor interviewed Registered Nurse (RN)-G who stated R8 had been feeling stressed due to R8 wanting to go to another facility but R8 felt staff was not doing enough to find new placement. RN-G stated R8 liked to walk the hallways in the facility and walk the path on the smoking patio and R8 was not aware R8 could not for walks off the facility grounds without a staff member present. RN-G stated the patio gate was open and when R8 walked through the gate. R8 shut the gate once he exited the patio. When RN-G went to retrieve R8, RN-G was not able to exit the patio as RN-G was not able to release the gate latch. Once the gate latch was released, RN-G was able to exit the patio area to follow after R8. RN-G stated R8 never left her sight and that the social worker assistant (SWA)-H caught up with R8 by employee parking lot. RN-G stated R8 is currently on one hour checks and will ask staff if R8 wants to go for a walk. Nursing staff hold onto R8's smoking supplies and is a supervised smoker. RN-G stated R8 has had no behaviors since getting wander guard off R8's ankle.
On 8/16/2023 at 9:46 AM Surveyor interviewed SWA-H who stated when R8 was admitted R8 was on monitoring due to R8 always stating he wanted to go home. R8 was put on medications to help with anxiety of being in a new place and R8 was able to come off monitoring. SWA-H stated R8 started to have increased anxiety back in June when R8 completed therapy and stated that R8 wanted to find R8's forever home and R8 started to refuse medications so the nurse practitioner discontinued the medications. SWA-H noted R8 to have some increased anxiety but was not concerned for elopement; staff did elopement assessments on R8 and was found to be no to low risk of elopement and never had a history of making attempts to elope from the facility. SWA-H stated it was a shock R8 left the patio gates and that SWA-H caught up to the resident in the employee parking lot to the right of the smoking patio and walked with R8 down the hill onto a sidewalk. SWA-H stated SWA-H and R8 walked on the sidewalk and back up the hill and into the smoking patio. SWA-H stated SWA-H then placed the wander guard on R8's right ankle. SWA-H states R8 will go into SWA-H office frequently during the day stating R8 wants to go home. SWA-H states SWA-H is continuing to find placement closer to R8's family. SWA-H does not recall another situation where R8 was found outside unsupervised. SWA-H stated that at time R8 would get frustrated when the 1:1 was following R8 and R8 would try to walk away from the staff that was assigned 1:1 with R8. SWA-H did not recall the situation when R8 was outside unsupervised on 7/17/2023.
On 8/17/2023 at 10:08 AM Surveyor interviewed CNA-I who stated CNA-I was scheduled to be with R8 during the night for 7/16/23 into the morning of 7/17/2023. CNA-I stated CNA-I never left R8 alone and did not recall the oncoming CNA that took over the 1:1 responsibility. CNA-I stated R8's normal routine is to sleep and then R8 wakes up anywhere between 2:00 to 4:00 AM to go out and have a cigarette. CNA-I stated R8 usually gets dressed for the day and then will lay back down after R8 smokes a cigarette. CNA-I stated if scheduled to be 1:1 and an emergent situation happens with another resident, or someone needs help. The staff is not to leave the 1:1 unless there is another staff to take the place, or 1:1 will notify someone that another resident needs them. CNA-I stated staff are not to leave the resident that is scheduled a 1:1. CNA-I does not recall a situation on 7/17/2023 that required assistance of all staff and would lead to R8 being left unsupervised. CNA-I stated CNA-I would have stayed with R8 until the next scheduled 1:1 came to take over. CNA-I stated CNA-I usually works until 6:15 AM.
On 8/17/2021 at 12:51 PM Surveyor interviewed CNA-J who states CNA-J was scheduled to do 1:1 with R8 on 7/17/2023. CNA-J does not recall R8 ever being outside unsupervised or a fall taking place that required all staff to attend. CNA-J does not recall the staff member that was assigned to R8 prior to CNA-J shift stating at 6:00 AM on 7/17/2023. CNA-J stated that CNA-J would do fifteen minute checks on R8 if in R8's bedroom and then would walk with R8 (1:1) when R8 was out of room. CNA-J denied R8 ever being unsupervised on 7/17/2023.
On 8/17/2023 at 1:23 PM Surveyor interviewed MDS-K who stated MDS-K came in the side door by the employee parking lot to start shift on 7/17/23 and noted R8 standing at the nurse's station by Unit 4. MDS-K stated R8 appeared to be agitated. MDS-K stated MDS-K has a good rapport with R8. MDS-K was able to calm R8 down and went out to the patio with R8 and R8 had a cigarette. MDS-K stated MDS-K did not know anything about R8 being found outside while unsupervised prior to MDS-K meeting staff and R8 in the hallway. MDS-K could not remember the staff member that was with R8 in the morning.
On 8/21/2023 at 8:47 AM Surveyor interviewed DON-B who stated she never investigated the situation of R8 being found outside unsupervised on 7/17/23 because DON-B did not think R8 was outside. DON-B stated RN-G would have told DON-B if R8 got out unsupervised. Surveyor read DON-B the progress notes that RN-G charted. DON-B stated that what RN-G charted in progress notes would make it sound like R8 was found outside unsupervised. DON-B stated the issue was not investigated to see what happened. DON-B does not know if R8 was outside unsupervised or not on 7/17/23. DON- B stated the other residents know not to let another resident follow them outside onto the patio. DON-B stated that R8 could have followed the resident out onto the patio when the door was open, because R8 was 1:1 and R8 would not have been unsupervised.
On 8/21/2023 at 9:47 AM Surveyor interviewed social worker (SW)-L who stated R8 has a better rapport with SWA-H so R8 tends to go to SWA-H. SW-L and SWA-H maintain good communication regarding R8 and R8's needs. SW-L recalls the elopement on 7/14/2023 with R8 and does recall a time SWA-.H told her about R8 being on smoking patio unsupervised and being brought back inside. SW-L could not recall any other details regarding the situation.
On 8/21/2023 at 12:05 PM Surveyor told DON-B and nursing home administrator (NHA)-A of surveyors concerns that the situation with R8 on the morning of 7/17/2023 were not investigated to know if R8 was found outside unsupervised. NHA-A stated that NHA-A's understanding of elopement was if a resident got off facility grounds. NHA-A questioned if R8 was in the patio, would it have been an elopement. Surveyor stated the progress notes written on 7/17/2023 state R8 let outside so it did not define outside of facility or outside on patio because it was never investigated. NHA-A and DON-B stated they will look into situation.
On 8/22/2023 at 12:34 PM Surveyor interviewed RN-G who stated R8 was outside on the patio with another resident unsupervised by facility staff on 7/17/2023. The morning CNA came on shift and went out to get R8 to come into the facility. R8 became angry and was arguing with the CNA. RN-G stated she could not recall who the CNA was that was on duty at the time and who was supposed to be 1:1 with R8. Surveyor clarified that on 7/17/23 R8 was noted to be outside on the patio without staff supervision and RN-G agreed.
On 8/22/2023 at 3:10 PM Surveyor informed DON-B and NHA-A of concern that R8 was found outside on patio the morning of 7/17/2023 unsupervised. Surveyor expressed concern that the situation was not investigated as to why R8 was outside on patio alone and not supervised by R8's 1:1. No further information was provided at this time.
Based on interview and record review, the facility did not ensure that 3 (R10, R11 and R8) of 7 sampled residents' environment was as free as possible of accident hazards and provided with the supervision necessary to prevent accidents.
* R10 was admitted to the facility with a history of drug abuse. On 4/29/23, 5/4/23, 8/7/23 and 8/8/23, R10 overdosed on drugs and had to have Narcan administered. The facility did not investigate or monitor the resident and did not put effective interventions, including increased supervision, in place to prevent subsequent overdoses. On 8/7/23, the facility did not notify the MD or call 911 after administering Narcan for R10's overdose.
* R11 was admitted to the facility with a history of drug abuse. On 5/4/23 and 8/3/23, R11 overdosed on drugs and had to have Narcan administered. The facility did not investigate or monitor the resident and did not put effective interventions in place to prevent subsequent overdoses.
The facility's failure to provide a safe environment by failing to monitor, supervise, and prevent residents from subsequent overdoses on illegal drugs created a finding of immediate jeopardy that began on 4/28/23. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the Immediate Jeopardy on 8/22/23 at 3:07 PM.
The immediate jeopardy was removed on 8/24/23, however; the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor the effectiveness of their action plan and as evidenced by:
* R8 eloped from the facility on 7/14/2023 and was put on one-to-one for supervision. On 7/17/2023 R8 was found outside on the smoking patio without the supervision of a one-to-one staff person, there was no investigation into how R8 was able to get out on the smoking patio and if R8 was supposed to be under one-to-one supervision with a staff member.
Findings include:
Surveyor reviewed facility's Safety for Residents with Substance Use Disorder policy with an implementation date of 1/4/22. Documented was:
Policy:
It is the policy of this facility to create an environment as free of accident hazards as possible for residents with a history of substance use disorder.
Definitions:
Substance Use Disorder (SUD) is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.
Policy Explanation and Compliance Guidelines:
1. Residents with a history of SUD will be assessed for risks including the potential to leave the facility without notification and use of illegal/prescription drugs. Care plan interventions will be implemented to include increased monitoring and supervision of the resident and their visitors.
2. When substance use is suspected, (in the facility or upon return from an absence from the facility) which could lead to overdose, facility staff should implement the care plan interventions, which includes notification of the resident's physician or non-physician practitioner.
3. Care planning interventions will address risks by providing appropriate diversions for residents and encouraging residents to seek out facility staff to discuss their plan of care, including discharge planning, rather than leaving to seek out substances which could endanger the resident's health and/or safety .
6. Residents with SUD may try to continue using substances during their stay in the nursing home.
Facility staff will assess the resident for the risk for substance use in the facility and have knowledge of signs and symptoms of possible substance that include, but are not limited to:
a. Frequent leaves of absence with or without facility knowledge
b. Odors
c. New needle marks
d. Changes in resident behaviors, especially after interaction with visitors of absences from facility:
i. Unexplained drowsiness
ii. Slurred speech
iii. Lack of coordination
iv. Mood changes
Surveyor reviewed the facility's Resident Possession and Use of Illegal Substances policy with an implementation date of 1/4/22. Documented was:
Policy:
It is the policy of this facility to uphold the resident's right to retain and use personal possessions, unless to do so would infringe upon the rights or health and safety of other residents. The possession and use of illegal substances by residents will not be tolerated.
Policy Explanation and Compliance Guidelines:
1. Facility staff will have knowledge of signs, symptoms, and triggers of possible illegal substance use, which includes but is not limited to:
a. Changes in resident behavior
b. Increased, unexplained drowsiness
c. Lack of coordination
d. Slurred speech
e. Mood changes
f. Loss of consciousness
2. If the facility determines through observation that a resident may have access to illegal substances that they brought into the facility or secured from an outside source, the facility will not act as an arm of law enforcement. In accordance with state laws, a referral will be made to local law enforcement.
3. To protect the health and safety of residents, the facility will provide additional monitoring and supervision, which includes denying access or providing supervised visitation to individuals who have a history of bringing illegal substances into the facility.
4. If facility staff identifies items or substances that pose risks to residents' health and safety and are in plain view, they will confiscate them.
5. Facility staff will not conduct searches of a resident or their personal belongings, unless the resident or resident representative agrees to a voluntary search and understands the reason for the search.
Surveyor reviewed facility's Opioid Overdose Management policy with an implementation date of 4/18/23. Documented was:
Policy:
It is the policy of this facility to recognize and treat opioid overdose per current standards of practice.
Definitions:
Medication Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a whole-patient approach to the treatment of substance abuse disorders.
Opioids include prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone, hydrocodone, Fentanyl, hydromorphone, and buprenorphine, as well as illegal drugs such as heroin and illicit potent opioids such as Fentanyl analogs (e.g., carfentanil).
Opioid Use Disorder (OUD) is a problematic pattern of opioid use leading to clinically significant impairment or distress.
Overdose refers to taking more than the normal or recommended amount of something, often a drug. It can result in serious, harmful symptoms, or death.
Policy Explanation:
Whether intentional, unintentional, or undetermined, opioid overdose continues to be a health crisis in the United States. Recognizing the signs of overdose and quickly responding can prevent brain injury and death.
Compliance Guidelines:
1. The facility will review the residents' medications and history to determine if opioids are in use or the have a history of addiction, opioid use disorder (OUD), or are on a medication assisted treatment prof for OUD.
2. The facility will keep naloxone (Narcan) readily available and located in a designated area to be administered as per facility protocol and standing naloxone (Narcan) orders.
3. The facility will periodically check to ensure that naloxone (Narcan) is not expired or changed characteristics and will have the pharmacy replace as needed.
4. The facility will train all staff to recognize the signs of opioid overdose and respond to it according facility policy.
5. If a resident exhibits any of the following overdose symptoms, the facility will call 911, initiate basic life support, if indicated, and administer naloxone as per facility protocol and manufacturer's instructions:
a. Extremely pale face or clammy to the touch
b. Limp body
c. Blue or purplish color to fingernails or lips
d. Vomiting or making gurgling noises
e. Inability to awaken or speak
f. Breathing or heartbeat slows or stops.
According to an article at www.medicalnewstoday.com, Narcan can cause certain side effects:
More common side effects of Narcan
Narcan can cause certain side effects, some of which are more common than others. These side effects are usually temporary, lasting a few days or weeks after the drug is given.
These are just a few of the more common side effects reported by people who took Narcan in clinical trials:
- nose that's dry, stuffy, painful, or swollen inside
- high blood pressure
- muscle pain or spasms
- headache
- opioid withdrawal
Mild side effects of Narcan
Mild side effects can occur with Narcan use. This list doesn't include all possible mild side effects reported with the drug.
Mild side effects of Narcan can include:
- bone pain
- constipation
- nose that's dry, stuffy, painful, or swollen inside
- dry skin
- high blood pressure
- muscle pain or spasms
- toothache
- headache
These side effects are usually temporary, lasting a few days or weeks.
https://www.medicalnewstoday.com/articles/drugs-narcan-side-effects#more-common-side-effects
1.) R10 was admitted to the facility 9/27/22 with diagnoses that included Metabolic Encephalopathy, Lower Extremity Wounds, Sepsis, Opioid Dependency, Diabetes Mellitus 2 and Psychoactive Substance Abuse.
Surveyor reviewed R10's Minimum Data Set (MDS) Assessment with an assessment reference date of 7/7/23. Documented under Cognition was a brief interview mental status (BIMS) score of 15 which indicated cognitively intact.
Surveyor reviewed R10's Progress Notes. Documented on 4/28/23 at 11:00 PM was Resident was noted laying on the floor beside the bed at 2300. Assisted resident to the [wheelchair (w/c)]. Resident tells writer he placed himself on the floor to cool off. He stated that the floor was cool and he felt hot . Alert x 4 but slowed thought process and noted with lethargy . Risk and benefit given but unable to verbalize understanding due to lethargy . During frequent assessment at [11:20 PM] writer noted resident with increased weakness, unable to hold head up, not arousable, able to communicate intermittently but loses ability due to lethargic state. Eyes noted to be constricted and unable to answer questions appropriately intermittently and displays verbal aggression to staff when cognition is assessed. Writer questioned if the resident is under the influence of illegal drugs or substance and when asked yelled at writer stating you are over reacting, Why are asking me this?'' Paramedics called and arrived around [11:30 - 11:35 PM]. Resident refuses assessment with paramedics. Unable to obtain vitals. Refused transport to the ER for evaluation and treatment. Paramedics stayed in the facility to ensure safety of the resident due to questionable state/change of condition. Writer and paramedics noted a change in residents' mentation. Resident was intermittently unresponsive. Staff nurse noted medication which was not prescribed to the resident laying on the resident's bed (morphine). The paramedics notified police. Police arrived to the facility shortly after. Police spoke to the resident independently without writer present. The police informed writer that the paramedics could not transport the resident due to the resident having the right to refuse ER transport. Police left the facility at [11:55 PM] with paramedics .
On 4/28/23 the facility put a care plan in place for R10's substance use. Documented was:
Focus:
I have a history of substance use disorder [related to (R/T)] Use of/addiction to illegal drugs. My drug(s) of choice is/was: Prescription analgesics
Use of/addiction to illegal drugs. My drug(s) of choice is/was: oxycodone and morphine, Heroin
4/28/23- Suspected Overdose
Goal:
- I will demonstrate an understanding that substance use is not permitted in the facility as evidenced by: Verbally able to state through the next review.
Interventions:
- 4/28/23- Narcan administered per policy
Sent to ER for evaluation
MD/Family updated
Psych Services updated-will see on next facility visit
[police] on scene
room checked for other illegal substances
Social services to follow up with resident
- Account for any traumas in my past that may influence my substance use and help me avoid triggers
- Administer medications that are prescribed to me as part of my medication assisted treatment (MAT) and observe for side effects.
- Assist me in attending support groups with others who also have substance use disorder.
- Contact emergency services immediately if I exhibit any signs of overdose and administer opioid reversal agents as indicated.
- Educate me on the risks of leaving the facility to seek out substances and/or early unplanned discharge.
- Educate resident on ways to utilize coping skills to deal with feelings of desire for my preferred substance of choice.
- Encourage and allow me to openly express my feelings, and to express fears and worries
- Encourage frequent contact with my family and friends that are supportive of my recovery and do not encourage substance use, as desired by me.
- Encourage my family to be an active part in my care plan and discharge planning process so that I have an active support system in the community as desired by me.
Surveyor reviewed R10's Progress Notes. Documented on 4/29/23 at 4:18 AM was Writer noted the resident in the dining room sitting in his w/c near a table. Resident's head was tilted toward trunk. Writer attempted to arouse resident with tactile and verbal stimuli and resident was unresponsive. Head tilted upward to ensure airway and respirations. Respirations noted, no cyanosis noted or pallor noted, drooling/ secretions noted from mouth, and eyes fixated and constricted- unreactive to light. Pulse noted. Writer called for assistance from co- nurse and facility staff. Transported the resident to the nurse's station while co- nurse called 911. Narcan obtained. paramedics arrived facility and Narcan administered per orders at [4:22 AM]. Resident was arousable and responsive within 2 minutes of administration of Narcan. Resident assessed by paramedics and police at seen (sic). Resident refuses ER transport. Police notified resident that ER services were non optional at this time due to severity of event with plausible/ suspected overdose. Resident departed from the facility at [4:25 AM] with police dispatch and paramedics on stretcher . Prior to departure, another facility resident provided police with a cut straw found on the facility patio where resident was smoking earlier in the evening. Statement provided by this resident to the police. Police kept item. Police noted resident to have a clear plastic bag of white powdery substance in the resident's hand. Police confiscated this item as well.
Non- prescribed Morphine tablet taken by police. Resident's personal cell phones (3) taken by police. Alert and responsive at time of the time of departure.
R10's care plan was updated after the overdose on 4/29/23. Documented was:
Focus:
4/29/23- overdose-Narcan administered, admitted to hospital taking Heroin daily
Intervention:
4/29/23- returned from hospital after [against medical advice (AMA)], NP aware new orders received.
Surveyor noted there was no resident specific interventions put in place to prevent further overdoses including the root cause to R10's drug use, education on illegal drug use and facility policy of no tolerance for drug use in the facility. After R10 returned from the hospital AMA the incident was not investigated to determine how he came to have narcotics in the building or if R10 was stable to return to the facility. There was no indication the facility investigated as to whether there was a pattern of R10 leaving the facility or having visitors who may have been bringing the narcotics into the building. There was no investigation into the cut straw found on the patio, the clear plastic bag with white powdery substance and the morphine tablet.
Surveyor reviewed Progress Notes for R10. Documented on 4/30/23 at 7:07 PM was Resident returned to facility after being admitted to hospital on [DATE] for possible [overdose]. Facility received call from hospital that resident left hospital AMA and no discharge summary given and would not give one since he left AMA. This writer spoke with [NP] and verified orders for resident. Order was to continue all previous medications but discontinue oxycontin order and[TRUNCATED]
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0678
(Tag F0678)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not have an effective system to ensure residents' advanced directives for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not have an effective system to ensure residents' advanced directives for emergency end-of-life care/code status were accurate and carried out as the resident wished and did not follow facility policies to call a Code Blue when a resident was found pulseless and non-breathing. This affected 1 of 1 residents (R1) who expired while at the facility and 11 of 16 sampled residents (R11, R30, R27, R28, R29, R20, R7, R22, R23, R24, R25) whose code statuses identified delays in obtaining resident/responsible party signatures, witness signatures, signatures of the physician/nurse practitioner and at times issues with code status orders.
R1's code status election forms were documented as follows:
The first one was for a full code status election signed by R1 on [DATE] and Nurse Practitioner (NP)-FF on [DATE].
A second full code status election was signed by R1 on [DATE] with NP-FF signing this form on [DATE].
A third code status election form was completed however, R1 elected a no code status. This form was signed by R1 on [DATE] with NP-FF's signature dated [DATE].
R1's last expressed wish on [DATE] was to be no code; however, the last signed order on [DATE] was to be full code. Staff did not identify this discrepancy, making it unclear what staff should do if the resident became pulseless and non-breathing.
On [DATE], staff found R1 unresponsive outside the facility. Staff did not assess R1, did not call a Code Blue, and did not begin cardiopulmonary resuscitation (CPR); staff did call 911 even though facility policies direct staff to call 911 only if full code. Emergency responders began CPR when they arrived and were not shown R1's wishes and orders until 20 minutes after arriving. The Emergency Paramedic report states: Facility did produce a DNR order approximately 20 minutes into resuscitation efforts. Resuscitation efforts were discontinued at that time. Patient remained in asystole (flat line) during entire resuscitation.
During interviews with Director of Nursing (DON)-B Surveyor was informed of the facility expectation that a code blue would be called for a cardiac/unresponsive resident. DON-B shared the facility has code blue instructions noted on the back of employee identification badges that identify if dealing with a situation involving Cardiac/Unresponsive: staff are to announce Code Blue & Location X3 (3 times), DNR/Full Code? (determine if), (obtain) Crash Cart, CPR- Nurse Only (provide), 911 Called (If Full Code). The steps of this Code Blue procedure were not carried out fully/timely by facility staff during this change in condition for R1. DON-B shared the facility did not have a specific facility policy and procedure regarding the expectations for calling a code in emergency situations. DON-B indicated they were providing the code expectations on the back of the facility staff badges as they were replacing staff badges. DON-B indicated the facility had completed mock code drills regarding CPR and provided Surveyors with the facility drill form. It was noted this form indicated facility staff should initiate CPR while verifying code status which would not be appropriate.
During survey, facility staff identified different locations in the medical records (paper and electronic) where they would go to in order to locate a resident's code status. On [DATE] DON-B stated the place she expected staff to go to for this information was the front of the resident paper medical record and review the red or green form located in the paper medical record. This expectation was not clearly designated in a facility policy and procedure.
The facility's failure to have an effective system, to include policy and procedures, to ensure residents code status is reflected in the medical record and through orders, that staff know where to obtain the resident's code status information, how to alert other staff of the need for assistance with an unresponsive resident, and to convey accurate, timely assessment and code status information to first responders culminated into a situation of an immediate jeopardy that started on [DATE].
Nursing Home Administrator (NHA) - A, Director of Nursing (DON)- B, Regional Director of Operations-GG, Senior Director of Clinical Services RN-OO was notified of the immediate jeopardy on [DATE] at 11:00 am.
The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity level of F (potential for harm/widespread) as the facility continues to implement and monitor their action plan, for the 37 residents who have chosen to be full code and the 49 residents who have chosen a Do Not Resuscitate code status.
Findings include:
1. R1's medical record reviewed on [DATE] and [DATE] indicates R1 was admitted to the facility on [DATE]. R1 was responsible for himself, with no activated power of attorney for health care.
R1's admitting diagnoses consisted of fracture of orbit, unspecified, subsequent encounter for fracture with routine healing, fracture of one rib, anxiety disorder, major depressive disorder, recurrent, mild other asthma, gout, unspecified injury of spleen, chronic obstructive pulmonary disease, alcohol abuse with alcohol-induced mood disorder, type 2 diabetes mellitus .
R1's admission Minimum Data Set (MDS) dated [DATE] assessed R1 to be cognitively intact with daily decision-making skills scoring a 15 of the Brief Interview for Mental Status. R1 was assessed to have moderate depression with a mood score of 10. The MDS indicates R1 had little interest or pleasure doing things, feeling down, depressed or hopeless, trouble falling asleep, trouble concentrating, feeling tired or having little energy,
R1's advanced directives:
On [DATE], at 17:27 (5:27 PM), R1's medical record documents, admitted to room [room number] per ambulance with belongings and attendants.Friendly and cooperative.
Surveyor notes there is no documentation facility staff discussed or obtained R1's code status preference upon admission to the facility.
On [DATE], R1's medical record documents R1 signed the facility Resident Code Status form identifying the Code Status Protocol R1 selected was a full code status. R1 signed this form via electronic signature. A facility witness electronically signed the form on [DATE] and Nurse Practitioner (NP)-FF electronically signed on [DATE].
Surveyor notes R1's code status form dated [DATE] was completed 2 days after R1's admission to the facility and was scanned into R1's electronic medical record on green paper (green paper indicated a full code status).
On [DATE], R1's medical record documents [R1] arrived at the facility at 0530 (5:30 AM), VVS (vital signs stable) left BKNA [sic] (Below the Knee Amputation), splint on left stump, splint on right ankle, BKNA [sic] site ace wrapped with cam boot on, no excessive drainage, no s/s (signs/symptoms) of infection, resident was in good spirits.
On [DATE], R1's medical record documents R1 signed the facility Resident Code Status form and again elected a full code status. The facility witness signed on [DATE]. NP-FF signed on [DATE], 142 days after R1 signed and the form was scanned into R1's electronic medical record on green paper.
R1's care plan dated [DATE] documents: [R1] has elected a full code status. Interventions include:
-maintain [R1]'s chart to include notation of Full Code status. Date initiated: [DATE]; revision on: [DATE].
-Provide all life sustaining measures (i.e., CPR (Cardiopulmonary Resuscitation), Dated initiated: [DATE], revision on: [DATE] .
- Update physician and responsible party, if [Preferred Name] [sic] elects to change code status as indicated by change in [his/her] [sic] preference. Date initiated: [DATE], revision on: [DATE].
Surveyor notes R1 was admitted to the facility on [DATE] and R1's care plan was not updated to include R1's elected code status preference until [DATE].
On [DATE], at 14:23 (2:23 PM), R1's medical record documents, res (resident) out at [name of hospital] for surgery early this shift.
R1's Orthopedic Surgery (Hospital) Discharge summary dated [DATE], documents, Major Procedures: [DATE]: Targeted Muscle Reinnervation for pain control nerve transfers. Code Status at discharge: Full Code.
On [DATE], at 15:57 (3:57 PM), R1's medical record documents, resident readmitted to facility post-surgical procedure on left stump. resident alert able to make needs known. denies pain/discomfort. non removal dressing in place to left stump. pain pump in place to left mid-thigh. ortho (orthopedic) to be called in am (morning) for clarification on removal of pump when completed. no further skin issues noted. resident independent with ADLs (Activities of Daily Living). medications reviewed and signed by [NP-FF]. resident code status DNR (Do Not Resuscitate) per his request. consent to tx. (treat) signed.
Surveyor notes there is no documentation R1's physician was informed of R1's desired change in code status upon return to the facility. Surveyor notes R1's prior code status was a full code and R1's code status upon discharge from the hospital, on the same day, was documented as a full code.
Surveyor notes R1's medical record does not include a signed no code status form in R1's paper chart or electronic medical record.
R1's care plan dated [DATE] documents: [R1] and/or responsible party have elected a DNR-CC (Do Not Resuscitate) code status. Interventions include:
-Maintain [R1]'s chart to include order and notation of code status. Date initiated: [DATE] .
-Update physician and responsible party if [R1] and/or responsible party elect to change code status as indicated by change in condition/treatment or [his/her] [sic] preference. Date initiated: [DATE].
Surveyor notes R1's medical record progress notes document R1 elected a no code status on [DATE] however, R1's care plan was not updated to reflect the change in code status until [DATE].
On [DATE], at 1:42 PM, Surveyor interviewed DON-B who stated the expectation is the nurses will review a resident's code status with the resident upon admission and readmission and at that time a new code status form would be signed by the resident and facility staff if there was a change in code status. DON-B stated she believed R1 changed their code status after returning from the hospital following the (BKA) amputation. DON-B stated the code status election forms are copied on to colored paper. Red for no code/stop and green for full code/go. Surveyor shared that a red no code form could be located in R1's charts. DON-B stated she would look for R1's no code status form since it was not located in R1's electronic medical record or in the overflow paper chart provided to this Surveyor.
On [DATE], at 2:12 PM, DON-B provided Surveyor with a photocopy of R1's DNR code status form signed on [DATE] by R1 and a facility witness. The area where R1's physician signed was completed however this Surveyor noted the date appeared to be filled in on the photocopy provided by DON-B. DON-B stated she believed it was dated [DATE].
On [DATE], at 3:17 PM, Surveyor interviewed Medical Records (MR)-II and asked if she could locate the original code status forms signed by R1 on [DATE] and [DATE]. Surveyor observed MR-II go into in the room attached to MR-II's office and came back out and stated she was unable to locate the originals of R1's code status forms signed on [DATE] and [DATE].
MR-II stated the procedure for obtaining a resident's code status was the original signed copy by the resident would be faxed to the physician for a signature, a copy would go into the resident's paper chart on the unit and the original would go into a book at the nurse's station for the NP to sign. When the faxed copy is signed and returned by the physician it is placed in the paper chart and then the faxed copy is replaced when the original is signed by the NP later. MR-II states she believes if the code status order is changed the code status paperwork goes to the NP for signature. MR-II stated if MR-II identifies a discrepancy she will notify the unit managers. MR-II stated any time a resident leaves the facility for more than 24 hours a new code status form is signed by the resident, the facility witness, and NP. MR-II stated when a resident leaves the facility all the paperwork from the paper chart is scanned into the electronic medical record and the originals are shredded. MR-II stated the original signed code status forms dated by R1 on [DATE] and [DATE] were scanned into R1's electronic medical record then shredded. Surveyor informed MR-II that R1's DNR form dated [DATE] could not be located in R1's electronic medical record. MR-II stated she was trained that the original of any document that was scanned into the medical record could be shredded after scanned.
On [DATE], at 11:19 AM, MR-II informed Surveyor they were unable to locate the original, hard copies, of R1's code status forms signed by R1 on [DATE] and [DATE]. MR-II stated she was closing out R1's medical record and only half of the paper chart has been scanned into the EMR at this time. Surveyor informed MR-II R1's code status form signed on [DATE] is not scanned into the EMR. MR-II states she would have to check and would get back to Surveyor.
On [DATE], at 11:53 AM, MR-II provided Surveyor with an original code status form signed by R1 and facility witness on [DATE]. This form was on red paper and did not have a physician signature or date. This original copy was creased and appeared to have been folded into quarters at one time. MR-II informed Surveyor Social Work Assistant (SWA)-H had the original form and MR-II stated she was not sure why SWA-H had the original form or why it was folded. MR-II stated the original form was not signed because it was never faxed to R1's physician for signature. Surveyor asked MR-II what part SWA-A or the Social Work Department plays in the code status process. MR-II stated she could not answer that.
On [DATE], at 12:04 PM, Surveyor interviewed SWA-H who stated, the nursing staff goes over the code status forms with the residents and faxes the form to the NP for signature. SWA-H stated if a resident decides to change their code status SWA-H would have a nurse get the signature of the resident, the physician order and update the doctor. SWA-H stated she was R1's assigned Social Worker from the time of R1's admission and did not recall having any conversations with R1 related to desired code status as that is a nursing function. SWA-H stated she located R1's original DNR form downstairs in medical records in the bins that are used to store paperwork before it is scanned into the EMR or filed in overflow. SWA-H stated the original DNR form was to be scanned into the EMR. SWA-H states she did work in medical records in the past and does continue to help in medical records from time to time. SWA-H stated when she assists in medical records, she does not shred any original documents once scanned into the EMR. SWA-H verified the signatures on R1's code status forms is of NP-FF.
On [DATE], at 2:24 PM, Surveyor interviewed Registered Nurse (RN)-JJ who stated she did not recall readmitting R1 to the facility on [DATE]. RN-JJ stated she did not recall having a conversation with R1 related to code status or R1's election for a change in code status from a full code to a no code. RN-JJ stated the usual protocol is for RN-JJ to sign the code status form with a resident that is admitted or readmitted , fax the form to the physician for signature and put a note into the medical record. RN-JJ stated she would then change the physician's order to reflect the code status and put the unsigned (by physician) form into the resident's paper chart. RN-JJ stated she would review the code status with the physician when she verifies the orders. RN-JJ stated it depends on the time of the admission if the physician will fax back the code status form signed right away. RN-JJ again stated she did not recall readmitting R1 on [DATE].
On [DATE], at 12:26 PM, DON-B provided Surveyor with a copy of a progress note written by SWA-H. The progress noted dated [DATE], at 14:07 (2:07 PM), documented as a late entry entered on [DATE], at 14:12 (2:12 PM), documents, Care plan held, resident and facility IDT (Interdisciplinary Team) in attendance. resident currently own person, and is remaining a DNR code status. has sister as emergency contact. Resident residing at the facility until prosthesis is fitted and able to be worn, and resident able to walk. which therapy will pick up once resident receives his prosthesis. spoke briefly about living arrangements, resident unsure at this time, but will keep writer updated. at this time resident does not have any additional questions writer will follow up as needed.
On [DATE], at 12:34 PM, Surveyor interviewed SWA-H related to the progress noted written as a late entry for [DATE]. SWA-H reviewed a copy of the progress note and stated if she wrote she reviewed R1's code status with R1 then she did. SWA-H stated that she did not pull out the code status form and review it with R1 during the care conference. Surveyor asked SWA-H if she knew why R1 elected a no code status after previous election of a full code status. SWA-H stated she believed the change in code status was related to R1's leg amputation. SWA-H stated before R1 had the amputation they had a lot going on and believe R1's amputation changed things.
On [DATE], at 1:02 PM, Surveyor interviewed DON-B. Surveyor reviewed R1's three code status forms with DON-B. Surveyor reviewed R1's initial full code status form dated [DATE], signed by NP-FF on [DATE], the second full code status from signed by R1 on [DATE], signed by NP-FF on [DATE], the third code status form, the change to a no code status, signed by R1 on [DATE]. Initially the no code status form provided to this Surveyor dated [DATE] was a photocopy with a date for the physician signature appearing to be added to the photocopy, dated [DATE]. The second copy provided of the [DATE] no code, code status form was on red paper and was unsigned and undated by R1's physician or NP. DON-B stated her expectation for a completed code status form would be signed by the resident, facility witness and within a week of those signatures the physician or NP signature would be obtained. DON-B stated a resident's code status election would be considered complete when the physician or NP signed the code status form. DON-B stated it is possible the discrepancy in the physician signature dates could be due to an audit completed by the physician or someone else and while the audit was completed the physician or NP was signing with the current date of the audit, but DON-B could not be sure. Surveyor explained the concern for the discrepancy in the physician signature on R1's code status form and if the code status forms are considered complete once the physician or NP signs the form then R1 would be considered a full code status since the form with the most recent signature from NP-FF was the full code status signed by the NP as of [DATE]. DON-B stated she understood this Surveyor's concern.
R1's progress notes state:
[DATE] 12:54 (12:54 pm) nurses note: No A/E (adverse effects) to increased K+ (potassium) and Prednisone. Awaiting BMP (basic metabolic panel) results.
[DATE] 03:10 (3:10 am) nurses note: No adverse effected [sic] noted to increase in potassium and prednisone. Pt. (patient) in bed has slept this shift. Afebrile.
[DATE] 19:58 (7:58 pm) nurses note: Late Entry: RN was passing out PM (evening) medications, when a nurse, (LPN-NN) came up to me and asked me to come outside, because (R1's name) is out front and he is dead. I ran outside with her and found him sitting in his wheelchair, not breathing. I called 911 at approximately 1930 (7:30 pm) to report this and asked (LPN- NN) to stay with him. I ran inside to be certain he was a DNR (Do not Resuscitate). I grabbed the crash cart, looked up his code status and began running outside. I did take the crash cart. When I arrived back out front, on the scene, police officers and paramedics were there. I helped get him out of his wheelchair and once he was on the ground, a police officer started chest compressions. I told the officer he was a DNR. He stopped after what seemed like a couple of minutes. Another officer took me and (LPN-NN) aside. Told us to stay with him and not talk to anyone else. We stayed outside with him, for approximately 45 minutes, before he let us return inside. He came with us inside. I began handing out medication to my residents. Signed by RN-KK
As of [DATE] there are no further progress notes in R1's record after the above note dated [DATE] 7:58 pm.
On [DATE] at 3:50 pm, Surveyors interviewed RN-KK who shared she was getting ready to pass out medication, that she (RN-KK) was on unit 4. LPN-NN came and said R1 was outside, I think he is dead. RN-KK stated, R1 was outside in the front slumped over in his wheelchair. RN-KK stated at the time she was 99% sure he was DNR. RN-KK stated, she called 911 reported it as she ran in to check his DNR status and to get the crash cart. RN-KK reported she immediately called 911 and then called DON-B before running in to get the crash cart and to confirm R1's code status. RN-KK stated she spoke to DON-B for about a minute. RN-KK stated she looked at R1's medication administration record for R1's code status and then went to get the crash cart.
RN-KK stated by the time she got outside the paramedics and police were there. R1 was pulled out of the wheelchair, and she thought the police officer did chest compressions. RN-KK told Surveyor she stated, No he's a DNR.
When asked, RN-KK indicated they did not show the first responder R1's code status that was in writing.
RN-KK stated the police then pulled us aside to ask questions and wanted to know when the last time was that we saw R1. RN-KK stated that around dinner time she spoke to R1 who was in the best mood and at that time, he went outside, and I started passing medications. RN-KK stated that was the last time she saw R1 until LPN-NN came to get her.
On [DATE] at 4:35 pm, Surveyors interviewed LPN-NN regarding R1's change in condition on [DATE]. LPN-NN reported on [DATE] at about 7:25 pm she walked out front and had a jacket on. She looked to the right and saw R1 in his wheelchair leaning to the left and from a distance he appeared to be sleeping. LPN-NN stated she decided to walk over to R1 and wake him to come into the building as he was still wearing short sleeves and shorts. LPN-NN stated the closer she got to R1 she noticed everything was blue, his face, both arms, right leg all blue.
LPN-NN stated she shook R1 and no response. LPN-NN stated she had no phone on her, so she left R1 to come into the building. LPN-NN stated she went to wing 4 and got nurse RN-KK. LPN-NN reported to RN-KK there was an emergency out front, I knew he (R1) was not alive, she needed to come with me. LPN-NN stated we both went out the front door together walked up to R1. RN-KK shook R1 with no response, so she (RN-KK) called DON-B first and then called 911. LPN-NN stated, we never had someone pass away outside and was not sure about the policy. LPN-NN stated she should have announced (referring to overhead paging code blue) but that is when (the resident) is in the building.
LPN-NN stated the way he (R1) looked and how cold he was, he was gone for a while, didn't just happen. LPN-NN stated (RN-KK) was standing next to me talking to 911. LPN-NN reported that they were told by 911 to start CPR. LPN-NN stated, I think they thought we would do the CPR, but we didn't have a crash cart and between the two of us there was no way to get R1 out of the wheelchair. LPN-NN stated RN-KK had to get the equipment and by the time RN-KK came back the police were there and asking for help.
LPN-NN reported she did not have a conversation with RN-KK regarding what R1's code status was. RN-KK then went to get the crash cart because R1 was a heavy man and there was no way the 2 of us were going to get R1 out of the chair. 911 was there within minutes before she (RN-KK) was out there with the crash cart.
LPN-NN stated by the time RN-KK came back with the crash cart, that is when they (police) started doing CPR. Once police came, they started CPR, and the ambulance came and took over for the police officers. LPN-NN stated I had no idea what his (R1's) code status was, he wasn't my resident. 3 police officers and male Certified Nursing Assistants (CNAs) (CNA -QQ and RR) assisted R1 out of the wheelchair and onto a board. The police determined R1 was not breathing and had no pulse, which we determined that too.
LPN-NN stated when the police came, I could step aside, the ambulance showed up within a minute and the EMTs came out and started working on him. LPN-NN stated no one asked us (referring to the police and EMTs) about R1's code status. LPN-NN stated she could not speak for RN-KK if RN-KK told them R1's code status.
LPN-NN reported the paramedic went into the facility to get R1's code status form, to check on R1's code status. I don't know who helped him (paramedic). The paramedic came back with a red sheet to visually show co-workers in writing R1's code status. This is when they stopped CPR on R1.
Surveyor noted on [DATE], LPN-NN did not announce an overhead Code Blue page upon leaving R1 and entering the facility to find RN-KK on wing 4.
Together LPN-NN and RN-KK went back outside to check on R1.
LPN-NN and RN-KK did not bring R1's hard medical record and/or code status form to present it to the first responders.
RN-KK did not conduct a physical assessment of R1.
Surveyor noted while outside with LPN-NN, RN-KK then called the Director of Nursing (DON)-B to convey the situation. DON-B informed RN-KK to call 911 in which RN-KK did call 911. 911 instructed RN-KK to start CPR. RN-KK and LPN-NN did not have a crash cart, so RN-KK went back into the facility to find out R1's code status and to obtain a back board. RN-KK did not overhead page a code blue upon her reentry into the facility.
Surveyor spoke to Sergeant-MM on [DATE] at 1:55 pm who stated, when he arrived on [DATE], there were 7-10 people/staff standing in a circle around (R1) but no one did anything to help. It was like they were in a panic. I said let's start life saving measures and they brought out a board we didn't use. (R1) was in a wheelchair. 2 males helped (Sergeant-MM) get resident out of the wheelchair and onto the ground. No one at the facility did CPR. Sergeant-MM stated he was the only officer to conduct CPR while another office put AED (automated external defibrillator) pads on R1's chest. When the fire/rescue department came they took over the CPR and Sergeant-MM was relieved from doing the CPR. Sergeant-MM then gave instructions to his staff to start an investigation.
It was the Fire/Rescue team who ultimately stopped the CPR. After (R1) was pronounced deceased , Sergeant-MM spoke to the staff member who found (R1). Sergeant-MM stated he was told (R1) went outside about an hour prior to passing away. (R1) was blue and found with a burning cigarette in his right hand. Sergeant-MM stated the facility never relayed (R1's) code status upon Sergeant-MM's arrival or while Sergeant-MM was conducting CPR on (R1).
Surveyor reviewed the Police Incident Report dated, [DATE] 19:31 (7:31 pm) which indicated in part;
On [DATE] at approximately 7:31 pm, I (Sergeant-MM) along with Officer SS, TT, and UU, were dispatched to the [name of facility] [address of facility] for a report of a male not breathing. [Name of county] County Communications (RCC) advised a male was currently slumped over in his wheelchair and was unresponsive. Upon arrival, I observed a male sitting in his wheelchair on the front sidewalk of the main entrance slumped over and blue. I identified the male as (R1) from previous law enforcement contacts. I further observed several nurses/aids surrounding him in a circle, but no life saving measures being performed.
I approached (R1) and asked two unidentified males to help me lift (R1) off of his wheelchair and onto the ground. Once complete, I started CPR until the [name of city] Rescue members relieved me of my duties. I then instructed Officer SS, TT, and UU to canvass the area and begin their investigation .
Surveyor reviewed the Patient Care Report Narrative documented: [Name of city] .dispatched for PNB (pulseless non-breathing) at [name of facility].responded to location lights and sirens without delay. According to dispatch information, patient was found unresponsive in front of the building in his wheelchair. Patient was said to have gone outside an hour prior. PD (police department) was first to arrive on scene. They started CPR and placed AEDs advising no shock. Patient was moved to the ground by PD. Upon EMS (Emergency Medical Services) arrival patient was found supine on the ground unresponsive, cold, and pale. CPR was continued by PD until LUCAS ([NAME] University Cardiac Assist System) (device)) was placed and started. Rapid assessment of patient was completed. Pupils were fixed non constricted. Patient was cool to the touch with no rigor or mottling. Patient smells of alcohol, there was a bottle found near him. There were no other obvious abnormalities. Patient was placed on our monitor using PD pads. The monitor showed asystole. Compressions were continued. Ventilation via BMV (bag mask ventilation) was started along with placement of an IGEL (ventilating device). O2 (oxygen) was started at 15 liters per minute (LPM). Patient bagged easily monitoring showing an Etco2 (End-tidal carbon dioxide - the level of carbon dioxide released at the end of an exhaled breath) in the 50's. Patient airway was suctioned to clear secretions. There was vomiting. Chest rise was good with each ventilation. IV access was attempted X2 in patient left hand but unsuccessful .all subsequent pulse was asystole. Facility did produce a DNR order approximately 20 minutes into resuscitation efforts. Resuscitation efforts were discontinued at that time. Patient remained in asystole during the entire resuscitation. Patient was left with PD, ME (medical examiner) was contacted.
Arrest witnessed by: Not witnessed
CPR Care provided prior to EMS arrival: Yes
Who Provided CPR Prior to EMS arrival: First responder (Fire, Law, EMS)
AED use prior to EMS arrival: Yes, applied without defibrillation.
Date/Time resuscitation discontinued: [DATE] 19:57:00 (7:57 pm).
Reason CPR/Resuscitation Discontinued: Protocol Requirements Complete
End of EMS Cardiac Arrest Event: Expired in the field
On [DATE] at 1:52 pm, Surveyor interviewed DON-B regarding R1's change in condition on [DATE] DON-B stated, Registered Nurse (RN)-KK called her on [DATE] at 7:29 pm and it was reported R1 was deceased . Surveyor noted this call to DON-B from RN-KK was prior to RN-KK calling 911 for emergency assistance for R1.
On [DATE] at 8:00 am, 8:45 am, 8:50 am, and at 2:15 pm, Surveyor interviewed DON-B.
During these conversations, DON-B informed Surveyors the facility's CPR policy does not have specific instructions on how to implement the facility's use of a red/no code form or a green/full code form.
On [DATE] at 8:45 am, DON-B reported the facility has a code blue expectation staff are to carry out for a resident who may not be breathing and/or is pulseless. DON-B stated staff would page over head a code blue 3 times for all available staff, call 911 if full code, and that the facility conducts monthly mock code blue drills. DON-B reported once a code blue is called, all available staff are to go to the designated location of where the code blue is being called, staff are to grab the crash cart and resident's chart. DON-B was asked for a policy and procedure regarding the code blue expectations. DON-B indicated she would have to see if they have one.
DON-B reported not having an in-house defibrillator. DON-B stated the nurse takes charge and directs the staff as to who s[TRUNCATED]
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 F0740
(Tag F0740)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R11) of 3 residents reviewed received and the facility prov...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R11) of 3 residents reviewed received and the facility provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.
R11 was admitted to the facility with a history of Substance Use Disorder (SUD). On 11/19/22, 3/17/23, 5/4/23 and 8/3/23 R11 overdosed on drugs and had to have Narcan (Naloxone) administered.
There is no indication if care planned interventions were followed through on, and whether they were evaluated for effectiveness.
The facility did not assess the resident for the need of behavioral health services and specialized drug counseling. The facility did not establish plans to assess for withdrawal symptoms and treatment of those symptoms but rather focused on only monitoring for substance use and overdose.
The facility put a Behavioral Contract in place on 9/3/23, 4 months after it was added as an intervention to prevent overdoses.
R11's first Substance Abuse Risk Evaluation was on 9/5/23 after R11 already had 4 previous overdoses. This Substance Abuse Risk Evaluation did not address interventions pertaining to counseling or mental health concerns related to SUD. This assessment does not address how far back R11's history of substance abuse goes. It does not address if R11's substance abuse is associated with past traumas, stress and/or triggers. This assessment does not address past meaningful activities or relationships, and/or support systems/treatment which R11 may have been involved with in the past.
The lack of evaluating R11's care plan interventions for effectiveness, the lack of assessing R11's history and current substance abuse, and implementing an effective behavioral contract contributed to R11 having another overdose on 9/9/23 requiring the administration of Narcan as a life saving measure.
Findings include:
According to The National Institute of Mental Health:
.When someone has a SUD and another mental health disorder, it is usually better to treat them at the same time rather than separately. People who need help for a SUD and other mental disorders should see a health care provider for each disorder. It can be challenging to make an accurate diagnosis because some symptoms are the same for both disorders, so the provider should use comprehensive assessment tools to reduce the chance of a missed diagnosis and provide the right treatment.
It also is essential that the provider tailor treatment, which may include behavioral therapies and medications, to an individual's specific combination of disorders and symptoms. It should also take into account the person's age, the misused substance, and the specific mental disorder(s) .
https://www.nimh.nih.gov/health/topics/substance-use-and-mental-health
According to the Substance Abuse and Mental Health Services Administration: Naloxone is a temporary treatment and its effects do not last long. Therefore, it is critical to obtain medical intervention as soon as possible after administering/receiving naloxone .Use of naloxone causes symptoms of opioid withdrawal. Medical assistance must be obtained as soon as possible after administering/receiving naloxone. Opioid withdrawal symptoms include: feeling nervous, restless or irritable, body aches, dizziness or weakness, diarrhea, stomach pain, or nausea, fever, chills or goose bumps, sneezing or runny nose in the absence of a cold.
Opioid overdose is life-threatening and requires immediate emergency attention .Opioid overdose can happen: .with illicit drug use, if a person takes opioid medications prescribed for someone else, if a person mixes opioids with other medications, alcohol, or over the counter drugs.
R11 was admitted to the facility on [DATE] with diagnoses that included Chronic Multifocal Osteomyelitis, Hypertensive Urgency and Anxiety.
Surveyor reviewed R11's MDS (Minimum Data Set) Assessment with an assessment reference date of 3/2/23. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact.
R11 had a history of substance abuse and overdosed on 11/19/22, 3/17/23, 5/4/23 and 8/3/23 under the influence of drugs and alcohol. After each overdose there was no assessment of the resident's mental health and no specialized drug related counseling initiated. Surveyor noted there was no plan or assessment established to monitor R11 for signs/symptoms of possible withdrawal from narcotics or alcohol to provide support.
On 10/22/22 the facility put a care plan in place for R11's substance use. Documented was:
Focus:
- Resident has a history of alcohol abuse/dependency
- 11/19/22 drug overdose incident, sent to ER
- 3/5/23 [alcohol (ETOH)] use suspected
- 3/17/23 - Under the influence of ETOH or drugs
Goal:
Resident will refrain from using non-prescribed substances and/or alcohol through the next review date.
Interventions:
- 10/22/22 resident at bar drinking, risk vs benefit given
- 11/19/22 - returned from the ER no new recommendations
- 11/19/22 administer Narcan if drug overdose suspected
- 11/19/22 - social services and psych services to follow up with resident
- 3/17/23 - [new order (NOR)]: Obtain [urinalysis (UA)] Drug Screen, [discontinue (DC)] Oxycodone, Hold all medications if under the influence
- 3/19/23 - UA [positive] for THC/Opiates
- hold medication and update MD if resident is suspected of being under the influence
- If you suspect resident has been using non-prescribed substances, notify supervisor immediately.
Surveyor noted that psych services should have followed up with R11 as indicated in the 11/19/22 care plan intervention.
There was no follow up by psych services documented. There were no added psychosocial interventions or assessments to prevent mental health concerns, potential further drug use and no interventions to monitor for and treatment of withdrawl signs and symptoms.
On 5/3/23 the facility put a care plan in place for R11's drug use. Documented was:
Focus:
I have a [history] of substance use disorder [related to (R/T)] Use of/addiction to prescription drugs. My drug(s) of choice is/was: pain medications
Use of/addiction to illegal drugs. My drug(s) of choice is/was: marijuana, fentanyl, cocaine
Use of/addiction to alcohol
history of drug overdose
7/3/23 ETOH use
8/3/23-Suspected drug use
I will not use the substances that I am/was addicted to through the next review.
Goal:
I will work with a therapist/counselor to help me with my SUD through the next review. (5/3/23)
Interventions:
- 5/3/23 Account for any traumas in my past that may influence my substance use and help me avoid triggers.
- 5/3/23 Assist me in attending support groups with others who also have substance use disorder.
- 5/3/23 Encourage and allow me to openly express my feelings, and to express fears and worries.
5/5/23 Counseling by AODA and therapeutic psychosocial services have been offered with accommodations for coordination of these services.
- 5/3/23 Offer a behavioral contract if I am cognitively able to consent, and only if it will encourage me to follow this plan of care.
- 5/3/23 Report changes in my mood status to my physician.
- 5/3/23 Report any suspected use of substances to my physician.
- 5/3/23 Support my strengths and provide me with positive affirmations.
- 5/4/23 Narcan x 1 administered with positive results
[police] at the facility-interviewed by officer
MD aware, declined any family update
Social services to follow up with resident
Monitor resident every 4 hours for [signs and symptoms (s/sx)] of substance use/overdose symptoms and update MD if positive
social services to follow up with resident regarding substance abuse education and counseling-resident declined.
- 5/5/23 Ensure that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.
Ensure that the direct care staff interact and communicate in a manner that promotes mental and psychosocial well-being.
Provide meaningful activities which promote engagement, and positive meaningful relationships between residents and staff, families, other residents and the community. Those activities that address the residents' customary routines, interests, preferences, etc. and enhance the resident's well-being.
- 5/5/23 Counseling by AODA and therapeutic psychosocial services have been offered with accommodations for coordination of these services.
- 5/11/23 beer cans found in room
- 6/6/23 Referred to [psychologist]
- 8/3/23 Narcan administered, 911 called, resident refused to go to ER
- 8/22/23 When [R11] goes on pass with (Person D) nurse to evaluate upon his return to the facility for change in condition/ or signs/symptoms of drug usage.
- 8/22/23 Encourage visitation in high traffic areas with (Person D).
Surveyor noted that R11 should have followed up with a counselor for SUD but the resident declined on 6/6/23. There was no further follow up or offer of psych services or counseling for SUD. There were no added psychosocial interventions or assessments to prevent mental health concerns and potential further drug use.
Surveyor noted there is no indication if the facility pursued the care planned intervention as to whether R11 experienced traumas in the past and if there are triggers that may be influencing R11's substance abuse. There is no information indicating how the facility is assisting resident to attend support groups with others, whether they are assisting with transportation, companionship with attendance, online attendance etc. There is no indication if R11 is openly expressing his feelings and what fears and worries R11 may have as indicated in the care plan. There is no indication as to what activities R11 may find meaningful and how the facility may be promoting those activities and relationships.
Surveyor reviewed R11's MD Orders. Documented with a start date of 5/5/23 and an end date of 9/3/23 was:
Monitor resident every 4 hours for [signs and symptoms (s/sx)] of substance use/overdose: sudden changes in mood and behavior, drowsiness, lack of coordination, loss of consciousness etc. If resident has symptoms update MD. Y=symptoms N=no symptoms
every 4 hours for substance abuse.
Surveyor reviewed R11's Medication Administration Record (MAR) for 8/23/23 through 9/3/23. Documented on the following dates were:
8/23/23 at 4:00 PM: 4
8/24/23 at 12:00 AM: Y
8/24/23 at 12:00 PM: Y
8/27/23 at 4:00 PM: Y
8/30/23 at 12:00 PM: Y
8/30/23 at 4:00 PM: Y
8/30/23 at 8:00 PM: Y
9/2/23 at 4:00 PM: Y
9/3/23 at 4:00 AM: Y
Surveyor noted that 4 documented on 8/23/23 indicated see nurses notes. There was no documentation in nurses notes related to drug use signs and symptoms. Surveyor noted R11 had an overdose on 8/23/23 requiring administration of Narcan. Review of the above documentation indicates R11 continued to be noted to be under the influence of possible drugs and alcohol with no assessment or details into the symptoms, type of substance used, if R11 was experiencing withdrawal symptoms and without consultation with the physician as the order indicates. (Cross-reference F580).
On 9/3/23 the facility put a Behavior Contract in place for R11. Documented was:
Police involvement has been required secondary to the possession of illicit drugs found in your room, unsecured, at the bedside.
The police have taken the illicit drugs and have an open investigation.
We have learned, recently, you may be involved with continued illicit drug use at this facility. This has been reported to law enforcement and an investigation will continue.
You were made aware of your rights as a resident upon admission to our facility. You do not have a right, however, to place others at risk.
While a resident at our facility we ask for you to commit to the following:
- A room search (Which will include all of the following): To confirm illicit drugs are not inside your room that would place other residents in our facility at risk. The room search will include you voluntarily showing us your pockets, wheelchair, and anything on your person.
- Once a room search is completed, the following will continue:
- A room search will be completed after taking a leave of absence from the facility for an outing
- After any visitations
- Visitations with your identified [Person D] will take place in open supervised areas
(Secondary to past police involvement and known drug activity which has already been reported to the police with an active and open police investigation)
Should you refuse this agreement:
- An assignment will be provided and scheduled to have 1:1 supervision on you at all times
- Your privacy will be provided during self-cares and personal cares in rooms that are not in direct contact with any other resident
You have intentionally involved yourself in illegal activity and have demonstrated a risk to those who live here.
Our commitment is for the safety of you and every resident that resides inside this facility.
The document was updated to include the following. Documented was:
Revision 9.4.2023: In accordance with the Federal Rules of Participation under F563 [(right to receive/deny visitors] please see the attached regulations) Your identified (Person D) is restricted from any visitation with you at this facility. (Person D) has a history of bringing in illegal substances which places you and other residents health and safety at risk, should your (Person D) attempt visitation at our facility with you, law enforcement will be notified. A restraining order will be pursed.
*We are eliminating the prior supervised visits as this has the potential to place our staff at risk. Safety for all is our only priority.
R11 signed the document on 9/3/23 and the revised document on 9/4/23.
R11's care plan was updated on 9/3/23. Documented was:
Interventions:
- 9/3/23 resident was placed on 30 min check while awake and 1 hour checks while in bed. Signed behavior contract allowing staff to search room, person and wheelchair
- 9/3/23 Resident agreed to voluntary room search, therefore supervision will be set to hourly checks.
- 9/9/23 resident placed on 1 to 1 observation due to suspected OD (overdose) Narcan given and 911 called, refused to go to ER, police served search warrant.
Surveyor noted a Behavioral Contract intervention was identified as an intervention on R11's Care Plan on 5/3/23 but was not put in place until 9/3/23. Surveyor noted there was no assessment of R11's Mental Health prior to the Behavioral Contract and no assessment of the psychosocial effects the room searches and restriction of visitors would have on R11.
Surveyor reviewed R11's Substance Abuse Risk Evaluation with an assessment date of 9/5/23. Documented was:
A. Risk Questions
A. Does the resident currently or have a history of illegal drug use?
a. Yes
B. Does the resident currently or have a history of substance abuse?
a. Yes
C. Does the resident currently or have a history of substance abuse with IV access?
b. No
D. Does the resident currently or have a history of homelessness?
a. Yes
E. Does the resident's family currently or have a history of substance use?
a. Yes
F. Does the resident currently or have a history of association with substance using peers?
a. Yes
G. Does the resident currently or have a history of misusing prescription drugs?
a. Yes
Resident will be considered High-Risk for substance use if yes is answered to any of the risk factors above.
Surveyor noted this 9/5/23 Substance Abuse Risk Evaluation was the first assessment for SUD. Surveyor also noted this Substance Abuse Risk Evaluation did not address any interventions, counseling or mental health concerns related to SUD.
This assessment identifies R11 as having a history of substance abuse however this assessment does not address how far back this history goes, it does not address if R11's substance use is associated with past traumas, stress and/or triggers. This assessment does not address past meaningful activities or relationships, and/or support systems/treatment R11 may have been involved with. The assessment also does not address what possible withdrawal may be for R11.
A Care Plan was put in place 9/7/23 for R11's continued drug use.
Focus:
[R11] has a history having possession of illicit drugs on his person, and in room
Goal:
- Resident will behave in a safe manner consistent with resident conduct policies through the next review date.
- Resident will comply with the rules and terms of his/her sentencing as required by state law through the next review date.
- Police involved and opened a case and investigating
- resident has signed a behavior contract which includes.
A room search to be completed after taking a leave of absence
from the facility. If not agreeing to a room search resident will be
placed on 1 on 1 supervision.
- [Person D] is restricted from entering the facility.
Interventions:
- Observe resident for behavioral changes. Update MD as indicated.
- Refer resident to a mental health professional for evaluation.
Surveyor noted this was the first time facility was assessing for behavioral changes, however the care plan does not identify resident specific behavioral changes to watch for. Another intervention was to include evaluation of mental health but the facility did not follow up on the past assessments of R11's mental health. Surveyor also noted increased monitoring for signs and symptoms of drug use and overdose. Surveyor noted there was no indication R11 was being monitored for possible withdrawal from either alcohol or drug use.
Surveyor reviewed R11's Progress Notes. On 9/9/23 at 8:57 PM documented by Licensed Practical Nurse (LPN)-DD was The resident was diaphoretic, breathing, pinpoint pupils. The resident was sitting on the chair at 1530 hrs (3:30 pm). Prior to this he was seen on the resident smoking patio and was in a pleasant mood. The author when saw the resident tried to tap and try to wake him up but the response was very slow. Upon seeing the situation I called for assistance from other staff. 911 was called, Narcan was administered, and a Vital sign was taken. The resident is 1:1 monitoring.
Surveyor noted that even with the Behavioral Contract and Care Plans including increased monitoring, R11 still overdosed and needed Narcan administered. Surveyor also noted no assessment of mental health after the overdose.
On 9/13/23 at 12:34 PM Surveyor interviewed Social Worker Assistant (SWA)-H. Surveyor asked about R11's SUD and counseling or rehabilitation. SWA-H stated he has declined psych services in the past because R11 does not think he has a problem. Surveyor asked if R11 was asked after the overdoses to use psych or counseling services. SWA-H stated no because he had declined in the past.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that staff promptly consulted with a physician when residents ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure that staff promptly consulted with a physician when residents experienced significant changes of condition for 1 (R11) of 4 residents reviewed for change of condition.
R11 had a history of drug and alcohol abuse and had an order to update the MD if any signs and symptoms were noted of drug use. The facility did not update the MD on 9 different occasions when staff documented R11 had overdose signs and symptoms.
Findings include:
R11 was admitted to the facility on [DATE] with diagnoses that included Chronic Multifocal Osteomyelitis, Hypertensive Urgency and Anxiety.
Surveyor reviewed R11's MDS (Minimum Data Set) Assessment with an assessment reference date of 3/2/23. Documented under Cognition was a BIMS (brief interview mental status) score of 15 which indicated cognitively intact.
R11 had a history of substance abuse and overdosed on 11/19/22, 3/17/23, 5/4/23 and 8/3/23 under the influence of drugs and alcohol.
Surveyor reviewed R11's MD Orders. Documented with a start date of 5/5/23 and an end date of 9/3/23 was:
Monitor resident every 4 hours for [signs and symptoms (s/sx)] of substance use/overdose: sudden changes in mood and behavior, drowsiness, lack of coordination, loss of consciousness etc. If resident has symptoms update MD. Y=symptoms N=no symptoms
every 4 hours for substance abuse.
Surveyor reviewed R11's Medication Administration Record (MAR) for 8/23/23 through 9/3/23. Documented on the following dates were:
8/23/23 at 4:00 PM: 4
8/24/23 at 12:00 AM: Y
8/24/23 at 12:00 PM: Y
8/27/23 at 4:00 PM: Y
8/30/23 at 12:00 PM: Y
8/30/23 at 4:00 PM: Y
8/30/23 at 8:00 PM: Y
9/2/23 at 4:00 PM: Y
9/3/23 at 4:00 AM: Y
Surveyor noted that 4 documented on 8/23/23 indicated see nurses notes. There was no documentation in nurses notes related to drug use signs and symptoms.
On 9/13/23 at 11:58 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor showed TAR to DON-B and asked what the Y's meant on the dates above. DON-B stated that R11 had signs and symptoms. Surveyor asked if the MD was called per order. DON-B stated there is no documentation of anything, so no. Surveyor asked what the 4 was for. DON-B stated there should be a nurses note but there is nothing charted. Surveyor asked what was the correct process for staff to do if they see signs and symptoms of drug use. DON-B stated call the MD or NP and update them and call her as well. DON-B stated that it should have been done for each of these occasions.
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 interview and record review, the facility did not report 3 of 7 reportable incidents (involving R10), reviewed for abuse to the State Agency.
* R10 was in a sexual relationship with an emplo...
Read full inspector narrative →
Based on interview and record review, the facility did not report 3 of 7 reportable incidents (involving R10), reviewed for abuse to the State Agency.
* R10 was in a sexual relationship with an employee at the facility, Dietary Aide (DA)-O. Nursing Home Administrator (NHA)-A interviewed DA-O on 6/28/23 and 7/22/23 and asked questions about the relationship. NHA-A was also aware that R10 had been to DA-O's home; that was confirmed during an interview on 8/8/23. The facility did not investigate these allegations and did not report any of the allegations of abuse to the State Agency.
Findings include:
Surveyor reviewed facility's Policy and Procedure: Abuse and Neglect Reporting and Investigating with a revision date of 5/9/19. Documented was:
.IDENTIFICATION, INVESTIGATING, AND REPORTING OF ABUSE:
Abuse is defined differently under both State and Federal law and Regulation. Please review the key definitions in this policy that should be considered when determining whether an event constitutes abuse.
Definitions:
Resident Abuse under the Federal Certification Guidelines 42 C.F.R. $483.12 is defined as follows:
1. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse; sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled by technology .
REPORTING:
All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the charge nurse. The charge nurse is responsible for immediately reporting the allegations of abuse to the administrator or designated representative.
All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the state survey agency no later than two (2) hours after the allegation is make, if the events that caused the allegation involved abuse and result in serious bodily injury or not later than twenty-four (24) hours if the events that cause the allegation involve abuse but do not result in serious bodily injury.
If there is a reasonable suspicion that the allegation of abuse constitutes a crime committed against the resident by any person whether or not the alleged perpetrator is employed by the facility, the Elder Justice Act requires the matter must also be reported to law enforcement, If the allegation of abuse results in serious bodily injury to a resident, a report must be made to law enforcement no later than two (2) hours after the allegation is made. If the allegation of abuse does not result in serious bodily injury a report must be made to law enforcement no later than twenty-four (24) hours (See Elder Justice Act requirements) .
A report shall be made by calling or emailing, your survey agency as they have defined to do. If the person in charge is the alleged abuse, the administrator of [Director of Nursing (DON)] shall directly report the abuse to the survey agency, pursuant to the deadlines established above .
Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Survey agency. This written report shall be forwarded to the Survey agency within five days (or Survey agency required time) of the initial report .
During an interview about a resident to resident altercation, NHA-A asked DA-O about R10. Documented on 6/28/23 was:
.[NHA-A]: Are you and [R10] dating?
[DA-O]: (laughed) Oh no! I am just trying to help him .
There was no other interviews completed and no investigation into the allegation of a relationship between DA-O and R10. This did not get reported to the State Agency as an allegation of abuse.
On 7/22/23 Certified Nursing Assistant (CNA)-J observed DA-O in R10's room. CNA-J told Social Worker (SW)-L. DA-O, CNA-J and SW-L wrote statements.
NHA-A prepared the following about the event on 7/22/23. Documented was:
Investigation on complaint
7-22-23
On 7-24-23 [SW-L] brought to my attention that [DA-O] was in [R10's] bathroom.
This occurred at approx. 10:30 a.m.
[R10] had the door open to the bathroom; [DA-O] was bending over helping with his bandage.
[SW-L] stated that [DA-O] shortly went to the kitchen to work.
The administrator looked up [DA-O's] work hours for 7-22-23.
She clocked in at 11:00 and clocked out at 7:05 PM
[DA-O] was not in working hours when she was with [R10].
There was no other interviews completed and no investigation into the allegation of a relationship between DA-O and R10. This did not get reported to the State Agency as an allegation of abuse.
On 8/7/23 and 8/8/23 R10 overdosed on illegal drugs. The NHA-A interviewed DA-O with Detective-V after the overdose because the facility was concerned DA-O was giving R10 drugs since she was with him for the overdoses on 8/7/23 and 8/8/23. NHA-A asked DA-O about R10 coming to her house. Documented was:
.[NHA-A]: Has [R10] ever been to your house?
[DA-O]: No
[NHA-A]: It has been reported by staff that [R10] was seen at your house, has [R10] been to your house?
[DA-O]: Puts her head down and stated, yes, I made a bad decision and had him come over .
There was no other interviews completed and no investigation into why DA-O had R10 at her house. This was the third time an inappropriate allegation was not investigated about DA-O and R10. This did not get reported to the State Agency as an allegation of abuse.
On 8/21/23 at 12:18 PM Surveyor interviewed NHA-A. Surveyor asked about the incidents/events on 6/28/23, 7/22/23 and the knowledge that R10 had been to DA-O's house. Surveyor asked why these incidents were not investigated. NHA-A stated that these were just rumors and she cannot look into all rumors. Surveyor asked how does she know they are just rumors and not facts if she does not investigate. NHA-A stated I guess I can't. Surveyor asked why the allegations of a relationship were not reported to the State Agency. NHA-A stated it would not be abuse because he is consenting so therefore not reportable.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not thoroughly investigate 4 of 7 reportable incidents reviewed for abuse...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not thoroughly investigate 4 of 7 reportable incidents reviewed for abuse and misappropriation involving R10 and R15.
* R10 was in a sexual relationship with an employee at the facility, Dietary Aide (DA)-O. Nursing Home Administrator (NHA)-A was made aware of inappropriate incidents on 6/28/23 and 7/22/23 between DA-O and R10 that were not fully investigated.
NHA-A was also aware that R10 had been to DA-O's home and did not investigate the incident.
* On 8/9/23 R15 reported missing $30.00. The facility's investigation did not include interviews with direct care staff to see if they had any knowledge of R15's missing money. The facility's investigation did not include interviewing other residents on R15's unit to see if any other resident may have had missing money/items.
Findings include:
Surveyor reviewed facility's Policy and Procedure: Abuse and Neglect Reporting and Investigating with a revision date of 5/9/19. Documented was:
.IDENTIFICATION, INVESTIGATING AND REPORTING OF ABUSE:
Abuse is defined differently under both State and Federal law and Regulation. Please review the key definitions in this policy that should be considered when determining whether an event constitutes abuse.
Definitions:
Resident Abuse under the Federal Certification Guidelines 42 C.F.R. $483.12 is defined as follows:
1. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse; sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology .
10. Misappropriation of resident property, means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent .
INVESTIGATION:
Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. The facility will use, the checklist for concerns and self-reports for guidance.
The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident.
The investigation should include consideration of the following, based on circumstances of the allegations as applicable:
1. Review the complete documentation of the allegation of Resident abuse
2. Review the Resident's medical record to determine events. leading up to the incident
3. If there is indication that injury has or may have occurred, a physical assessment must be completed by the Director of Nursing or charge nurse immediately
4. Documentation of any physical assessment conducted will be made in the Resident's chart and a copy of this documentation will be included in the abuse investigation file
5. The Director of Nursing or designated nurse will notify the Resident's attending physician of the alleged incident. The responsible family member or responsible party, as documented on the Resident's chart, will be notified of the incident and advised of the status of the investigation and the actions and reporting being taken.
6. If there is a reasonable suspicion that sexual assault has occurred, the treating physician should be notified to discuss arranging for a rape kit examination. After emergency medical assistance is provided, no admittance further in room until police provides facility with clearance to enter the room.
7. Interview the person(s) reporting the incident and the alleged perpetrator and document witness statements.
8. Interview all witnesses to the incident and document all witness statements
9. Attempt to interview the resident (as medically appropriate); if the resident's response is unintelligible, record this, along with objective observations of the resident.
10. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident
11. Interview the resident's roommate, family members and visitors if appropriate
12. In circumstances where the allegation involved an employee, Interview other residents to whom the accused employee provides care or services
13. In circumstances where the allegation Involves another resident, interview other residents and employees, where appropriate, to determine if there were witnesses to any alleged abuse involving the alleged perpetrator
14. Review all events leading up to the alleged incident
The following guidelines will be used when conducting interviews:
1. Each interview, if possible, will be conducted separately and in a private location
2. The purpose of the interview will be explained thoroughly too each person involved in the interview process.
Witness reports will be reduced to writing. Witnesses will be requested to sign and date such reports. A copy of reports will be maintained with the investigation file.
Following investigation, the Administrator or designated agent will be responsible for forwarding the results of the investigation to the Survey agency. This written report shall be forwarded to the Survey agency within five days (or Survey agency required time) of the initial report.
INITIAL/IMMEDIATE PROTECTION DURING FACILITY INVESTIGATION:
Upon receiving a report of an allegation of resident abuse, neglect, exploitation or mistreatment, the facility shall immediately implement measures to prevent further potential abuse of residents from occurring while the facility investigation is in process. If this involves an allegation of abuse by an employee, this will be accomplished by separating the employee accused of abuse from all residents through the following or a combination of the following, if practicable: (1) suspending the employee; and/or (2) segregating the employee by moving the employee to an area of the facility where there will be no contact with any residents of the facility.
Following the completion of the facility investigation, if the facility concludes that the allegations of resident abuse are unfounded the employee will be allowed to return to job duties involving resident contact.
1.) DA-O had a relationship with R1 prior to her being employed at the facility and prior to him being a resident. After a resident to resident altercation on 6/25/23 between R10 and R1, NHA-A interviewed DA-O about R10 and R1. Documented on 6/28/23 was:
Discussion with [DA-O] regarding [R10] and [R1]
6-28-23
Present:
[Food Services Director (FSD)-Q]
[NHA-A]
I entered [FSD-Q's] office and asked to speak with [DA-O], [FSD-Q] went to get [DA-O].
[NHA-A]: What is going on with you and [R10]?
[DA-O]: What do you mean?
[NHA-A]: You seem to be hanging around [R10] much more than you used to, and you do not seem to be paying attention to [R1] any more.
[DA-O]: Yes, I am
[NHA-A]: Are you with [R1] anymore?
[DA-O]: No, he is an ass. I tried to help him, and he continues to drink and act like an a**h*** to everyone.
[NHA-A]: Are you and [R10] dating?
[DA-O]: (laughed) Oh no! I am just trying to help him
[NHA-A]: Help him with what?
[DA-O]: Get clean, off of drugs so he can go be with his wife.
[NHA-A]: What do you do to help him?
[DA-O]: When he is frustrated and angry we talk, he opens up to me a lot. When he feels he wants to get high he calls me and we talk, I talk him down.
[NHA-A]: That is a huge responsibility [DA-O], have you asked him to see a professional to help him?
[DA-O]: tried but he doesn't trust anyone but me.
[NHA-A]: I need to discuss with you hanging around [R10] in front of [R1], this is a very big issue as I am sure you know. You were very large support for [R1] and in a relationship prior to [R1] coming to [facility] and now you dumped him to be with [R10], who we all know [R1] and [R10] do not get along. This is causing many altercations between [R1] and [R10].
[DA-O]: Yea, I know. I don't mean to make [R1] mad but [R10] wants my help, and he listens to me.
[NHA-A]: I want to make it clear that you are not to have any contact with [R10] while you are on the clock working in the kitchen, the same rules apply when you were with [R1].
[DA-O]: It is not like that, I am just talking with [R10] to help him, he wants to get better and be with his wife.
There was no other staff interviews completed and no investigation into the allegation of a relationship between DA-O and R10. R1 and R10 were not interviewed and neither were any other residents.
On 7/22/23 Certified Nursing Assistant (CNA)-J observed DA-O in R10's room. CNA-J told Social Worker (SW)-L. CNA-J wrote a statement that documented:
On Saturday July 22, 2023, I walked by [R10's] room and witnessed [DA-O] in the bathroom with the resident. I notified [SW-L].
On 7/22/23 SW-L wrote a statement about DA-O in R10's room. Documented was:
I, [SW-L], was doing rounds around 10:40 AM. I witnessed [DA-O] in [R10's] bathroom with [R10]. I asked if everything was OK and [R10] replied yes. [DA-O] then walked out of the bathroom.
On 7/25/23 DA-O wrote a statement about the event on 7/22/23. Documented was:
On the day in question, I came in at 6 AM to bring Dietary Aide [DA-BB] to work. When I came in I saw [R10] and we conversated (sic) for a little while.
I then went and ran some errands and came back. When I came back [R10] told me he was about to go wash his leg and rewrap it. He said he wanted me to see how good they healed. When I got to [R10's] room he was in the bathroom washing his leg so I walked in and stood in the doorway of his bathroom as he showed me how good his legs looked. All doors remained open
Then [SW-L] walked in and asked him if he was OK. He replied yes at this time I was gathering some items he asked me to get for when he was done and was going to rewrap them. We at that point realized [R10] needed more rolled gauze so I walked down to the nurses' station and asked [Licensed Practical Nurse (LPN)-S] for some . When [LPN-S] came back up I took the roll of gauze to [R10] and asked him if he needed anything else before I walked away. He said no so I left and went and clocked in and started doing my job.
NHA-A prepared the following about the event on 7/22/23. Documented was:
Investigation on complaint
7-22-23
On 7-24-23 [SW-L] brought to my attention that [DA-O] was in [R10's] bathroom.
This occurred at approx. 10:30 a.m.
[R10] had the door open to the bathroom; [DA-O] was bending over helping with his bandage.
[SW-L] stated that [DA-O] shortly went to the kitchen to work.
The administrator looked up [DA-O's] work hours for 7-22-23.
She clocked in at 11:00 and clocked out at 7:05 PM
[DA-O] was not in working hours when she was with [R10].
On 8/21/23 at 9:57 AM Surveyor interviewed SW-L. Surveyor asked if anyone had reported anything inappropriate between R10 and DA-O to her. SW-L stated on 7/22/23 CNA-J came to her office and stated that a kitchen staff member was in R10's room. SW-L stated she went to R10's room and DA-O and R10 were in his bathroom. SW-L stated DA-O was hunched over his legs with a white towel in her hand. SW-L stated she asked DA-O what she was doing. SW-L stated DA-O responded just wiping his legs. SW-L stated she wrote a statement and had CNA-J write a statement. Surveyor asked if anyone else was asked to write a statement. SW-L stated no.
There was no other staff interviews completed and no investigation into the incident when DA-O was in R10's bathroom. No other residents were interviewed either.
On 8/7/23 and 8/8/23 R10 overdosed on illegal drugs. The NHA-A interviewed DA-O with Detective-V after the overdose because the facility was concerned DA-O was giving R10 drugs since she was with him for the overdoses on 8/7/23 and 8/8/23. Documented by NHA-A was:
Interview between [Police] and [DA-O]
August 8, 2023
Interviewer: [Detective-V]
[Detective-V]: Introduced herself to [DA-O].
[Detective-V]: How do you know [R10]?
[DA-O]: He is a resident here
[Detective-V]: What kind of relationship do you have with [R10]?
[DA-O]: We don't have sex it is not like that
[Detective-V]: I was not referring to that I just asked what kind of relationship with [R10] do you have
[DA-O]: We are friends that is it. We talk about his wife.
[Detective-V]: This morning you told my officer to look in [R10]s wallet because there may be drugs in it, how did you know that?
[DA-O]: I didn't know that
[Detective-V]: Then why did you tell the officer to look in his wallet?
[DA-O]: He is always protective of his wallet, he sleeps with it.
[Detective-V]: What position do you do?
[DA-O]: I work in the kitchen, I am a dietary aide
[Detective-V]: How do you know he sleeps with his wallet?
[DA-O]: He usually has a lot of money in his wallet and he is very protective of his money, I assumed he slept with it.
[Detective-V]: I was told that you helped [R10] Detox from drugs, how did you do that
[DA-O]: Yes, I did. I was his support, I would just talk to him about his wife and that he wants to get out of here.
[Detective-V]: Did you provide anything else?
[DA-O]: No, we would just talk about him getting clean and getting out of here and be with his wife.
[Detective-V]: Do you have a relationship with [R10] outside of the facility?
[DA-O]: No
[NHA-A]: Has [R10] ever been to your house?
[DA-O]: No
[NHA-A]: It has been reported by staff that [R10] was seen at your house, has [R10] been to your house?
[DA-O]: Puts her head down and stated, yes, I made a bad decision and had him come over.
[Detective-V]: What did you and [R10] do when he was in your house?
[DA-O]: We just watched movies.
[Detective-V]: Is that the only time he has been at your house?
[DA-O]: Yes
[Detective-V]: Is there anything else you need to tell me before we end
[DA-O]: No, that is pretty much it
[Detective-V]: Ok, I need you to know I found three phones in [R10's] room, we will be getting a search warrant for them, I will be dumping these phones, so if there is anything you need to tell me or you are not telling me it will show up on the phone.
Let me ask again, is there anything you need to tell me that may be on the phones?
[DA-O]: No, I cannot think of anything.
NHA-A asked DA-O if R10 had been to her house during the interview. There was no other documentation or investigation in any record that R10 had been to DA-O's house.
On 8/21/23 at 12:18 PM Surveyor interviewed NHA-A. Surveyor asked about the incidents/events on 6/28/23, 7/22/23 and the knowledge that R10 had been to DA-O's house. Surveyor asked why these incidents were not investigated more or statements taken from other staff and residents. NHA-A stated that these were just rumors and she cannot look into all rumors. Surveyor asked how does she know they are just rumors and not facts if she does not investigate. NHA-A stated I guess I can't.
2.) According to a facility self-report, on 8/9/23 R15 reported she was missing money from her purse in the amount of $30.00. R15 reported noticing the money was missing two days ago but was unsure when it actually went missing. R15 waited 2 days before reporting the missing money. The facility self-report documented R15 was not very upset. She said she did not report at first because it was not a big deal but then felt that she should report the money missing. The police were notified and R15 was reminded to use her lock box that she has access to.
The facility's investigation included a written statement from Receptionist-C dated 8/10/23 which indicated in part;
On 8/9/23, R15 reported to Receptionist-C she had $30.00 stolen out of her purse. R15 stated $10.00 was just tossed in her purse and a $20.00 bill was in her wallet and her change purse which was full of change was dumped out inside her purse. Receptionist-C and R15 went into Administrator-A's office for an investigation. R15 reported the situation to Administrator-A with Receptionist-C as witness. Administrator A told Receptionist-C to call R15's husband and to ask how much money had he given R15 in the last couple of weeks.
R15's husband informed Receptionist-C he had given R15 about $30.00 the day before but could not recall exactly how much was given. He also said he had given R15 approximately $50.00 throughout last week.
The facility's self report also included 2 statements by Director of Nursing (DON)-B.
The first one was dated 8/9/23 which stated, On August 9th 2023 R15 reported to this writer that she was missing $30.00 out of her purse. Resident stated that her roommate gave her a $10.00 bill for subway on Monday night and she just kept it in her purse and she already had a $20.00 bill in there just kind of in her purse, not wallet. The last time she knew for sure it was in her purse was on 8/7/23 after her roommate gave her the $10.00.
A second statement by DON-B which was not dated indicates, on August 9th, this writer (DON-B) spoke to R15's roommate. Roommate stated on 8/7/23 she gave R15 a $10.00 bill for a Subway sandwich's that were brought in. Roommate stated she watched R15 put the money in her purse that was sitting on the floor next to R15's recliner. That was the last time roommate saw it. Roommate stated no one had come into their room that she was aware of.
Included in the facility's self-report investigation included a Trauma Informed Care Evaluation dated 8/11/23 which included various questions to determine if R15 experienced Trauma. The score was: NA (not applicable) as R15 indicated none of the mentioned circumstances (natural disaster, serious accident at work, home, or recreation etc.) applied to R15.
The facility also had called the police department.
The facility investigation also included a typed interview with R15. This interview does not indicate who was asking R15 the questions nor is it signed.
This typed interview indicated R15 came to my office on August 9, 2023 at 3:45 pm and stated she had money taken out of her purse. R15 indicated she was pretty sure it was $30.00. R15 stated her ex-husband came a few days ago and brought Subway sandwiches for R15 and her roommate. Her roommate offered to pay for them so she offered R15 $10.00 and R15 took the $10.00 and put it in her purse, right before dinner around 4:45 pm.
R15 stated around 7:00 pm she went into her purse and saw the money missing. R15 did not think it was that big a deal. She searched her room and could not find it.
R15 did not see anyone in her room however there were people up and down the hall at that time. R15 had nothing else to report.
On 8/17/23 at 2:06 pm, Surveyor interviewed Licensed Practical Nurse (LPN) - M who indicated they really haven't had missing items on the unit. LPN-M stated the only thing missing was just at the end of last weekend, I wasn't here. R15 told me when I came back that her former husband brought in sandwiches and gave 1 to the roommate who in turn gave her $10.00 which R15 put in her purse. Later that day they said she actually had $30.00 missing however R15 said it was $10.00. LPN-M stated R15 has been asking all staff for money recently. She asked me for $100.00 and by my look said well $75.00 will do. LPN-M stated, I told her I had no money .No one will giver her (R15) money. LPN-M stated the following day she asked R15 what she wanted the money for. R15 stated she had wanted someone to take her to kwik trip and then two days later stated she wanted to order something from Amazon .
LPN-M stated R15 first reported it to receptionist-C or NHA-A. LPN-M stated the first time she heard about R15's missing money was from R15 and it was in the amount of $10.00 however no one goes into R15's room except staff. LPN-M indicated she was asked about the money and stated the facility self-reported it. LPN-M stated, I believe they did ask other staff and residents because it was a complete investigation.
On 8/21/23 at 8:50 am, Surveyor confirmed with Receptionist-C that R15 reported the missing money to her. Receptionist-C reported R15 came to her first to report the missing money and then they went to the Administrator's office.
On 8/21/23 Surveyor interviewed R15 who stated she was missing $30.00. When Surveyor asked R15 if the facility helped look for the money, R15 said no not really. R15 stated, I looked everywhere. Nothing happened before with my purse. No, the facility did not investigate, then stated, I have no idea what they would do, if they investigated they would have found change at the bottom of my purse and inspected my wallet. R15 then stated they did conduct a little investigation, they called my ex-husband and asked if he brought in money and he said yes. They called the police who came here and talked to me, was told to use her lock box and now has a key for it.
Surveyor noted R15's quarterly Minimum Data Set (MDS) dated [DATE] assesses R15 as being cognitively intact for daily decision making skills with a brief interview mental status score of 15.
On 8/21/23 at 9:00 am, Surveyor spoke to Nursing Home Administrator (NHA)-A as to whether she obtained any additional interviews of those staff who worked on R15's unit during the time frame of when R15 had the money and when the money went missing.
NHA-A thought she had interviewed a few additional staff members but could not locate any other statements. NHA-A stated she did not interview any additional staff.
Surveyor also asked NHA-A if she had interviewed any additional residents on R15's unit (unit 6) to see if any other residents would report either missing money or missing items.
NHA-A stated she did not interview any additional residents other than R15 and R15's roommate.
Surveyor shared with NHA-A that without interviewing additional staff who may be aware of R15's missing money and/or if they may have witnessed anyone in R15's room the investigation was not thorough. Surveyor shared with NHA-A without interviewing other residents on R15's unit she would not be aware if other residents may have experienced misappropriation of resident property.
The facility's self report investigation's final disposition stated, at the conclusion of the investigation, we at the [name of facility] have concluded that the cased is unsubstantiated for misappropriation of resident's property. Resident's statements and interviews with witnesses do collaborate findings. Social Service will follow up with [R15] to ensure she is using her lock box and being safe with her belongings. [R15] was educated on safely guarding her belongings that are kept in her room by using the lock box that is provided to her. [R15] understood.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility did not complete a performance review for 5 of 5 CNAs (Certified Nursing Assistants) reviewed. This had the potential to affect a pattern of all 85 r...
Read full inspector narrative →
Based on interview and record review, the facility did not complete a performance review for 5 of 5 CNAs (Certified Nursing Assistants) reviewed. This had the potential to affect a pattern of all 85 residents who reside in the facility as the 5 CNA's work throughout the building as needed.
Findings include:
On 8/28/23, the facility policy titled Competency Evaluation, dated 12/22 was reviewed and read: Subsequent and or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. Employee competency forms are maintained by the Staff Development Coordinator's office for the current training year, then forwarded to the Human Resources Director for placing into the employee's personnel file.
On 8/28/23 at 9:00 AM, the Surveyor asked for the performance reviews for:
CNA-N who was hired by the facility on 10/08/21,
CNA-W who was hired by the facility on 01/02/07,
CNA-X who was hired by the facility on 10/13/09,
CNA-Y who was hired by the facility on 01/24/19, and
CNA-Z who was hired by the facility on 01/02/07.
On 8/28/23 at 10:30 AM performance evaluations were reviewed and indicated: CNA-N had no performance evaluation, CNA-W's last performance evaluation was 4/7/19, CNA-X's last performance evaluation was 11/4/16, CNA-Y's last performance evaluation was 9/13/21 and CNA-Z's last performance evaluation was 2/3/20.
On 8/28/23 at 1:15 PM, Director of Nurses-B was interviewed and indicated no performance evaluations in the past 12 months could be found for CNA-N, CNA-W, CNA-X, CNA-Y, or CNA-Z. DON-B indicated they should be done yearly.
On 8/28/23 at 2:00 PM, Administrator-A and DON-B were informed of the of the above findings. Additional information was requested if available. None was provided.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility's assessment, last updated 8/8/23, indicates the number/average range of residents the facility can care for with active or current substance use dis...
Read full inspector narrative →
Based on record review and interview, the facility's assessment, last updated 8/8/23, indicates the number/average range of residents the facility can care for with active or current substance use disorders is 15 residents. The facility's assessment was not specific in regards to residents with substance abuse disorders and the level of care they are able to provide for those residents.
The facility assessment does not include available resources for narcotic substance abuse that is available to the residents for support services. The facility assessment does not indicate if the facility has a professional in substance abuse with drug and treatment expertise who would be able to assist with resident support and facility resources.
This deficient practice has the potential to affect the 15 residents (per facility assessment) who are active with or experience substance disorders.
Findings include:
During this onsite complaint investigation, the survey team was informed of two (R10 and R11) residents residing in the facility with diagnosis of substance disorders and who had repeated overdoses while in the facility. The facility used Narcan for these overdoses.
R10 was noted to have overdosed on 4/29/23, 5/4/23, 8/7/23 and 8/8/23.
R11 was noted to have overdosed on 5/4/23 and 8/3/23.
On 8/17/23 Surveyors interviewed Nursing Home Administrator (NHA)-A and Director of Nursing (DON) -B who, when trying to determine how the residents are accessing the drugs such as Fentanyl, resulting in these overdose, stated the residents blame each other for bringing in the drugs. NHA-A stated even though the residents have had overdoses, they deny having a substance abuse disorder. Surveyors also learned during this onsite visit that dietary aide (DA-O) reported to the police they (DA-O) provided R10 with illegal drugs (heroin) as a means of assisting R10 with detoxing. (Cross reference F600 and F689)
On 8/15/23, Surveyor reviewed the facility's Assessment Tool last updated 8-8-23 and last reviewed by Assessment and Assurance/Quality Assurance Performance Improvement (QAA/QAPI) committed on 8-10-23.
The facility's assessment documented the following in part;
Requirement
Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and resources the facility needs to care for their residents.
Purpose
The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well being.
The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the resident requires.
Overview of the Assessment Tool
.
The tool is organized in three parts.
1. Resident profile including numbers, diseases/conditions, physical and cognitive abilities, acuity, and ethnic/cultural/religious factors that impact care.
2. Services and care offered based on resident needs (includes types of care your resident population requires; the focus is not to include individual level care plans in the facility assessment.)
3. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems. a facility based and community-based risk assessment, and other information that your may choose.
Part 1: Our Resident Profile
This section indicates the facility is licensed to provide care for 123 residents with an average daily census range from 102 - 114 residents.
This section also identifies the diseases/conditions/ physical and cognitive disabilities, or combination of conditions that require complex medical care and management that the facility accepts.
Under category 1.3 the facility accepts:
Psychiatric/Mood Disorders with common diagnoses such as psychosis (hallucinations, delusions, etc. impaired cognition, mental disorder, depression, bipolar disorder (i.e. mania/depression), schizophrenia, post-traumatic stress disorder, substance use disorder, anxiety disorder, behavior that needs interventions.
Acuity
This section states, Describe your residents' acuity levels that help you to understand potential implications regarding the intensity of care and services needed. The intent of this is to give an overall picture of acuity - over the past year, or during a typical month .
This section of the assessment indicates the facility number/average or range of residents for
Behavioral Symptoms and Cognitive Performance: 79
Special Care High: 14
Special Care Low: 5
Clinically Complex: 9
Rehabilitation: 26
Rehabilitation plus extensive services: 0
Under Special Treatments and Conditions
The assessment indicates the following:
Mental Health-
Behavioral Health Needs: 29
Active or Current Substance Use Disorders: 15
In the General Care for Mental Health and behavior section the assessment indicates:
Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such
as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, substance abuse disorder, trauma/PTSD (post traumatic stress disorder), other psychiatric diagnosis, intellectual or developmental disabilities, substance abuse and ETOH (alcohol intoxication) abuse, Alcohol Anonymous weekly meetings.
In the Medications section the assessment indicates: Awareness of any limitations of administering medications .Assessment/management of polypharmacy, standing order for NARCAN Administration.
Additionally the assessment indicates Behavioral and Mental Health provides, SAMHSA (Substance Abuse and Mental Health Services Administration), AA (alcoholics anonymous)meetings.
Under staffing plan, the facility identifies:
Licensed nurses providing direct care with a total number needed or average or range as 17.
Nurse aides total number needed or average or range of 31.
etc.
The assessment also identifies staff training/education and competencies that are necessary to provide the level and type of support and care needed for the facility's resident population which included in part;
Workplace Relationships
NARCAN administration (LPN, RN)
Substance Use Disorder and hot to identify symptoms
Identification of resident change in condition .
Surveyor noted the facility's assessment indicates the facility may accept residents with substance disorders however it does not identify what level of resident care the facility is capable of caring for with a substance disorder. The facility's assessment does not indicate if they are capable of caring for individuals with a history of substance disorder, or individuals who are actively using and receiving treatment, and/or if they are capable of caring for individuals who may be going through detox/withdrawals. The assessment does not indicate how they would differentiate the care provided to those who may have a history of substance abuse disorder versus an individual who may be actively going through withdrawals.
The facility's assessment references Alcohol Anonymous (AA) weekly meetings, it also references behavioral and mental health providers, Substance Abuse and Mental Health Services Administration (SAMHSA). The assessment also references the use of Narcan.
Surveyor noted according to samhsa.gov; SAMHSA is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. According to their website, Congress established the Substance Abuse and Mental Health Administration (SAMHSA) in 1992 to make substance use and mental disorder information, services, and research more accessible. Region 5 covers Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin.
The assessment does not reference local support resources that a resident may actively participate in for substance abuse (drug abuse) such as narcotics anonymous.
On 8/16/23, Social Work Assistant - H informed surveyor the facility is trying to find a narcotics anonymous support group who will come to the facility however at this time, they have not been able to find one.
On 8/21/23 12:38 pm, NHA-A informed Surveyor the facility does have the ability for residents to attend local community narcotics anonymous meeting as a resource providing surveyor with a list of these resources which were not reference in the facility assessment. NHA- A also informed Surveyor that the residents also have access to only narcotic anonymous support groups.
NHA-A reported that R10 and R11 deny having substance abuse disorders, even though both have had multiple drug overdoses while in the facility, and have not wanted to utilize these resources.
Surveyor noted DA-O was providing R10 with narcotic drugs to assist R10 in detoxing. NHA-A was aware DA-O was acting as a self appointed support system for R10 for R10's substance abuse disorder. There is no evidence NHA-A spoke to DA-O as to the inappropriateness of DA-O acting as a support system for R10's substance abuse. There is no indication the facility spoke to R10 regarding the use of an prorogate professional for R10's substance abuse disorder, rather than using DA-O as a resource for his detox issues.
The facility's assessment under staffing does not indicate who at the facility may be heading up the care for substance abuse disorders. The facility's assessment does not indicate if the facility has an experienced professional in the area of substance abuse with drug and treatment who would be able to assist with resources and support residents with a history of substance abuse and/or who may be actively detoxing.
On 8/21/23 at approximately 11:15 am, Surveyor interviewed the facility's Medical Director -AA who stated the facility is doing what they can. Medical Director -AA stated residents are their own person and can go outside and have their personal property, all that can pose challenges.
Medical Director-AA stated last week at the Quality Assurance Performance Improvement meeting they talked about smoking, alcohol, drugs and they are trying to come up with things which is a challenge and an ongoing battle.
Medical Director-AA thought the use of narcotics anonymous would be helpful as he was aware of the overdoses and the use of the Narcan. Medical Director-AA stated once a resident is stable they should come to the facility however not all information is provided by the hospital.
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 F0566
(Tag F0566)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review 1 of 1 (R1) resident's employed by the facility did not have a care plan or a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review 1 of 1 (R1) resident's employed by the facility did not have a care plan or appropriate job description before employment at the facility began. This deficient practice has the potential of affecting all 97 residents in the building.
* R1 has a history of resident-to-resident abuse and excessive alcohol consumption while in the facility. Before employment, the facility had R1 sign a job description for a Certified Nursing Assistant (CNA) and a policy that indicated R1 would answer call lights of other residents.
Finding include:
R1 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse and left foot amputation. R1's annual Minimum Data Set (MDS) dated [DATE] was reviewed and R1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated R1's cognitive status for daily decision making skills was fully intact with both long- and short-term memory.
R1's medical record was reviewed and indicated that on 6/22/23, R1 was engaged in an altercation with another resident and had hit the resident. R1 was arrested as a result.
On 7/2/23 R1's medical record indicated R1 was in a verbal altercation with another resident. On 8/11/23 R1's medical record indicated he was drinking alcohol and got into a verbal altercation with another resident.
On 8/17/23 R1's care plan for abusive behaviors dated 12/10/22 was reviewed and indicated: poor impulse control and substance abuse, history of altercation with peers.
Interventions in R1's care plan included: if drinking alcohol place on 1 to 1 supervision immediately, intervene before behaviors escalate. R1's care plan did not address anything regarding R1's employment with the facility.
On 8/17/23 R1's employee file was reviewed, and the following documents were included in his file and signed by R1:
A job description for a CNA which included: provide daily perineal care, perform vaginal irrigation, give sponge baths, provide daily range of motion exercises, must be a licensed CNA. This was signed by R1 on 7/20/23.
A call light pledge which included: I will not walk by a call light without stopping. It is the facility's expectation that the moment a staff member identifies a call light is ringing it will be answered within reason. This was signed by R1 on 7/20/23.
A care plan attestation which included: I understand it is an expectation for me to review the plan of care prior to providing any and all cares. This was signed by R1 on 7/20/23.
On 8/17/23 at 9:45 AM Human Resources Manager (HR)-E was interviewed and indicated R1 was employed as a maintenance assistant on 7/20/23. HR-E indicated she did not know what R1's job duties were and was not given any direction as to what R1's responsibilities would be. HR-E indicated she knew of R1's aggression toward peers and R1's substance abuse. HR-E was asked why R1 had signed a job description for a Certified Nursing Assistant. HR-E indicated that was a mistake. HR- E was asked why R1 signed a call light pledge he would answer other residents call lights. HR-E indicated all employees are required to answer call lights. HR-E was asked if R1's history of peer altercations and substance abuse would be a concern with him answering other residents call lights. HR-E indicated that it would be a concern. HR-E was asked why R1 had signed a care plan attestation indicating he would review other residents plans of care. HR-E indicated it was a mistake that R1 signed it.
On 8/17/23 at 10:30 AM Maintenance Manager (MM)-F was interviewed and indicated R1 has not done any work in resident's rooms since he started on 7/20/23. MM-F indicated she was not given any instructions on what work R1 could or could not do in the facility. MM-F indicated she was not sure if R1 will complete any work in resident rooms. MM-F indicated R1 has been a good employee and has worked sanding and staining benches, opening, and discarding boxes and picking up debris outside.
On 8/21/23 at 9:00 AM R1 was observed in the hallway painting the handrails. R1 indicated he likes his new job and just received his first check. R1 indicated he was not told he must use any part of his pay to pay for his stay at the facility.
The above findings were shared with the Administrator-A and Director of Nurses-B at the daily exit meeting on 8/21/23 at 3:00 PM. Additional information was requested if available. None was provided.
Mar 2023
14 deficiencies
1 IJ
CRITICAL
(J)
📢 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
Pressure Ulcer Prevention
(Tag F0686)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R29 is a long-term resident at the facility with diagnosis including, unspecified severe protein calorie malnutrition, Chron...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R29 is a long-term resident at the facility with diagnosis including, unspecified severe protein calorie malnutrition, Chronic Kidney Disease stage 4, and Chronic Obstructive Pulmonary Disease.
R29's quarterly MDS (Minimum Data Set) Assessment documents R29 has a BIMS (Brief Interview for Mental Status) of 14, indicating R29 is cognitively intact; R29 is at risk for pressure injuries and has one stage three pressure injury.
R29's skin integrity care plan, initiated on 07/18/2019, documents:
Resident has Potential for impaired skin integrity r/t (related to): decreased mobility, unspecified severe protein calorie malnutrition, dermatitis, left hip brace and has interventions that include:
10/11/22 skin prep to left heel .
10/28/22- soft boots on at all times
in-house wound MD to follow .
11/22/22-Tx as ordered .
2/14/23-new treatment to left lateral heel .
2/21/23-new treatment to left lateral heel .
pressure redistribution mattress; initiated on 09/16/2019
Assist with reposition PRN (As needed)
Surveyor reviewed R29's medical record and noted the following nurses progress note dated 10/11/2022 at 3:53 PM:
Resident returned from the hospital, writer looked at residents' heels, noted faint discoloration to L heel measuring 2cm x 2cm. Denies pain to area. [Name of Nurse Practitioner] NP (Nurse Practitioner) from [name of group] notified. New orders received to apply Skin Prep to area . Surveyor noted R29 had been hospitalized from [DATE] to 10/11/22. R29's medical record contained no documentation of a DTI prior to 10/4/22.
Surveyor noted R29 had the following physician's order dated 10/11/22 and discontinued on 10/28/23: L (Left) HEEL: Cleanse area with saline, apply skin prep daily and PRN (As needed).
On 03/01/23 at 10:12 AM, Surveyor interviewed Unit Manager LPN (Licensed Practical Nurse) J. LPN J informed Surveyor she noticed the DTI to R29's left heel upon admission and received an order for skin prep and soft boots.
Surveyor reviewed R29's medical record and noted R29's care plan was not updated until 10/28/22 to include the intervention of soft boots on at all times. Surveyor could not locate pressure off-loading interventions added on 10/11/22 when the DTI was first discovered.
On 03/02/23 at 9:39 AM, Surveyor interviewed DON (Director of Nursing) B and Corporate Nurse Consultant G. Surveyor asked if there were off-loading interventions added to R29's care plan after the discovery of the DTI on 10/11/22. DON B stated she would check R29's medical record and get back to Surveyor.
On 03/02/23 at 1:50 PM, DON B informed Surveyor there were no pressure off-loading interventions added at the time of the DTI discovery on 10/11/22.
No additional information was provided.
Based on observation, interview, and record review, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure injuries for 2 (R7, R29) of 6 residents reviewed for pressure injuries.
* R7 developed a facility acquired, Stage 4 pressure injury with an exposed tendon under a splint that had been applied to R7's hand. There was not a doctor order for R7's splint. The splint did not appear to have been removed for cares to check R7's skin impairment, the splint was not on the care plan or care delivery guide.
Facility failure to obtain a doctor's order, care plan, and provide care for R7's splint caused R7 to develop a Stage 4 pressure injury with exposed tendon created a finding of immediate jeopardy that began on 1/6/2023.
Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 3/2/2023 at 3:28 PM. The immediate jeopardy was removed on 1/8/2023. However the deficient practice continues at a scope/severity of D as evidenced by the following example.
* R29 was readmitted to the facility with a deep tissue injury (DTI). The facility did not comprehensively assess the area upon admission or establish a care plan until later.
Findings include:
The facility policy entitled Pressure Injury Prevention and Management' implemented on 1/6/2023 states: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Policy Explanation and Compliance Guidelines: . 2. The facility shall establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. 3. Assessment of Pressure Injury Risk . e. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. 4. Interventions for Prevention and to Promote Healing a. After completing a thorough assessment/ evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. e. the goals and preferences of the resident and or/authorized representative will be included in the plan of care. 6. Modifications of Interventions b. Interventions on a resident's plan of care will be modified as needed.
1.) R7 was admitted to the facility on [DATE] and has diagnoses that include: encephalopathy, anxiety, major depressive disorder, dementia, muscle wasting and atrophy.
R7's annual Minimum Data Set (MDS) dated [DATE] indicated R7 had severely impaired cognition with Brief Interview for Mental Status (BIMS) score of 00 and assessed R7 as needing extensive assist with bed mobility, dressing, eating, toileting, and hygiene, and total dependence with transferring and bathing. R7 was non ambulatory, used a Hoyer lift for transferring and had a Broda wheelchair. R7 was incontinent of bowel and bladder and wore a brief.
R7's Braden score on 1/10/2023 was 13 indicating R7 was high risk for developing pressure injuries.
R7's Potential for Impaired Skin Integrity was initiated on 2/19/2021 with the following interventions:
- pressure redistribution mattress
- apply cushion to wheelchair
- Complete Braden scale upon admission, weekly X4, quarterly, with significant change of condition and as needed
- lotion with skin cares
- Weekly skin assessment
- Monitor skin with all cares. Report any changes to Nurse
- Update Physician as needed, refer to Registered Dietician and therapy as needed.
- Tubi grips to bilateral upper arms, put on in AM and take of at bedtime. Offer long sleeve shirts to resident if available- initiated 8/5/2022
- Encourage to Free float heels in bed- initiated 11/15/2021
- Barrier cream after each incontinent episode and as needed- initiated 11/15/2021
- Encourage to reposition approximately every 2-3 hours and as needed-initiated 11/15/2021
On 8/18/2022 the Nurse Practitioner (NP) wrote an order for Occupational Therapy (OT) to evaluate and treat R7 due to R7 having stiff, swollen fingers and knuckles of the left hand.
On 8/24/2022 OT started to see R7 per NP order.
On 8/30/2022 OT implemented R7 to start wearing a palm guard with finger separators. OT noted deficits with positioning of R7's left upper extremity (LUE) impacting the risk of skin breakdown and functional use of LUE. OT applied a long skinny pillow under R7's elbow to support the elbow and the LUE to improve positioning while R7 was up in R7's Broda wheelchair. OT wrote up education for nursing to educate staff on R7's [NAME] guard schedule and how to position the LUE while R7 was in Broda wheelchair.
On 10/21/2022 R7 was discharged from therapy with the following discharge recommendations: staff were educated on the use of the palm guard and Isotoner glove for the left hand.
Surveyor noted that R7 did not have a care plan initiated regarding R7's [NAME] guard with finger separators for R7's left hand or to have R7's left hand brace removed for cares or to check skin impairment.
On 1/6/2023 at 12:39 PM in the progress notes, nursing charted R7 was noted to have a new open area to the base on R7's left thumb. R7 had been wearing a splint and the splint was removed. Nursing assessed the Skin. Nursing contacted R7's Power of Attorney (POA) and the NP. Nursing obtained a new order to have R7 seen in house by the wound doctor. The wound doctor was made aware and will see R7 on their next visit. Nursing obtained treatment orders and applied the treatment to R7.
On 1/6/2023 on the Initial Wound Assessment, nursing documented the base of the left thumb had a Stage 4 pressure injury measuring 1.1 cm x 1.5 cm x 0.2 cm with 100% non-granulating tissue with exposed tendon.
R7's Impaired Skin Integrity Care Plan was initiated on 1/6/2023 with the following interventions:
- Complete Braden scale upon admission, weekly X4, quarterly, with significant change of condition and as needed
- Consult in-house wound physician
- Measure area weekly
- Monitor of signs/ symptoms of infection
- Monitor of signs/ symptoms of worsening skin tissue
- Monitor pain and offer as needed analgesic as ordered
- Monitor skin with all cares. Report any changes to Nurse/ physician.
- Wound team to follow
- Treatment as ordered
- Update physician with changes in wound status and PRN (as needed).
On 1/10/2023, the wound physician assessed R7's pressure injury to the base of the left thumb. The wound physician documented the Unstageable pressure injury measured 0.4 cm x 0.95 cm x 0.1 cm with early granulation tissue. The wound physician ordered the following treatment: cleanse the wound with normal saline, pat dry, apply skin prep to area around the wound, apply Xeroform dressing and bandage the wound daily and as needed. The wound physician documented the wound was crusted over with no tendon exposed at that time with no signs or symptoms of infection.
On 1/17/2023 R7's measurements were: 1.39 cm X 0.59 cm X 0.1 cm, stage 4, 75-99% granulation tissue. The treatment was changed from Xerofoam dressing to bordered foam dressing.
R7's Stage 4 pressure injury to the left thumb was assessed weekly and had the following measurements:
-1/24/2023: 1.2 cm X 0.3 cm X 0.1 cm with early granulation tissue.
-1/31/2023: 0.7 cm X 0.2 cm X 0.1 cm with early granulation tissue.
-2/7/2023: 0.4 cm X 0.2 cm X 0.1 cm with early granulation tissue.
-2/14/2023: 0.2 cm X 0.2 cm X 0.1 cm with early granulation tissue.
-2/21/2023: 0.1 cm X 0.1 cm X 0.1 cm with early granulation tissue.
On 2/28/2023, R7's measurements were: 0.93 cm X 0.68 cm X 0.1 cm, stage 4, 76% granulation with no other percentage type. (The wound base description should have 100% tissue type documented.) New treatment orders were received to cleanse R7's pressure injury with normal saline, protect around the wound with skin prep, cover with foam dressing every Tuesday, Thursday, Saturday, and as needed and to apply a washcloth under the left hand contractures to prevent further skin breakdown. An order was received to check skin integrity under washcloth every shift.
On 3/2/2023 at 12:27 PM, Surveyor observed Licensed Practical Nurse (LPN)-O change R7's dressing to R7's left thumb per the wound physician's orders. Surveyor observed light brown drainage on the dressing. Surveyor observed R7's pressure injury at the base of R7's left thumb, measuring approximately 0.5 cm X 0.5 cm, with no depth noted, and pink tissue at wound base. Surveyor asked LPN-O how R7 developed the pressure injury. LPN-O stated R7 had a [NAME] soft brace for R7's contractures and the corner of R7's brace by the thumb area was doubled over and R7 would squeeze it tightly because of R7's contractures. Surveyor asked LPN-O if LPN-O ever took off R7's brace. LPN-O stated third shift staff would take R7's brace off and morning staff would put R7's brace on. LPN-O stated LPN-O never took off R7's brace. Surveyor asked LPN-O if LPN-O could show Surveyor R7's brace. LPN-O stated R7's brace was thrown out, but the brace was a palm guard, and the brace would go over the thumb and Velcro together. LPN-O stated that R7's brace had sheepskin under the fingers so R7 could not bend R7's fingers into R7's palm of the hand due to the contractures.
On 3/2/2023 at 12:55 PM Surveyor asked the Director of Rehab (DoR)-P if therapy was consulted for R7 to be seen for a brace. DoR-P stated therapy had an order for R7 for OT to evaluate and treat R7 for stiff, swollen fingers and knuckles of the left hand. DoR-P stated R7 was seen from 8/24/2022 - 10/21/2022.
On 3/2/2023 at 12:55 PM Surveyor asked OT-Q if OT-Q recommended a brace for R7. OT-Q stated OT-Q recommended a palm guard with finger separators for R7's left hand because of R7's contractures. OT-Q stated R7 could not tolerate the finger separators and recommended staff to take off or not wear the palm guard if R7 developed skin issues. Surveyor asked if OT-Q saw R7 to assess R7's brace. OT-Q stated OT-Q had not seen R7 since discharging from therapy in October 2022.
On 3/2/2023 at 1:25 PM Surveyor asked the Regional Nurse Consultant (RNC)-G what orders R7 had for the palm guard with finger separator brace. RNC-G stated to Surveyor that the Nursing Home Administrator (NHA)-A had the past noncompliance binder and Surveyor would need to talk with NHA-A. Surveyor asked RNC-G to clarify about the binder for R7. RNC-G stated when R7's pressure injury was found RNC-G realized that R7 did not have orders for a brace and R7 was not supposed to have a brace.
On 3/2/2023 at 1:30 PM Surveyor asked the NHA-A for information regarding R7's pressure injury that was found on 1/6/2023. NHA-A stated that when staff found R7's pressure injury on R7's left thumb, staff noted that there was not an order for R7 to have a brace and R7 did not have a care plan to do checks on R7's skin under the brace or to remove R7's brace.
The facility's failure to obtain a doctor's order, care plan, and provide cares for R7's splint caused R7 to develop a Stage 4 pressure injury with exposed tendon created a finding of immediate jeopardy. The facility removed the jeopardy on 1/8/2023 when it had completed the following:
- Audited all residents with splints/ medical devices.
- Talked with staff regarding what residents were wearing splints.
- Had therapy provide a list of all residents with splints.
- Education was given to Nursing and CNAs regarding orders for splints, checking for skin impairment, and who to inform if a resident has a device and is not on the resident's care card.
- facility to perform random audits of residents with/ without splints X4 weeks.
- Audit of communication between therapy and nursing for use of devices.
The deficient practice continues as a scope/severity of D based on the following examples:
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on interviews, record reviews and facility document reviews, the facility did not implement measures to protect a resident from sexual abuse. This was discovered in 2 facility self reports invol...
Read full inspector narrative →
Based on interviews, record reviews and facility document reviews, the facility did not implement measures to protect a resident from sexual abuse. This was discovered in 2 facility self reports involving (R23 & R76) of 9 facility self-report investigations.
On 2/15/23 R23 touched R76 inappropriately in their genital area. R23 had a documented history of previously engaging in inappropriate activity with residents including kissing other residents. The facility had not assessed residents, including R76, for their ability to understand and consent to sexual activity/relations. The facility self report indicates the social worker sat down with R23 and R76 to clarify their relationship. The self report continues to indicate the power's of attorney for both R23 and R76 were contacted and stated they do not have an issue with their relationship but would prefer that the residents were not visiting in each others rooms. The consent for a relationship is not something that can be deferred to a responsible party. The facility did not take steps to prevent this incident from occurring as no assessment had been completed regarding R23's ability to understand what consent is from other parties/residents for sexual behavior. R23's care plan did not specify the level of supervision R23 required to prevent additional inappropriate behavior. On 2/15/23 it was reported that R23 was observed by other residents touching R76 in appropriately. The facility, through interview, expressed skepticism the 2/15/23 incident occurred. The facility stated R23 is in a relationship with R76 despite the lack of consent or assessment of R76 and awareness of R76's psychosocial history.
Findings include:
The facility's Abuse policy and procedure dated 10/24/22 was reviewed by Surveyor. The purpose is to provide protections for the health, welfare and rights of each resident residing in the facility. The Prevention section indicates: The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of needs and behaviors which might lead to conflict or neglect; this includes sexually aggressive behavior such a as saying sexual things, inappropriate touching/grabbing.
Surveyor reviewed the Facility Self-Report investigation from 2/15/23 at 4:00 PM regarding R23 and R76. Another Resident reported to the Nurse that R23 and R76 were in the Dining Hall, and they saw R23 rubbing R76's vagina area over their clothes. R76 was wearing an incontinence brief and pants. R23 and R76 were separated and placed on 15-minute checks. R23 and R76 each have a Legal Representative. The investigation concluded R23 and R76 are in a relationship and their Legal Representatives are aware of the relationship and prefer them to visit in a common area. The facility final conclusion in their self report was that R76 and R23 are in a relationship despite R76 inconsistently understanding what a relationship is.
R76 has diagnoses of Dementia, Bipolar disorder and borderline personality disorder. R76 on 2/21/22 was protectively placed with a court ordered Guardian.
On 11/30/22 an Annual MDS (minimum data set) assessment indicates a 5 for BIMS (brief interview of mental status) which indicates severe cognitive impairment. A BIMS assessment was conducted on 2/17/23 that indicates a 3 for severe cognitive impairment.
On 2/17/23 (Surveyor noted after the 2/15/23 incident with R23) a Trauma Informed Care Evaluation was completed for R76. This evaluation indicates R76 has had unwanted or uncomfortable sexual experiences by male resident, and this was reported to the State Agency by the facility; R76 does not recall any unwanted or uncomfortable sexual experiences by male resident; R76 has experiences with a life-threatening illness of severe neurocognitive disorder.
On 2/20/23 a Recommendations for Addressing Resident Relationships Intimacy and Sexuality History. This assessment indicates R76 is not in a relationship; they currently are not involved in a relationship; is not currently interested in having a relationship.
R76's plan of care indicates The resident has a psychosocial well-being problem related to inability to meet role expectations initiated 2/1/23. Indicates on 2/1/23 resident chooses to be in a relationship with a peer. The plan of care does not define or have interventions related to this peer relationship.
R76's plan of care indicates 2/15/23 Resident has experienced trauma related to unwanted or uncomfortable sexual experience by a male resident boyfriend (R76) initiated 2/17/23. The interventions include the residents to visit in a common area.
On 2/28/23 at 1:07 PM Surveyor spoke with R76 who walked into the Social Worker's office. R76 was smiling and pleasant. R76 did not recall a boyfriend (R23), nor any dating in the facility. R76 indicated all their friends are special.
R23's medical record was reviewed by Surveyor. R23 has diagnoses of multiple sclerosis, paraplegia, developmental disorder of scholastic skills. R23 has a Power of Attorney (POA) and POA is activated since 12/5/2019.
R23's plan of care indicates Resident displays socially inappropriate behaviors related to intellectual disability dated 6/1/2022 includes:
* 6/1/22- residents separated, no adverse outcomes or change in behavior noted.
Social services to follow up as needed. Resident was educated that this behavior is
inappropriate due to the other resident being unable to say she wants to be kissed.
Resident verbalized understanding.
* 2/15/23 inappropriate touching of another resident within a dating relationship.
INTERVENTIONS:
-6/01/22 Resident was educated not to kiss other residents due to some residents
can't say if they want to be kissed.
-2/16/23 Resident was educated on intimate expressions allowed by girlfriend's responsible party due to severe cognitive impairment unable to consent to intimacy. Residents to visit in common areas secondary to cognitive defect with inability to give consent.
On 2/20/23 R23 had a Recommendation for Addressing Resident Relationships Intimacy and Sexual History assessment conducted. Surveyor noted this was after the incident with R76. This assessment indicates R23 is in a relationship with R76. There is not a defining explanation of what this relationship involves.
On 2/22/23 R23 had a Resident Interviewing Assessment completed. The assessment indicates R23 understands what sexual contact means. The assessment does not indicate R23 is in a sexual relationship in the facility or wants to have sex.
On 2/27/23 at 2:16 PM Surveyor spoke with R23 about any relationships in the facility. R23 indicates R76 and R23 are good friends. They like R76 and they just hold hands in the common area. They just love each other and like companionship.
On 2/28/23 at 12:52 PM Surveyor spoke with SW (Social Worker)-E who assisted with the sexual abuse investigation on 2/15/23. SW-E just had interviewed R23 and R76 separately to complete the relationship assessments. SW-E felt R76 could give consent to a relationship with R23 regardless of mental capacity. SW-E did not involve any of R23 or R76's family or friends at the time of the relationship assessments.
On 2/28/23 at 3:19 PM Surveyor spoke with RNC (Regional Nurse Consultant)-G, DON (Director of Nurses)-B and Administrator-A at the Exit Meeting. Surveyor shared concerns with R23 and R76's ability to fully comprehend and consent to an intimate relationship. Surveyor requested the sexual history and trauma assessment policy and procedure
On 3/02/23 8:01 AM DON-B and RNC-G spoke with Surveyor. RNC-G indicated they monitor R23's interactions with any residents. RNC-G felt the kiss on the check from 6/1/22 was not sexual. They indicated they will revise the plan of care to be more detailed for actual relationships. They have not seen anything besides hand holding from R23 and the kiss was a peck on the cheek on 6/1/22. They felt the sexual contact on 2/15/23 by R23 and R76 did not really happen. R23 would not be physically able to touch R76 and R76 would say no if someone tried to touch them. RNC-G indicated SW-E supplied their own assessment forms. Surveyor noted here there is not a specific policy and procedure. Surveyor noted the facility self report indicates R76 is inconsistent in her comprehension and the self report puts the responsibility on R23 to be aware of R76's inconsistency regarding their relationship status rather than a facility responsibility.
On 3/20/23 at 3:30 PM Administrator-A and DON-B were given the above findings at the daily exit conference. Additional information was requested if available. None was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R462 was admitted to the facility on [DATE] with diagnosis including Metabolic Encephalopathy, Alcohol Dependence and Non-tr...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R462 was admitted to the facility on [DATE] with diagnosis including Metabolic Encephalopathy, Alcohol Dependence and Non-traumatic Brain Dysfunction.
R462's quarterly Minimum Data Assessment (MDS), dated [DATE], documented R462 had a BIMS (Brief Interview for Mental Status) of 8, which indicated R462 had cognitive deficits. R462's Healthcare Power of Attorney (HCPOA) was activated on 04/21/22. R462 had a Representative Payee, appointed on 01/03/2023, to manage finances.
R45 was admitted to the facility on [DATE] with diagnoses including Multiple Fractures, Paraplegia, Other Psychoactive Substance Use, Anxiety and Depression. R45's most recent quarterly MDS on 01/09/23 documented R45 had a BIMS of 15 indicating R45 is cognitively intact.
Surveyor reviewed a Facility Self Report which alleged potential financial misappropriation between R45 and R462. The incident was discovered on 01/09/2023, but the full report was not submitted until 02/13/2023. Per the self-report, R462 was packing belongings to discharge from the facility when nursing staff noted multiple carbon copies of checks made out to R45 and made out to cash. The facility's Social Worker filled out and filed the report with the State.
On 03/01/23, at 8:15 AM, Surveyor interviewed SW (Social Worker) E. (SW E filed the self-report). SW E informed Surveyor she was made aware of the incident on 01/09/23 when nursing staff informed her they found carbon copies of checks on R462's person made out to R45 and some made out to cash. Per SW E, R462 was discharging from the facility that day and nursing staff were assisting R462 with packing when the carbon copies were noted. SW E informed Surveyor she filed the incident report the same day, however, SW E was unaware the follow up investigation was due within five days and that is why the completed report was late. SW E stated she spoke with a Social Worker Consultant who informed her the police need to be notified, however, per SW E the police were not notified because she and the nursing staff had asked R462 if they wanted the police called and R462 stated no. SW E stated she notified R462's healthcare power of attorney and representative payee. SW E stated she also informed Adult Protective Services. SW E informed Surveyor she felt R462 had some cognitive deficits, however, SW E stated R462 seemed intoxicated most days and spent time going back and forth to R45's room. Per SW E, there was a previous allegation of financial exploitation of R462 by R45. SW E stated she was not employed at the facility at the time of that incident and the other Social Worker would have additional information. Per SW E, R45 denied any wrongdoing and informed SW E, R462 gave R45 permission to write checks and buy things for R462.
Surveyor's attempts to interview R45 were unsuccessful:
On 02/27/23 at 9:53 AM, Surveyor observed R45 lying in bed with eyes closed. Surveyor knocked on the open door, but R45 did not answer.
On 02/28/23 at 11:00 AM, Surveyor noted R45 was not in room. Surveyor was unable to locate R45 at that time.
On 03/01/23 at 8:00 AM, Surveyor observed R45's door shut. Surveyor knocked on the door, however no one answered.
On 03/01/23 at 9:50 AM, Surveyor observed R45's room was empty. Surveyor was unable to locate R45 at that time.
On 03/02/23 at 8:15 AM, Surveyor observed R45's door shut. Surveyor knocked on the door; no one answered.
On 03/01/23 at 12:35 PM, Surveyor interviewed NHA (Nursing Home Administrator) A. NHA A informed Surveyor SW E notified NHA A about the incident on 01/09/23 and contacted Adult Protective Services. Per NHA A, SW E did not get statements from staff/residents, nor did SW E contact the police. NHA A stated R462 did not want the police contacted and told staff they gave permission for R45 to use the bank account. NHA A did acknowledge the police should have been contacted. NHA A stated there has been education for staff regarding reporting incidents.
On 03/01/23 at 2:30 PM, during the end of the day meeting with NHA A, DON (Director of Nursing) B, and Corporate Nurse Consultant G surveyor relayed the concern of not submitting the Facility Self Report timely, non-notification of the police and not completing a thorough investigation.
No additional information was provided.
Based on interviews/ and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 3 Residents (R162, R94 & R462) of 5 residents reviewed who potentially had a crime committed against them.
R94 had a resident-to-resident verbal altercation in which R162 expressed being very afraid of R94. The facility did not notify the police of R94's threat to R162.
Agency Certified Nursing Assistant (CNA) Z was verbally and physically abusive towards R94 and Agency CNA Z was asked to leave the facility. The facility did not call the police. Additionally, the facility did not investigate threats made to another resident by CNA Z that staff referenced in their statements.
R45 had an allegation of misappropriation of R462's funds and the facility did not call the police and the investigation was not completed and submitted to the state agency.
Findings include:
The facility abuse policy dated 10/24/22 indicate: .
VII. Reporting/response
All alleged violations will be reported to the administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes.
1.) R94 was admitted to the facility on [DATE] with diagnoses of alcohol induced mood disorder, amputation of left lower leg and anxiety disorder.
The quarterly MDS (minimum data set) dated 12/7/22 indicate R94 is cognitively intact and is independent with ADLs (activity of daily living) and transfers.
The facility self report dated 12/18/22 indicate R94 and R164 were roommates. R164 was watching a show on his phone when R94 got mad at R164 because R164 did not turn the volume down. R94 because verbally aggressive and threatened to break R164 or R164's phone. R94 left the room. R164 told the nurse he was in fear for his life because of R94's threat. R164 was moved immediately to a different room.
The self report indicate Nursing Home Administrator (NHA) A and Director of Nursing (DON) B were made aware.
There is no evidence in the self report the police were called because R164 stated he was in fear for his life because R94 threatened R164.
On 3/1/23 at 9:30 a.m. Surveyor interviewed NHA A and Assistant Administrator D. Surveyor asked if the police were called when R164 indicated he was fearful of what R94 threatened he would do to R164. Assistant Administrator D stated R164 was scheduled to be discharged the next day. Assistant Administrator D stated they did not call the police.
2) Surveyor reviewed a self report dated 2/12/23 involving R94 and Agency Certified Nursing Assistant (CNA) Z. The investigation indicates on 2/12/23, Agency CNA Z became verbally abusive toward R94 and pushed R94's arm off the door jam. R94 became very upset and staff escorted R94 away from Agency CNA Z and into the dining room. Agency CNA Z was told to leave the building immediately and NHA A and DON B were notified.
The facility allegation investigation statement included details the allegation was R94 was in another resident's room. CNA-Z came in to the room and R94 attempted to engage in a conversation with CNA Z. CNA Z allegedly came back with threatening remarks calling R94 a cripple and a little man and allegedly threatened to fight R94 outside. R94 allegedly stood up and CNA Z pushed R94 at the arm almost knocking him off balance. Staff statements clearly indicated that CNA Z was the aggressor in this situation and that an altercation occurred between CNA Z and R94. Additionally, staff statements indicate even stronger language was used by CNA Z than what the facility indicates in their investigation details. Additionally, facility staff indicated in statements that CNA Z threatened other residents indicating he would beat their a**. There is no indication the facility further investigated or reported the threats CNA Z made to other residents as indicated in the staff statements.
There is no evidence in the self report the police were called regarding Agency CNA Z being verbally abusive and physically pushing R94's arm off the door jam.
On 3/1/23 at 9:30 a.m. Surveyor interview Nursing Home Administrator (NHA) A and Assistant Administrator D. Surveyor asked if the police were called regarding the 2/12/23 incident. Assistant Administrator D stated they did not call the police. Assistant Administrator D stated it was difficult to get Agency CNA Z's statement after they left the building. Agency CNA Z would not return the facility's or the Agency's phone calls and messages.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and interview, the facility did not ensure investigations of allegations of neglect involving 2 Residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and interview, the facility did not ensure investigations of allegations of neglect involving 2 Residents (R61 & R42) of 2 allegations of neglect were reported timely to the state agency.
The facility did not ensure investigated allegations of neglects involving R61 and R62 were submitted timely to the state agency as facility administration forgot to submit the investigations to the state agency.
Findings include:
1.) R61 was admitted to the facility on [DATE] with diagnoses of epilepsy, depression, bipolar disorder, anxiety, and obesity. R61's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R61 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 00 and needed extensive assistance with bed mobility and cares.
On 1/4/2023 at 8:22 PM in the progress notes, nursing charted R61 fell out of bed while receiving care by a Certified Nursing Assistant (CNA). The progress note at 9:25 PM stated the CNA was providing cares to R61 and while repositioning R61, the left lower extremity slid off the bed and R61 started sliding off the air mattress. The CNA attempted to assist R61 into the bed but was unable and assisted R1 to the floor. R61 did not hit their head. X-rays were ordered for left knee pain.
A facility self-report for the incident on 1/4/2023 was initiated. The report stated the incident was discovered on 1/5/2023 and was signed by Assistant Administrator (AA)-D on 1/12/2023. The report was submitted to the State Agency on 1/19/2023.
In an interview on 3/1/2023 at 3:19 PM, Surveyor asked AA-D why the facility reported incident stated the incident was discovered on 1/5/2023 when staff were present at the time of the incident on 1/4/2023. AA-D stated AA-d did not have access to the reporting system until 1/5/2023 so that was when AA-D could report the incident so AA-D used that date. AA-D stated AA-D should have put down 1/4/2023 instead of 1/5/2023. Surveyor asked AA-D why the report was not filed with the State Agency until 1/19/2023. AA-D stated AA-D does the investigation into any incident reports, but it did not take two weeks to investigate a fall. AA-D stated when AA-D made out the report, AA-D printed out the report but did not hit the submit button. AA-D stated AA-D signed the report on 1/12/2023 but on 1/19/2023 discovered the report had not been submitted. Surveyor asked AA-D how AA-D became aware of the late submission for the report. AA-D stated the State system sends an email saying the final report had not been received so that is what alerted AA-D to the report not being submitted.
On 3/2/2023 at 8:16 AM, Surveyor met with Director of Nursing-B and Regional Nurse Consultant-G and shared the conversation with AA-D regarding the late reporting of the Facility Self Report. No further information was provided at that time.
2.) R42 was admitted to the facility on [DATE] with Diagnoses of Dementia, mild protein-calorie malnutrition, and Major depressive disorder. R42 was admitted into Hospice on 11/1/2022. R42's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated R42 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 00 and needed extensive assistance with bed mobility and cares.
On 11/23/2022 at 3:30 PM the Hospice Certified Nursing Assistant (CNA) nursing alleged that R42 had a strong smell of urine. Nursing went to assess R42 and found R42's brief saturated with urine. R42's buttocks was reddened caused by fecal matter.
A facility self- report for the incident on 11/23/2022 was initiated. The report stated the incident was discovered on 11/23/2022 and was signed by the Assistant Administrator (AA)-D on 11/30/2022. The report was submitted to the State Agency on 12/12/2022.
In an interview on 3/1/2023 at 3:19 PM. Surveyor asked AA-D why the report was not filed with the State Agency until 12/12/2022. AA-D stated when AA-D made out the report, AA-D printed out the report but did not hit the submit button. AA-D stated AA-D signed the report on 11/30/2022 but on 12/12/2022 discovered the report had not been submitted. Surveyor asked AA-D how AA-D became aware of the late submission for the report. AA-D stated the State system sends an email saying the final report had not been received so that is what alerted AA-D to the report not being submitted.
On 3/2/2023 at 8:16 AM, Surveyor met with Director of Nursing-B and Regional Nurse Consultant-G and shared the conversation with AA-D regarding the late reporting of the Facility Self Report. No further information was provided at that time.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accorda...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure residents received treatment and care in accordance with professional standards for 1 (R262) of 22 sampled residents.
* R262 had an order on admission to have a shower daily. The order was not transcribed and R262 only received a weekly shower while in the facility.
Findings include:
R262 was admitted to the facility on [DATE] status post a cerebral shunt replacement and had a surgical wound to her head.
On 3/1/23 R262's hospital discharge instruction dated 12/27/23 were reviewed and read: Post operative VP (Venticulooeritoneal) shunt instructions. Showering: please shower daily. Gentle cleaning and rinsing of the incision is ok.
On 3/1/23 R262's treatment and daily care records were reviewed. Showering daily was not included in the records. Shower weekly on Tuesday was on the care record and documented as completed while R262 was at the facility.
On 3/2/23 at 10:30 AM Regional Nurse Consultant-G was interviewed and indicated the facility was unaware of R262's daily instructions for showering but the facility would not have had staff to complete daily showering. Regional Nurse Consultant-G indicated the facility should have called R262's physician with any concerns with the hospital orders and they did not.
On 3/1/23 R262's medical record was reviewed and no adverse outcome related to not being showered daily was found\,
The above findings were shared with the Administrator and Director of Nurses at the daily exit meeting on 3/1/23 at 2:30 PM. Additional information was requested if available. None was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R463 was admitted to the facility on [DATE] and had diagnoses that included CVA (Cerebral Vascular Accident) with left sided...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R463 was admitted to the facility on [DATE] and had diagnoses that included CVA (Cerebral Vascular Accident) with left sided hemiparesis. R463 was discharged from the facility in December 2022.
R463's admission MDS (Minimum Data Set) Assessment documented R463 had a BIMS (Brief Interview for Mental Status) of 12 which indicated R463 was cognitively intact.
R463's fall care plan initiated on 11/29/2022 documented, Resident has the potential for falls, accidents and incidents related to CVA, history of falls, unaware of safety needs, left eye visual defect, 2nd toes of both feet amputated, and had interventions which included, Resident re-educated by staff RN to use call light for transfers and not to attempt to get up unassisted .given non-skid socks; Bed in low position with mat on floor; Mattress changed to a scoop mattress; and staff re-educated to use gait belt with transfers.
Surveyor reviewed fall documentation from 12/21/2022 which stated, CNA (certified nursing assistant) called writer into room, resident kneeled down to the floor during a transfer with the assist of the CNA. Resident was being transferred from the wheelchair to his bed at the time of the fall .CNA was educated to use a gait belt to help [resident's name] transfer .No injuries were obtained .Staff did not use a gait belt. Staff was re-educated that a gait belt should be used for safe transfers.
On 03/01/23 at 10:15 AM, Surveyor interviewed Unit Manager, LPN (Licensed Practical Nurse) J. LPN J informed Surveyor R463 was very impulsive and the facility implemented numerous fall interventions. Surveyor asked if staff should use a gait belt when transferring a resident who requires an assist of one. LPN J stated yes, staff should always use a gait belt.
On 03/02/23 at 9:39 AM, Surveyor interviewed DON (Director of Nursing) B and Corporate Nurse Consultant (CNC) G. Surveyor relayed the concern of R463 suffering a fall while being transferred by a CNA who was not using a gait belt. CNC G informed Surveyor the facility did education with the staff regarding using a gait belt for transfers. Surveyor asked to view the education and any other additional information the facility may have on the concern.
No additional information was provided.
Based on observation, record review, and interview, the facility did not ensure adequate supervision and assistive devised were used to prevent accidents for 3 (R61, R37, and R463) of 6 residents reviewed for falls.
R61 fell out of bed on 1/4/2023 while receiving cares with the assist of one Certified Nursing Assistant (CNA). The facility staff were not following F61's plan of care: R61 required the assist of two CNAs when receiving cares per the Care Plan.
R37 had three falls out of bed, 11/5/2022, 11/23/2022, and 12/15/2022, without having a body pillow in place. R37 was to have a body pillow in place per plan of care. Multiple observations were made during the survey of no body pillow in place when R37 was in bed.
R463 fell on [DATE] when being transferred with no gait belt in place. R463 was to have a gait belt used when transferring per plan of care.
Findings include:
The facility policy and procedure entitled Falls and Fall Risk, Managing from MED-PASS ©2001 revised on 3/2018 states: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.
1.) R61 was admitted to the facility on [DATE] with diagnoses of epilepsy, depression, bipolar disorder, anxiety, and obesity. R61's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R61 was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 00 and needed extensive assistance with bed mobility and cares.
R61's Potential for Falls Care Plan had the following interventions initiated on 12/28/2020: two-person assist with cares/repositioning
On 1/4/2023 at 8:22 PM in the progress notes, nursing charted R61 had a fall when a CNA was providing care. The nurse practitioner and Director of Nursing (DON) were updated.
On 1/4/2023 at 9:25 PM in the progress notes, Licensed Practical Nurse (LPN)-N charted a CNA was providing cares to R61 and while repositioning R61, the left lower extremity slid off the bed and R61 started sliding off the air mattress. The CNA attempted to assist R61 into bed but was unable and assisted R61 to the floor. The nurse practitioner ordered an x-ray for left knee pain and swelling.
The facility incident report stated the fall occurred on 1/4/2023 at 7:30 PM. The immediate intervention was to have 2 CNAs provide cares due to R61's size and weight. The interdisciplinary team met on 1/5/2023 and determined the CNA was not following the care card to have two staff assist with cares and repositioning. The immediate intervention was to re-educate staff for not following the care card and requesting an alternating pressure mattress with bolsters when available. A self-report was filed with the State Agency.
R61's Potential for Falls Care Plan was revised on 1/4/2023 with the following intervention: re-education to staff for not following the care card - CNA is not returning to the facility; will request alternating pressure mattress with bolsters when available. On 1/10/2023 the intervention was revised to read: x-rays ordered to left knee and lower back; negative for fracture.
In an interview on 3/1/2023 at 9:13 AM, Surveyor reviewed with DON-B and Regional Nurse Consultant-G R61's fall on 1/4/2023. Surveyor shared with DON-B and Regional Nurse Consultant-G the incident investigation stated there was a self-report for the incident. Surveyor asked to review the self-report. Regional Nurse Consultant-G stated Nursing Home Administrator (NHA)-A was looking for the report.
On 3/10/2023 at 1:23 PM, Surveyor received the facility self-report of R61's fall on 1/4/2023. The self-report stated who the CNA was that was involved in R61's fall and the report named the nurse that assessed R61 prior to moving R61 back into bed with a Hoyer lift. Surveyor noted the nurse that did the assessment was an LPN, not a Registered Nurse (RN).
In an interview on 3/1/2023 at 3:01 PM, LPN-N stated R61 fell out of bed when a CNA was repositioning R61. LPN-N stated R61 was not centered in the bed and the foot slipped off the air mattress. LPN-N stated the CNA tried to keep R61 from falling, but R61 was too big to stop. Surveyor asked LPN-N who assessed R61 prior to moving R61. LPN-N stated the RN in the building at the time came over to the unit and assessed R61. Surveyor noted the RN made a note in R61's medical record of the fall at that time. LPN-N stated R61 was supposed to be a two-person assist and the CNA was not following the care plan.
In an interview on 3/2/2023 at 8:16 AM, Surveyor shared with DON-B and Regional Nurse Consultant-G the concern R61 fell out of bed on 1/4/2023 due to the CNA not following the care plan and having someone assist the CNA with R61's cares and repositioning. Regional Nurse Consultant-G stated some of the staff were educated on following care plans, but not all the staff were educated. No further information was provided at that time.
2.) R37 was admitted to the facility on [DATE] and has diagnoses that include diffuse traumatic brain injury, Large B-cell lymphoma, malignant neoplasm of the brain treated with radiation, retroperitoneal mass, history (HX) if intracranial mass, and HX chemotherapy.
R37's quarterly Minimum Data Set (MDS) dated [DATE] indicated R37 had severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 00 and coded R37 needing extensive assist with bed mobility, transferring, and dressing and total assist with toilet use, hygiene, and bathing, R37 self-propels in a wheelchair and requires an EZ stand transfer with assist X2 for transferring. R37 in incontinent of bowel and bladder and wore a brief.
R37's Risk for falls Care Plan was initiated on 2/23/2018 with the following interventions:
- Follow therapy recommendations for transfers/ mobility.
- Anticipate and meet residents needs. Encourage resident to call for assistance.
- Body pillows when resident in bed- initiated 5/30/2018
- Ensure resident to stay in high traffic areas- initiated 8/15/2018
- Assist to toilet resident upon rising, before and after meals, at bedtime and with rounds during the night- initiated 3/1/2019
- Not to leave resident in bed fully dressed in the morning. Get the resident up when he wakes in the morning and bring him to common area- initiated 12/27/2019
- have all necessary persons/ equipment ready before bringing resident to his room for cares- initiated 3/9/2020
- Staff not to bring resident to the dining room until staff are present- initiated 4/10/2022
- Taken off the night shift get up list- initiated on 7/23/2022
- bed in lowest position, mat on floor, bowel and bladder patterning- initiated 7/31/2019
- Resident to have footrests up when in wheelchair- initiated 9/9/2019.
- Ensure foot pedals are in place before pushing wheelchair- initiated 9/9/2019
- Staff to ensure lid is placed on water cup- initiated 9/30/2021
- Lid to be placed on coffee cup- initiated on 8/9/2022
- Dycem under wheelchair cushion- initiated 12/8/2022
- Immediate intervention: placed Dycem to top of wheelchair cushion and offer resident to lay down after meals- initiated 12/10/2022
R37's care card has the following interventions listed for R37's needs:
- Body pillows when in bed.
- Bed in low position.
- Dycem to top of wheelchair cushion and under the cushion.
- Make sure all equipment is in the room prior to starting.
- Don't bring the resident to dining room until staff are present.
- Encourage to stay in high traffic areas.
- Air pressure mattress (settings marked on box).
- Make sure floor mat in down. Resident to lay down after meals.
- Encourage to be up for meals only.
On 11/5/2022 at 9:00 PM in the progress notes, nursing charted nursing was called to R37's room by R37's roommate. Found R37 lying on R37's left side on floor mat. R37's bed was in low position, call light was within reach but not on. R37 was in gown in bed and barefoot. R37 was not incontinent at time of incident.
On 11/6/2022 the Interdisciplinary Team (IDT) reviewed R37's fall from 11/5/2022 and documented the root cause of R37's fall was related to R37 rolling out off the mattress. R37 is care planned to have body pillow when in bed.
R37's Risk for Falls Care Plan was revised on 11/5/2022 with the following intervention: Staff educated to follow care card for safety interventions. Let the nurse know if something is unavailable or not in place.
On 11/23/2022 at 8:30 PM in the progress notes, nursing charted R37 was found on R37's floor mat. R37 had no injuries, bruising, cuts, or abrasions. R37 denies pain or hitting R37's head. Neurological checks within normal ranges. Vital signs stable (110/76, 96, 16, Temperature 98.1, pulse oximetry 95% at room air). R37 did not have incontinence and had gripper socks on R37's feet.
On 11/24/2022 the IDT reviewed R37's fall from 11/23/2022 and documented the root cause of R37's fall was to be determined from R37's body pillow not being in place.
R37's Risk for Falls Care Plan was revised on 11/23/2022 with the following intervention: Staff was re-educated regarding following the care cards to have body pillow in place.
On 12/15/2022 at 6:15 PM in the progress notes, nursing charted R37 experienced an un-witnessed fall without injury. R37 was in bed which was in the lowest position. R37 was found lying on the fall mat beside R37's bed. R37 was tangled in R37's bed covers and laying beside the bed. R37's bedside table was by R37's bed. R37 had no noted injuries at time of fall. Vital signs taken (127/84, 76, 18, temperature 97.7, pulse oximetry 97% on room air. R37 denied pain. R37's neurological checks within normal ranges. R37 unable to tell nursing what R37 was attempting to do. R37 was placed in bed minutes before R37 was found lying on floor mat. R37 did not use call light that was next to R37 and was not incontinent at time of fall. Nursing charted that R37 presented with anxiety prior to fall when R37 was asked to take a bath.
On 12/16/2022 the IDT reviewed R37's fall from 12/15/2022 and documented that R37 was supposed to have a body pillow when in bed. There was not a body pillow in R37's room.
R37's Risk for Falls Care Plan was revised on 11/15/2022 with the following interventions: Staff educated to place body pillow when resident in bed.
On 3/1/2023 at 12:42 PM Surveyor observed a floor mat on the floor next to R37's bed. There was not a body pillow on R37's bed or in R37's bedroom that Surveyor was able to tell.
On 3/1/2023 at 3:07 PM Surveyor observed R37 lying in R37's bed. R37 was covered with sheets. R37 was positioned on the very edge of R37's mattress tilted on R37's left side. R37's floor mat was on the floor next to R37's bed and R37's bed was in lowest position. Surveyor did not observe a body pillow on R37's bed.
On 3/1/2023 at 3:10 PM Surveyor asked Certified Nursing Assistant (CNA)-R what interventions R37 should have in place when lying in bed. CNA-R stated that R37's bed needs to be low to the ground and R37's fall matt next to bed. CNA-R also stated that R37 should be positioned close to the wall. Surveyor asked CNA-R if R37 should have any body pillows placed in bed with R37 when lying down. CNA- R stated CNA-R was not aware of R37 needing a body pillow. Surveyor showed CNA-R how R37 was lying in bed. CNA-R assisted R37 move away from the edge of the mattress. CNA-R did not put a body pillow on R37's bed per R37's care plan and care card interventions state.
On 3/2/2023 at 7:52 AM Surveyor observed R37's bed was made and fall mat on the floor. There was not a body pillow in R37's bed or in R37's room.
On 3/2/2023 at 7:59 AM Surveyor asked CNA-S what interventions R37 had in place for when R37 laid down in bed. CNA-S stated R37 needed to have R37's bed low to the ground with a fall matt on the floor. Surveyor asked CNA-S if R37 needed a body pillow to prevent R37 from falling out of bed. CNA-S stated CNA-S was not sure, CNA-S did not have a chance to look over R37 yet.
On 3/2/2023 at 8/19/2023 Surveyor informed the Director of Nursing (DON)-B and the Regional Nurse Consultant (RNC)-G of Surveyors concern of R37 not having interventions in place for 3 of R37's falls and observations of body pillow not being in room and CNA's not know of R37's intervention of needing a body pillow when R37 was in bed.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 2 (R17 and R262) of 7 residents reviewed for weight loss had t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 2 (R17 and R262) of 7 residents reviewed for weight loss had their nutritional care needs recognized, evaluated, and addressed to provide adequate parameters of nutritional status.
* A review of R17's admission weight on 8/10/22 was documented at 198 pounds in the medical record and the admission nutritional assessment documented an admission weight of 220 pounds. The Dietician disputed the admission weight value with no further follow up or reweigh. R17's documented weight on 8/30/22 was 177.6 pounds which was a 10.30% weight loss from 198 pounds. The facility did not implement an intervention until 10/25/22.
* R262 was not assessed for fluid needs on admission. R262 was not screened for beverage preferences and there was no care plan for dehydration.
Findings include:
The facility policy, entitled Nutrition and Hydration Guideline, dated 10/3/22, states: Purpose: The intent of this requirement is that the resident maintains, to the extent possible, acceptable parameters for nutritional and hydration status through:
Providing nutritional and hydration care and services consistent with the nutritional comprehensive assessment
Recognizing, evaluating, and addressing the needs of every resident, including but limited to, those at risk or already impaired nutrition and hydration
Providing a therapeutic diet that considers the clinical condition, and preferences, when there is a nutritional indication.
Assessment
A comprehensive nutritional assessment should be completed on any resident identified as being at risk for unplanned weight loss/gain and/or compromised nutritional status. The interdisciplinary team a comprehensive nutritional assessment, the interdisciplinary team clarifies: Nutritional issues, needs and goals. The nutritional assessment may utilize existing information from sources:
RAI (Resident Assessment Instrument)
Assessments from other disciplines
The existing medical record
Observations
Direct care staff interviews
Resident and family interviews
The assessment should identify those factors that place the resident at risk for inadequate nutrition/hydration. The nutritional assessment may include the following information:
Weight
Weight can be a useful indicator of nutritional status, when evaluated within the context of the individual's personal history and overall condition. Weight goals should be based on a resident's usual body weight or desired body weight.
Upon admission:
Obtain a weight
Consider a weight for the first 3 days
Weigh weekly x 4 weeks
Monthly and as directed by the physician
As needed i.e.: diuretic changes, observed edema, significant changes in condition, food intake has declined and persisted (e.g., for more than a week), or there is other evidence of altered nutritional status or fluid and electrolyte imbalance
Suggested Parameters for Evaluating Unplanned or Undesired Weight Loss
Interval
Significant Loss
Severe Loss
1 month
5%
>5%
3 months
7.5%
>7.5%
6 months
10%
>10%
Food and fluid intake
The nutritional assessment includes an estimate of calorie, nutrient and fluid needs, and whether intake is adequate to meet those needs. It also includes information such as the route (oral, enteral, or parenteral) of intake, any special food formulation, meal, and snack patterns (including the time of supplement or medication consumption in relation to the meals), dislikes, and preferences (including ethnic foods and form of foods such as finger foods); meal/snack patterns, and preferred portion sizes. While there is no reliable calculation to determine an individual's fluid needs, an assessment should consider those characteristics pertinent to the resident, such as age, medical diagnoses, activity level, etc.
Care Planning
Information gathered from the nutritional assessment and current dietary standards of practice are used to develop an individualized care plan to address the resident's specific nutritional concerns and preferences.
The care plan, to the extent possible should:
Identify causes of impaired nutritional status
Reflect the personal goals and preferences
Identify resident-specific interventions and a time frame and parameters for monitoring
The care plan should be:
Updated as needed, such as when the resident's condition changes, goals are met, interventions are determined to be ineffective, or as new causes of nutrition-related problems are identified
Include the resident, resident representative
Physician as needed
Interventions
Interventions related to a resident's nutritional status must be individualized to address the specific needs of the resident. Examples of care plan development considerations can include, but are not limited to:
Diet Liberalization
Talk with the resident, their family and representative (whenever possible) and provide information pertaining to the risks and benefits of a liberalized diet
Work with the physician and other nursing home professionals (dietary manager, nurses, speech therapists, etc.), using the care planning process, to determine the best plan for the resident; and
Accommodate needs, preferences, and goals
Weight-Related Interventions
For at risk residents, the care plan should include nutritional interventions to address underlying risks and causes of unplanned weight loss or unplanned weight gain, based on the comprehensive or any subsequent nutritional assessment. The development of these interventions should involve the resident and/or the resident representative to ensure the resident's needs, preferences and goals are accommodated.
Food Intake
Improving intake with wholesome foods is preferable to adding nutritional supplements. However, if the resident is not able to eat recommended portions at meal times, to consume between-meal snacks/nourishments, or if he/she prefers the nutritional supplement, supplements may be tried to increase calorie and nutrient intake.
Examples of other interventions to improve food intake include:
Fortification of foods (e.g., adding protein, fat, and/or carbohydrate to foods such as hot cereal, mashed potatoes, casseroles, and desserts)
Offering smaller, more frequent meals
Providing between-meal snacks or nourishments
Increasing the portion sizes of a resident's favorite foods and meals
Providing nutritional supplements
1.) R17 was admitted to the facility on [DATE]. R17's diagnoses include Parkinson's disease, type 2 diabetes mellitus without complications, polyneuropathy, vascular dementia, muscle weakness and depression.
A review of the admission MDS (Minimum Data Set), dated 8/17/22 documents a BIMS (Brief Interview for Mental Status) score of 3 indicating R17 is severely cognitively impaired. R17 needs extensive assistance with bed mobility and personal hygiene and total dependence for transfers and toileting. R17 eats independently and requires set up help only. R17's height is 72 inches and weight is documented at 198 pounds. Section M of the MDS also documents that R17 is at risk for the development of pressure injuries.
A review of the Quarterly MDS, dated [DATE] documents R17's height as 72 inches and weight 175 pounds. It also documents that R17 has had a weight loss of 5% or more in the last month or 10% or more in the last 6 months and that R17 is not on a prescribed weight loss regimen. Section M of the Quarterly MDS also documents that R17 has 1 stage 3 pressure injury.
Surveyor reviewed R17's Individual Care Plan which documents that R17 has increased nutrient needs (protein/calories) due to skin integrity AEB (as evidenced by) need for nutritional interventions and regular nutritional intake monitoring, date initiated 8/12/22 with the following interventions: weigh resident per facility protocol/MD order and monitor weights, record and monitor nutritional intake daily, and provide diet as ordered date initiated 8/12/22. Interventions initiated on 9/15/22 include provide nutritional supplements as ordered and monitor intake: Mighty Shake TID (three times daily) (for weight loss/wound healing) and ProSource 30 ml TID (for wound healing) and provide MVI (multivitamin injection) as ordered. Intervention initiated 10/6/22 include encourage resident to be up for meals.
Surveyor reviewed R17's Physician Orders which documents the following: Mighty Shake two times a day for weight loss/wound healing, date initiated 10/25/22 and discontinued 11/15/22. Mighty Shake three times a day for weight loss/wound healing, date initiated 11/16/22. Pressure injury risk: weekly weights for 4 weeks every evening shift, every Wednesday for 4 weeks, date initiated 11/8/22 and discontinued 12/6/22. Weekly weights for 3 weeks every day shift every Wednesday until 8/31/22, date initiated 8/17/22 and discontinued 8/31/22. ProSource Liquid (Nutritional Supplements) Give 30 ml by mouth two times a day for wound healing, date initiated 8/23/22 and discontinued 10/25/22. ProSource Liquid (Nutritional Supplements) Give 30 ml by mouth three times a day for wound healing, date initiated 10/25/22.
Surveyor reviewed R17's weights documented in the Weights and Vitals Summary which were documents as the following:
08/10/22 198 lbs.
08/16/22 198 lbs.
08/30/22 177.6 lbs.
09/20/22 178.2 lbs.
10/18/22 179.2 lbs.
11/01/22 172.8 lbs.
11/08/22 171.0 lbs.
11/15/22 159.6 lbs.
11/22/22 158.2 lbs.
11/29/22 163 lbs.
12/06/22 158.2 lbs.
12/13/22 159 lbs.
12/20/22 158.2 lbs.
12/27/22 175.6 lbs.
1/10/23 175.2 lbs.
01/21/23 179.6 lbs.
01/31/23 178 lbs.
02/02/23 171.2 lbs.
02/07/23 174 lbs.
02/14/23 174 lbs.
02/21/23 175 lbs.
03/01/23 176 lbs.
Surveyor notes that on 08/16/2022, the resident weighed 198 lbs. On 08/30/2022, the resident weighed 177.6 pounds which is a 10.30 % loss.
Surveyor notes that on 11/08/2022, the resident weighed 171 lbs. On 11/15/2022, the resident weighed 159.6 pounds which is a 6.67 % loss in one week.
Surveyor notes the admission weight was obtained on 8/10/22 of 198 pounds. A second weight was documented on 8/16/22 of 198 pounds. A third weight was documented on 8/30/22 of 177.6 pounds. The next weight was documented on 9/20/22 of 178.2 pounds. Per facility policy and procedure, the facility should have weighed R17 again in the weeks between 8/16/22 and 8/30/22 and the week after 8/30/22. The policy states to weigh weekly times 4 weeks post admission. There is no documentation that R17 refused to have weights obtained.
Surveyor reviewed R17's Nutritional Assessment with an assessment date of 8/12/22. Documented was: Most recent weight 220.4 pounds, status: overweight. Nutritional Assessment/Recommendations documents: Resident receiving HCC diet (diet rich in polyunsaturated fatty acids .) due to diagnosis of diabetes. Tolerating well and denies and c/s difficulties, GI upset. He reports good appetite, denying any recent changes. Encourage fluids throughout day - may be at risk for dehydration due to sepsis, dementia diagnosis. No food preferences to obtain at this time. Current body weight 220.4 pounds, resident report usual body weight 210 pounds. Noted weight history from last admission 2017-2018 was in 250s. Goal is weight maintenance at current body weight AEB no significant changes. Goal: resident to consume at least 75% of meals with no difficulties. Plan/Recommendations: diet per MD order, monitor food and fluid intake, weights per facility protocol.
Surveyor notes this Nutritional Assessment is using 220.4 lbs. as an admission weight which is not the admission weight of 198 lbs. which is used in the MDS and the Weights and Vital Summary in the medical record. There is a noted discrepancy of what the accurate admission weight is for R17 and no recommendation for a reweigh.
Surveyor reviewed a Quarterly Nutritional Assessment with a date of 11/14/22 which documents most recent weight as 171 pounds. Significant weight changes is marked yes. Nutritional Assessment/Recommendations documents: current weight is 171 pounds, triggering significant weight loss of 13.6% x 90 days from 8/16/22 weight of 198 pounds. Question accuracy of 8/16 weight, but weight in past has been much higher. Resident previously reported usual body weight was 210 pounds. Intake is 75-100%, take Mighty Shakes BID and 30ml ProSource TID for weight and wound healing. No new recommendations at this time. Continue to monitor weights. Care plan reviewed. Goals: Resident to consume at least 75% of meals with no difficulties, no significant weight changes through next assessment. Plan/Recommendations: Continue plan of care, monitor weights, supplement changes PRN.
Surveyor notes there are no additional Nutritional Assessments in the medical record.
Documented in R17's Progress Note for Nutrition on 9/15/22 at 13:17 was, Follow-up on weights/skin. Weight 178# (pounds) (8/30) and 198# (8/16). Question accuracy of weights; will request reweigh/current monthly weight to further eval. BMI 24.1-WNL (within normal limits). Per weekly wound assessment, unstageable sacrum. Diet downgraded per ST (Speech) to mech soft with NTL (nectar thick liquids). Good appetite, PO (by mouth) intakes 76-100%. Assisted at meals. Accepts fluids. ProSource 30ml BID (twice daily) in place to aid in skin healing (200kcal, 20g pro). BS (blood sugars) 100s; controlled. Meds reviewed. Increased nutrition needs due to wound healing. Rec 1. Increase ProSource to 30ml TID 2. Add Mighty shake 4oz BID 3. MVI QD 4. Reweigh. Continue to monitor.
Surveyor cannot locate a physician order for Mighty Shake 4 oz two times per day after this recommendation was documented. A physician order for Mighty Shakes two times per day was started on 10/25/22. This is over 30 days from when it was originally recommended. Surveyor cannot locate a physician order for increase ProSource to 30ml three times per day. A physician order for ProSource 30 ml three times per day was started on 10/25/22. This is over 30 days from when it was originally recommended.
Documented in R17's Progress Note for Nutrition on 10/21/22 at 9:56 AM was, Follow-up on weights/skin. Wt 179# (10/18), 178# (9/20), 198# (8/16). Anticipate error in admit weight but noted resident weight much higher in the past. Weight stabilizing in 170s now x 2 months. Continue to monitor weights. BMI 24.3-WNL. Mech soft diet with NTL. Tolerating diet. PO intakes 50-100%. Feeds self after set-up. Accepts fluids. BS 90-100s. Per weekly wound assessment 10/18, Unstageable - sacrum and trauma - right great toe. ProSource 30ml BID (200kcal, 20g pro) in place to aid in skin healing. Inc needs due to skin healing and weight loss. Will rec again to help meet nutrition needs 1. Increase ProSource to 30ml TID (300kcal, 30g pro) 2. Add Mighty shake 4oz BID 3. Add MVI QD 4. Encourage intake. Monitor.
Surveyor notes the request again by the Dietician to increase ProSource 30ml to three times per day and add Mighty Shake 4oz two times per day. Both these recommendations were added to physician orders on 10/25/22.
On 3/01/23, at 10:50 AM, Surveyor interviewed Dietician-W regarding R17's admission weight discrepancy. Dietician-W stated that admission weight of 198 came from hospital documentation. Dietician-W stated that he was aware of the 20 pound weight loss in the first month, however he didn't think that there really was an actual 20 pound weight loss and questioned the admission weight. Dietician-W stated he did not remember requesting a reweigh of the resident, but that would have been practice. Dietician-W stated since he questioned the weight loss, he and did not recommend any interventions at that time. He further explained that he added Mighty Shakes and ProSource in October and then increase them in November. Surveyor asked why there was a delay in getting the Mighty Shakes started in September when he originally recommended them, and Dietician-W stated it must have been missed. Dietician-W informed Surveyor that R17 was eating well and was not refusing meals. He further stated that R17's BMI was within normal range and therefore did not see a reason to recommend more frequent weights either.
On 3/01/23, at 3:11 PM, at the end of day meeting with Nursing Home Administrator-A (NHA) and Director of Nursing-B (DON), Surveyor requested the facility policy and procedures on nutrition and weight loss.
On 3/02/23, at 8:39 AM, Surveyor interviewed DON-B with NHA-A present in the room, about expectations if a resident has a significant weight loss. DON-B informed Surveyor that if a significant weight loss is found they would document it, call family and medical doctor (MD), notify the dietician, see what recommendations the dietician or MD have and get a reweigh. Surveyor asked DON-B if she was aware of a significant weight loss for R17 within his first month of admission. DON-B stated she was not sure and would have to look into it. Surveyor asked DON-B to clarify what the statement Weigh Resident per facility protocol/MD order and monitor weights in a care plan. DON-B stated that if the doctor orders weekly weights versus us just getting a resident monthly weight. Surveyor asked DON-B to explain the process after a weight loss is documented. DON-B explained that the dietician sends over recommendations in an email after nutritional assessments are completed. If any recommendations are requested, then herself or a unit manager would put the order in. DON-B did not remember adding any interventions in after the weight loss for R17 in August or September. Surveyor explained concerns that the nutrition assessments on 8/12/22 and 11/14/22 both reference that the dietician did not believe the admission weight and therefore did not believe a significant weight loss within the first month. DON-B stated that if the dietician didn't believe the admission weight, then he should have done a reweigh. Surveyor also explained the concern that a significant weight loss was documented on 8/30/22 for R17 and a recommendation was requested on 9/15/22 to add Mighty Shakes two times per day however this order was not started until 10/26/22. DON-B stated that she would look more into this.
On 3/2/23, at 1:52 PM, Surveyor asked DON-B if they had found any documentation of a Mighty Shake being started in September, and she stated no.
No additional information was provided at this time.
2.) R262 was admitted to the facility on [DATE] with diagnosis that included Clostridium difficile (C-Diff), Urinary tract infection (UTI). R262 was also admitted to the facility with an order for nectar thickened liquids.
On 2/28/23 R262's Initial Minimum Data Set (MDS) dated [DATE] was reviewed and indicated R262 had a Brief interview for Mental Status score of 13 (no memory impairment).
On 3/1/23 R262's physicians orders were reviewed and included: Provide a large cup of water several times a day with a start date of 1/15/23 and continued to discharge on [DATE]. Another order read: Push fluids. Resident very dehydrated. She does not like water with a start date of 1/20/23 and continued to discharge on [DATE]. R262 required Intravenous hydration starting 1/20/23 and continued until she was discharged to the hospital on 1/22/23.
On 3/1/23 at 10:50 AM Dietician-W was interviewed and indicated he did not calculate R262's estimated daily fluid needs, protein needs or calorie needs on her initial nutritional assessment. Dietician-W indicated this was not done until 1/19/23 when the regional dietician completed this, Dietician-W indicated he would have considered R262 at high risk of dehydration due to her C-Diff diagnosis, need for thickened liquids and history of dehydration. Dietician-W indicated he never asked R262 of her fluid preferences and did not know she disliked water.
On 3/1/23 R262's fluid intake records were reviewed and indicated she was drinking at least 1,000 milliliters (ml) a day until 1/16/23 when she only consumed 640 (ml). She was reassessed on 1/19/23 and her estimated fluid needs calculated at 1,335 ml a day. Over the next 3 days she was carefully monitored and assessed to be dehydrated and IV hydration was started on 1/20/23 until her discharge to the hospital on 1/22/23.
On 3/1/23 the facility's policy titled Hydration dated 10/22 which read: The dietician will assess hydration as part of the comprehensive nutritional assessment within 72 hours of admission, annually, and upon significant change in condition. The dietary manager or designee shall obtain the resident's beverage preferences upon admission.
The above findings were shared with Administrator-A and Director of Nurses-B at the daily exit meeting on 3/1/23 at 2:30 PM. Additional information was requested if available. None was provided.
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 interview and record review, the facility did not ensure that 1 (R85) of 5 residents reviewed receiving psychotropic me...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 1 (R85) of 5 residents reviewed receiving psychotropic medication were free from unnecessary drugs.
*R85 had orders for a psychotropic medications and did not have specific documented targeted behavior monitoring and/or specific reasons for use of the medication in their medical records. R85 did not have specific targeted behaviors for administration of psychotropic medication addressed in her plan of care.
Findings include:
On 3/1/23 the facility's policy titled Psychotropic Management Guidelines dated 08/22 was reviewed and read: Upon admission the Licensed Nurse will implement the following: Physicians order for the medication including an approved diagnosis or Target Behavior. The Interdisciplinary Team will individualize the resident care plan and address the diagnosis and specific behavior for the drug.
R85 was admitted on [DATE] with a diagnosis that included Dementia and Depression
R85's Initial MDS (Minimum Data Set) dated 1/16/23 documents that R85 had a Brief interview for Mental Status Score of 0 (severe impairment) and no behaviors exhibited for the period of the assessment.
On 3/1/23 R85's current physician order's were reviewed and read: Quetiapine Fumarate (Seroquel) 25 mg (milligrams); Give by mouth at bedtime for depression. The start date for the medication was 1/9/23.
On 3/1/23 R85's care plan for use of antipsychotic medication dated 1/9/23 was reviewed and read: R85 uses psychotropic medication related to behavior management. R85's behavior that needs managing is not specified.
On 3/1/23 R85's behavior monitoring documentation was reviewed and indicated monitor for the following: itching, picking at skin, restlessness, hitting, increase in complaints, biting spitting, cussing, racial slurs, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusing care. This had a start date of 1/9/23 and nowhere in R85's medical record could these behaviors be found. Nowhere in the behavior monitoring is depressive like symptoms for which the medication was diagnosed for on admission.
On 3/2/23 at 10:30 AM Regional Nurse Consultant-G was interviewed and asked if R85 had any behavior monitoring or care plan for specific behaviors related to R85's need for Seroquel. Regional Nurse Consultant-G indicated that R85 did not have specific targeted behaviors identified for R85's behavior monitoring or care plan but did have a list of behaviors not specific to her to monitor for. Regional Nurse Consultant-G indicated the behavior monitoring listed in R85's behavior charting is what is put in as a default and not individualized as it should be.
The above findings were shared with the Administrator and Director of Nurses at the daily exit meeting on 3/1/23 at 2:30 PM.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility did not ensure that medical records contained documentation related to Influe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility did not ensure that medical records contained documentation related to Influenza and/or Pneumococcal immunizations for 3 (R20, R105, R85) of 5 residents reviewed for immunizations.
R20's medical record did not contain documentation indicating the facility offered or administered the Influenza or Pneumococcal vaccine.
R103's medical record did not contain documentation indicating the facility offered or administered the Pneumococcal vaccine.
R85's medical record did not contain documentation indicating the facility offered or administered the Influenza or Pneumococcal vaccine.
Findings include:
The facility policy, entitled Pneumococcal Vaccine, revised October 2019 states: All residents will be offered pneumococcal vaccines to aid in preventing pneumonia/ pneumococcal infections. Policy Interpretation and Implementation 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccination status will be conducted within five working days of the resident's admission in not conducted prior to admission. 4. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician- approved pneumococcal vaccination protocol. 6. For residents who receive the vaccines, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. 7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.
The facility policy, entitled Influenza Vaccine, revised October 2019 states: All residents and employees whoa have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Policy Interpretation and Implementation 1. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated, or the resident or employee has already been immunized. 2. Residents admitted between October 1st and March 31st shall be offered the vaccine within five working days of the . resident's admission to the facility. 5. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. 6. A resident's refusal of the vaccine shall be documented on the Informed Consent for Influenza vaccine and placed in the resident's medical record. 11. Administration of the influenza vaccine will be mad in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.
1.) R20 was admitted to the facility on [DATE]. R20's medical record did not contain documentation related to proof of vaccination administration or declination for the Pneumococcal or Influenza vaccines.
2.) R103 was admitted to the facility on [DATE]. R103's medical record did not contain documentation related to proof of vaccination administration or declination for the influenza vaccine.
3.) R85 was admitted to the facility on [DATE]. R85's medical record did not contain documentation related to proof of vaccination administration or declination for the pneumococcal or influenza vaccines.
On 3/2/2023 at 10:34 AM Surveyor informed the Nursing Home Administrator (NHA)-A, the Director of Nursing (DON)-B, the Regional Nurse Consultant (RNC)-G, and Licensed Practical Nurse Unit Manager (LPNUM)-G of Surveyors concerns regarding R20, R103, and R85 not having vaccinations documented. DON-B stated DON-B will investigate R20, R103, R85 and provided necessary documentation.
On 3/7/2022 at 4:36 PM Surveyor received an email from DON-B with the following information:
R20- Provided immunization record documenting R20 received Pneumococcal vaccines. There was no documentation showing R20 received the influenza vaccine.
R103- signed consent forms for the influenza vaccine. Signed consent form does not indicate if R103 received vaccine.
R85- Signed consent form documenting R85 received the COVID-19 vaccinations. There is no documentation showing R85 received the pneumococcal or influenza vaccine.
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, interviews, and observations, the facility did not implement their abuse policy in regards to screening 3 of 8 employees (Certified Nursing Assistant(CNA)-AA, Licensed Practica...
Read full inspector narrative →
Based on record review, interviews, and observations, the facility did not implement their abuse policy in regards to screening 3 of 8 employees (Certified Nursing Assistant(CNA)-AA, Licensed Practical Nurse (LPN)-J and CNA-BB.
* CNA-AA was hired on 6/14/22. Caregiver and criminal background checks were not completed until 3/1/23. The Background Information Disclosure (BID) was not completed by CNA-AA until 3/1/23.
* LPN-J was hired on 4/22/22. Caregiver and criminal background checks were not completed until 3/1/23.
* CNA-BB was hired on 7/27/16. Caregiver and criminal background checks were not completed every 4 years. The Background Information Disclosure (BID) was not found by the facility.
This had the potential to affect a pattern of residents residing at the facility.
Findings include:
On 3/1/23 the employee background information was reviewed for a sample of 8 employees the following employees did not have the required background check information available:
* CNA-AA was hired on 6/14/22. Caregiver and criminal background checks were not completed until 3/1/23. The Background Information Disclosure (BID) was not completed by CNA-AA until 3/1/23. Per the facility policy all 3 should have been completed before CNA-AA started working in the building.
* LPN-J was hired on 4/22/22. Caregiver and criminal background checks were not completed until 3/1/23. Per the facility policy all 3 should have been completed before CNA-AA started working in the building.
* CNA-BB was hired on 7/27/16. Caregiver and criminal background checks were not completed every 4 years. The last criminal and caregiver background check provided by the facility was 8/17/17. The Background Information Disclosure (BID) was not found by the facility and should have been completed before starting to work and every 4 years per the facility policy.
On 3/2/23 at 10:48 AM Administrator-A was interviewed and indicated criminal and caregiver background checks as well as BID forms should be completed before an employee starts working and at least every 4 years after that. Administrator-A indicated no further background checks for CNA-AA, LPN-J and CNA-BB could be found.
On 3/1/23 the facility policy titled Abuse dated 10/24/22 was reviewed and read: Prior to employment all required background checks and state required database checks will be completed.
The above findings were shared with the Administrator and Director of Nurses on 3/1/23 at 3:00 PM at the daily exit meeting. Additional information was requested if available. None was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure antibiotic protocols were used to prevent the unnecessary admi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure antibiotic protocols were used to prevent the unnecessary administration of antibiotics to 9 (R3, R34, R12, R11, R5, R84, R8, R38, and R13) of 19 residents reviewed for antibiotic usage.
*R8, R38, R3, R34, R12, R11, R19, R84, and R13 did not meet the criteria for the use of an antibiotic.
Findings include:
The facility policy and procedure entitled Antibiotic Stewardship from MED-PASS ©2001 revised on 12/2016 states: Antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program.
Policy Interpretation and Implementation:
1. The purpose of our Antibiotic Stewardship Program is to monitor the use of antibiotics in our residents.
2. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community.
8. When a nurse calls a physician/prescriber to communicate a suspected infection, he or she will have the following information available:
a. Signs and symptoms;
b. When symptoms were first observed;
c. Resident's hydration status;
d. Current medication list;
e. Allergy information;
f. Infection type;
g. Any orders for warfarin and results of last INR;
h. Last creatinine clearance or serum creatinine, if available; and
i. Time of the last antibiotic dose.
11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.
In an interview on 3/2/2023 at 10:34 AM, Director of Nursing (DON)-B stated the facility uses McGeer's criteria as their standard of practice for antibiotic stewardship. DON-B stated an Infection Report form is filled out by the nurses on the floor and then the unit manager or DON-B, acting as the Infection Preventionist, completes the form to make sure the resident is not getting an unnecessary antibiotic.
1. R3 had an Infection Report Form filled out on 12/2/2022. The form indicated R3 had increased urgency and frequency with urination with no other areas marked. The section asking if surveillance criteria was met was checked no. R3 was prescribed Bactrim DS twice daily for fourteen days. The form was completed by DON-B.
2. R34 had two Infection Report Forms filled out on 12/9/2022. The forms indicated R34 had new or changed lung examination and leukocytosis; no other symptoms were marked. The section asking if surveillance criteria was met was checked no. R34 was prescribed doxycycline 100 mg twice daily for ten days. The second form stated the Nurse Practitioner was educated.
3. R12 had an Infection Report Form filled out on 12/12/2022. The form indicated a chest x-ray demonstrated a new infiltrate and R12 had increased cough. No other criteria were indicated. The section asking if surveillance criteria was met was checked no. R12 was prescribed Levaquin 500 mg every other day for five days and Zithromax 250 mg daily times four days. The form was completed by DON-B.
4. R11 had an Infection Report Form filled out on 12/12/2022. The form indicated R11 had heat, redness, and tenderness or pain to the left lower leg. Only 3 symptoms were listed with criteria needing four symptoms. The section asking if surveillance criteria was met was checked no. R11 was prescribed Bactrim DS twice daily for seven days. The form was completed by DON-B.
5. R19 was sent to the hospital on [DATE] with an indwelling urinary catheter that was clogged due to blood clots. A urinalysis was done in the hospital and came back positive for an infection. R19 had an Infection Report Form filled out on 12/18/2022. The form indicated R19 had gross hematuria and bacteria in the urine. Information on symptoms was filled in for both with and without having a catheter. The lab report stated it was a clean catch sample, so the sample was not from a catheter. The form did not show R19 met the criteria needed for an antibiotic. The section asking if surveillance criteria was met was checked no. R19 was prescribed Cipro 500 mg twice daily for seven days. The lab results came back, and the organism was resistant to Cipro so the order was changed to Bactrim DS twice daily for seven days.
6. R84 had an Infection Report Form filled out on 12/19/2022. The form indicated R84 had difficulty urinating or pain with no other symptoms. The section asking if surveillance criteria was met was blank. R84 was prescribed Macrobid 100 mg twice daily for seven days.
7. R8 had an Infection Report Form filled out on 12/31/2022. The form indicated R8 had redness and swelling but did not specify the site of the inflammation. The form indicated four symptoms were needed to meet the criteria and only two symptoms were listed. The section asking if surveillance criteria was met was checked no. R8 was prescribed Doxycycline 100 mg twice daily for ten days. The form was completed by DON-B.
8. R38 had an Infection Report Form filled out on 2/1/2023. The form indicated R38 had difficulty urinating or pain, increased urgency, and frequency, but no lab results to show any bacteria was present. The section asking if surveillance criteria was met was blank. R38 was prescribed Rocephin 1 gram once, and then Macrobid 100 mg twice daily for five days. No signature was on the form.
9. R13 had an Infection Report Form filled out on 2/1/2023. The form indicated R13 had pus and serous drainage from the left heel and acute functional decline. The section asking if surveillance criteria was met was checked no. R13 was prescribed clindamycin 450 mg twice daily for four weeks. No signature was on the form.
On 3/2/2023 at 10:34 AM, Surveyor shared with DON-B the concern Infection Report forms were not filled out completely or the resident did not meet the criteria by having the number of symptoms to indicate the use of an antibiotic. Surveyor shared a large number of residents were reviewed that did not meet the McGeer's criteria for infection. DON-B stated other nurses were filling in for DON-B when DON-B was not available. DON-B stated the physician or Nurse Practitioner should have been notified the resident did not meet criteria and then should have documented the conversation. No further information was provided at that time.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility did not store food in accordance with professional standards for...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility did not store food in accordance with professional standards for food service safety. This has the potential to affect all 108 residents.
* Surveyor observed 18 unopened boxes on the floor of the freezer. Boxes were there for two days of the survey.
* Surveyor observed large amounts of ice buildup in the freezer. Ice buildup was scattered across the ceiling, down the walls and on boxes of food.
* Food brought in by residents and family members were stored in a refrigerator in the shared activity and dining room and food items were not discarded by the use by date of the food.
Findings include:
A facility policy, entitled Food Receiving and Storage, dated October 2017, specified: Foods shall be received and stored in a manner that complies with safe food handling practices.
1. Food Services, or other designated staff, will maintain clean food storage areas at all times.
6. Food in designated dry storage areas shall be kept off the floor .
12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements.
A facility policy, entitled Food Brought by Family/Visitors, dated October 2017, specified: Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. The policy also indicate: The nursing staff will discard perishable foods on or before the 'use by' date.
On 2/27/23, at 9:30 AM, during the initial tour of the kitchen, Surveyor observed 18 boxes on the floor of the freezer. Dietary Supervisor-L (DS) indicated that they just received a delivery that morning. Surveyor also observed large amounts of ice buildup hanging down over the entire ceiling of the freezer. Ice buildup was also observed down the walls, on a vertical pipe, as well as on boxes of food.
On 2/28/23, at 10:21 AM, Surveyor looked at a resident refrigerator that was in the shared activity and dining room. The outside refrigerator door was observed to have a sign posted that stated, All food must be named by owner and dated on date it was open, otherwise it will be thrown away. Absolutely no undated or unlabeled bedtime snacks. A second sign was observed on the door that stated, Refrigerator will be checked daily. Label food with date opened. Food will be trashed 3 days after label date or if not labeled.
Surveyor opened the refrigerator door and observed a Styrofoam box with takeout food inside and a resident name and a date of 2/21 on the cover. There is no use by date on the Styrofoam box. An open bag of triple cheddar cheese that was not sealed, labeled with a resident name, room number with no date on package when it was opened or use by date. An open container of [NAME] Ready Care thickened lemon flavored water with no date when opened and the container is more than half used.
On 2/28/23, at 10:30 AM, Activity Director-M (AD) assisted Surveyor in identifying items in the refrigerator. AD-M stated that the refrigerator contained food items for residents that reside in wing 6. AD-M informed Surveyor that she checks the refrigerator daily and checks temperatures. AD-M stated that staff and residents know that if food is not labeled and dated it can get tossed. AD-M stated that they keep food items for 5-7 days and then ask the resident if they can toss it. Surveyor asked about the Styrofoam box with a date of 2/21. AD-M stated that was the use by date and she would ask resident if they still wanted the item. Surveyor then picked up the [NAME] Ready Care thickened lemon flavored water. Surveyor and AD-M noted the container was open and half used. Surveyor asked AD-M when the carton was opened, and she stated she was not sure. Surveyor asked how long they would keep an opened container and AD-M stated until the expiration date printed on the container. Surveyor and AD-M read the text on the container that said, keep up to 7 days after opening. AD-M was unaware it should be discarded after 7 days.
On 2/28/23, at 10:57 AM, Surveyor and DS-L did a second walk through of the freezer. Surveyor observed 18 boxes on the floor in the freezer. DS-L confirmed that those were the same boxes from yesterday's delivery. DS-L stated she will get around to putting them away today. Surveyor asked DS-L about the ice buildup on the ceiling, walls and on the boxes in the freezer. DS-L stated she didn't know why it's like that. She stated that it's been like this for the past week and had not informed maintenance of the situation. DS-L stated she would contact maintenance after we were done.
On 2/28/23, at 1:47 PM, Surveyor interviewed DS-L. DS-L informed Surveyor that she is responsible to check deliveries and make sure all items are accounted for. She then rotates the supply and puts all items away. DS-L stated that it is not typical for boxes to be left on the floor in the freezer. DS-L stated that she just had so much in the freezer that she needed to rotate things around and it didn't get completed until this afternoon.
On 2/28/23, at 2:44 PM, at the end of day meeting with Nursing Home Administrator-A (NHA) and Director of Nursing-B (DON) Surveyor informed them of the above findings. Surveyor requested a policy and procedure for storage of food and storage of resident food from an outside source. NHA-A informed Surveyor that there was a power outage on 2/22/23 from 730-945 PM at the facility.
On 3/02/23, at 8:51 AM, Surveyor interviewed NHA-A regarding storage of resident food from an outside source. NHA-A explained when food is brought in, staff are required to put resident name and date opened/received. If put in refrigerator the food items must be used by 5 days later or staff talks to the resident and tells them why we must discard the items. NHA-A stated that AD-M is responsible to check the activity room refrigerator daily.
No additional information was provided at the time.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility did not ensure a facility-wide assessment was conducted to determine what resources were necessary to competently care for its residents during both ...
Read full inspector narrative →
Based on interview and record review, the facility did not ensure a facility-wide assessment was conducted to determine what resources were necessary to competently care for its residents during both day-to-day operations and emergencies. This had the potential to affect all 108 residents residing at the facility.
*The Facility Assessment Tool, dated 1/7/2023, did not identify the facility's need for the Infection Preventionist role or the designated hours per week necessary to perform their duties. An Infection Preventionist is responsible for managing the facility's Infection Prevention and Control Program.
*The Facility Assessment Tool, dated 1/7/2023, did not include a completed facility-based and community-based risk assessment, utilizing an all-hazards approach to create an emergency preparedness plan, including a water management plan, that met current standards of practice.
*Nursing Home Administrator (NHA)-A revised the Facility Assessment Tool during the survey in front of Surveyor without communication with the Medical Director, Director of Nursing (DON), or the Governing Body of the facility and provided the revised Facility Assessment to Surveyor without changing the dates from the previous Facility Assessment. If Surveyor had not witnessed NHA-A altering the Facility Assessment, the revised Facility Assessment would have been mis-represented by the dates it had been reviewed by the Medical Director, the DON, and the Governing Body and the information revised was unknown to the Medical Director, the DON, and the Governing Body.
Findings include:
Infection Preventionist
On 2/27/2023, Surveyor reviewed the Facility Assessment Tool dated 1/7/2023. The Facility Assessment Tool did not identify the need for the role of Infection Preventionist (IP) or identify the designated hours per week necessary for the IP to perform their duties.
Surveyor noted the Infection Preventionist was responsible for managing the facility's Infection Prevention and Control Program. Surveyor noted the survey team had concerns with antibiotic stewardship with residents not meeting criteria for antibiotic use. (Cross Reference F881)
In an interview on 3/2/2023, at 10:34 AM, Surveyor interviewed NHA-A, Director of Nursing (DON)-B, Licensed Practical Nurse Unit Manager (LPN UM)-J, and Regional Nurse Consultant-G regarding the role of the Infection Preventionist. DON-B stated LPN UM-J is currently being trained to be the Infection Preventionist so DON-B can give up doing that role in addition to being the DON full time. Surveyor shared with NHA-A, DON-B, LPN UM-J and Regional Nurse Consultant-G that the Facility Assessment Tool did not have an Infection Preventionist position listed or the staffing plan for the Infection Preventionist to meet the needs of the residents.
Emergency Preparedness/Water Management Plan
The Facility Assessment Tool documented the facility would complete a facility-based and community-based risk assessment, using an all-hazards approach (an integrated approach focusing on capacities and capabilities critical to preparedness for the full spectrum of emergencies and natural disasters.) The [name of facility] had developed a complete emergency preparedness plan that is maintained in its own policy and procedure manual that is used to train staff and is updated with the facility assessment.
In an interview on 3/2/2023 at 10:34 AM, Surveyor asked NHA-A, DON-B, LPN UM-J, and Regional Nurse Consultant-G about their Water Management Plan dated 3/1/2023, dated two days after the start of the survey. Surveyor reviewed the Water Management Plan, and it included a general overview and descriptions of control measures but did not include any diagram specific to the facility. Surveyor requested from NHA-A any diagrams the facility had related to their Water Management Plan. NHA-A stated a third party had come out and had made diagrams of the water system and NHA-A would reach out to them to get the diagrams. (Cross Reference F880.) NHA-A provided a summary log of Legionella Test Results dated 2/15/2023 that tested six areas.
On 3/2/2023 at 12:57 PM, NHA-A provided a Potable Flow Diagram and a Utility Flow Diagram. NHA-A stated the third party would be coming back the following week to continue with their assessment of the water to determine more controls and to further complete the water management diagram.
Facility Assessment Tool Revision (during survey)
On 3/2/2023 at 10:34 AM, Surveyor shared with NHA-A, DON-B, LPN UM-J, and Regional Nurse Consultant-G the concern of the Infection Preventionist not being listed on the Facility Assessment Tool. As Surveyor was going over the concerns of the Facility Assessment regarding the Infection Preventionist, NHA-A was on the computer changing information on the Facility Assessment Tool to reflect the needs of the facility. NHA-A stated NHA-A had been revising the Facility Assessment tool since the survey started on 2/27/2023. NHA-A then provided to Surveyor the revised Facility Assessment Tool.
Surveyor reviewed the Facility Assessment Tool provided on 3/2/2023 and compared it with the Facility Assessment Tool that had been provided on 2/27/2023 at the start of the survey. The persons (names and titles) involved in completing the assessment, the dates of assessment or updates, and the dates of assessment reviewed with QAA/QAPI committee were the same for both assessments.
-The number/average or range of residents listed on the 2/27/2023 assessment listed 24 residents with behavioral symptoms and cognitive performance and 11 with reduced physical function. On the 3/2/2023 assessment, 79 residents had behavioral symptoms and cognitive performance and 93 with reduced physical function.
-For respiratory treatments, the 2/27/2023 assessment listed zero (0) with ventilator or respirator needs. On the 3/2/2023 assessment, 12 residents were listed as needing a ventilator or respirator.
-For other treatments, the 2/27/2023 assessment listed 2 residents for IV (intravenous) medications, injections was blank, dialysis was 4, ostomy care was 1, hospice was 4, and isolation or quarantine was zero. On the 3/2/2023 assessment, 3 residents for IV medications, 18 for injections, dialysis was 3, ostomy care was 3, hospice was 6, and isolation or quarantine was 3.
-For assistive device used to ambulate, the 2/27/2023 assessment listed 10 residents. On the 3/2/2023 assessment, 60 residents were listed.
-The 2/27/2023 assessment did not list an Infection Preventionist in the overall staff or on the general staffing list. On the 3/2/2023 assessment, the Infection Preventionist was listed in each area.
The revised Facility Assessment Tool provided on 3/2/2023 did not have that date listed anywhere on the tool and the revisions were not reviewed by the Medical Director, the DON, or the Governing Body. The tool had not been brought to QAPI for review or approval.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
2.) R29 is a long-term resident at the facility with diagnosis including, unspecified severe protein calorie malnutrition, chronic kidney disease stage 4, and Chronic Obstructive Pulmonary Disease.
R2...
Read full inspector narrative →
2.) R29 is a long-term resident at the facility with diagnosis including, unspecified severe protein calorie malnutrition, chronic kidney disease stage 4, and Chronic Obstructive Pulmonary Disease.
R29's quarterly MDS (Minimum Data Set) Assessment documents R29 has a BIMS (Brief Interview for Mental Status) of 14, indicating R29 is cognitively intact; R29 is at risk for pressure injuries and has one stage three pressure injury.
Surveyor reviewed R29's medical record and noted the following active physician's order:
Left lateral heel: Cleanse with 1/2 strength Dakin's solution, protect periwound [sic] with skin prep, apply hydrofera [sic] blue or dermablue [sic] (cut to size) to wound bed. Cover with bordered gauze, cover with ABD (Abdominal pad), secure dressing with kerlix. Change daily and PRN (As Needed).
On 03/01/23 at 10:33 AM, Surveyor observed LPN (Licensed Practical Nurse) I perform wound care to R29's left lateral heel wound. LPN I placed a barrier on R29's beside table and set up wound care supplies which included a bottle of ½ Dakin's and a can of normal saline spray. At this time, Surveyor noted R29 already had two additional cans of the normal saline spray on their bedside table.
On 03/01/23 at 10:38 AM, LPN I used scissors to remove the previous gauze dressing from R29's left foot/ankle. LPN I placed the scissors on R29's bedside table. Surveyor noted LPN I did not disinfect the scissors. After the wound was cleansed, LPN I used the same scissors to cut the hydrofera blue to the correct size. LPN I also used the same scissors to cut the ABD pad. LPN I did not disinfect the scissors after using them on the old dressing and prior to using them on the clean supplies.
On 03/01/23 at 10:52 AM, Surveyor observed LPN I remove the wound care supplies from R29's room and place them on top of the medication cart. Surveyor asked LPN I if the wound care supplies were specific to the resident. LPN I stated, the bottle of Dakin's is specific to R29 but the cans of Saline spray were used on multiple residents. LPN I stated anything left in R29's room should belong to R29. LPN I placed the can of saline spray in R29's drawer in the medication cart and informed Surveyor this can should be R29's since we have so many cans of saline spray. LPN I left the other two cans of saline spray which were removed from R29's room, on top of the medication cart.
On 03/01/23 at 2:51 PM, Surveyor interviewed DON (Director of Nursing) B, whom is also the facility's Infection Preventionist. Surveyor relayed observations of LPN I using scissors to remove an old dressing and then using the same scissors to cut clean supplies without disinfecting the scissors. DON B informed Surveyor, yes, they should clean the scissors when going from dirty to clean. DON B was not sure if the cans of saline spray were resident specific. Surveyor explained LPN I stated the saline cans were used for multiple residents. Surveyor relayed the concern of using the same can of saline spray for multiple residents after the can was taken into a resident's room. Surveyor also relayed the observation of LPN I removing two additional cans of saline spray from R29's room, and placing them on top of the medication cart. DON B agreed if the can of saline spray was in a resident room, then it should be resident specific.
No additional information was provided.
Based on interview and record review the facility did not ensure as part of their infection prevention and control program they had an effective water management plan based upon the individual characteristics of the facility.
The facility failed to implement a Water Management program to prevent the transmission of Legionnaires Disease which has the potential to affect all 108 residents residing in the facility.
Based upon observation and interview, the facility failed to provide infection control measures according to professional standards of practice for 1 (R29) of 4 Residents reviewed for wound care. The facility did not disinfect a scissors used during wound care when transitioning from dirty to clean supplies.
Findings include:
1.) The facility policy and procedure entitled Legionella Water Management Program from MED-PASS ©2001 revised 7/2017 states:
1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team.
2. The water management team will consist of at least the following personnel:
a. The infection preventionist;
b. The administrator;
c. The medical director (or designee);
d. The director of maintenance; and
e. The director of environmental services.
3. The purpose of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease.
4. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a Legionella water management program.
5. The water management program includes the following elements:
a. An interdisciplinary water management team;
b. A detailed description and diagram of the water system in the facility, including the following:
1) Receiving;
2) cold water distribution;
3) Heating:
4) Hot water distribution; and
5) Waste.
c. the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including:
1) Storage tanks:
2) Water heaters;
3) Filters;
4) Aerators;
5) showerheads and hoses;
6) Misters, atomizers, air washers and humidifiers;
7) Hot tubs;
8) Fountains; and
9) Medical devices such as CPAP machines, hydrotherapy equipment; etc.
d. The identification of situations that can lead to Legionella growth, such as:
1) construction;
2) Water main breaks;
3) Changes in municipal water quality;
4) The presence of biofilm, scale or sediment;
5) Water temperature fluctuations;
6) Water pressure changes;
7) Water stagnation; and
8) Inadequate disinfection.
e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants);
f. The control limits or parameters that are acceptable and that are monitored;
g. A diagram of where control measures are applied;
h. A system to monitor control limits and the effectiveness of control measures;
i. A plan for when control limits are not met and/or control measures are not effective; and
j. Documentation of the program.
6. The Water Management Program will be reviewed at least once a year, or sooner if any of the following occur:
. The control limits are consistently not met;
b. There is a major maintenance or water service change;
c. There are any disease cases associated with the water or system; or
d. There are changes in laws, regulations, standards or guidelines.
The Facility Assessment Tool, dated 1/7/2023, did not include a completed facility-based and community-based risk assessment, utilizing an all-hazards approach to create an emergency preparedness plan, including a water management plan, that met current standards of practice. The Facility Assessment Tool documented the facility would complete a facility-based and community-based risk assessment, using an all-hazards approach (an integrated approach focusing on capacities and capabilities critical to preparedness for the full spectrum of emergencies and natural disasters.) The [name of facility] had developed a complete emergency preparedness plan that is maintained in its own policy and procedure manual that is used to train staff and is updated with the facility assessment.
Surveyor requested from Nursing Home Administrator (NHA)-A on 2/27/2023, 2/28/2023, 3/1/2023, and 3/2/2023 the facility Water Management program to review.
On 3/2/2023 at 9:30 AM, NHA-A provided Surveyor with the Water Management Plan dated 3/1/2023, two days after the start of the survey. The Water Management Plan included abbreviations and acronyms, team members (regional maintenance and regional director with no local facility representation), an overview of the plan with an overview diagram, notification and communication process, and written control measures. No diagrams accompanied the Water Management Plan showing the specifics of the facility.
In an interview on 3/2/2023 at 10:34 AM, Surveyor asked NHA-A, Director of Nursing (DON)-B, Licensed Practical Nurse Unit Manager (LPN UM)-J, and Regional Nurse Consultant-G about their Water Management Plan dated 3/1/2023. Surveyor shared with NHA-A the observation of Unit 5 having only one resident that had been moved off that unit on 2/27/2023 leaving the unit empty. NHA-A stated there had been twelve residents living on the unit for the last eight months. NHA-A stated they have implemented a Friday Flush which means every Friday, the toilets, sinks, and showers are flushed every Friday on Unit 5 along with any other empty rooms in the facility. NHA-A stated maintenance goes to the basement to ensure the water temperature in the heater tanks is at 140 degrees. NHA-A stated the facility will be getting a flush spigot to the heating tank to make it easier to flush in the future. NHA-A stated a third party individual had been out to the facility and doing all the flushes and showing them the measures to take with the water supply. NHA-A stated the janitor sinks, basement sinks, and shower rooms are all part of the Friday Flush. NHA-A stated they also make sure the water is going down the drains in the shower room so there is not any standing water. NHA-A stated NHA-A was aware ice machines are a big risk and they are following manufacturer's guidelines by changing the filter every 90 days. NHA-A stated the facility was built in 1964. NHA-A stated staff are getting certification through the CDC for legionella training. Surveyor requested from NHA-A any diagrams the facility had related to their Water Management Plan. NHA-A stated the third party that had come out and had made diagrams of the water system and NHA-A would reach out to them to get the diagrams. NHA-A provided a summary log of Legionella Test Results dated 2/15/2023 that tested six areas. Surveyor asked NHA-A for any logs showing the Friday Flushes had been completed. NHA-A did not provide any of that documentation. Surveyor asked NHA-A for any diagrams showing the Water Management Plan. NHA-A stated the third party developed a lot of building diagrams and NHA-A would have to try and contact the third party to get them by email because they were not in the facility.
On 3/2/2023 at 12:57 PM, NHA-A provided a Potable Flow Diagram and a Utility Flow Diagram. NHA-A stated the third party would be coming back the following week to continue with their assessment of the water to determine more controls and to further complete the water management diagram. No further information was provided at that time.
Dec 2022
7 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure it provided an environment that was free of accid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure it provided an environment that was free of accident hazards and safe for 43 residents of 45 residents reviewed for safety concerns. The facility identified at the time of the survey, 40 residents smoked and utilized the smoking patio at the facility. Additional concerns exist regarding R7 and R4.
On 12/6/22 Surveyor observed R20 being taken out to the smoking patio by Certified Nursing Assistant (CNA)-P and observed R20 actively had oxygen on. The CNA was heard speaking to R20 about not wearing oxygen and smoking prior to the CNA leaving R20 unsupervised. R20 was then observed interacting with other residents on the patio including R21 who told R20 to take off her oxygen as they walked to R20. R20 was next observed with her oxygen tank and her nasal cannula in her lap as it was actively emitting oxygen. R20 was observed to have a lit cigarette in her mouth at that time while the oxygen was running in her lap.
R20's Smoking Assessment dated 12/01/22 indicated the resident liked to smoke, could light cigarettes without difficulty, did not need to have her lighter and cigarettes stored by staff for safety, and had been educated on smoking procedures. The smoking assessment did not indicate the resident used oxygen or delineate safety precautions related to smoking and oxygen use. It was later determined that facility staff stored the resident's smoking paraphernalia, and the smoking assessment was inaccurate.
The facility identified that any given time there are currently 40 residents in the facility that actively smoke and could be present on the patio when a resident has oxygen in use.
During interview with the Director of Nursing (DON-B) on 12/07/22 at 9:00 a.m., DON-B said, [R20] is the only resident who smokes that wears oxygen. One resident [R24] who smokes needs a smoking apron. Three residents who smoke including [R1] and [R16] go out on the 500-hall patio [Wing-5 patio (non-designated smoking area)]. DON-B indicated the three residents were allowed to smoke on the Wing-5 patio to accommodate social distancing during the coronavirus disease 2019 (COVID-19) pandemic. On 12/07/22 at 9:27 a.m., DON-B provided a list of three residents that included R3 and R20 indicating that the facility keeps their smoking paraphernalia. DON-B said, The nurse keeps their smoking material locked in the cart and the resident must ask for it.
The facility identified multiple residents with varying levels of supervision or safety concerns related to smoking and did not have a system in place to ensure safety while smoking.
The facility's failure to ensure the safety of residents who smoke and those that are smokers that use oxygen created a situation of immediate jeopardy that started on 12/6/22. Administrator (NHA)-A and Regional Director of Operations (RDO)-E were notified of the immediate jeopardy on 12/7/22 at 10:34 am. The immediate jeopardy was removed 12/7/22 when the facility implemented an action plan. The deficient practice continues at a scope and severity (s/s) of a G (actual harm/isolated) based upon the example regarding R7.
R7 was left unsupervised while on the toilet resulting in a fall with three subsequent fractures.
R4 was identified as at risk for elopement and was not provided with appropriate interventions to minimize the resident's risk for elopement and was later located walking on a local highway.
Observations of the smoking area of the facility identify safety concerns related to debris that could possibly be ignited while resident's smoke.
Findings include:
1.) Supervision to Prevent Accidents and Accident Hazards - Smoking
The Facility Smoking Policy - Residents, 2001 Med-Pass, Inc (Revised July 2017) was provided by DON-B on 12/07/22 at 8:45 a.m. The policy stated, This facility shall establish and maintain safe resident smoking practices 2. Smoking is only permitted in designated resident smoking areas, which are located outside of the building. 3. Oxygen use is prohibited in smoking areas. 4. Metal containers, with self-closing cover devices, are available in smoking area .13. Residents are not permitted to give smoking materials to other residents.
A facility policy titled, Smoking Guideline, that was dated 10/24/22, specified: The facility may designate certain areas for resident smoking. The facility must ensure precautions are taken for the resident individual safety, as well as the safety of others in the facility. Such precautions may include smoking only in designated areas, supervising residents whose assessment and care plans indicate a need for assisted and supervised smoking, limiting the accessibility of matches and lighters by residents who need supervision when smoking for safety reasons. Smoking by residents when oxygen is in use is prohibited, and any smoking by others near flammable substances is problematic and prohibited. Additional measures may include informing all visitors of smoking policies and hazards.
The facility provided a list of residents who smoked. Out of the 40 residents on the list who smoked, R20 was identified as the only resident who was receiving oxygen. During an interview with Director of Nursing (DON)-B on 12/07/22 at 9:00 a.m., DON-B said, [R20] is the only resident who smokes that wears oxygen. One resident [R24] who smokes needs a smoking apron. Three residents who smoke including [R1] and [R16] go out on the 500-hall patio [Wing-5 patio (non-designated smoking area)]. DON-B indicated the three residents were allowed to smoke on the Wing-5 patio to accommodate social distancing during the coronavirus disease 2019 (COVID-19) pandemic.
On 12/07/22 at 9:27 a.m., DON-B provided a list of three residents that included R3 and R20 indicating that the facility keeps their smoking paraphernalia. DON-B said, The nurse keeps their smoking material locked in the cart and the resident must ask for it.
According to records reviewed by Surveyor, R20 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes, and hemiplegia and hemiparesis to the left side. The resident had a left below the knee amputation and was receiving hemodialysis.
On the Minimum Data Set (MDS) R20 scored a 12 on the Brief Interview for Mental Status (BIMS) dated 12/01/22 suggesting the resident had moderately impaired cognition. According to a physician's order and observations made during the survey, R20 was receiving oxygen by way of nasal cannula from a portable oxygen tank.
R20's admission Agreement dated 11/29/22 stated, 12. Smoking, Alcohol, and Drugs - If designated smoking areas are provided, smoking is permitted in designated areas of the Center only and only to the extent permitted by the Residents medical records. If a Resident requires assistance to smoke, you agree to do so only with appropriate assistance. All lighters and matches shall be kept at the nursing station. Residents may not keep lighters and matches in their rooms or on their person.
R20's baseline care plan dated 11/29/22 indicated the resident had a self-care deficit related to the left below knee amputation; required one-to-two-person assistance for personal hygiene, toilet use, and transfers using a Hoyer® mechanical lift; had a potential for falls; and had cognitive impairment manifested by impaired compromised decision making and inability to understand course of treatment, care, and prognosis/likely outcome. [R20] has a need for a responsible adult to make health care and/or financial decisions on her behalf, has anemia due to dialysis and is on humidified oxygen. R20's baseline care plan dated 11/29/22 did not address smoking.
R20 had a physician's order dated 11/30/22 that read, O2 (oxygen) at two to six (2-6) liters per minute via nasal cannula continuously while in room for chronic obstructive pulmonary disease to keep sats (oxygen saturation levels) above 90 percent.
R20's Smoking Assessment dated 12/01/22 indicated the resident liked to smoke, could light cigarettes without difficulty, did not need to have her lighter and cigarettes stored by staff for safety, and had been educated on smoking procedures. The smoking assessment did not indicate the resident used oxygen or delineate safety precautions related to smoking and oxygen use. It was later determined that facility staff stored the resident's smoking paraphernalia, and the smoking assessment was inaccurate.
The following was observed by the Surveyor on 12/06/22 beginning at 4:00 p.m. Certified Nursing Assistant (CNA-P) transported R20 in her wheelchair to the smoking patio near the dining room. R20 had a portable oxygen cannister and was receiving oxygen through a nasal cannula. CNA-P moved the resident to a non-smoking area of the patio under the easement of the facility with the resident's back against a brick wall, locked the wheelchair brakes, and told R20 to take off her oxygen to smoke. CNA-P then returned to the facility. There were no other staff members on the smoking patio. There were nine other residents on the smoking patio; seven of the residents were smoking. R16 and R21, who were seated at a table about six to eight feet away from R20, yelled across the patio telling R20 to turn off her oxygen to smoke. R21 walked over to R20 and assisted R20 to take the oxygen tank off the back of the wheelchair and placed the oxygen tank on R20's lap; the nasal cannula was also on the resident's lap at this time. R20 had a lit cigarette in her mouth following the interaction with R21. When the Surveyor asked R20's name, the Surveyor could hear the oxygen tank running. The Surveyor immediately went into the building to find the Director of Nursing or a nurse in charge and first located the Regional Registered Nurse (RRN-Q). RRN-Q accompanied the Surveyor to the patio, extinguished R20's cigarette, and brought the resident inside.
According to the facility map provided by DON-B on 12/05/22 at 3:30 p.m., R20 was not smoking in the designated smoking area. The designated smoking area is marked by yellow paint on the ground on the concrete patio itself. One side of the line is a designated smoking area, and the other side is non-smoking. R20's wheelchair was positioned in the non-smoking area against the brick building under the overhang.
During an interview on 12/06/22 at approximately 4:15 p.m., R16 said, They bring people like her [pointing to R20] out [on the patio] and leave them [without supervision]. R16 expressed concerns that a resident could catch fire and I [R16] would feel responsible.
During an interview on 12/06/22 at 4:55 p.m., R21 said she helped R20 place the oxygen tank on her lap as described above. R21 stated that R20 demanded a cigarette and R21 provided a cigarette and lit it for her. R21 said this was the first time she had ever seen R20 and the first time she had ever seen CNA-P, but, according to R21, CNA-P did tell the residents on the patio that it was ok for R20 to smoke without her oxygen tank on. R21 said all the residents know people with oxygen can't smoke. R21's most recent MDS dated [DATE] was coded to indicate the resident scored 15 on the BIMS suggesting R21 was cognitively intact.
On 12/06/22 at 5:14 p.m., RRN-Q said, We educated everyone about smoking that is in the building now. Her smoking assessment said she wasn't going to smoke [the resident preferred not to smoke while at the facility]. R20 is her own person and can make her own decisions. We will try to educate her. I don't know why she needs oxygen, but maybe we can dc [discontinue] it.
In an observation on 12/07/22 at 9:42 a.m., the Surveyor saw a resident smoking in the same non-designated smoking area under the easement near the designated smoking area by the dining room in his wheelchair.
During interview on 12/07/22 at 9:42 a.m., the Administer (NHA-A) said the admissions packet was the only document that residents signed acknowledging the smoking policy. NHA-A stated, The residents are informed, upon admission, that smoking is not permitted in common areas of the center. The designated areas provided for residents are evaluated.
On 12/08/22 at 4:10 p.m., a Licensed Practical Nurse Manager (LPNM-G) said, No one is supposed to smoke within 15 feet of the building and the area under the overhang is not a designated smoking area.
The facility's failure to ensure Resident's are supervised and safe while smoking created a situation of immediate jeopardy that was removed on 12/7/22 when the facility implemented the following action plan:
* Ad Hoc QA meeting was held to educate the entire leadership team on our plan and follow up.
* All licensed and unlicensed personnel were educated on the policy regarding smoking, residents that choose to smoke and have oxygen, not giving residents smoking materials, where the designated smoking area is located and the safety equipment that is in the designated smoking area.
* All education will be completed with staff in the building currently and all other staff will be educated prior to his/her next scheduled shift.
* All residents that currently smoke were assessed for the smoking abilities, all care plans were reviewed and updated as necessary for their individual needs. The care delivery guides were reviewed and updated if a resident is an independent smoker or what level of assistance they need to smoke and where there smoking material are located if applicable. The facility smoking policy and procedures were reviewed to ensure that they are based on the current standards of practice. The facility will ensure that all residents currently residing in the facility are educated on the reviewed smoking policy, that they should not be sharing smoking materials with other residents and where the only designated smoking area is located. All new admissions will be educated on the smoking policy on admission to the facility. All resident education will be completed with residents that currently smoke in the facility.
* The facility will ensure that smoking assessments are completed timely on new admissions that choose to smoke or any resident that chooses to start smoking. The social service department was educated on completing smoking assessments timely on 12/7/22. The facility will educate all staff to notify the DON/NHA if any resident chooses to start smoking. All education will be completed with staff that are currently in the building and all other staff will be educated prior to his/her next scheduled shift.
* All residents that smoke have the potential to be affected by the alleged deficient practice. One resident was identified that currently is choosing to smoke and wears oxygen. The identified resident wasre-evaluated for their ability to smoke, she remains a supervised smoker and her smoking materials will be kept in the nurse's station. The identified residents plan of care was reviewed and updated. Her care delivery guide was updated to reflect her level of supervision needed, where her smoking materials are kept and to remove her oxygen prior to exiting into the smoking area. The resident was educated on the smoking policy, removing her oxygen prior to entering the smoking area and where her smoking materials will be kept if she chooses to smoke.
* The social service department was educated on completing smoking assessments timely on 12/7/22. The facility will educate all staff to notify the DON/NHA if any resident chooses to start smoking so that a smoking assessment can be completed, and their care plan and care delivery guide can be updated. All education will be completed with staff that are currently in the building and all other staff will be educated prior to his/her next scheduled shift.
* As per above the facility will ensure that all residents currently residing in the facility are educated on the reviewed smoking policy, sharing smoking materials and where the only designated smoking area is located.
* All new admissions will be educated on the smoking policy, where the designated smoking area is located and sharing smoking materials on admission to the facility. All resident education will be completed with residents that currently smoke in the facility.
* The facility will ensure that smoking assessments are completed timely on new admissions that smoke or any resident that chooses to start smoking. The social service department was educated on completing smoking assessments timely on 12/7/22. The facility will educate all staff to notify the DON/NHA if any resident chooses to start smoking to ensure a smoking assessment is completed and their care plan/care delivery guide is updated. All education will be completed with staff that are currently in the building and all other staff will be educated prior to his/her next scheduled shift.
* NHA/Designee will audit the designated smoking area for residents with oxygen equipment, randomly 7 times per day Monday through Sunday x 2 weeks, then 5 times per day Monday through Sunday x 2 weeks, then 3 times per week Monday through Sunday x 2 weeks, then randomly through the week x 2 weeks. All audits will be brought to QAPI for review until the IDT determines there is no longer a risk identified.
The deficient practice continues at a scope and severity of a G (actual harm/isolated) based upon the example regarding R7.
2.) A policy titled Falls and Fall Risk, Managing Policy Statement, revised March 2018, stated the following: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions 7. ln conjunction with the attending physician, staff will identify and implement relevant interventions . to try to minimize serious consequences of falling .
According to records reviewed by Surveyor, R7 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident.
R7's admission Minimum Data Set (MDS) documented the resident was usually able to understand others and was sometimes understood by others; the resident's vision was adequate, and resident did not wear a hearing aid. The resident scored a 2 on the Brief Interview for Mental Status (BIMS) suggesting severely impaired cognition. The MDS indicated the resident required limited assistance with bed mobility and transfers and walking in the resident's room; R7 required total assistance for bathing and toileting. According to the MDS, R7's balance was not steady, and the resident was only able to stabilize with staff assistance.
R7's care plan, dated 09/15/22, was in place prior to the 10/20/22 fall described below and included the following information: The resident is at risk/has potential for falls, accidents R/T [related to] current diagnosis- hx [history] of falls, gait imbalance, generalized weakness, hx of CVA [cerebrovascular accident] with weakness R [right] side. The related care plan problem stated, Injuries will be minimized through the review date. Interventions/approaches were as follows:
9/15/22 - Fall assessment to be completed upon admission after falls, quarterly. Follow therapy - recommendations for transfers and mobility. Review information on past falls and attempt to determine the cause of falls.
10/20/22- Send to ER [emergency room] and do not leave on toilet unattended. This approach was added following the 10/20/22 fall.
R7's care card (not dated) included the following: Fall Risk - No, Continent of bowel and bladder and a check and change and utilizes a brief, Transfers with Hoyer. The care card did not include that R7 was at high risk for falling.
R7's Bedside/ [NAME] report dated 09/15/22 included the following information: Provide and encourage use of adaptive equipment bedpan .
A fall risk assessment dated [DATE] indicated R7 was at high risk for falls with a score of 21.0
The physical therapy evaluation dated 09/16/22 also indicated the resident was at high risk for falls and had a fear of falling with unsteadiness to the resident's gait, requiring total support to the right upper extremity. Toilet transfers were not attempted due to medical condition or safety concerns.
On 10/20/22 at approximately 6:45 p.m., according to Licensed Practical Nurse Manager (LPNM)-G who was interviewed by the Surveyor on 12/10/22, a Certified Nursing Assistant alerted LPNM-G that R7 was on the floor. LPNM-G entered R7's room and found the resident on her right side on the floor complaining of pain in her right shoulder. LPNM-G notified the medical provider and x-rays were ordered; ultimately the resident was transferred to acute care for further evaluation. According to LPNM-G, R7 sustained three fractures, including a right shoulder fracture, a right hip fracture and a right wrist fracture. During an interview with R7 after the fall she told the staff she was leaning forward and was unable to hold herself and fell. According to LPNM-G, after transferring the resident to acute care she started an investigation; LPNM-G obtained statements from staff working on the wing where R7 resided and determined the resident was assisted to the toilet by Certified Nursing Assistant (CAN)-Z who was provided by a staffing agency. A written statement from CNA-AA (a second agency CNA) further explained that R7 had been on a bedpan for 45 minutes prior to the fall and was taken off the bedpan and taken to the toilet by CNA-Z where the resident was left while CNA-Z went to lunch.
R7's roommate (R27) was interviewed on 12/13/22 at 2:00 p.m. R27 stated that CNA-Z came into the room when R7 put on her call light to go to the bathroom. CNA-Z assisted R7 to the toilet and told R7 to call when she was done using the bathroom. R27 heard R7 fall about five minutes after she was assisted to the toilet.
In summary, R7 was admitted to the facility on [DATE] following a cerebrovascular accident with right sided weakness. She was assessed at high risk for falling with a score of 21.0. Therapy had not attempted toilet transfers due to medical concerns or safety concerns. The resident was placed on the toilet by CNA-Z and left unattended while she went to lunch. R7 fell off the toilet fracturing her right wrist, right hip, and right shoulder. The Bedside care card/ [NAME] indicated to use a bedpan. According to interview with LPNM-G, the grab bar by the toilet and call light in the bathroom are on the right side of the toilet and, due to R7's right sided weakness, the resident could not reach these. R7 was unable to hold herself upright due to the resident's physical limitations and therefore could not avoid falling. The resident was transferred to acute care for treatment and had not returned to the facility as of the dates of the survey.
3.) During observations made by Surveyor on 12/07/22, the facility failed to provide appropriate and safe cigarette butt receptacles and failed to adhere to designated smoking areas. Used coffee containers with cardboard sides, were being used by residents and possibly staff on two facility patios for cigarette ash and butt disposal. On the Wing-5 patio, that was not a designated smoking area, a red garbage can was observed with overflowing paper refuse such as fast-food containers, that prevented closure of the lid. This garbage can also contained multiple cigarette butts. Cigarette butts were observed throughout the Wing-5 patio space near piles of unraked leaves and two cardboard storage boxes that contained wheelchair cushions. A combustible coffee can that was half-filled with cigarette butts was observed on the metal patio table in Wing-5. No approved safety ash receptacles were observed on the Wing-5 patio and facility administration was unaware that people had been smoking in this area.
On 12/07/22 from 9:02 a.m. to 9:13 a.m., the Wing-5 patio was observed with Licensed Practical Nurse Manager (LPNM)-G and Director of Nursing (DON)-B. LPNM-G told the Surveyor that during a recent facility quarantine for a respiratory virus, the smokers were smoking on the Wing-5 patio to limit resident movement in the building. LPNM-G stated that she was unaware when the last time anyone smoked on this patio and that the door codes had been changed recently to limit resident access this area.
Upon entering the Wing-5 patio area on 12/07/22 with LPNM-G and DON-B, a round metal patio table and metal chairs were observed. Multiple cigarette butts, too numerous to count, and crushed beer cans were observed on the cement under the patio table. In the center of the metal table, a combustible, cardboard sided, used coffee container was observed half filled with cigarette butts. A red garbage can was observed to be overfilled with paper waste including fast food packages and liquor bottles that prevented the safety lid from closing. No approved ash receptacle was observed in this area. Approximately four feet away from the metal table, were two sealed cardboard boxes that contained wheelchair cushions. Next to these cardboard boxes were small piles of unraked leaves. When the clear, over-filled garbage bag was lifted out of the red waste can, numerous cigarette butts and used alcohol bottles could be seen amongst the garbage.
On 12/07/22 at 9:32 a.m., Maintenance Supervisor (MS-J), the Regional Director of Operations (RDO-E), and the Assistant Administrator (AA-D) were observed on the patio removing smoking materials. RDO-E indicated not being aware people were using this area for smoking and this was not a designated smoking area. DON-B indicated not knowing how long it had been since anyone smoked in this area and did not know if staff were using this area to smoke. None of the staff knew who was drinking alcohol on the Wing-5 patio.
On 12/07/22 at 9:42 a.m., the designated smoking area near the facility dining room was observed to have eight used coffee containers placed on the ground and on the tables. Five of these containers were combustible with cardboard siding and three were solid metal and non-combustible. All of the containers had cigarette butts in them. Two tall tower approved ash receptacles were also observed on this patio.
4.) According to records reviewed by Surveyor, R4 was admitted to the facility on [DATE] and discharged to home on [DATE]. The resident's diagnoses included cerebral infarction, respiratory failure, hypoxic ischemia, and rhabdomyolysis.
According to the admission Minimum Data Set (MDS) dated [DATE], R4 had adequate hearing, was understood, and was able to understand others. The MDS was coded to indicate R4 scored 11 on the Brief Interview for Mental Status (BIMS) which suggested moderately impaired cognition. According to the MDS, R4 required limited assistance for bed mobility, transfers, dressing, and bathing, and supervision for locomotion off the unit.
An Elopement Risk Review dated 07/18/22 indicated R4 was not at risk for elopement. In contrast, the 08/01/22 Elopement Risk Review identified the resident as at risk for elopement; Director of Nursing (DON)-B and facility staff were unable to provide an explanation as to why R4 became at risk for elopement. Risk factors identified in the assessment included the resident being ambulatory, having predisposing conditions and a cognitive impairment, and taking antidepressants.
Review of R4's care plan indicated there was no plan to prevent R4 from eloping from the facility despite the resident being identified as at risk for elopement.
A smoking assessment, which was completed on 07/18/22 identified R4 as someone who did not currently smoke, although the resident had previously smoked.
An investigation completed by the facility on 08/10/22 indicated that on 08/07/22 at approximately 4:00 p.m., R4 was observed leaving the facility through the gate in the smoking patio by an unidentified resident. The unidentified resident did not report this to anyone at the time of the observation, according to DON-B, however the unidentified resident was interviewed at a later time. Around 4:20 p.m., R4 was brought back to the facility by a community man that saw her walking up the highway [on the highway] and stopped to help her. R4 stated to the male, who found the resident, that she was going home. According to facility staff, R4's home was over an hour away from where the facility was located.
During interview with DON-B on 12/06/22 at 1:00 p.m., DON-B stated that the resident refused to wear a Wanderguard ® device and confirmed that there were no additional interventions to prevent the resident from eloping. The resident continued to smoke and spent time on the smoking patio, which was surrounded by a chain link fence that could be opened at the entrance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and interview conducted by Surveyor 15522, the facility did not provide an environment that was sanitary, orderly, and well-maintained in one of three shower rooms observed.
Find...
Read full inspector narrative →
Based on observation and interview conducted by Surveyor 15522, the facility did not provide an environment that was sanitary, orderly, and well-maintained in one of three shower rooms observed.
Findings include:
During the initial tour of the shower room on Wing-3 on 12/05/22 at 2:30 p.m. with the Director of Nursing (DON-B), it was noted that the shower room was being used as a storage area and contained a wheelchair and storage bins. The door to the shower room was locked with keycode entry and residents did not have access to this room without staff assistance. The floor was cluttered with a gait belt, used gloves (that were inside out), and multiple empty shampoo and soap containers. A used razor was located on the shower room handrail in the shower, along with half-filled containers of soap products. The cupboard door was broken and lying on the floor. The sink was stained with a rust color. DON-B stated that the room was also being used as a showering space for residents. At the time of the initial tour observation, DON-B stated the staff should not be using the shower room for storage and agreed that it was not sanitary and needed attention.
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 F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide an ongoing program of activities for 1 Resident ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide an ongoing program of activities for 1 Resident (R11) of 28 sampled residents designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.
R11 did not have an activities plan and was not observed participating in recreational activities during the survey.
Findings include:
On 12/13/22 the Director of Activities (DA-KK) provided a policy and procedure titled, Activity Evaluation, that was last revised June 2018. The document included the following: In order to promote the physical, mental, and psychosocial well-being of residents, an activity evaluation is conducted and maintained for each resident at least quarterly and with any change of condition that could effect his/her participation in planned activities. The policy further stated under section 7, Each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs.
According to records reviewed by Surveyor 15522, R11 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, moderate protein - calorie malnutrition, developmental disorder, blindness in both eyes, major depressive disorder, bipolar disorder, and anxiety disorder. The resident had a jejunostomy tube.
According to R11's quarterly Minimum Data Set (MDS) dated [DATE], R11 had adequate hearing, sometimes understood others, and was sometimes understood by others; R11's vision was highly impaired. A staff assessment for cognition was conducted and noted R11 had memory problems and the resident's decision making skills were severely impaired. R11 did not experience delirium, however, the MDS was coded to indicate R11 experienced inattention at times. According to the MDS, R11 did not experience behavioral symptoms. R11 required extensive assistance for bed mobility and activities of daily living and total assistance for transfers, bathing, and locomotion on and off the unit. R11 utilized a wheelchair for mobility and did not ambulate.
According to the 09/01/22 annual MDS assessment for daily preferences, it was very important for R11 to be involved in favorite activities and listening to music the resident liked; being around animals such as pets was also noted as very important. R11 had an Amazon Alexa device in his room that he could use to request music to be played.
The annual comprehensive review conducted by activities staff was not completed prior to the 09/01/22 MDS assessment and activities staff did not identify approaches based on R11's care needs and preferences. R11's care plan dated 07/30/21- 08/31/22 did not include information related to activities. R11's Bedside care card, which was not dated included the following information: have music or TV playing .
During interview on 12/13/22 DA-KK indicated that R11 attended four activity programs in September 2022, four in October 2022, and two in November 2022; R11 did not participate in any activities in December 2022. According to DA-KK, the facility went into COVID-19 lockdown from 11/18/22 through 12/09/22.
R11 was observed daily throughout the survey from 12/05/22 to 12/09/22 and 12/12/22 to 12/13/22; R11 was observed in his room during all observations. At times music was playing in R11's room and at other times it was quiet (for example, on 12/06/22 at 10:30 a.m. and 1:00 p.m., there was no music playing). R11 was observed while sitting in their room or in bed without any stimulation. R11 did not respond appropriately to questions asked by the Surveyor and it was determined R11 was not interviewable.
During an interview with DA-KK on 12/13/22 at approximately 2:00 p.m., she agreed there was no care plan related to R11's activity preferences and the comprehensive assessment was not complete.
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility did not ensure medications were properly administered th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and policy review, the facility did not ensure medications were properly administered through a gastrostomy tube to prevent complications and maintain the integrity of the tube; a resident's (R19's) gastrostomy tube was not flushed prior to or in between each medication administered for one of three residents observed.
Findings included:
Director of Nursing (DON)-B provided a facility policy on 12/09/22 titled, Administering Medications through an Enteral Tube, that was dated November 2018. The policy indicated the enteral tube was to be flushed with at least 15 milliliters (ml) of warm purified water prior to medication administration and staff were to, administer each medication separately and flush between medications .flush tubing with at least 15 milliliters (ml) of warm purified water (or prescribed amount).
A review of the Face Sheet completed by Surveyor indicated the facility admitted R19 on 02/23/21 with diagnoses that included dysphagia and gastrostomy status [presence of a feeding tube]. The MDS dated [DATE] was coded to indicate R19 had a BIMS score of 8 suggesting moderately impaired cognition and used a feeding tube while a resident at the facility.
R19's care plan that was initiated on 03/01/21 stated, medications administered orally, but can be administered per G-tube [gastrostomy tube] if unable to take them orally. The care plan identified problems with the gastrostomy tube clogging on 06/11/22 and 07/25/22. Interventions directed staff to sent [send] to ER [emergency room] for G-tube unclogging or replacement.
R19 had the following physician orders:
o
04/28/22: Cyclobenzaprine HCL [hydrochloride] tablet, 5 milligrams (mg), by mouth three times a day for muscle spasm.
o
04/28/22: Quetiapine fumarate tablet 100 mg, 1 tablet by mouth three times a day for depression.
o
04/28/22: Gabapentin tablet 600 mg, give 1 tablet by mouth three times a day for nerve pain.
o
04/28/22: Meds may be administered via G-tube if unable to take them orally.
On 12/06/22 at 1:00 p.m., a Registered Nurse (RN-L) was observed administering medication for R19. RN-L told the Surveyor that R19 received 280 milliliters (ml) of water every four hours for hydration and that R19 had a long history of tube clogging. RN-L crushed cyclobenzaprine, quetiapine fumarate, and gabapentin and placed each medication into a separate plastic cup with approximately 60 ml of water to dissolve the medications. RN-L checked for gastrostomy tube placement by inserting an enteral syringe into the gastrostomy tube port, injecting air into the gastrostomy tube, and auscultating with a stethoscope. RN-L then poured each medication separately into the enteral syringe allowing each medication to flow into the gastrostomy tube. No water flush was provided in between each of the three medications administered. After the last medication was administered, RN-L poured 280 ml of water into the enteral syringe allowing water to flow into the gastrostomy tube by way of gravity.
Following the observation of medication administration, the Surveyor discussed flushing the gastrostomy tube with water prior to and in between administration of medications through the tube. RN-L agreed that flushes with water should have been provided during the administration of medication for R19.
During an interview on 12/13/22 at 1:10 p.m., DON-B indicated that flushing prior to administration of medications and between medications would be her expectation and that she would be conducting a policy review.
In summary, RN-L did not flush a gastrostomy tube prior to and in between medication administration in accordance with facility policy and to reduce the risk of gastrostomy tube clogging and maintain the integrity of the tube.
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 F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide the necessary behavioral health care and service...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 resident (R11) of a sample of 28 residents.
Findings include:
According to records reviewed by Surveyor, R11 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, moderate protein - calorie malnutrition, developmental disorder, blindness in both eyes, major depressive disorder, bipolar disorder, and anxiety disorder. R11 had a jejunostomy tube.
According to R11's quarterly Minimum Data Set (MDS) dated [DATE], R11 had adequate hearing, sometimes understood others, and was sometimes understood by others; R11's vision was highly impaired. A staff assessment for cognition was conducted and noted R11 had memory problems and R11's decision making skills were severely impaired. R11 did not experience delirium, however, the MDS was coded to indicate R11 experienced inattention at times. According to the MDS, the staff assessment for mood (PHQ-9-OV) was completed with a score of zero (no depression present). According to the MDS, R11 did not experience behavioral symptoms. R11 required extensive assistance for bed mobility, eating, dressing, toilet use, and personal hygiene and total assistance for transfers, bathing, and locomotion on and off the unit. R11 utilized a wheelchair for mobility and did not ambulate; R11 was incontinent of bowel and bladder.
R11's bedside care card, which was not dated included the following information: Use two person assist with a Hoyer lift .abdominal binder on, soft touch call light .WC [wheelchair] .two people when working with J-tube [Jejunostomy Tube]. Announce who you are when entering room and have music or TV playing .legally blind, tube feeding .
R11's care plan, which was dated 07/30/21 to 10/02/22 included the following information:
o
Behavior Problem - physically abusive/hitting staff during care. Disruptive/yelling out during cares. Depression and Bipolar 9/01/2021- snapped the double tubes of his tube feeding set-up. Note that staff did not conduct a root cause analysis to determine why R11 was experiencing physical and verbal behaviors of potential distress during care and did not track the behavioral symptoms to determine antecedents.
o
Resident has Impaired Mobility-Total assist for all ADL [activities of daily living] completion .
The bedside care card and care plan did not address R11's schedule regarding when R11 stayed in bed and got out of bed and did not address R11's history related to pulling out R11's jejunostomy tube.
During the initial tour on 12/05/22 at 2:30 p.m., R11 was observed in bed. Music was playing in R11's room and R11 was singing along with the tunes.
On 12/06/22 at 10:00 a.m., R11 was again observed in bed; R11 was unable to be interviewed due to R11's cognitive status. At the time of the observation, R11 who had a call light within reach, was overheard saying, I want to get up. After Surveyor inquiry, staff assisted R11 out of bed.
During survey, R11 was observed during care and transfers. During the observations, R11 did not demonstrate any behavioral symptoms.
During an interview with a Licensed Practical Nurse (LPN-M) on 12/06/2022 at 1:45 p.m., LPN-M stated R11 had not been out of bed for approximately two months due to behaviors. According to LPN-M, R11 pulled out R11's J-Tube many times, gouges staff's arms, and hurts them [staff] leaving scars.
Interviews on 12/09/22 at 10:47 and 11:18 a.m. with Certified Nursing Assistants (CNA)-S and CNA-T, who were both full time CNAs on the wing where R11 resided, confirmed R11 had not been out of bed for approximately two months. According to staff, R11 remained in bed as an attempt to minimize R11's behaviors including physical behavioral symptoms directed toward staff during care.
DON-B was interviewed on 12/06/22 at 4:00 p.m. and stated she was not aware that R11 was not out of bed during the past two months.
In summary, R11 was experiencing behavioral symptoms including physical behavioral symptoms directed toward staff during care and the staff determined that it was in R11's best interest to remain in bed due to those behaviors for approximately two months. Staff did not conduct a root cause analysis to determine why R11 was experiencing physical and verbal behaviors of potential distress during care and did not track the behavioral symptoms to determine antecedents. The isolation to bed was not documented on R11's care plan or care card. There was no intervention/plan that would indicate that R11 was to be in bed or out of bed during certain times and no approaches for staff to use during the delivery of care to minimize R11's behavioral symptoms. DON-B was not aware that R11 was confined to the bed. After the Surveyor questioned the plan for R11, R11 was observed out of bed in a wheelchair in R11's room. R11 appeared to be enjoying music from the Amazon [NAME] and singing along.
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 did not store food in accordance with professional standards for food service safety. Food items provided by the facility and food broug...
Read full inspector narrative →
Based on observation, interview and policy review, the facility did not store food in accordance with professional standards for food service safety. Food items provided by the facility and food brought in by residents and family members were stored in a dining room refrigerator; food items were not consistently labeled in a manner to differentiate the source and use by date of the food and a log was not maintained indicating the temperature was monitored. This has the potential to affect all residents who eat food or store items in the dining room refridgerator which is accessible to most of the facility residents.
Findings include:
A facility policy provided by Director of Nursing (DON)-B on 12/12/11 at 10:11 a.m. titled, Food Brought by Family/Visitors, and dated October 2017, specified: Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. The policy also indicated, The nursing staff will discard perishable foods on or before the 'use by' date The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).
On 12/09/22 at 12:12 p.m., two refrigerators were observed in the shared activity and dining room. One refrigerator was observed to have a padlock on the door restricting access and a temperature monitoring paper log taped to the outside. Director of Activities (DA)-KK indicated that the padlocked refrigerator belonged to the activity department and did not include personal resident food items. DA-KK said that the second refrigerator located at the end of the kitchen counter contained food items that belonged to individual residents and was monitored by the nursing department. This was the only refrigerator in the facility that was used for storage of resident food items.
On 12/09/22 at 12:15 p.m., the second refrigerator was observed to have a sign posted on the outside that stated, refrigerator will be checked daily, label food with date opened, food will be trashed after label date or if not labeled. There was no temperature monitoring paper log on this refrigerator. The Surveyor opened the refrigerator and observed no refrigerator thermometer. Many food items stored in the refrigerator had no names or dates on them as described below. The Surveyor also observed a tray of food items that appeared to come from the kitchen that had computer-printed labels with names on them for some of the food items; however, fifteen sandwiches in individual sandwich bags were not labeled with names or dates.
On 12/09/22 at 12:55 p.m., AA-D assisted the Surveyor in identifying the contents of the second refrigerator. AA-D took out food items such as ham salad in a deli container that was partially empty; the container was not labeled with a resident name or date. Multiple sealed pre-packaged meals were stacked in the refrigerator with no names or dates on them. In the refrigerator door, multiple deli meats including Polish deli ham and turkey slices were stored; some of the storage bags were not fully closed. The bags were labeled with a resident room number but not names or use by dates. A partially consumed Braunschweiger meat roll was observed in an unzipped Ziploc® type bag with no label indicating resident name or date. A pumpkin pie with no label indicating resident name or date was also observed stored in this refrigerator. An opened sweet potato pie box contained a partially consumed pie; the box was not labeled with a name, room number or date. Two unlabeled large Styrofoam® cups with lids were opened by AA-D who indicated the cups contained milk; AA-D disposed of the milk by pouring it down the sink drain. Two Sun Meadow total health system boxes were observed on the inside shelf of the refrigerator door; the boxes were not labeled with names and dates.
On 12/09/22 at 1:12 p.m., DON- B stated she did not know the owner of all of the pre-packaged food items and that housekeeping was responsible for overseeing that refrigerator.
On 12/09/22 at 1:55 p.m., AA-D told the Surveyor that he cleaned out the refrigerator and found the thermometer buried behind all the food items. During observations made during the remainder of the survey, no further concerns were identified.
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 F0949
(Tag F0949)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility did not provide behavioral health training for staff who cared for residents who were diagnosed with a mental, psychosocial, or substance use disorde...
Read full inspector narrative →
Based on interview and record review, the facility did not provide behavioral health training for staff who cared for residents who were diagnosed with a mental, psychosocial, or substance use disorder (SUD), or had a history of trauma and/or posttraumatic stress disorder consistent with the facility assessment. During interviews with facility staff 4 residents (R2, R10, R14, and R17) of a sample of 28 were identified as being affected by the lack of staff training.
Findings include:
The most current Facility Assessment Tool provided on 12/06/22 at 11:35 a.m. by Administrator (NHA)-A stated that common diagnoses treated by staff included impaired cognition, anxiety disorder, depression, behavior that needs interventions, peripheral vascular disease, hemiparesis, Alzheimer's disease, non-Alzheimer's disease, and chronic obstructive pulmonary disease. Special Treatments and Conditions listed on the Facility Assessment Tool included: Mental Health: Behavioral health needs, active or current substance use disorders. Services and care we offer based on our resident's needs- Mental Health and behavior: Manage the medical conditions and medical related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD [posttraumatic stress disorder], other psychiatric diagnosis, intellectual or developmental disabilities.
During staff interviews it was noted that direct care staff were not trained on behavioral health needs and management or substance use disorders (SUDs).
During an interview on 12/13/22 at 8:38 a.m., Certified Nursing Assistant (CNA)-II, said she received no training on SUDs or behavioral health.
On 12/13/22 at 9:29 a.m., a Registered Nurse Unit Manager (RNUM-CC) said R17, who has a substance use disorder, can go out of the facility whenever he wants and staff cannot stop him. RNUM-CC said signs indicating R17 used alcohol included mood changes and lethargy but there is no way to communicate to the [nursing assistant] staff [signs or symptoms indicating R17 was using alcohol was not included in the care plan or care card]. RNUM-CC said R17's falling might be a sign of substance use. RNUM-CC said R17 has a history of going out of the facility and obtaining drugs and alcohol. RNUM-CC reportedly took care of R17 and administered Narcan when the resident overdosed with alcohol, marijuana, and fentanyl that he got from someone outside the facility. RNUM-CC said that after the incident they provided training about alcoholism, but it was general training, not symptoms or signs to look for by the Certified Nursing Assistants. The CNAs are not specifically trained on SUDs. [R17] was referred to psychiatry/psychology but refused to see them. We cannot do anything because [R17] is their own responsible party. Now that [R17] is not on 15-minute checks, the CNAs don't keep track of when he is in the building or out, or if he is misusing drugs or alcohol.
On 12/13/22 at 8:45 a.m., CNA-JJ described a SUD as taking drugs or alcohol. CNA-JJ stated that she did not receive training on SUDs or behavioral health needs.
On 12/13/22 at 10:32 a.m., Licensed Practical Nurse (LPN)-GG said she received training on SUDs at her previous job, but not at this facility.
On 12/13/22 at 10:34 a.m., RN-HH said they provided care for a resident who was obviously drunk, and that the resident returned to the facility with a six pack of beer to put in the refrigerator for later. It was unclear when this incident occurred; the resident was no longer residing in the facility at the time of survey.
On 12/13/22 at 10:42 a.m. during an interview with the Social Services Director (SSD-FF), SSD-FF said, [R17] has episodes of taking narcotics and drinking alcohol. I believe he bought something on the street and was doing an ingestible substance. The only thing I can do is to encourage [R17] to be careful of [about] what he buys at the gas station, like gummies and alcohol, as he independently walks around everywhere. When the Surveyor asked about staff training on behavioral health needs, alcoholism or substance use disorders, SSD-FF said, I ask the Ombudsman for outside resources. The CNAs are so new with a high turnover rate, so we need to remind the nursing caregivers to provide care. SSD-FF stated, The CNAs don't have a lot of training through the Wisconsin training, or they are agency nurses. Programs with substance use and alcohol are a much-needed thing that I want to implement in the future. The only program we offer about SUD is a smoking cessation group [that was offered] before the [coronavirus disease 2019] outbreak. We want our facility to be safe. I would love to have some information on behavioral health and substance use disorders for [R2, R10, R14, and R17].
During an interview on 12/13/22 at 12:28 p.m. with Social Services (SS)-R, SS-R said, [R17] has been involved and has been accused of drinking and doing drugs. [R17's] case workers from the insurance company said the family has brought him drugs and alcohol. SS-R said, The day [R17] had the suspected overdose [on 11/19/22], [R17's] son was here, and I [SS-R] notified the case workers. The case workers said that was common for [R17] to have drugs and alcohol. The nursing staff would have gone to [SSD-FF] and told [SSD-FF] about drinking and drugs. Alcohol and drugs are substances that would be included in SUDs. I think it would be good to have education on SUDs and behavioral health needs.
On 12/13/22 at 12:43 p.m., CNA-DD who was responsible for providing care for R17 (who had a SUD as indicated above), said she never received training on substance abuse or behavioral health. CNA-DD was not aware of R17 being out of the building and did not know R17's whereabouts. R17 was not in the facility on 12/13/22; according to sign out documentation, the resident was on a walk. R17 returned to the facility at 12:45 p.m.
Dec 2021
20 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 4 (R59, R97, R93 and R18) of 22 residents reviewed for qu...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that 4 (R59, R97, R93 and R18) of 22 residents reviewed for quality of care received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, that will meet each resident's physical, mental, and psychosocial needs.
1. R59 had orders for 2 Comprehensive Metabolic Panel (CMP) lab draws to be completed on 11/8/21 and 11/15/21. The labs were not ordered and never completed. There was no follow up from the facility to ensure the labs were completed as ordered. On 11/15/21 R59 was hospitalized for acute renal failure Stage 3, hypocalcemia with recent treatment of hypercalcemia, mild hyperkalemia and decreased bicarbonate. These changes and abnormal lab values could have been identified had the 11/8/21 and the 11/15/21 labs been drawn.
2. R97 had a surgical wound. The facility did not follow MD orders for care and treatment.
3. R93 sustained a toe injury and was not having diabetic foot checks or care to that area.
4. R18 had missing assessments of blisters to the right lower leg and R18 was not comprehensively assessed for six days when readmitted to the facility.
The example involving R59 is being cited at a scope/severity of a G (actual harm/isolated).
Findings include:
1. Surveyor reviewed facility's Lab Diagnostic Test Results - Clinical Protocol policy with a revision date of November 2018. Documented was:
Assessments and Recognition
1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.
2. The staff will process test requisitions and arrange for tests.
3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility .
R59 was admitted to the facility 9/2/21 with diagnoses that included Cyst of Pancreas, Chronic Kidney Disease Stage 3 and Severe Protein Calorie Malnutrition.
Surveyor reviewed Progress Notes documented by Former Nurse Practitioner (NP)-D. Documented on 10/6/21 was:
[History of Present Illness (HPI)]: The patient was admitted to the [facility] on 9/2/21 after a 2-week long hospital stay. The patient presented to the hospital with abdominal pain, nausea and vomiting. After further review, the patient recently underwent a pancreatic necrosectomy and a diverting colostomy with a GJ tube that was converted to a G-tube due to necrotizing infected pancreatitis with colonic pancreatic fistula. After further workup, the patient was found to have [acute kidney injury (AKI)]. She was started on IV fluids and given pain medications and antiemetics.
Due to the patient's dementia, she is unable to contribute to historical health information. After further review, the patient's health history includes hypertensive heart failure, hyperlipidemia, coronary artery disease, anemia, and on a long-term anticoagulant. She has seasonal/environmental allergies, chronic obstructive pulmonary disease and obstructive sleep apnea. She has anxiety and depression and is followed by psych. The patient is malnourished, has dysphagia, gastro-esophageal reflux disease, and the presence of colostomy. She has hypothyroidism, diabetes mellitus type II, and chronic kidney disease stage 3 without the use of insulin. She has rheumatoid arthritis, osteoporosis and an unsteady gait with a history of falls .
CARE PLAN / ASSESSMENT ICD 10 or [diagnosis (DX)]:
Chronic kidney disease, unspecified
-New order for repeat [Basic Metabolic Panel (BMP)]
-Monitor intake and output
-Monitor weight
-Monitor BMP
-Monitor vitals
-Avoid nephrotoxic medications .
Surveyor reviewed BMP labs ordered and drawn on 9/16/21. Results were reviewed by NP-D and no new orders were given.
Lab results were:
Potassium: 4.3 (normal reference range 3.4 - 5.1)
Blood Urea Nitrogen (BUN): 35 High (normal reference range 6 - 23)
Creatinine: 2.35 High (normal reference range 0.70 - 1.30)
Calcium: 12.4 High (normal reference range 8.4 - 10.2)
Surveyor reviewed BMP labs ordered and drawn on 9/24/21. Results were reviewed by NP-D and no new orders were given.
Lab results were:
Potassium: 3.8 (normal reference range 3.4 - 5.1)
BUN: 29 High (normal reference range 6 - 23)
Creatinine: 2.11 High (normal reference range 0.70 - 1.30)
Calcium: 12.2 High (normal reference range 8.4 - 10.2)
Surveyor reviewed BMP labs ordered and drawn on 10/1/21. Results were reviewed by NP-D and no new orders were given.
Lab results were:
Potassium: 3.8 (normal reference range 3.4 - 5.1)
BUN: 36 High (normal reference range 6 - 23)
Creatinine: 1.88 High (normal reference range 0.70 - 1.30)
Calcium: 11.9 High (normal reference range 8.4 - 10.2)
Surveyor reviewed BMP labs ordered and drawn on 10/6/21. Results were reviewed by NP-D and no new orders were given.
Lab results were:
Potassium: 4.1 (normal reference range 3.4 - 5.1)
BUN: 32 High (normal reference range 6 - 23)
Creatinine: 1.88 High (normal reference range 0.70 - 1.30)
Calcium: 12.1 High (normal reference range 8.4 - 10.2)
Surveyor reviewed R59's MD orders with a date of 10/12/21. Documented was discontinue Sodium Bicarbonate. There was no further BMP, CMP or other labs to monitor Potassium, BUN, Creatinine, Calcium or Sodium Bicarbonate from 10/12/21 through 11/5/21. NP-D was not employed at the facility after 10/18/21 and MD-L continued to follow R59 and write orders.
Surveyor reviewed R59's MD-L's orders with an order date of 11/5/21. Documented with a start date of 11/8/21 was CMP, one time only for 1 Day. This order was documented Completed on 11/9/21. Documented with a start date of 11/15/21 was CMP and [Vitamin D], one time only for 1 Day. This order was documented Completed on 11/16/21.
Surveyor reviewed R59's hard chart, Electronic Medical Record and lab results provided by the facility. There were no lab results from 11/8/21. The lab results from 11/15/21 included a stool sample lab and a blood test but did not include a CMP or Vitamin D lab test as ordered.
Surveyor reviewed R59's Progress Notes with a date of 11/15/21. Documented at 3:35 PM was Patient transported to a local ED after discussing her condition with [NP]. Patient had been complaining of headache past several days .
Surveyor reviewed Hospital Paperwork with an admission date of 11/15/21 and discharge date of 11/24/21. Documented was:
Hospital Course .
Acute renal failure on stage 4 chronic kidney disease
Electrolyte derangements including Hypocalcemia with recent treatment for hypercalcemia, hyperkalemia, hypomagnesemia .
-IV fluids per Nephrology. Creatinine on admission 3 (with baseline creatinine on 09/23/2021 2.1) -> improved 1.9 with fluids, at baseline.
-calcium gluconate per nephrology
-ionized calcium ordered
-phosphorus normal
-Vitamin-D ordered
Mild hyperkalemia
-no acute changes on [electrocardiogram (EKG)]
-use IV fluids
-nephrology on consult, started on Veltessa. Placed on 70 mEq per day oral potassium restriction. Continue oral sodium bicarbonate. Attached 5.9 -> 5.6.
-cleared for discharge and follow with Nephrology outpatient
Severe Hypomagnesemia - replaced and corrected, replaced
Decreased bicarbonate
-likely secondary to her renal disease
-has been on sodium bicarbonate .
Laboratory values:
11/15/21 [4:05 PM]
BUN: 56 High (normal reference range 6 - 23)
Creatinine: 3.03 High (normal reference range 0.70 - 1.30)
Calcium: 5.3 Low (normal reference range 8.4 - 10.2) .
On 12/02/21 at 10:43 AM Surveyor interviewed Registered Nurse (RN)-G. Surveyor asked who puts lab orders in and the process followed. RN-G stated the nurse who takes the order is in charge of putting in the labs. RN-G stated they go in 2 places; first the order is entered into the patients Electronic Medical Record and second they are entered into the lab online system so lab comes out to draw it. RN-G stated this is done on the computer with a login and password. Surveyor asked if someone was in charge of checking to make sure the labs were completed and drawn. RN-G stated she was not sure and that would be above me noting someone in management.
On 12/2/21 at 12:02 PM Surveyor interviewed anonymous Medical Professional (MP)-U. Surveyor asked MP-U why a medical professional would order labs. MP-U stated they would order labs on admission to get a baseline and then routinely as needed depending on the patient. Surveyor asked what labs would be monitored for R59. MP-U said BMP to include BUN and Creatinine and electrolytes. Surveyor asked if the labs on 11/8/21 and 11/15/21 were drawn, would it be possible to correct or possibly avoid the acute renal failure and electrolyte derangements that R59 needed to be hospitalized for. MP-U stated yes, by monitoring these labs you could have monitored and see if they were trending up. MP-U stated it certainly would have given an indication that something was going on with the resident that could have allowed a change in treatment and avoid hospitalization.
On 12/02/21 at 2:04 PM Surveyor interviewed Regional Nurse Consultant (RNC)-C. Surveyor asked who puts lab orders in and the process followed. RNC-C stated the nurse who takes the order is in charge of putting in the labs. Surveyor asked how the lab receives the order. RNC-C stated the orders are entered into the labs online portal called Test Direct. Surveyor asked if the facility has any system to know what labs were completed. RNC-C stated the facility has a lab binder. Surveyor asked if that confirms labs were drawn per order. RNC-C stated no. Surveyor noted the CMP labs on 11/8/21 and 11/15/21 that were not drawn. RNC-C stated she is not sure why they were not drawn. RNC-C checked the online portal system and those 2 labs were never put into the system to be drawn. RNC-C stated the nurse who took that order should have entered them into the online portal. Surveyor asked if there was any other documentation noting why these labs were not completed. No additional information was provided.
4.) R18 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia, diabetes with peripheral angiopathy, chronic obstructive pulmonary disease, peripheral venous insufficiency, and congestive heart failure. R18's Annual Minimum Data Set (MDS) assessment dated [DATE] indicated R18 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and coded R18 as being independent with bed mobility and transfers.
R18's Impaired Skin Integrity Care Plan was initiated on 1/4/2020.
On 9/17/2021 at 2:57 AM in the progress notes, a Registered Nurse (RN) charted R18 had fluid draining down the right lower leg and two open areas were noted on the right lower lateral shin draining serous drainage with no signs of infection. Nursing charted the area appears to be opened blisters related to edema. Nursing notified the Nurse Practitioner.
R18's Impaired Skin Integrity Care Plan was revised with interventions to elevate the legs to reduce edema and have the wound team monitor the wounds.
On 9/17/2021, an Initial Wound Assessment was completed on both open areas of the right lower leg measuring 2.0 cm x 2.2 cm x 0.1 cm and 0.5 cm x 2.0 cm x 0.1 cm with the wound base 75% granulation and 25% slough for both areas.
On 9/17/2021, an SBAR Communication Form was completed indicating R18 had a skin wound or ulcer in an area where a wound had been before, with edema and a blister.
On 9/18/2021, a treatment was started of oil emulsion non-adhesive dressings to both areas followed by an ABD bandage and wrapped with rolled gauze and tubi grip daily.
No documentation of weekly comprehensive assessments was found of the right lower leg wounds after the initial assessment on 9/17/2021.
On 10/12/2021, R18 was transferred to the hospital.
On 10/18/2021 at 11:03 PM in the progress notes, an RN charted R18 was readmitted to the facility at 5:30 PM and a skin assessment was completed. No skin assessment documentation was found on 10/18/2021.
A treatment to the right lower leg was continued as prior to hospitalization.
No Admit/Readmit Assessment was completed on 10/18/2021 when R18 returned to the facility.
On 10/24/2021 an Admit/Readmit Assessment was completed and the Skin Integrity section of the form documented R18 had a vascular wound to the left lower leg measuring 4.0 cm x 3.2 cm with no depth and a description stating the wound was venous. The documentation of the location of the wound was incorrect: the wound was on the right lower leg. This assessment was six days after R18 had been readmitted to the facility.
On 10/26/2021 on the Weekly Wound Assessment form, nursing documented the vascular wound to the right lower leg measured 4.0 cm x 3.2 cm x 0.1 cm with 100% granulation.
The wound to the right lower leg was comprehensively assessed weekly from 10/26/2021 until the time of the survey.
In an interview on 11/29/2021 at 3:06 PM, R18 stated there is a wound to the right lower leg that gets a treatment almost every day and R18 had no concerns with the wound treatment being completed. Surveyor verified that a treatment was ordered to be completed every three days.
In an interview on 12/6/2021 at 12:27 PM, Surveyor shared with Director of Nursing (DON)-B and Regional Nurse Consultant-C the concerns R18 did not have weekly comprehensive assessments of the right lower leg wounds after the initial discovery on 9/17/2021 until R18 was admitted to the hospital on [DATE], when R18 was readmitted to the facility on [DATE] a complete assessment was not done for six days until 10/24/2021, and the skin assessment was not completed until 10/26/2021. Regional Nurse Consultant-C stated the readmission assessment on 10/24/2021 should have been the right leg instead of the left leg. Surveyor asked when would the facility expect a readmission assessment to be completed. Regional Nurse Consultant-C stated it should have been done as soon as the resident got into the building. Regional Nurse Consultant-C agreed with Surveyor the wounds should have been assessed weekly and documented in R18's medical record. No further information was provided at that time.
2.) R93 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Diabetes Mellitus and Anxiety Disorder.
R93's admission MDS (Minimum Data Set) dated 11/5/21 documents a BIMS (Brief Interview for Mental Status) score of 11, indicating that R93 has moderate cognitive impairment.
R93's Diabetes Mellitus management care plan dated as initiated on 11/1/21 documents under the Interventions section, Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness.
On 11/29/21 at 10:24 a.m., Surveyor interviewed R93 regarding the quality of care at the facility. R93 informed Surveyor that he had recently stubbed his right big toe on the dresser and that a nurse came and just put a Band-Aid on it. R93 informed Surveyor that he was concerned that since then, nursing staff had not come to evaluate the area and or change the Band-Aid.
Surveyor reviewed R93's medical record, including R93's MAR (Medication Administration Record) and TAR (Treatment Administration Record) and was unable to locate any documentation that facility staff had assessed or treated R93's right toe and or that facility staff was inspecting R93's feet daily as documented in R93's diabetes management care plan.
On 11/30/21 at 2:51 p.m., Surveyor observed CNA (Certified Nursing Assistant)-N remove R93's socks. Surveyor observed some dried blood on R93's left toe nail and a scab on his right toe.
On 11/30/21 at 2:59 p.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. NHA-A informed Surveyor that she would get nursing staff to assess R93's feet and would follow up with Surveyor.
R93's nursing note dated 11/30/21 at 4:06 PM documents, Nurses Note Text: This writer was informed that resident complained that he bumped his toe on his dresser a few days ago and a nurse put on band aid on it. Writer went and talked to resident he states that maybe 5-6 days ago he bumped his right big toe un the dresser and he got a small cut he stated he told a nurse and she put a band aid on it. No band aid noted. Right great toe has a 1.5 x 1.5 (centimeter) scab on it no s/sx (signs or symptoms) of infection. Resident denies any pain. No treatment needed at this time. NP (nurse practitioner) aware NNO (no new orders).
On 12/1/21 at 10:32 a.m., Surveyor informed DON (Director of Nursing)-B and RN (Registered Nurse) Consultant-C of the above findings. Surveyor asked RN Consultant-C if R93 should be getting daily foot checks as documented in R93's diabetes management plan of care.
RN Consultant-C reviewed R93's medical record and informed Surveyor that R93 should be getting daily foot checks as documented in R93's plan of care. RN Consultant-C informed Surveyor that she had added daily foot checks to R93's TAR (Treatment Administration Record) so that it could be completed daily.
No additional information was provided.
3.) R97 was admitted to the facility on [DATE] with diagnoses that included Quadriplegia, Bipolar Disorder, Schizophrenia, Diabetes Mellitus Type II and Sepsis.
R97's admission MDS (Minimum Data Set) dated 8/29/21 documents a BIMS (Brief Interview for Mental Status) score of 10, indicating that R97 is moderately cognitively impaired.
Section G (Functional Status) documents that R97 requires extensive assistance and a two person physical assist for his bed mobility needs.
Section G0400 (Functional Limitation in Range of Motion) documents that R97 has impairment to one side of his upper extremities and no impairment to either side of his lower extremities.
Section M (Skin Conditions) documents that R97 was admitted to the facility with 1 surgical wound present upon admission to the facility.
R97's Skin Integrity care plan dated as initiated on 8/23/21 documents under the Focus section, Resident has impaired skin integrity .surgical wound to RLE (right lower extremity)- resolved 11/23/21.
Under the Interventions section it documents, Treatment as ordered.
R97's wound assessment dated [DATE] documents, right lower extremity- surgical incision; measurements: 12.5 (centimeters) x 4.3 cm x 0; Description: scab; Treatment: betadine.
Surveyor noted that R97 received weekly wound assessments and daily treatments for his Right lower extremity surgical wound from 8/24/21 to 9/14/21.
R97's Tissue Analytics assessment as completed by Wound MD (Medical Doctor)-P and dated 9/14/21 documents, Location: Right shin; Length: 10.23 cm, Width: 2.67 cm, Depth 0.10 cm, Etiology: Trauma, Woundbed Assessment: Eschar: 76-100%, Plan of Care: Discussed with facility staff.
Surveyor noted that per Wound MD-P's documentation, R97's right shin surgical wound was debrided by Wound MD-P on 9/14/21.
R97's Tissue Analytics post debridement assessment as completed by Wound MD-P, dated 9/14/21 documents, Location: Right Shin; Length: 10.93 cm, Width: 3.20 cm; Depth 0.20 cm; Etiology: Trauma; Woundbed Assessment: Granulation 1-25%, Slough 51-75%; Orders: Cleanse wound with saline; protect periwound with skin prep, apply silver gel to wound bed, cover wound with ABD (Army Battle Dressing), secure dressing with Kerlix, change daily, Change PRN (as needed) for soiling and/or saturation.
R97's Orthopedic Clinic Visit Notes dated 9/21/21 documents, RLE (Right Lower Extremity): Right lower extremity incision is open. Please put on wound vac (vacuum) on this incision that is okay today when patient arrives back to facility. Dressing changes need to bed 3 x (times) a week.
R97's Physician Progress Notes from the orthopedic clinic dated 9/21/21 documents, Ortho trauma, Okay to shower/needs shower; cover right leg in shower. Please put wound vac on right leg today; please do dressing changes 3 times a week. Please call us with wound concerns.
Surveyor was unable to locate any documentation in R97's medical record that R97's physician or Wound MD-P was notified of the above orders. Surveyor was unable to locate any documentation that any facility staff followed up on R97's orthopedic clinic orders dated 9/21/21.
Surveyor was unable to locate any documentation in R97's medical record that the above orders for a wound vacuum to be applied to R97's right lower extremity wound were followed and implemented by facility staff on 9/21/21.
R97's wound assessment dated [DATE] documents, right lower extremity- surgical incision; measurements: 13.2 (centimeters) x 2.16 cm x 0.2; Description: 75% granulation 25% slough, small drainage; Treatment: change to skin prep.
R97's Tissue Analytics wound assessment as completed by Wound MD-P, dated 9/28/21 documents, Location: Right Shin; Length: 6.05 cm, Width: 2.16 cm; Depth 0.20 cm; Etiology: Trauma; Woundbed Assessment: Granulation 51-75%, Slough 1-25%; Orders: Cleanse wound with saline; protect periwound with skin prep, apply santyl to wound bed, cover wound with bordered gauze, change daily, Change PRN (as needed) for soiling and/or saturation.
Surveyor was unable to locate any documentation that R97's 9/21/21 wound vacuum orders were implemented by the facility. Surveyor was unable to locate any documentation from Wound MD-P that he was aware of R97's 9/21/21 wound vacuum orders or any documentation from Wound MD-P that stated why a wound vacuum was inappropriate for R97.
R97's Tissue Analytics wound assessment as completed by Wound MD-P, dated 10/5/21 documents, Location: Right Shin; Length: 10.73 cm, Width: 3.28 cm; Depth 0.20 cm; Etiology: Trauma; Woundbed Assessment: Granulation 51-75%, Slough 1-25%; Orders: Cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep, apply santyl to wound bed, apply alginate to wound bed, change daily, change PRN (as need) for soiling and/or saturation.
Surveyor was unable to locate any documentation that R97's 9/21/21 wound vacuum orders were implemented by the facility. Surveyor was unable to locate any documentation from Wound MD-P that he was aware of R97's 9/21/21 wound vacuum orders or any documentation from Wound MD-P that stated why a wound vacuum was inappropriate for R97.
R97's Tissue Analytics wound assessment as completed by Wound MD-P, dated 10/12/21 documents, Location: Right Shin; Length: 10.73 cm, Width: 3.28 cm; Depth 0.20 cm; Etiology: Trauma; Woundbed Assessment: Granulation 51-75%, Slough 1-25%; Orders: Cleanse with 1/2 strength Dakin's solution, protect periwound with skin prep, apply santyl to wound bed, apply alginate to wound bed, change daily, change PRN (as need) for soiling and/or saturation.
Surveyor was unable to locate any documentation that R97's 9/21/21 wound vacuum orders were implemented by the facility. Surveyor was unable to locate any documentation from Wound MD-P that he was aware of R97's 9/21/21 wound vacuum orders or any documentation from Wound MD-P that stated why a wound vacuum was inappropriate for R97.
R97's Tissue Analytics wound assessment as completed by Wound MD-P, dated 10/12/21 documents, Location: Right Shin; Length: 9.82 cm, Width: 3.31 cm; Depth 0.10 cm; Etiology: Trauma; Woundbed Assessment: Granulation 76-100%; Orders: Cleanse wound with saline, protect periwound with skin prep, apply Xeroform gauze (cut to size) to wound bed, cover wound with ABD (Army Battle Dressing), Secure dressing with Kerlix, change daily, change PRN (as needed) for soiling and/or saturation.
Surveyor was unable to locate any documentation that R97's 9/21/21 wound vacuum orders were implemented by the facility. Surveyor was unable to locate any documentation from Wound MD-P that he was aware of R97's 9/21/21 wound vacuum orders or any documentation from Wound MD-P that stated why a wound vacuum was inappropriate for R97.
R97's Orthopedic Clinic Visit Notes dated 10/15/21 documents, RLE (Right Lower Extremity): Right lower extremity incision is open (orthopedics is following this wound). Please put on wound vac (vacuum) on this incision that is okay today when patient arrives back to facility. Dressing changes need to bed 3 x (times) a week; Plan: Doctor is following this wound as this is their incision from surgery so we will be providing instructions for wound care. Please continue to use of wound vac until we see him back in clinic on 10/26/21. Patient needs to see infectious disease team- Infectious Disease Clinic at 414- .
R97's Physician Progress Notes from the orthopedic clinic dated 10/15/21 documents, See attached. Put wound vac on asap (as soon as possible); Keep on until our next visit. Change vac dressing 3 times a week.
Surveyor was unable to locate any documentation in R97's medical record that the above orders for a wound vacuum to be applied to R97's right lower extremity wound were followed and implemented by facility staff on 10/15/21. Surveyor was also unable to locate any documentation from facility staff that the infectious disease clinic was contacted by facility staff for R97 as documented in R97's Orthopedic Clinic Visit Notes dated 10/15/21.
R97's nursing note dated 10/15/21 documents, Type: Nurses Note Text: MD CONTACT: Staff Member contacted B@B (name of facility) today. Stated that this resident was to have a Wound Vac and wanted to know why it had not been started. Author could not answer that question; informed her that author would have to review the orders. Dr (doctors)'s office would like a supervisor to contact them regarding this issue.
R97's nursing noted completed by LPN (Licensed Practical Nurse)-S and dated 10/15/21 documents, Type : Nurses Note Text: Writer received phone call from ortho office. Resident was seen and orders to have wound vac placed. Writer explained resident has been seen by wound doctor here in facility and Wound MD-P has stated wound vac is not appropriate this RLE wound. Writer gave ortho office Wound MD-P, phone number and faxed over wound assessment to ortho office. At this time wound vac is not ordered by Wound MD-P and continue treatment as ordered and wound is healing evidenced by assessment.
On 12/2/21 at 1:02 p.m., Surveyor interviewed Wound MD-P regarding R97's right shin surgical wound. Surveyor asked Wound MD-P if he was aware of R97's orthopedic recommendations dated 9/21/21 and 10/15/21 for a wound vacuum placement on R97's right lower extremity. Wound MD-P informed Surveyor that he was informed by LPN-S that the orthopedic clinic wanted a wound vacuum placed on R97's right lower extremity on 10/15/21 and not prior to that. Wound MD-E informed Surveyor that he was not aware that the wound vacuum recommendation was initially made on 9/21/21. Wound MD-P informed Surveyor that due to the granulation in R97's right lower extremity wound, he felt that a wound vacuum was inappropriate for R97.
Surveyor asked Wound MD-P if he had been made aware that R97's right lower extremity wound was referred to the infectious disease clinic on 10/15/21. Wound MD-P informed Surveyor that he was not made aware that R97's right lower extremity wound was referred to the infectious disease clinic on 10/15/21.
Surveyor asked Wound MD-P if he had spoken to the orthopedic clinic regarding the disagreement on the placement of a wound vacuum for R97, as Surveyor was unable to locate any documentation in R97's medical record that he (Wound MD-P) had documented a reason for disregarding the orthopedic surgeon's physician orders. Wound MD-P informed Surveyor that he never spoke to the orthopedic clinic regarding the disagreement on the placement of a wound vacuum for R97 as he assumed LPN-S had informed the clinic to contact him (Wound MD-P). Wound MD-P informed Surveyor that he felt the wound vacuum order was for another wound and not R97's right lower extremity, but informed Surveyor that he was not aware of R97's orthopedic clinic orders or recommendations.
On 12/2/21 at 3:07 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. At the time, no additional information was provided.
On 12/6/21 at 2:47 p.m., Surveyor informed LPN-S of the above findings. Surveyor asked LPN-S if she had been aware that R97's orthopedic clinic had provided physician orders for the placement of a wound vacuum on R97's right lower extremity on 9/21/21. LPN-S informed Surveyor that she was not aware that R97's orthopedic clinic had provided physician orders for the placement of a wound vacuum on R97's right lower extremity on 9/21/21. Surveyor asked LPN-S if she had been made aware that R97's right lower extremity wound was referred to the infectious disease clinic on 10/15/21. LPN-S informed Surveyor that he was not made aware that R97's right lower extremity wound was referred to the infectious disease clinic on 10/15/21.
Surveyor asked LPN-S if she had reached out to the orthopedic clinic to inform them that Wound MD-P did not want a wound vacuum placed on R97's right lower extremity on 10/15/21. LPN-S informed Surveyor that she only reached out to the orthopedic clinic to provide them with Wound MD-P's contact information and that she assumed Wound MD-P would clear up any confusion with the orthopedic clinic.
No additional information was provided as to why the facility did not ensure that R97's right lower extremity wound received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure residents were monitored for weight loss and comprehensively a...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure residents were monitored for weight loss and comprehensively assessed when a weight loss occurred for 1 (R91) of 6 residents reviewed for weight loss.
R91 was admitted on [DATE] with a weight of 221.4 pounds. On 11/11/2021, R91 weighed 172.4 pounds, a 49-pound weight loss or 22.13%. The physician and dietician were not notified of the weight loss and R91 was not reweighed to determine if the weight was accurate.
Findings include:
The facility policy and procedure entitled Weight and Hydration Management Practice Guidelines dated 2/2016 states: Obtaining Weight: . 2. Weigh all residents upon admission and readmission, weekly for four weeks and then monthly or as indicated by physician orders and/or the medical status of the resident. admission weight will be input in (electronic charting system) to establish baseline weight. 4. As residents are weighed, staff can compare current weight to previous weight. Residents with weight variance are reweighed within 24 hours. Weight variance include and require reweight: a. Weight change of 5 lbs. 8. Residents identified as significant weight loss will have a SBAR completed and physician and family will be notified. 10. Registered dietician will be informed of any residents with significant weight loss for assessment and recommendations.
R91 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, anxiety, and depression. admission weight was 221.4 pounds. R91's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R91 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and coded R91 being independent with eating. The Nutrition Care Area Assessment (CAA) documented R91 had morbid obesity.
The hospital discharge summary documented R91 weighed 220 pounds on 10/28/2021.
R91's diet order on admission was a regular diet with thin liquids. No restrictions were ordered.
On 11/4/2021, Registered Dietician (RD)-K initiated a Nutritional Assessment on R91. RD-K documented R91 was morbidly obese and on a restricted diet. RD-K documented R91's intake had been good and remained a moderate risk due to R91 not liking pork, having no bottom teeth with top dentures, and Speech Therapy was consulted to determine the best consistency of food for R91. The Nutritional Assessment was signed 11/10/2021.
On 11/8/2021, R91's diet was downgraded to a low fat, low cholesterol diet of mechanical soft texture with regular thin consistency liquids.
On 11/9/2021 at 11:22 AM in the progress notes, nursing charted R91 was tolerating the downgraded mechanical soft diet with a good appetite and no issues with chewing or swallowing.
On 11/9/2021 at 8:01 PM in the progress notes, nursing charted R91 did not have any issues related to the recent diet change and appetite is good consuming 100% of the meal without difficulty chewing or swallowing.
On 11/10/2021 at 10:40 AM in the progress notes, nursing charted R91 was being monitored for recent abdominal pain; no gastrointestinal upset that shift with no complaint of nausea, vomiting, or loose stools. Nursing charted no issues were noted from the recent downgrade to mechanical soft diet.
A Nutritional Care Plan was initiated on 11/10/2021 for R91 being on a low fat, low cholesterol mechanical soft diet with interventions to encourage diet compliance, provide diet per order, a speech therapy evaluation, and weigh R91 per orders.
On 11/11/2021, R91 weighed 172.4 pounds.
No documentation was found indicating the physician was notified, the Registered Dietician was notified, or a re-weight was completed to verify the accuracy of the 49-pound weight loss in thirteen days, a 22.13% weight loss.
On 11/29/2021 at 1:50 PM, Surveyor observed R91 in a wheelchair in the common area participating in activities.
On 11/30/2021 at 8:11 AM, Surveyor observed R91 sleeping in bed.
On 12/1/2021 at 2:24 PM in the progress notes, RD-K charted a weight loss of approximately 50 pounds was noted from 10/29/2021 and a reweight was requested. RD-K noted R91 was eating very good and was awaiting a reweight.
On 12/1/2021 at 8:04 PM in the progress notes, nursing charted R91 was upset with the mechanical soft diet. Nursing charted therapy was consulted and R91 had issues with pocketing food, having a bolus of food in the back of the throat, and a wet voice after eating.
On 12/2/2021 at 4:42 PM in the progress notes, the physician documented a routine visit note. The physician documented R91 had a history of alcoholism with alcoholic liver disease and lab values form 11/15/2021 were reviewed. Significant lab values included high glucose 197, high bilirubin 2.8, high alkaline phosphate 191, and low albumin 2.8. (High glucose, high bilirubin, high alkaline phosphate, and low albumin can be attributed to liver disease. Low albumin may also show malnutrition.) The physician documented R91's weight was labile and difficult to determine a trend but appeared to be down ten pounds from the average 180 pounds and was on diuretics to control edema. The physician documented R91 was concerned about the diet and wants to eat pizza, but the low fat, low cholesterol diet was not giving R91 many options due to the soft mechanical diet. The physician documented no concerns were reported by nursing staff. The physician documented R91 had a good appetite and wanted more food and had no significant weight change. The Assessment/Plan section of the physician note stated: Severe protein caloric malnutrition: alb 2.6. Start protein supplement.
On 12/3/2021, R91's diet order was changed to regular mechanical soft diet; the restrictions had been lifted.
A protein supplement, as stated in the physician note, was not added to R91's orders.
R91's Nutrition Care Plan was not revised with the change in diet order.
In an interview on 12/2/2021 at 4:31 PM, RD-K stated RD-K saw R91 for the first time on 11/4/2021 because RD-K was new to the facility at that time. RD-K stated Speech Therapy had decreased R91's diet to a mechanical soft due to difficulty chewing and swallowing. Surveyor asked RD-K if the facility had notified RD-K when R91 had a 49-pound weight loss. RD-K stated no, the facility had reached out to RD-K regarding other residents but did not say anything about R91's weight loss. Surveyor asked RD-K if RD-K would have expected to be notified of R91's weight loss. RD-K stated yes, it would be an expectation to be notified when there was that much of a weight loss. RD-K stated the facility should have done a re-weight at the time the drastic weight loss was recognized, but RD-K stated that had not been done. RD-K stated RD-K looked at R91 on 12/1/2021 and requested a re-weight to be completed. RD-K looked in R91's electronic record during the interview and stated R91 still had not been re-weighed.
On 12/3/2021, R91 weighed 180.6 pounds.
In an interview on 12/6/2021 at 12:23 PM, Surveyor shared with Director of Nursing (DON)-B and Regional Nurse Consultant-C the concerns regarding R91's weight loss. R91 weighed 221.4 pounds on admission on [DATE] and weighed 172.4 pounds on 11/11/2021, a loss of 49 pounds, or 22.13%. Surveyor shared the hospital had documented R91 weighing 220 pounds just prior to admission to the facility which was similar to the facility admission weight. R91 was not weighed weekly as per the facility policy for new admissions, a re-weight was not obtained on 11/11/2021 when the weight was significantly less than the previous reading, and the physician and dietician were not notified of the significant weight loss.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility did not ensure that 1 (R80) of 22 residents reviewed had a clean, comfortable, sanitary, orderly and homelike environment.
* R80's room...
Read full inspector narrative →
Based on observation, interview and record review, the facility did not ensure that 1 (R80) of 22 residents reviewed had a clean, comfortable, sanitary, orderly and homelike environment.
* R80's room was observed to have brown stains at the base of his feeding pole. R80's room heating and cooling unit was observed to have the front plastic cover off, exposing wires and internal components.
Findings include:
On 11/29/21 at 10:20 a.m., Surveyor observed R80's room to have brown stains at the base of his feeding pole. Surveyor noted that the stains, brown in color, appeared to be from R80's enteral feeding formula.
Surveyor also observed the heating and cooling unit to have front plastic cover off, exposing wires and internal components.
On 11/29/21 at 3:40 p.m., Surveyor observed R80's room to have brown stains at the base of his feeding pole. Surveyor noted that the stains, brown in color, appeared to be from R80's enteral feeding formula.
Surveyor also observed the heating and cooling unit to have front plastic cover off, exposing wires and internal components.
On 11/30/21 at 8:53 a.m., Surveyor observed R80's room to have brown stains at the base of his feeding pole. Surveyor noted that the stains, brown in color, appeared to be from R80's enteral feeding formula.
Surveyor also observed the heating and cooling unit to have front plastic cover off, exposing wires and internal components.
On 11/30/21 at approximately 3:10 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. At the time, no additional information was provided.
On 12/1/21 at 8:46 a.m., NHA-A informed Surveyor that housekeeping had cleaned R80's feeding pole and that maintenance had reattached the face of R80's heating and cooling unit
No additional information was provided as to why the facility did not not ensure that R80 had a clean, comfortable, sanitary, orderly and homelike environment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 2 (R118, R119) of 2 Residents reviewed for involuntary dis...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 2 (R118, R119) of 2 Residents reviewed for involuntary discharge received a 30 day involuntary discharge notice and or a discharge notice containing specific regulatory requirements.
* The involuntary discharge notice provided to R118 on 6/22/21 did not include:
The location to which R118 was to be discharged to or transferred to, the email address for the entity receiving appeals to the 30 day involuntary discharge notice, the email address for the Office of the Long-term Care Ombudsman and the mailing and email address and telephone number for the protection and advocacy of individuals with a mental disorder, even though R118 was admitted with a diagnosis of Major Depressive Disorder.
On 10/14/21, R118 was transferred to the hospital for a change in condition. As of 11/30/21, R118 remains in the hospital awaiting placement. The facility denied R118 readmission without providing R118 with an updated or revised involuntary discharge notice with appeal rights.
* On 10/23/21 R119 requested to be sent out to the emergency room (ER). R119's Nurse Practitioner was made aware however did not give an order for R119 to be sent out.
In order for R119 to be purse further treatment outside of the facility, R119 was presented with a form titled Leaving Nursing Center Against Advice. R119 made a mark on this form. On 10/23/21, R119 was then sent to the emergency room and was admitted into the hospital.
As of 11/30/21, R119 was still in the hospital waiting for discharge. As of 12/01/21, the facility has refused to take R119 back.
The facility did not provide R119 with an involuntary discharge notice with appeal rights.
Cross Reference F626
Findings include:
Surveyor reviewed 2 facility policies and procedures in regards to R118's discharges to the hospital and being denied re-admission to the facility, which included;
1. Transfer or Discharge Notice-revised October 2016
Our facility shall provide a Resident and/or Resident's representative with a 30 day written notice of an impending transfer or discharge.
Policy Interpretation and Implementation (states in part)
3. The Resident and/or representative will be notified in writing of the following information:
a. The reason for the transfer or discharge
b. The effective date of the transfer or discharge
c. The location to which the Resident is being transferred or discharged
d. A statement of the Resident's rights to appeal the transfer or discharge, including:
1. Name, address, email and telephone number of entity which receives such requests
2. Information about to obtain, complete, and submit an appeal form
3. How to get assistance completing the appeal process
e. The facility bed-hold policy
f. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman
g. The name, address, email and telephone number of the agency responsible for the protection and advocacy of Residents with intellectual and developmental(or related) disabilities
h. The name, address, email and telephone number of the agency responsible for the protection and advocacy of Residents with a mental disorder or related disabilities
i. The name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices
4. A copy of the notice will be sent to the Office of the State Long-term Care Ombudsman.
5. The reasons for the transfer or discharge will be documented in the Resident's medical record.
6. If the information in the notice changes prior to the transfer or discharge, the recipients of the notice will be updated as soon as practicable.
11. In determining the transfer location for a Resident, the decision to transfer to a particular location will be determined by the needs, choices, and best interest of that Resident.
2. Transfer or Discharge, Preparing a Resident for-revised December 2016.
Residents will be prepared in advance for discharge.
1) R118 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Type 2 Diabetes Mellitus, Neuromuscular Dysfunction of Bladder, Other Psychoactive Substance Abuse, and Major Depressive Disorder. R118 is his own person.
R118's Quarterly Minimum Data Set (MDS) dated [DATE] documents R118's Brief Interview for Mental Status (BIMS) score of 15 which indicates R118 is cognitively intact for daily decision making skills. R118 has a Patient Health Questionnaire (PHQ-9) score of moderate depression. There are no behaviors documented.
Surveyor reviewed R118's comprehensive care plan and noted the following focused problem:
R118 requires discharge planning related to R118's preference to return to the community.
Initiated 5/8/20. Revised 9/22/20
Surveyor notes R118's discharge planning focused problem was not updated when R118 was issued the 30 day involuntary discharge notice on 6/22/21.
Surveyor reviewed the 30 day discharge notice given to R118 on 6/22/21. Surveyor notes the reason for discharge is for the safety of the individuals in the facility is endangered. A discharge meeting was scheduled for 7/1/21. There is no documentation in R118's EMR the discharge meeting occurred.
Surveyor notes the 30 day discharge notice given to R118 on 6/22/21 does not contain the following required information;
1. The location to which R118 was to be discharged to or transferred to.
2. The email address is not provided for the entity receiving appeals to the 30 day involuntary discharge notice.
3. The email address is not provided for the Office of the Long-term Care Ombudsman. Further, the name of the designated Ombudsman is incorrect on the 30 day involuntary discharge notice.
4. The 30 day involuntary discharge notice did not contain the contact information (mailing and email address and telephone number) responsible for the protection and advocacy of individuals with a mental disorder, even though R118 was admitted with a diagnosis of Major Depressive Disorder.
Surveyor notes upon review, there is no documentation in R118's EMR that R118 was given the 30 day involuntary discharge notice on 6/22/21 and that it was explained to R118 in a language and manner that R118 could understand. Further, there is no documentation that R118 was explained how to appeal the involuntary discharge notice and that assistance was offered to help with the appeal process. R118's EMR does not contain documentation the state ombudsman was notified of the 30 day involuntary discharge notice. R118's EMR did not contain documentation from R118's primary physician of the specific needs that could not be met, facility attempts to meet those needs, and the service available at the receiving facility to meet R118's needs.
Surveyor reviewed R118's medical record which documents;
On 10/14/21 3:42 AM Nurses Note Text: [R118] has orders to collect urine specimen to rule out UTI (Urinary Tract Infection). Assisted nurse with replacing suprapubic catheter due to poor urinary output. Foley tubing noted with large amounts of sediment clogging urinary flow. Multiple attempts made to reinsert the suprabubic catheter, all unsuccessful. Unable to get a urinary return. [R118] has a history of obstruction. Bladder scan shows no large volume residual -- 50-100cc noted. [R118] is screaming. [R118's] mentation is also changed. [R118] is alert x 4 but presents with hysteria. Called on call MD from .Health and orders given to send to ER. Paramedics arrived to send the ER. [R118] continues to scream and attempting to throw self into floor. [R118] is yelling I'm drunk and high. Called (name of Hospital) and gave report. Vitals stable upon departure. Declines family update. All documentation sent with [R118].
No updated transfer or discharge notice with appeal rights was provided to R118 upon his discharge to the hospital on [DATE].
The facility provided Surveyor with a transfer/bed hold document for [R118] and [R118] requested a bed hold. A written note on this document indicated the document was reviewed with R118 at the hospital by an un-named case manager on 10/15/21 and signed by the facility.
This document does not indicate any information pertaining to an involuntary discharge.
This notice indicated:
Effective date discharge/transfer:10/14/21,(name of facility) is transferring/discharging R118 to (name of hospital) for the following reasons:(this part Surveyor notes was left blank)
The document lists the state agency and the state long -term care ombudsman information if R118 wanted to appeal the transfer/discharge.
On 11/30/21 at 1:04 PM, Surveyor spoke to hospital social worker (HSW-Q) for R118. HSW-Q stated the facility stopped returning calls. HSW-Q stated the Administrator (NHA-A) informed HSW-Q the facility would not take R118 back because of R118's behaviors. HSW-Q called Ombudsman (O-R) and was told by O-R that R118's 30 day involuntary discharge notice was not valid because there was no discharge destination listed on it. HSW-Q validated that as of 11/30/21 R118 remains in the hospital awaiting placement at this time.
On 12/01/21 at 12:52 PM, Surveyor interviewed NHA-A in regards to R118's discharge. NHA-A gave a 30 day involuntary discharge notice to R118, but does not have documentation R118 received the 30 day notice or understood the 30 day involuntary discharge notice. NHA-A stated the facility originally denied re-admission because R118 had an expensive IV. NHA-A stated then R118 ran out of bed hold days and informed the hospital the facility would not allow R118 to return to the facility because of behaviors. Surveyor noted however, R118's EMR did not document R118 as having behavioral issues from May 2021 through October 14, 2021.
NHA-A stated NHA-A did not offer to assist HSW-Q with R118's discharge planning from the hospital.
On 12/02/21 at 1:57 PM, Surveyor spoke to O-R in regards to R118. O-R does not remember having any contact directly with R118. O-R did speak to HSW-Q on 10/26/21 and informed HSW-Q R118's 30 day discharge notice was not valid due to it not containing documentation of a discharge location. O-R did speak to R118 on 10/29/21 who indicated R118 may not want to return to the facility.
On 12/2/21 at 3:16 PM, Surveyor shared the concern with Administrator (NHA-A), Director of Nursing (DON-B), and Regional Nurse Consultant (RNC-C) that R118's 30 day involuntary discharge notice did not contain the required information per regulation. Surveyor's concern was acknowledged and no further information was provided at this time.
2) R119 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Neuromuscular Dysfunction of Bladder, Bipolar Disorder, and Attention Deficit Hyperactivity Disorder. R119 is her own person.
R119's Quarterly Minimum Data Set (MDS) dated [DATE] documents R119's Brief Interview for Mental Status (BIMS) score to be a 15, indicating R119 was cognitively intact for daily decision making. R119 had a PHQ-9 score of 3, indicating minimal depression. The MDS documented R119 had verbal behavioral symptoms and rejection of care 1-3 days during the assessment period.
Surveyor reviewed R119's medical record and noted the following nurses notes:
10/23/2021 9:41 AM Nurses Note Text: [R119] is requesting to be sent out to the emergency room (ER). [R119] tells writer she just doesn't feel good. [R119] says she feels like [R119] has a Urinary Tract Infection (UTI) and will not be cared for in the facility as [R119] feels she needs to. [R119] states, I think they don't even care and I'm leaving. Vitals taken and stable. NP (Nurse Practitioner) gives orders for Bactrim x 3 days and a repeat UA (urinalysis) with C&S (culture and sensitivity). Explained new orders to [R119]. [R119] declines treatment and states, I am leaving. NP aware. Explained AMA to the [R119]. Paperwork prepared and ready.
10/23/2021 9:41 AM Nurses Note Late Entry: [R119] tells writer [R119] isn't coming back. Tells writer watch my things, after I'm better I'll be back to get them and I'm not coming back here again. I'm getting out of this place. [R119] declines bed hold or alternatives to cares and signed AMA paperwork with Emergency Medical Technician (EMT) as witness, Certified Nursing Assistant (CNA), and this writer.
10/23/2021 9:45 AM Nurses Note Text: Called to get non- emergent transport - cannot get transport- called 911 to send to emergency room (ER) for evaluation and treat. [R119] aware and will update family on own per her statement.
10/23/2021 11:29 AM Nurses Note Text: [R119] departed via EMT transfer. Report given to EMT and paperwork given upon departure. [R119] declined cares before departure as [R119] wanted to leave right now no medications given.
10/23/2021 9:53 PM Nurses Note Text: Writer called (name of hospital) ER-[R119] was admitted for UTI and Aspiration Pneumonia at 4:00 PM. [R119] is her own person. Management aware.
On 11/30/21 at 1:06 PM, Surveyor spoke to Hospital Social Worker (HSW)-Q who stated that HSW-Q does not know how [R119] could have signed an AMA form being a quadriplegic and that [R119] was very sick and confused when [R119] arrived to the ER. HSW-Q stated [R119] was admitted to Intensive Care Unit(ICU). HSW-Q contacted the facility seeking readmission for R119. HSW-Q does not remember on what date HSW-Q spoke with a representative at the facility or with whom. HSW-Q was informed at this time, the facility would not allow R119 to return to the facility due to behaviors. HSW-Q stated that [R119] was still in the hospital waiting for discharge.
Surveyor reviewed documentation dated 10/23/21 from the hospital record and notes [R119's] chief complaint was coughing and respiratory failure, and [R119] required up to 8 liters of Oxygen (O2) on admission.
Surveyor reviewed the the AMA document dated 10/23/21. The AMA document is titled, Leaving Nursing Center Against Advice. The document indicates, I [R119] am leaving this nursing center against the advice of my attending physician and this nursing center's administration. By signing below, I acknowledge that I have been informed of the risk involved and hereby release the attending physician and nursing center staff from responsibility for an ill effects or damages which may result from my choosing to leave the center. Surveyor notes R119 signed an AMA document with a squiggly line dated 10/23/21 with 1 witness signature. Surveyor was unable to contact the witness.
On 12/1/21 at 11:05 AM, Surveyor interviewed Registered Nurse (RN-G) who was the RN involved with R119's AMA discharge. RN-G stated that RN-G had [R119] sign AMA because there was no physician order to leave. [R119] came to the desk stating [R119] had an UTI. Called the NP who ordered a collection of urine, and wanted to treat [R119] in house. RN-G stated the NP would not give an order to go to the ER. Tried to explain what the NP had stated to [R119], but [R119] kept calling RN-G the grim [NAME]. RN-G gave [R119] the AMA form to sign and [R119] said I don't have use of my hands. So RN-G told [R119] even a dot would work as a signature. RN-G does not know who the witness is.
Surveyor noted R119 signed the AMA document in order to obtain treatment outside of the facility.
On 12/01/21 at 12:57 PM, Surveyor spoke to NHA-A about R119's AMA discharge. NHA-A stated, I don't even know if we got a phone call to take [R119] back. NHA-A stated the facility would not take [R119] back into the facility due to [R119's] behaviors. NHA-A stated [R119] refused to let the facility care for [R119] at times .[R119] would sit in the chair for days . Had bad wounds and was noncompliant with the treatments. NHA- A stated [R119] would not use the electric chair on low mode and would vape in [R119's] room.
On 12/2/21 at 8:18 AM, Surveyor interviewed RN-G again and asked RN-G who instructed RN-G to have [R119] sign the AMA form. RN-G stated, no one did, I just knew that working in management at another facility; if you don't have an order it would be AMA. There is no documentation that RN-G consulted with facility management to discuss options for R119. Further, there is no documentation in R119's EMR that options to discharging AMA was discussed with R119.
There is no evidence in R119's medical record that the facility provided R119 with an involuntary discharge notice. The AMA form was presented to R119 in order to obtain outside treatment.
On 12/2/21 at 9:50 AM, Surveyor left a message for the NP who did not give an order for discharge. No return call was received.
As of 12/2/21, R119 has not been readmitted back into the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 2 (R118 and R119) of 4 Residents reviewed were permitted t...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 2 (R118 and R119) of 4 Residents reviewed were permitted to return back to the facility to the first available bed after a hospitalization. As of 11/30/21, both R118 and R119 remain in the hospital waiting for placement. As of 12/2/21, R118 and R119 have not been readmitted into the facility.
*R118 was given a 30 day discharge notice on 6/22/21 that was not valid. R118 discharged to the hospital on [DATE] and requested a bed hold. The facility informed the hospital they would not allow R118 to return to the facility.
*R119 requested to go to the hospital on [DATE] and the facility had R119 sign an Against Medical Advice (AMA) document. The facility informed the hospital they would not allow R119 to return to the facility.
Findings include:
Surveyor reviewed 3 facility policy and procedures in regards to R118 and R119's discharges to the hospital and being denied re-admission to the facility, which included;
1. Discharging a Resident Without a Physician's Approval-revised October 2016
A physician's order should be obtained for all discharges, unless a Resident or representative is discharging himself or herself against medical advice.
2. Transfer or Discharge Notice-revised October 2016
Our facility shall provide a Resident and/or Resident's representative with a 30 day written notice of an impending transfer or discharge.
3. Transfer or Discharge, Preparing a Resident for-revised December 2016
Residents will be prepared in advance for discharge.
1) R118 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Type 2 Diabetes Mellitus, Neuromuscular Dysfunction of Bladder, Other Psychoactive Substance Abuse, and Major Depressive Disorder. R118 is his own person.
R118's Quarterly Minimum Data Set (MDS) dated [DATE] documents R118's Brief Interview for Mental Status (BIMS) score of 15 which indicates R118 is cognitively intact for daily decision making skills. R118 has a Patient Health Questionnaire (PHQ-9) score of moderate depression. There are no behaviors documented.
Surveyor reviewed R118's comprehensive care plan and noted the following focused problems:
1. R118 has depression due to admission, disease process, and medication side effects.
Initiated 10/30/19, Revised 7/17/20
2. R118 has behavior problem, self mutilation, attention seeking due to self-physical abuse, self inflicting injuries. Initiated 10/30/12, Revised 1/19/21
3. R118 has an active use of alcohol. R118 becomes intoxicated and displays decreased control of social behavior/function. Initiated 1/8/20, Revised 1/12/21
4. R118 smokes/vapes. R118 has been vaping in room daily with disregard for facility's policy. Initiated 11/4/19; Revised 10/12/20
5. R118 requires discharge planning related to R118's preference to return to the community.
Initiated 5/8/20. Revised 9/22/20
Surveyor notes R118's discharge planning focused problem was not updated when R118 was issued the 30 day discharge notice on 6/22/21.
Surveyor reviewed the 30 day discharge notice given to R118 on 6/22/21. Surveyor notes the reason for discharge is for the safety of the individuals in the facility is endangered. A discharge meeting was scheduled for 7/1/21. There is no documentation the discharge meeting occurred.
There is no indication the 6/22/21 reason for discharge remained a current reason for discharge when the facility decided not to have accept R118 back into facility when R118 was hospitalized on [DATE].
Surveyor notes the 30 day discharge notice given to R118 on 6/22/21 does not identify a location to which R118 was to be discharged to or transferred to.
Surveyor notes on the discharge notice the the name of the ombudsman to be contacted is incorrect.
Surveyor notes the 30 day discharge notice did not contain the contact information responsible for the protection and advocacy of individuals with a mental disorder, even though R118 was admitted with a diagnosis of Major Depressive Disorder. (Cross Reference F623)
Surveyor reviewed R118's electronic medical record (EMR) progress notes starting with 5/21 forward. Surveyor was not able to locate any documentation of R118's behaviors while at the facility until 9/18/21. The following was documented:
09/18/2021 1:59 PM Nurses Note Text: [R118] came down on Wing 2 without a mask and entered another Resident's room at approximately 9:00 AM. Writer told [R118] he must wear a mask in facility. [R118] became very angry and began calling writer many foul names repeatedly. Writer asked [R118] to stop using that language and [R118] intensified. Several other Residents came out of their rooms to see what was going on. Writer called Charge Nurse to report incident. Instructed to call [NAME] Police, which was done. Police arrived and found [R118] on another Wing. They reprimanded [R118] and left. Immediately after leaving, [R118] came back down Wing 2 towards writer and again began a barrage of insults and foul names. Also stated ha! ha! That didn't do you any good did it? No further problems after that. Continue to observe.
09/18/2021 2:30 PM Nurses Note Text: [R118] very agitated during this shift. [R118] yelling at staff through out this shift. Writer talked with [R118] multiple times regarding [R118's] behavior and [R118] was able to be redirected for short periods of time. Writer notified that [R118] was at middle nurses station with behaviors hitting [R118's] head on the nurses desk multiple times. Writer did get [R118] to come back to [R118's] unit. [R118] did admit to writer that [R118] had smoked marijuana. Upon attempting to assess [R118], became verbally agitated with writer then said [R118] was leaving to go to the store and left down the hallway and out the door.
09/18/2021 3:58 PM Nurses Note Text: [R118] found outside on sidewalk by patio area on ground. writer unable to complete assessment of [R118] due to [R118] thrashing around on the ground. Staff unable to use Hoyer sling to get [R118] off ground due to thrashing. R118 admitted to use of marijuana and drinking four loko. 911 called for assistance, paramedics and police. arrived. resident whites of eyes had a tint of yellowing. resident taken to ER (emergency room) for further medical evaluation. Nurse Practitioner (NP) and Assistant Director of Nursing (ADON) aware of above.
10/14/21 3:42 AM Nurses Note Text: [R118] has orders to collect urine specimen to rule out UTI (Urinary Tract Infection). Assisted nurse with replacing suprapubic catheter due to poor urinary output. Foley tubing noted with large amounts of sediment clogging urinary flow. Multiple attempts made to reinsert the suprabubic catheter, all unsuccessful. Unable to get a urinary return. [R118] has a history of obstruction. Bladder scan shows no large volume residual -- 50-100cc noted. [R118] is screaming. [R118's] mentation is also changed. [R118] is alert x 4 but presents with hysteria. Called on call MD from .Health and orders given to send to ER. Paramedics arrived to send the ER. [R118] continues to scream and attempting to throw self into floor. [R118] is yelling I'm drunk and high. Called (name of Hospital) and gave report. Vitals stable upon departure. Declines family update. All documentation sent with [R118].
The facility provided Surveyor with a transfer and bed hold document for [R118] and [R118] requested a bed hold. A written note on this transfer/bedhold notice indicated the document was reviewed with R118 at the hospital by a un-named case manager on 10/15/21 and signed by the facility. This transfer and bed hold document does not reference any information pertaining to an involuntary discharge.
It reads as follows:
Effective date discharge/transfer: 10/14/21,(name of facility) is transferring/discharging R118 to (name of hospital) for the following reasons:(this part Surveyor notes was left blank)
The document lists the state agency and the state long -term care ombudsman information if R118 wanted to appeal the transfer/discharge.
The document contains the facility's bed hold policy. It details the right of a bed hold when leaving the facility for a temporary stay in an acute care hospital or elsewhere. It outlines the charges for bed hold if private pay or Medicare.
The document states if a Resident's hospitalization or therapeutic leave exceeds the bed hold period, the Resident will be readmitted to the first appropriate Semi-Private bed if the Resident requires the services provided by the facility and is eligible for Medicaid nursing facility services.
Surveyor notes R118 chose to have R118's bed hold by checking, Yes I would like a bed hold.
Surveyor notes upon review, there is no documentation in R118's EMR, that R118 was given the 30 day discharge notice and that it was explained to R118 in a language and manner that R118 could understand. R118's EMR does not contain documentation the state ombudsman was notified of the 30 day discharge notice. R118's EMR did not contain documentation from R118's primary physician of the specific needs that could not be met, facility attempts to meet those needs, and the service available at the receiving facility to meet R118's needs.
Surveyor notes R118 was being treated by a psychologist who last saw R118 on 6/15/21 and documented R118 affect and demeanor appeared fairly stable.
On 11/30/21 at 12:10 PM, Surveyor interviewed Social Worker (SW-E) in regards to R118's behaviors. SW-E indicated SW-E did not know much about R118. SW-E stated, the rumor was [R118] was drinking a lot, buying alcohol for other Residents, throwing self on the floor, refusing cares, smoking in the building, noncompliant, running into doorways, noncompliant with smoking and drinking .The facility tried re-approaching. Surveyor requested any documentation of R118's behaviors.
Surveyor reviewed R118's Treatment Administration Records (TARS) from May to October 2021. Surveyor notes the targeted behaviors are not R118 specific. Surveyor also notes that each month contains several days where no documentation is recorded on whether R118 displayed behaviors or not.
May 2021 - no behaviors documented
June 2021-
6/4/21 Sexually inappropriate, yelling/screaming,kicking/hitting
July 2021-
7/25/21-yelling/screaming,abusive language
7/26/21-abusive language
7/27/21-yelling/screaming,abusive language, wandering
7/31/21-abusive language
August 2021-no behaviors documented
September 2021 -no behaviors documented
October 2021-no behaviors documented
On 11/30/21 at 1:04 PM, Surveyor spoke to hospital social worker (HSW-Q) for R118. HSW-Q stated the facility stopped returning calls after HSW-Q first spoke to a representative at the facility. HSW-Q stated the Administrator (NHA-A) informed HSW-Q the facility would not take [R118] back because of [R118's] behaviors. HSW-Q does not recall the exact date NHA-A informed HSW-Q that [R118] could not return to the facility. HSW-Q called Ombudsman (O-R) and was told by O-R that [R118's] 30 day discharge notice was not valid because there was no destination listed on it. HSW-Q validated [R118] remains in the hospital awaiting placement at this time.
On 12/1/21 at 12:21 PM, Surveyor interviewed Activities Director (AD-F) who is familiar with R118. AD-F stated [R118] had no behaviors with AD-F. AD-F stated AD-F had heard [R118] was caught smoking in the facility a couple of times with an e-cigarette, and had verbal altercations (be rude to other Residents). AD-F stated [R118] attended parties, and social activities. [R118] was never disruptive, and respected AD-F. AD-F stated [R118] helped gather Residents and remind Residents of activities.
On 12/01/21 at 12:52 PM, Surveyor interviewed NHA-A in regards to R118's discharge. NHA-A gave a 30 day discharge notice to R118, but does not have documentation R118 received the 30 day notice or understood the 30 day discharge notice. NHA-A stated the facility originally denied re-admission because [R118] had an expensive IV. NHA-A stated then [R118] ran out of bed hold days and informed the hospital the facility would not allow [R118] to return to the facility because of behaviors. NHA-A stated [R118] was buying alcohol for other Residents, would get high and drunk and would run into things with [R118's] power wheelchair. NHA-A stated that [R118] was not able to be re-directed. NHA-A stated NHA-A did not offer to assist HSW-Q with [R118's] discharge planning from the hospital.
On 12/02/21 at 1:57 PM, Surveyor spoke to O-R in regards to R118. O-R does not remember having any contact directly with [R118]. O-R did speak to HSW-Q on 10/26/21 and informed HSW-Q [R118's] 30 day discharge notice was not valid due to it not containing documentation of a discharge location. O-R did speak to [R118] on 10/29/21 who indicated [R118] may not want to return to the facility.
As of 12/01/21, R118 has not been readmitted back into the facility.
2) R119 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Neuromuscular Dysfunction of Bladder, Bipolar Disorder, and Attention Deficit Hyperactivity Disorder. R119 is her own person.
R119's Quarterly Minimum Data Set (MDS) dated [DATE] documents R119's Brief Interview for Mental Status (BIMS) score to be a 15, indicating R119 was cognitively intact for daily decision making. R119 had a PHQ-9 score of 3, indicating minimal depression. The MDS documented R119 had verbal behavioral symptoms and rejection of care 1-3 days during the assessment period.
Surveyor reviewed R119's comprehensive care plan and noted the following focused problems:
1. R119 has a behavior problem due to refusal to get out of R119's motorized chair for staff to perform incontinence cares, catheter cares, repositioning, offloading, skin assessments, application of barrier cream, treatment to wounds, assist with meals/liquid intake.
Initiated 9/9/21, Revised 10/22/21
2. R119 displays socially inappropriate behaviors related to mental illness. Makes sexually inappropriate comments both to and about staff. Displays angry, aggressive behaviors as evidenced by swearing at staff and peers and threatening to hit staff and peers with electric wheelchair. Making false accusations about staff.
Initiated 5/28/21; Revised 8/5/21
3. R119 does not require active discharge planning as R119 is accepting of R119's need for long term placement. Initiated 5/28/21
Surveyor reviewed R119's Electronic Medical Record (EMR) for documentation of behaviors. Surveyor was not able to locate any documentation of behaviors in the progress notes. Surveyor notes that discharge planning for R119 started on 9/21/21, however, on 10/8/21 it is documented that R119 stated R119 could not discharge home at this time.
Surveyor notes R119's comprehensive care plan documenting the focused problem: discharge planning was not updated when discharge planning was initiated on 9/21/21.
Surveyor reviewed R119's Treatment Administration Record (TARS) for behavior documentation. Surveyor was not provided with August 2021 TARS upon request. The behavior documentation below are the days R119 had refusal of cares, refusing repositioning, and refusing to lay in bed. Surveyor also notes that each month contains several days where no documentation is recorded on whether R119 displayed behaviors or not. The expectation is for behaviors to be documented on per shift, daily.
September 2021-
9/10/21,9/11/21,9/12/21,9/13/21,9/15/21,9/16/21,9/17/21,9/25/21, 9/26/21
October 2021-
10/4/21,10/6/21,10/7/21,10/9/21,10/10/21,10/11/21,10/13/21,10/15/21,10/20/21
Surveyor notes the following was documented in regards to R119's Against Medical Advice (AMA) discharge:
10/23/2021 9:41 AM Nurses Note Text: [R119] is requesting to be sent out to the emergency room (ER). [R119] tells writer she just doesn't feel good. [R119] says she feels like [R119] has a Urinary Tract Infection (UTI) and will not be cared for in the facility as [R119] feels she needs to. [R119] states, I think they don't even care and I'm leaving. Vitals taken and stable. NP (Nurse Practitioner) gives orders for Bactrim x 3 days and a repeat UA (urinalysis) with C&S (culture and sensitivity). Explained new orders to [R119]. [R119] declines treatment and states, I am leaving. NP aware. Explained AMA to the [R119]. Paperwork prepared and ready.
10/23/2021 9:41 AM Nurses Note Late Entry: [R119] tells writer [R119] isn't coming back. Tells writer watch my things, after I'm better I'll be back to get them and I'm not coming back here again. I'm getting out of this place. [R119] declines bed hold or alternatives to cares and signed AMA paperwork with Emergency Medical Technician (EMT) as witness, Certified Nursing Assistant (CNA), and this writer.
10/23/2021 9:45 AM Nurses Note Text: Called to get non- emergent transport - cannot get transport- called 911 to send to emergency room (ER) for evaluation and treat. [R119] aware and will update family on own per her statement.
10/23/2021 11:29 AM Nurses Note Text: [R119] departed via EMT transfer. Report given to EMT and paperwork given upon departure. [R119] declined cares before departure as [R119] wanted to leave right now no medications given.
10/23/2021 9:53 PM Nurses Note Text: Writer called (name of hospital) ER-[R119] was admitted for UTI and Aspiration Pneumonia at 4:00 PM. [R119] is her own person. Management aware.
On 11/30/21 at 12:10 PM, Surveyor spoke to Social Work (SW)-E in regards to R119. SW-E was not present when R119 left for the hospital and did not have anything to do with R119 discharging AMA.
On 11/30/21 at 1:06 PM, Surveyor spoke to Hospital Social Worker (HSW)-Q who stated that HSW-Q does not know how [R119] could have signed an AMA form being a quadriplegic and that [R119] was very sick and confused when [R119] arrived to the ER. HSW-Q stated [R119] was admitted to Intensive Care Unit(ICU). HSW-Q contacted the facility seeking readmission for R119. HSW-Q does not remember on what date HSW-Q spoke with a representative at the facility or with whom. HSW-Q was informed at this time, the facility would not allow R119 to return to the facility due to behaviors. HSW-Q stated that [R119] was still in the hospital waiting for discharge.
Surveyor reviewed documentation dated 10/23/21 from the hospital record and notes [R119's] chief complaint was coughing and respiratory failure, and [R119] required up to 8 liters of Oxygen (O2) on admission.
Surveyor reviewed the the AMA document dated 10/23/21. The AMA document is titled, Leaving Nursing Center Against Advice. The document indicates, I [R119] am leaving this nursing center against the advice of my attending physician and this nursing center's administration. By signing below, I acknowledge that I have been informed of the risk involved and hereby release the attending physician and nursing center staff from responsibility for an ill effects or damages which may result from my choosing to leave the center. Surveyor notes R119 signed an AMA document with a squiggly line dated 10/23/21 with 1 witness signature. Surveyor was unable to contact the witness.
On 12/1/21 at 11:05 AM, Surveyor interviewed Registered Nurse (RN-G) who was the RN involved with R119's AMA discharge. RN-G stated that RN-G had [R119] sign AMA because there was no physician order to leave. [R119] came to the desk stating [R119] had an UTI. Called the NP who ordered a collection of urine, and wanted to treat [R119] in house. RN-G stated the NP would not give an order to go to the ER. Tried to explain what the NP had stated to [R119], but [R119] kept calling RN-G the grim [NAME]. RN-G gave [R119] the AMA form to sign and [R119] said I don't have use of my hands. So RN-G told [R119] even a dot would work as a signature. RN-G does not know who the witness is.
Surveyor noted R119 signed the AMA document in order to obtain treatment outside of the facility.
On 12/01/21 at 12:57 PM, Surveyor spoke to NHA-A about R119's AMA discharge. NHA-A stated, I don't even know if we got a phone call to take [R119] back. NHA-A stated the facility would not take [R119] back into the facility due to [R119's] behaviors. NHA-A stated [R119] refused to let the facility care for [R119] at times .[R119] would sit in the chair for days . Had bad wounds and was noncompliant with the treatments. NHA- A stated [R119] would not use the electric chair on low mode and would vape in [R119's] room.
On 12/2/21 at 8:18 AM, Surveyor interviewed RN-G again and asked RN-G who instructed RN-G to have [R119] sign the AMA form. RN-G stated, no one did, I just knew that working in management at another facility; if you don't have an order it would be AMA. There is no documentation that RN-G consulted with facility management to discuss options for R119. Further, there is no documentation in R119's EMR that options to discharging AMA was discussed with R119.
On 12/2/21 at 9:50 AM, Surveyor left a message for the NP who did not give an order for discharge. No return call was received.
On 12/2/21 at 3:16 PM, Surveyor shared the concern with Administrator(NHA-A), Director of Nursing(DON-B), and Regional Nurse Consultant(RNC-C) that R118 and R119 were not permitted to return to the first available bed in the facility.
As of 12/2/21, R119 has not been readmitted back into the facility.
Surveyor's concern was acknowledged and no further information was provided at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure 1 Resident (R88) of 5 sampled residents reviewed, met the PASR...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure 1 Resident (R88) of 5 sampled residents reviewed, met the PASRR (Pre-admission Screen and Resident Review) requirements.
R88 was admitted to the facility on [DATE] and the Level 1 PASRR documented R88 had no diagnosis of a major mental disorder. On 1/3/20 a diagnosis of bipolar disorder was entered in R88's medical record, the PASRR was not completed with the change in diagnosis information.
Findings include:
R88 was admitted to the facility on [DATE] with diagnoses that included anxiety. On 1/3/20 the diagnosis of bipolar disorder was added to R88's medical record.
On 12/1/21, R88's PASRR level 1 screen dated 1/2/20 was reviewed and indicated R88 was not suspected of having a serious mental illness but was on the medications Ativan (antianxiety), Seroquel (antipsycotic) and Zyprexia (Antipsycotic). The screen indicated that a PASRR level 2 was not indicated.
On 12/1/21 R88's diagnosis list was reviewed and read: 1/3/20 Bipolar disorder.
On 12/2/21 at 12:30 PM Admissions Coordinator-T was interviewed and indicated she completed R88's PASRR 1 on admission but bipolar was not on R88's discharge hospital paperwork. Admissions Coordinator-T indicated she only does the initial PASRR based on the paperwork the hospital provides and does not do any additional PASRR's after admission.
On 12/2/21 at 1:00 PM Regional Nurse Consultant-C was interviewed and indicated R88's PASRR level 1 should have been completed again with his diagnosis of Bipolar disorder and was not.
The above findings were shared with the Administrator and Director of Nurses on 12/2/21 at 1:00 PM. Additional information was requested if available. None was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R23 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Other Psychoactive Substance Use, and Anxiety Disord...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R23 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Other Psychoactive Substance Use, and Anxiety Disorder. R23 is her own person.
R23's Quarterly Minimum Data Set (MDS) dated [DATE] documents R23 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R23 is cognitively intact for daily decision making.
Surveyor reviewed R23's comprehensive care plan and notes R23 has a focused problem of R23 being an independent smoker and has no known history of inappropriate or hazardous smoking behaviors. Initiated 2/7/19 and revised 6/16/21.
Surveyor reviewed R23's electronic medical record (EMR) and notes 2 progress notes documented in regards to R23's smoking which indicated:
1. 9/19/21 Smoking materials to be kept at nurses cart every shift for smoking policy, refused.
2. 10/3/21 Smoking material to be kept and nurses cart every shift for smoking policy.
Surveyor notes R23's last smoking assessment completed is dated 12/4/19 and documents that R23 was caught smoking in room, explained safety concerns, staff is keeping cigarettes and lighter.
Surveyor notes per the facility's policy and procedure, smoking assessments are to be completed quarterly.
On 11/29/21 at 10:37 AM, Surveyor notes R23 has R23's own smoking materials and an E-cigarette charging at bedside.
On 12/2/21 at 3:16 PM, Surveyor shared the concern with Administrator (NHA-A), Director of Nursing (DON-B), and Regional Nurse Consultant(RNC-C) that R23's smoking assessment had not been completed since 12/4/19. RNC-C validated the smoking assessment should have been updated. No further information was provided by the facility.
3. R80 was admitted to the facility on [DATE] with a diagnosis that included Blindness in Right Eye and Left Eye, Developmental Disorder, Cerebral Palsy and Symptomatic Epilepsy and Epileptic Syndromes.
R80's Quarterly MDS (Minimum Data Set) dated 11/2/21 documents a BIMS (Brief Interview for Mental Status) score of 1, indicating that R80 is severely cognitively impaired.
Section G (Functional Status) documents that R80 requires limited assistance and one person physical assist for his bed mobility needs. Section G also documents that R80 has total dependence on staff and requires a two person physical assist for his transfer needs.
Section G0400 (Functional Limitation in Range of Motion) documents that R80 has impairment to both sides of his lower extremities.
R80's Falls CAA (Care Area Assessment) dated 8/3/21 documents under the Analysis of Findings section, R80 is at high risk for falls. Plan of care to be developed for safety and to reduce chance of falls.
R80's Falls Risk assessment dated [DATE] documents a score of 19, indicating that R80 is at high risk for falls.
R80's Falls care plan dated as initiated on 7/30/21 documents under the Interventions section, Place call light or other communication device within reach at all times.
On 11/29/21 at 10:20 a.m., Surveyor observed R80 laying supine in bed. Surveyor observed R80's call light to be on the chair at the foot of R80's bed and not within reach of R80 as documented in R80's falls plan of care.
On 11/29/21 at 3:40 p.m., Surveyor observed R80 laying supine in bed. Surveyor observed R80's call light to be on the chair at the foot of R80's bed and not within reach of R80 as documented in R80's falls plan of care.
On 11/30/21 at 8:53 a.m., Surveyor observed R80 laying supine in bed. Surveyor observed R80's call light to be on the chair at the foot of R80's bed and not within reach of R80 as documented in R80's falls plan of care.
On 11/30/21 at 11:46 a.m., Surveyor observed R80 laying supine in bed. Surveyor observed R80's call light to be on the chair at the foot of R80's bed and not within reach of R80 as documented in R80's falls plan of care.
On 11/30/21 at 1:02 p.m., Surveyor observed R80 laying supine in bed. Surveyor observed R80's call light to be on the chair at the foot of R80's bed and not within reach of R80 as documented in R80's falls plan of care.
On 11/30/21 at 2:35 p.m., Surveyor observed R80 laying supine in bed. Surveyor observed R80's call light to be on mattress at the foot of R80's bed and not within reach of R80 as documented in R80's falls plan of care.
On 12/2/21 at 8:59 a.m., Surveyor informed DON (Director of Nursing)-B and RN (Registered Nurse) Consultant-C of the above findings.
No additional information was provided as to why R80 did not have his call light in reach per his falls care plan intervention.
Based on observation, interview, and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 (R23 and R88) of 4 Residents reviewed for smoking and 1 (R80) of 8 Residents reviewed for falls.
R23 and R88 did not have smoking assessments for safety completed quarterly per facility policy. In addition R88 did not have a care plan for smoking.
R80 was observed not to have his call light in reach.
Findings include:
On 12/1/21, the facility policy titled, Smoking Policy Residents dated 7/2017 was reviewed and read: A resident's ability to smoke safely will be re-evaluated quarterly, upon significant change and as determined by staff.
1. R88 was admitted to the facility on [DATE] with diagnoses that included anxiety.
On 11/30/21 R88's smoking assessment dated [DATE] was reviewed and indicated R88 was safe to smoke independently. No additional assessments for R88's safety with smoking were found.
On 11/30/21 R88's care plan was reviewed and no care plan was found to address safety measures for smoking.
On 12/02/21 at 12:21 PM Director of Nurses-B was interviewed and indicated R88 did not have a care plan for smoking and did not have any additional smoking assessments other than the 7/12/20 smoking assessment.
On 12/1/21 at 1:30 PM R88 was observed out in the courtyard and appeared to be smoking safely.
The above findings were shared with the Administrator and Director of Nurses on 12/2/21 at 1:00 PM Additional information was requested if available. None was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not comprehensively assess 1 (R63) of 1 Residents reviewed for the use of...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not comprehensively assess 1 (R63) of 1 Residents reviewed for the use of urinary catheters. R63 had a urinary catheter placed on 6/17/21 without having a comprehensive bladder assessment completed for care and services.
Findings Include:
Surveyor reviewed the facility's Urinary Continence and Incontinence-Assessment and Management policy and procedure revised September 2010 and noted the following:
Policy Statement:
1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence.
2. Management of incontinence will follow relevant clinical guidelines.
3. The physician and staff will provide appropriate services and treatment to help Residents restore or improve bladder function and prevent urinary tract infections to the extent possible.
4. Indwelling urinary catheters will be used sparingly, for appropriate indications only.
Policy Interpretation and Implementation states impart:
1. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence.
3. Periodically (as required and when there is a change in voiding), staff will define each individual's level of continence, referring to the criteria in Minimum Data Set(MDS), as follows:
Not Rated: The Resident has an indwelling catheter, condom catheter, ostomy, or no urine output(dialysis).
15. If a Resident is admitted from the hospital with a newly placed indwelling catheter, the physician and staff will evaluate the potential for removing it, depending on the current condition and the rationale for its original placement
22. The staff and physician will evaluate the effectiveness of interventions and implement additional pertinent interventions as indicated.
24. The physician will identify situations in which an indwelling urethral or suprapubic catheter are indicated, and will document why other alternatives are not feasible.
a. Indwelling catheters shall not be used as a substitute for nursing care of the Resident with urinary incontinence.
b. If an indwelling catheter is needed, staff will monitor for and report complications such as evidence of a symptomatic infection.
R63 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Aphasia, Dyspagia, Anoxic Brain Damage, and Flaccid Neuropathic Bladder. R63 currently has a legal guardian.
R63's Quarterly Minimum Data Set (MDS) dated [DATE] documents R63's long and short term memory to be impaired and R63's cognitive status was unable to be assessed. R63 requires total dependence for bed mobility, transfers, dressing, toileting, and hygiene. R63's MDS also documents that R63 has a catheter. Surveyor noted R63 was not interviewable.
Surveyor notes there is a focused problem for catheter use for urinary retention and neurogenic bladder initiated on 6/17/21 for R63.
Surveyor notes the following on R63's current physician orders:
1. Foley catheter care 3x a day for retention-order start date-7/14/21
2. Ensure catheter securement device in place every shift- order start date-8/5/21
3. Insert 16F Foley catheter with 10CC bulb as needed for occlusion as needed-order start date-10/20/21
Surveyor reviewed R63' electronic medical record (EMR) and was unable to locate any documentation of an assessment for R63's indwelling catheter.
On 11/30/21 at 1:24 PM, Surveyor observed R63 to have an indwelling catheter.
On 12/2/21 at 8:14 AM, Surveyor shared the concern with Regional Nurse Consultant (RNC-C) that Surveyor was unable to locate a catheter assessment for R63's Foley catheter that was inserted on 6/17/21.
On 12/2/21 at 12:15 PM, RNC-C confirmed a catheter assessment had not been completed when R63's catheter was placed on 6/17/21. RNC-C stated that a Foley catheter assessment should have been completed at this time and further stated, there is one there now.
On 12/2/21 at 3:16 PM, Surveyor shared the concern with Administrator (NHA-A), Director of Nursing (DON-B), and Regional Nurse Consultant(RNC-C) that R63 did not have a Foley catheter assessment completed when R63 had the catheter inserted on 6/17/21. The concern was acknowledged and no further information was provided at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not have an updated comprehensive assessment for enabler bar...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not have an updated comprehensive assessment for enabler bars for 1 (R24) of 1 Residents observed with enabler bars during the survey process. Further, the facility did not have evidence of Interdisciplinary Team (IDT) involvement, no documentation of side rails being reviewed at care conference, and side rails were not documented on R24's Minimum Data Set (MDS) or comprehensive care plan.
Findings include:
Surveyor reviewed the facility's Side Rail Policy-Quarter/Assist rail issued October 2016 and notes the following:
Purpose: To ensure safety of Resident utilizing side rails/Assist rail on their bed
Procedure: Resident will utilize, upon request a quarter side rail or U(Assist rail) when in bed to assist with turning and positioning and getting out of bed. An Assist bar or quarter rail is not considered a restraint.
1. On implementation or request for a side rail and with change in functional status, the Resident will have a safety device assessment completed(located in PCC).
6. The Minimum Data Set(MDS) Coordinator will ensure care plan is implemented.
R24 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Cerebral Infarction, Vascular Dementia, and Major Depressive Disorder. R24 has an activated Health Care Power of Attorney (HCPOA).
R24's Quarterly Minimum Data Set (MDS) dated [DATE] documents R24 has a Brief Interview for Mental Status (BIMS) score of 5 indicating R24 demonstrates severely impaired skills for daily decision making. R24's MDS also documents R24 requires extensive assistance for bed mobility and transfers. Surveyor notes R24's MDS does not document that R24 has enabler bars.
Surveyor reviewed R24's comprehensive care plan for enabler bars and notes there is no documented focus problem for R24's enabler bars.
Surveyor reviewed R24's current physician orders and notes enabler bars x2 to aide with repositioning was obtained by phone on 3/27/21 with no start date.
Surveyor reviewed R24's physical therapy(PT) discharge summary and notes R24 met the goal of safely performing bed mobility tasks without use of siderails on 3/16/20. Surveyor also notes there was not a PT assessment for enabler bars completed before the enabler bars were ordered on 3/27/21.
Surveyor notes R24 has an enabler bar assessment completed 3/31/20 that documents the following was completed:
1. a physician's order reflecting the enabler bar, time frame to be used
2. consent form completed
3. update long term(IDT) care plan to reference use
4. review at minimum quarterly and as needed(PRN)
Surveyor notes that an assessment has not been completed on a quarterly basis, a physician's order was obtained on 3/27/21, 1 year after an enabler bar assessment was completed with no new assessment, and no current consent form was located in R24's electronic medical record (EMR).
On 11/29/21 at 10:28 AM, Surveyor observed R24 had enabler bars on both the right and the left side of R24's bed.
On 12/1/21 at 8:46 AM, Surveyor spoke to Licensed Practical Nurse (LPN-M) who is familiar with R24. LPN-M states that R24 does use the enabler bars for turning in bed.
On 12/2/21 at 3:16 PM, Surveyor shared the concern with Administrator (NHA-A), Director of Nursing (DON-B), and Regional Nurse Consultant (RNC-C) that R24 did not have evidence of Interdisciplinary Team (IDT) involvement, no documentation of side rails being reviewed at care conference, side rails was not documented on R24's Minimum Data Set (MDS) or comprehensive care plan, and the enabler bar assessment had not been updated since 3/31/21. The concern was acknowledged and no further information was provided at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R59) of 6 resident's drug regimen was free from unnecessary...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 1 (R59) of 6 resident's drug regimen was free from unnecessary medications.
R59 had an physician (MD) order to obtain and test a stool sample for Clostridioides difficile (C-diff) and to start an antibiotic for the potential infection on 11/11/21. The lab test was delayed and not completed until 11/15/21. R59's delayed results came back negative for C-diff. R59 received 10 doses of Vancomycin in the time frame of 11/11-11/15/21 that were not necessary; the doses within that 5 day time frame would not not have been administered if the results were obtained timely.
Findings include:
Surveyor reviewed facility's Lab Diagnostic Test Results - Clinical Protocol policy with a revision date of November 2018. Documented was:
Assessments and Recognition
1. The physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs.
2. The staff will process test requisitions and arrange for tests.
3. The laboratory, diagnostic radiology provider, or other testing source will report test results to the facility .
Surveyor reviewed facility's Administering Medications policy with a revision date of April 2019. Documented was:
.4. Medications are administered in accordance with prescriber orders, including any required timeframes .
21. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the [Medication Administration Record (MAR)] space provided for that drug and dose .
R59 was admitted to the facility 9/2/21 with diagnoses that included Cyst of Pancreas, Chronic Kidney Disease Stage 3 and Severe Protein Calorie Malnutrition.
Surveyor reviewed R59's MD orders with a start date of 11/11/21. Documented was Collect stool specimen to [rule out] C-diff related to diarrhea one time only. Documented with a start date of 11/11/21 was Vancomycin HCl Suspension. Give 125 mg by mouth four times a day for C- diff take 125mg [4 times daily orally] for c-diff.
Surveyor reviewed shipping manifest from facility pharmacy that documented Vancomycin medication shipped to facility on 11/11/21 at 9:02 PM.
Surveyor reviewed MAR for R59. Documented was:
Date: 11/11/21 Time: PM; Administered: 4 [Other / See nurse's notes]
Date: 11/11/21 Time: Eve; Administered: 4 [Other / See nurse's notes]
Date: 11/11/21 Time: Night; Administered: 4 [Other / See nurse's notes]
Date: 11/12/21 Time: AM; Administered: yes
Date: 11/12/21 Time: AM; Administered: yes
Date: 11/12/21 Time: Eve; Administered: 4 [Other / See nurse's notes]
Date: 11/12/21 Time: Night; Administered: 4 [Other / See nurse's notes]
Date: 11/13/21 Time: AM; Administered: yes
Date: 11/13/21 Time: AM; Administered: yes
Date: 11/13/21 Time: Eve; Administered: 4 [Other / See nurse's notes]
Date: 11/13/21 Time: Night; Administered: 1 [Hold / See nurse's notes] .
The medication was administered 11/14/21 and 11/15/21 per order. The resident was hospitalized on [DATE].
Surveyor reviewed Nurse's notes for R59. There was no documentation stating why the medication was not given for the 7 missed doses between 11/11/21 and 11/13/21. The nurses who did not administer the medications were unavailable for interview.
Surveyor reviewed R59's lab test results for stool sample to rule out C-diff. Documented under Collection Date/Time was 11/15/2021 1:38:00 PM. This was 4 days after the order date of 11/11/21. There was no documentation of why the stool sample was not collected for 4 days.
On 12/02/21 at 2:04 PM Surveyor interviewed Regional Nurse Consultant (RNC)-C. Surveyor asked who puts lab orders in and ensures the process is followed. RNC-C stated the nurse who takes the order is in charge of putting in the labs. Surveyor asked how the lab receives the order. RNC-C stated the orders are entered into the labs online portal called Test Direct. RNC-C stated the nurse would enter into the portal that the stool sample was ready for pickup. Surveyor asked what timeframe should be followed for stool samples to be picked up. RNC-C stated as soon as possible after the resident has a bowel movement. Surveyor noted that R59 had a colostomy bag. RNC-C stated then the sample as soon as the order was received and a nurse was able to access the resident's bag for a sample. RNC-C reviewed the online portal and noted there was no pick-up scheduled for 11/11/21. On 12/6/21 at 2:38 PM RNC-C reported to Surveyor that the sample was collected on 11/11/21 but not sent out until 11/15/21. RNC-C was unsure why there was a delay and noted the sample should have been picked up on 11/11/21.
R59's lab report from the 11/15/21 collection documented the stool sample was negative for C-diff. Surveyor noted R59 received 10 doses of the Vancomycin due to the delay in sending out the stool samples.
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 record review and staff interview, the facility did not ensure a residents psychotropic medication was monitored for in...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure a residents psychotropic medication was monitored for indications for use. This was observed with 1 (R61) of 5 residents reviewed for medications.
R61 is receiving psychotropic medications without identified, measureable targeted behaviors.
Findings include:
The facility's policy and procedures titled Behavioral Assessment, Intervention and Monitoring , revised March 2019, was reviewed by Surveyor. The procedures include documentation of specific targeted behaviors and expected outcomes. It also indicates other approaches and interventions tried prior to the use of antipsychotic medications.
R61's medical record was reviewed for unecessary medications. R61 started on Hospice on 10/4/21 and has disgnoses of Traumatic Brain Injury, Anxiety, Depression and behavorial disorder.
R61 currently is receiving the following medications:
- Buspirone 10 mg twice a day for anxiety with a start date of 6/26/2019.
- Lexapro 20 mg every day for depression with a start date of 8/15/2018.
- Lorazepam 0.5 mg every 4 hours as needed for restlessness/anxiety with a start date of 9/8/2021.
- Risperidone 2 mg everyday and 3 mg at bedtime for traumatic brain injury with behaviors with a start date of 7/13/2019.
- Trazadone 75 mg at bedtime for depression with a start date of 4/19/2018.
R61's Medication Administration Record and Treatment Administration Record for the current, and last month, were reviewed. There is no documented targeted behavior(s) identified with these medications.
Surveyor reviewed R61's medical record and the physician progress note on 11/3/2021 for a Routine Visit indicates the following: This is a [AGE] year-old Caucasian male who is a resident since 2017 with past medical history significant for traumatic brain injury with associated seizure disorder, dysphagia, depression, anxiety with behavioral disorder, history of COVID-19 infection in December 2020 who has been experiencing a steady decline and transitioned to hospice. He continues to have frequent yelling out episodes which is his baseline. On arrival for exam he is calm however does not converse much at baseline. He appear a bit calmer today and RN (Registered Nurse) states yelling out behaviors stable w/o (without) much change.
A 10/4/21 Psych Nurse Practitioner progress note indicates: medications and behaviors reviewed. No change in medication. Has had failed dose reductions in the past. Resident is stable on medication regimen.
R61 plan of cares were reviewed and had behaviors and detailed interventions.
On 12/01/21 at 10:51 AM Surveyor spoke with the RNC-C (Regional Nurse Consultant). Surveyor requested the facility's policy and procedures for behavior monitoring with psychotropic medications. Surveyor shared that R61 did not have did not have any behavior monitoring documented.
On 12/01/21 at 11:50 PM RNC-C supplied Surveyor with a blank behavior charting documentaion for R61. There was no additional documentation of resident's behavior monitoring.
There was no documentation to monitor the type, and frequency, of R61 behabiors that require the use of psychotropic medications.
.
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 interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized in accord...
Read full inspector narrative →
Based on interview and record review, the facility did not maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized in accordance with accepted professional standards and practices for 3 (R43, R59 and R200) of 4 residents reviewed.
1. R43 had conflicting documentation of pressure injuries. Skin assessments documented a pressure injury to buttocks when there was no pressure injury on R43's buttocks on 3 weekly assessments.
2. R43 and R59 did not have all lab results scanned into her electronic medical record (EMR). There was no documentation that the physician was made aware of the lab results. There was no reference in the progress notes pertaining to R43 and R59's labs on 1/10 or 1/17/22.
3. R200 refused a lab draw on 1/10/22. There was no documentation in his EMR that the Nurse Practitioner (NP) was notified.
Findings include:
1. R43 was admitted to the facility 9/21/21 with diagnoses that included Dementia without Behavioral Disturbances, Myelopathy, Other Megaloblastic Anemia and Chronic Pain Syndrome.
Surveyor reviewed R43's Care Area Assessments (CAA) with an assessment date of 9/28/21. Documented under Pressure Ulcer/Injury was Nature of the problem/condition: Risk for impaired skin integrity as evidenced by limited mobility and incontinence.
Surveyor reviewed R43's Weekly Wound Assessment Form documented by Regional Nurse Consultant (RC)-C with a date of 12/28/21. Documented under Wound Description was Site: Left heel . There were no other pressure injuries documented.
Surveyor reviewed R43's Weekly Skin Check Form documented by Licensed Practical Nurse (LPN)-V with a date of 12/31/21. Documented under Skin Check was Site: Coccyx. Description: open area, treatment in place. Site: Left heel. Description: Eschar .
Surveyor reviewed R43's Weekly Wound Assessment Form documented by RC-C with a date of 1/4/22. Documented under Wound Description was Site: Left heel . There were no other pressure injuries documented.
Surveyor reviewed R43's Weekly Skin Check Form documented by LPN-V with a date of 1/7/22. Documented under Skin Check was Site: Coccyx. Description: open area, treatment in place. Site: Left heel. Description: Eschar .
Surveyor reviewed R43's Weekly Wound Assessment Form documented by RC-C with a date of 1/11/22. Documented under Wound Description was Site: Left heel . There were no other pressure injuries documented.
Surveyor reviewed R43's Weekly Skin Check Form documented by LPN-V with a date of 1/14/21. Documented under Skin Check was Site: Right buttocks. Description: open areas, treatment in place. Site: Left heel. Description: Eschar, treatment in place .
Surveyor reviewed R43's Weekly Wound Assessment Form documented by RC-C with a date of 1/18/22. Documented under Wound Description was Site: Left heel . There were no other pressure injuries documented.
On 1/20/22 at 10:30 AM, Surveyor interviewed RC-C. Surveyor asked where R43's had pressure injuries. RN-C stated her left heel. Surveyor asked if she had any wounds on her coccyx or buttocks. RC-C stated no, that healed in October [2021]. Surveyor asked why on 3 separate Weekly Skin Check Forms, the coccyx/buttocks was documented. RC-C was unsure.
On 1/20/22 at 12:45 PM, Surveyor interviewed LPN-V. Surveyor asked where R43's had pressure injuries. LPN-V stated her left heel. Surveyor asked if she had any wounds on her coccyx or buttocks. LPN-V stated no. Surveyor asked why on 3 separate Weekly Skin Check Forms he documented a coccyx/buttocks pressure injury with treatment in place. LPN-V was unsure and could not explain why he documented that.
2. Surveyor reviewed facility's Lab Policy with an implementation date of 12/3/20. Documented was:
- When an order for a lab or specimen is received the nurse will put a one time order into [Point Click Care (PCC)] for the date that the lab will be drawn.
- The nurse will enter the correct lab into the Test Direct system and print out the lab order form.
- The nurse will take the order to the reception area and place it in the lab orders box.
- The nurse will then write the ordered lab or specimen on the Daily Lab Flow Sheet for the date that it is to be completed .
- At the beginning of each shift the nurse will check the lab book for labs to be completed that day and for lab results.
- Once a lab is drawn the phlebotomist will hand the completed lab draw slip to the nurse for the residents unit. The unit nurse will then highlight or initial that it was drawn.
- When the nurse begins the shift, they will check the faxes and or Test Direct for the lab results that are pending. Once lab results are received, they will be faxed to the MD/NP as soon as possible .
- Once the MD has been notified the nurse will highlight or initial that it was completed and place the results in the medical record.
- If a resident refuses a lab draw the nurse will document the refusal in PCC and schedule a redraw .
R43 was admitted to the facility 9/21/21 with diagnoses that included Dementia without Behavioral Disturbances, Myelopathy, Other Megaloblastic Anemia and Chronic Pain Syndrome.
R59 was admitted to the facility 9/2/21 with diagnoses that included Cyst of Pancreas, Chronic Kidney Disease Stage 3 and Severe Protein Calorie Malnutrition.
1. Surveyor reviewed Daily Lab Flow Sheet with a date of 1/10/22. Documented was Resident: [R43]. Date to be Drawn: 1/10/22. Lab to be Completed: [Complete Blood Count with Differential (CBC w/ Diff)], [Comprehensive Metabolic Panel (CMP)]. Received Results: [yes]. MD Notified: Faxed 1/11. New Orders: [no new orders (NNO).
Also documented was Resident: [R59]. Date to be Drawn: 1/10/22. Lab to be Completed: CBC w/ Diff, CMP. Received Results: [yes]. MD Notified: Faxed 1/11. New Orders: NNO.
Surveyor reviewed EMR and hard chart for R43 and R59. Labs drawn on 1/10/22 were not able to be located. There was no highlight or initial on the form verifying that the MD/NP received the results, only noted that they were faxed. Surveyor reviewed Progress Notes for R43 and R59. There was no documentation regarding labs on 1/10/22.
2. Surveyor reviewed Daily Lab Flow Sheet with a date of 1/17/22. Documented was Resident: [R43]. Date to be Drawn: 1/10/22. Lab to be Completed: CBC w/ Diff, CMP. Received Results: [yes]. MD Notified: [yes]. New Orders: NNO.
Also documented was Resident: [R59]. Date to be Drawn: 1/17/22. Lab to be Completed: CBC w/ Diff, CMP. Received Results: [yes]. MD Notified: [yes]. New Orders: NNO.
R43's date to be drawn was dated 1/10/22. Surveyor reviewed EMR and hard chart for R43 and R59. Labs drawn on 1/17/22 were not able to be located. There was no highlight or initial on the form verifying that the MD/NP received the results, only noted that they were faxed. Surveyor reviewed Progress Notes for R43 and R59. There was no documentation regarding labs on 1/17/22.
On 1/20/22 at 12:45 PM, Surveyor interviewed LPN-V. Surveyor asked how staff knows labs were verified received by the MD or NP. LPN-V stated he was unsure because they usually are received on 2nd shift and he works 1st shift. LPN-V stated he thinks staff check the results received box on the Flow Sheet. Surveyor asked where labs are kept after they are received. LPN-V stated most of the time they go in the chart.
On 1/20/22 at 1:05 PM Surveyor interviewed Director of Nursing (DON)-B. Surveyor asked how staff know the process with lab ordering, receiving and reviewing. DON-B stated there was a lab policy inservice on 12/3/21 will all nurses. On 12/20/21 there was another inservice on the policy as well because staff were not getting it. Surveyor asked how staff knows labs were verified received by the MD or NP. DON-B stated they place a checkmark next to the residents' name on the lab flow sheet and a Progress Note is written stating NNO or the new orders received. Surveyor asked where labs are kept after they are received. DON-B stated they are sent to Medical Records to get scanned in the chart. Surveyor noted that there were no labs from 1/10/22 and 1/17/22 in R43 or R59's chart. DON-B stated they are probably behind in scanning them in.
Surveyor noted on 1/20/22, LPN-V was unaware of the process for labs. Surveyor also noted there was no highlighted or initials on Flow Sheet documenting MD received results. Surveyor noted check mark next to name was not part of the policy. Surveyor also noted Progress Notes not completed for R43 or R59 on 1/10 or 1/17/22. Surveyor noted no labs in both charts verifying they were received.
3. On 1/20/22 at 10:53 a.m. Surveyor noted a physician order for R200 which documents CBC (complete blood count), CMP (comprehensive metabolic panel), HgA1c (glycated hemoglobin) [measures the amount of blood sugar attached to hemoglobin], Iron Level on 1/10/22. Directions one time only for med monitoring until 1/10/22.
On 1/20/22 at 11:12 a.m. Surveyor reviewed the Unit 5 & 6 lab book. For current month under tab 10 lab draw for day 1/10/22 under the section lab to be completed documents CBC, CMP, A1C, Iron Binding. Under the section received results documents No draw violently refused. Under the section MD notified, there is no documentation R200's MD (medical doctor) or NP (nurse practitioner) was notified. Under the new orders section documents NNO (no new orders).
On 1/20/22 at 11:15 a.m. Surveyor reviewed R200's medical record and was unable to locate documentation R200's physician/NP was notified of R200's lab draw refusal on 1/10/22.
On 1/20/22 at 11:29 a.m. Surveyor asked LPN (Licensed Practical Nurse)-J where Surveyor would be able to locate documentation a physician was notified of a Resident's refusal for a lab draw. LPN-J informed Surveyor it should be in the progress notes.
On 1/20/22 at 1:29 p.m. Surveyor asked MA (Medical Assistant)-CC if she remembers any nurse telling her R200 refused his lab draw on 1/10/22 as Surveyor could not locate any documentation in R220's medical record. MA-CC informed Surveyor she doesn't remember off the top of her head and she hasn't had a lot of interaction with R200. MA-CC informed Surveyor the nurses are suppose to communicate with her if she is here or they will contact the NP (Nurse Practitioner)-Y if they can't find her.
On 1/20/22 at 1:33 p.m. Surveyor spoke with NP-Y on the telephone. Surveyor informed NP-Y R200 refused his lab draw on 1/10/22 and Surveyor was unable to locate any documentation in R200's medical record she was notified of the refusal. NP-Y informed Surveyor she was looking at her notes, doesn't have anything written down but does remember them informing her of R200's refusal. NP-Y informed Surveyor she doesn't recall if she ordered further labs. NP-Y indicated she just recalls he wasn't going to allow the labs to be done and there is nothing that can be done.
Through interview Surveyor was able to determine NP-Y was notified of R200's refusal of the lab draw on 1/10/22 but there is no documentation in R200's medical record of NP-Y notification.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that 1 (R93) of 22 toilets reviewed was in a safe...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that 1 (R93) of 22 toilets reviewed was in a safe operating condition.
* R93's toilet was observed to be leaking water and waste when flushed.
Findings include:
R93 was admitted to the facility on [DATE] with a diagnosis that included Chronic Obstructive Pulmonary Disease, Urine Retention and Anxiety Disorder.
R93's admission MDS (Minimum Data Set) dated 11/5/21 documents a BIMS (Brief Interview for Mental Status) score of 11, indicating that R93 has moderate cognitive impairment.
Section G (Functional Status) documents that R93 requires limited assistance and one person physical assist for his toileting needs.
On 11/30/21 at 10:24 a.m., Surveyor interviewed R93 regarding the quality of life at the facility. R93 informed Surveyor that the toilet in his room was not working and leaking water. R93 informed Surveyor that when he uses the toilet, water, urine and feces water would leak onto the floor when the toilet was flushed. R93 informed Surveyor that he had informed facility staff but that all that facility staff would do was put towels underneath the toilet to catch the leaking water.
Surveyor observed R93's toilet bowl to be filled with clear water and observed a towel underneath R93's toilet that was soaked in water and what appeared to be urine.
On 11/30/21 at 1:05 p.m., Surveyor observed R93's toilet bowel to be filled with clear water and observed a towel underneath R93's toilet that was soaked and water and what appeared to be feces
On 11/30/21 at 2:48 p.m., Surveyor asked CNA (Certified Nursing Assistant)-N if she had been aware that R93's toilet was leaking water. CNA-N informed that she had observed R93's toilet to be leaking water when flushed since she started working at the facility approximately 3 weeks ago.
On 11/30/21 at approximately 3:10 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. At the time, no additional information was provided.
On 12/1/21 at 8:46 a.m., NHA-A informed Surveyor that a plumber had been called to fix R93's leaking toilet.
On 12/1/21 at 9:06 a.m., Surveyor interviewed Maintenance Director-O regarding R93's leaking toilet. Surveyor asked Maintenance Director-O if he had been aware that R93's toilet had been leaking when flushed.
Maintenance Director-O informed Surveyor that he was told a couple of weeks ago that R93's toilet was leaking and that he had called a plumber to come fix it but that it had been postponed.
No additional information was provided as to why the facility did not ensure that R93's toilet was in a safe operating condition.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not provide a working call light system for 1 (R93) of 22 sampled residents...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not provide a working call light system for 1 (R93) of 22 sampled residents.
Findings include:
R93 was admitted to the facility on [DATE] with a diagnosis that included Chronic Obstructive Pulmonary Disease, Urine Retention and Anxiety Disorder.
R93's admission MDS (Minimum Data Set) dated 11/5/21 documents a BIMS (Brief Interview for Mental Status) score of 11, indicating that R93 has moderate cognitive impairment.
Section G (Functional Status) documents that R93 requires limited assistance and one person physical assist for his toileting needs.
On 11/30/21 at 10:24 a.m., Surveyor interviewed R93 regarding the quality of life at the facility. R93 informed Surveyor that the call light in his room was not working. R93 informed Surveyor that he has pushed the call light multiple times to get help in going to the bathroom. R93 informed Surveyor that staff had previously told him that the call light outside his room did not light up and that it only flashed for assistance at the nursing station. R93 informed Surveyor that he did not know how long the call light had not been working but that it was longer than one week.
On 11/30/21 at approximately 10:25 a.m., Surveyor pressed R93's call light. Surveyor observed the call light button light up in R93's room wall but observed the call light outside the door not to be on or flashing. Surveyor walked down to the nursing station and observed the call light flashing on the panel, indicating that R93's room required assistance.
On 11/30/21 at 1:03 p.m., Surveyor observed R93's room call light flashing at the nursing station. Surveyor walked to R93's room and observed R93's call light panel inside of R93's room to be flashing and on, however the call light outside of R93's room was not on or flashing.
On 11/30/21 at 2:47 p.m., Surveyor informed RN (Registered Nurse)-H of the above findings. RN-H informed Surveyor that he was just told that the call light in R93's room was not working and that he had notified maintenance of the issue.
On 11/30/21 at 2:48 p.m., Surveyor asked CNA (Certified Nursing Assistant)-N if she had been aware that R93's call light outside of R93's room had not been working. CNA-N informed that she had observed R93's call light to not be working since she started working at the facility approximately 3 weeks ago.
On 11/30/21 at approximately 3:10 p.m., during the daily exit conference, Surveyor informed NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B of the above findings. At the time, no additional information was provided.
On 12/1/21 at 8:46 a.m., NHA-A informed Surveyor that maintenance had fixed R93's outside call light and that it was now functioning.
No additional information was provided as to why the facility did not provide a working call light system for R93.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 6 of 7 Residents (R13, R23, R24, R41, R46, & R96) and/or respon...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure 6 of 7 Residents (R13, R23, R24, R41, R46, & R96) and/or responsible party participated in the development of their person centered plan of care and making decisions about his or her care.
*R13's electronic medical record (EMR) had no documentation that a care conference has been scheduled or taken place to discuss R13's plan of care.
*R23's EMR documents the last care conference held was 10/20 for R23.
*R24's EMR documents the last care conference held was 10/1/20 for R24.
*R41's electronic medical record (EMR) had no documentation that a care conference has been scheduled or taken place to discuss R41's plan of care.
*R46's EMR documents the last care conference held was 1/7/20 for R46.
*R96's electronic medical record (EMR) had no documentation that a care conference has been scheduled or taken place to discuss R96's plan of care.
Findings Include:
Surveyor reviewed the facility's Resident Participation-Assessment/Care Plans policy and procedure revised December 2016 and notes the following:
Policy Statement
The Resident and his/her representative are encouraged to participate in the Resident's assessment and in the development and implementation of the Resident's care plan.
Policy Interpretation and Implementation
1. The Resident and his/her legal representative are encouraged to attend and participate in the Resident's assessment and in the development of the Resident's person-centered care plan.
4. The care planning process will:
a. Facilitate the inclusion of the Resident and/or representative
b. Include an assessment of the Resident's strengths and his/her needs
c. Incorporate the Resident's personal and cultural preferences in establishing goals of care
7. A 7 day advance notice of the care planning conference is provided to the Resident and his/her representative. Such notice is made by mail and/or telephone.
8. The Social Services Director or designee is responsible for notifying the Resident/representative and for maintaining records of such notices. Notices include:
a. The date, time, and location of the conference
b. The name of each person contacted and the date he/she was contacted
c. The method of contact
d. Input from the Resident or representative if they are not able to attend
e. Refusal of participation, if applicable
f. The date and signature of the individual making the contact
1) R13 was admitted to the facility on [DATE] with diagnoses of Diffuse Traumatic Brain Injury, Obesity, Major Depressive Disorder, Anxiety Disorder, Bipolar Disorder, and Schizoaffective Disorder. R13 is her own person and has a caseworker.
R13's Annual Minimum Data Set (MDS) dated [DATE] documents R13's Brief Interview for Mental Status (BIMS) score of 15, indicating R13 is cognitively intact for daily decision making. R13 is independent for all activities of daily living (ADLS).
Surveyor reviewed R13's EMR and was unable to locate documentation that a care conference had been scheduled or occurred for R13.
On 12/2/21 at 8:24 AM, Surveyor confirmed with R13 that R13 has not had a care conference meeting. R13 stated R13 would like a meeting to express R13's concerns and get answers on medical questions.
2) R23 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Other Psychoactive Substance Use, and Anxiety Disorder. R23 is her own person and has a caseworker.
R23's Quarterly Minimum Data Set (MDS) dated [DATE] documents R23 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R23 is cognitively intact for daily decision making. R23's MDS also documents R23 requires limited assistance for bed mobility and transfers. R23 requires supervision for dressing and extensive assistance for toileting.
Surveyor reviewed R23's EMR and notes there is documentation that R23 last had a care conference in October of 2020. Further, Surveyor notes there is no documentation in R23's EMR that R23 and/or representative were offered to, or participated in any form of review of R23's comprehensive care plan either by in person, video, or by phone since October of 2020.
On 11/29/21 at 10:37 AM, Surveyor spoke to R23 who can't remember the last time there was ever a care conference meeting for R23. R23 stated having a meeting is important because I am very involved in my care and sometimes I do not know what is going on.
3) R24 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Cerebral Infarction, Vascular Dementia, and Major Depressive Disorder. R24 has an activated Health Care Power of Attorney (HCPOA).
R24's Quarterly Minimum Data Set (MDS) dated [DATE] documents R24 has a Brief Interview for Mental Status (BIMS) score of 5 indicating R24 demonstrates severely impaired skills for daily decision making. R24's MDS also documents R24 requires extensive assistance for bed mobility and transfers.
Surveyor reviewed R24's EMR and notes there is documentation that R24 last had a care conference on 10/1/20. Further, Surveyor notes there is no documentation in R24's EMR that R24 and/or representative were offered to, or participated in any form of review of R24's comprehensive care plan either by in person, video, or by phone since 10/1/20.
4) R41 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Stage 3, Type 2 Diabetes Mellitus, and Unspecified Dementia. R41 has an activated Health Care Power of Attorney (HCPOA).
R41's admission MDS dated [DATE] documents R41 has a BIMS score of 3 indicating R41 demonstrates severely impaired skills for daily decision. The MDS also documents R41 requires extensive assistance for bed mobility and total dependence for toileting.
Surveyor reviewed R41's EMR and was unable to locate documentation that a care conference had been scheduled or occurred for R41 since admission and no documentation that R41's activated HCPOA had any input into R41's comprehensive care plan.
5) R46 was admitted to the facility on [DATE] with diagnoses of Hyperlipidemia and Unspecified Dementia. R46 has an activated Health Care Power of Attorney (HCPOA).
R46's Annual MDS dated [DATE] documents R46 has a BIMS score of 0, indicating R46 demonstrates severely impaired skills for daily decision. The MDS also documents R46 requires extensive assistance with bed mobility and transfers and requires total dependence for eating, toileting, and hygiene.
Surveyor reviewed R46's EMR and notes there is documentation that R46 last had a care conference on 1/7/20. Further, Surveyor notes there is no documentation in R46's EMR that R46's HCPOA were offered to, or participated in any form of review of R46's comprehensive care plan either by in person, video, or by phone since 1/7/20.
6) R96 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Peripheral Vascular Disease, Delusional Disorders, Major Depressive Disorder, and Shared Psychotic Disorder. R96 is his own person.
R96's Annual MDS dated [DATE] documents R96's BIMS score of 15 meaning R96 is cognitively intact for daily decision making. The MDS also documents R96 requires extensive assistance for bed mobility, and total dependence for transfers.
Surveyor reviewed R96's EMR and was unable to locate documentation that a care conference had been scheduled or occurred for R96.
On 11/29/21 at 2:49 PM, spoke with R96 who stated that R96 has not had a care conference in a long time, and thinks its been over 3 months. R96's friend has not been invited to a care conference and is usually invited. R96 feels it would benefit so staff is consistent with R96's cares. R96 remembers having a care conference where there was no warning it was being held and both R96 and R96's friend were not invited.
On 12/1/21 at 12:47 PM, Surveyor spoke to Administrator (NHA-A) about care conferences not being held for Residents on a quarterly basis. NHA-A stated NHA-A was made aware there was an issue of care conferences not being held when NHA-A became employed at the facility in June of 2021. NHA-A stated that it has been hard to catch up with care conferences because the facility has had so many new admissions but the goal is to get caught up by the end of the year.
NHA-A shared on 6/28/21 a plan for improved compliance was completed for care conferences not being done.
On 12/2/21 at 3:16 PM, Surveyor shared the concern with Administrator (NHA-A), Director of Nursing (DON-B), and Regional Nurse Consultant(RNC-C) that R13, R23, R24, R41, R46, and R96 had not participated in the development of their person centered plan of care and making decisions about his or her care with in formal meeting on a quarterly basis. The concern was acknowledged. No further information was provided at this time.
CONCERN
(E)
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 interview and record review the facility did not ensure that 6 (R1, R13, R18, R23, R87, & R96) of 7 sampled Residents r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 6 (R1, R13, R18, R23, R87, & R96) of 7 sampled Residents requiring assistance of staff for showers and/or unable to carry out activities of daily living received necessary services.
*Weekly showers were not recorded as being provided to R1 while at the facility and R1 would prefer 2 showers a week.
*Weekly showers were not recorded as being provided to R13 while at the facility and R13 would prefer 2 showers a week.
*Weekly showers were not recorded as being provided to R23 while at the facility and R23 would prefer 2 showers a week.
*Weekly showers were not recorded as being provided to R18 while at the facility.
*Weekly showers were not recorded as being provided to R87 while at the facility and R87 has not received shaving assistance.
*Weekly showers were not recorded as being provided to 96 while at the facility and R96 would prefer 2 showers a week.
Findings Include:
Surveyor reviewed the facility's Activities of Daily Living(ADLs), Supporting policy and procedure revised March 2018 and noted the following:
Policy Statement
Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).
Residents who are unable to carry out ADLs independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.
Policy Interpretation and Implementation
1. Residents will be provided with care, treatment, and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable.
2. Appropriate care and services will be provided for Residents who are unable to carry out ADLs independently, with the consent of the Resident and in accordance with the plan of care, including appropriate support and assistance with:
a. Hygiene(bathing, dressing, grooming, and oral care)
5. A Resident's ability to perform ADLs will be measured using clinical tools, including the Minimum Data Set (MDS).
6. Interventions to improve or minimize a Resident's functional abilities will be in accordance with the Resident's assessed needs, preferences, stated goals and recognized standards of practice.
7. The Resident's response to interventions will be monitored, evaluated, and revised as appropriate.
1) R1 was admitted to the facility on [DATE] with diagnoses of Epilepsy, Peripheral Vascular Disease, Unspecified Dementia with Behavioral Disturbance, Developmental Disorder of Scholastic Skills, and Major Depressive Disorder. R1 has a legal guardian.
R1's Quarterly MDS dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 10, indicating R1 demonstrates moderately impaired skills for daily decision making.
The MDS documents R1 is independent with ADLs but requires physical help in part of bathing activity with support provided.
R1's Annual MDS dated [DATE] documents R1 feels it is very important to the question of: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath.
Surveyor reviewed R1's comprehensive care plan which documents the focused problem of self care deficit due to cognitive deficits, decreased mobility, and generalized weakness.
Initiated 8/12/20
Intervention initiated on 9/24/20 documents R1 requires supervision for bathing.
R1 is scheduled for a shower on Wednesday on PM shift.
Surveyor requested R1's shower sheets for September, October, November of 2021. Surveyor was provided the following:
3 shower sheets for September dated 9/13/21, 9/17/21, 9/24/21-all documented that R1 received a shower on that date
October-no completed shower sheets and treatment administration record (TAR) indicates R1 received 1 shower for the month-10/7/21
November-no completed shower sheets and treatment administration record (TAR) indicates R1 received 3 showers for the month-11/3/21, 11/10/21, 11/17/21.
On 12/1/21 at 9:13 AM, R1 informed Surveyor that R1 can not remember the last time R1 had a shower. R1 stated R1 is upset about not getting a shower 2x a week.
2) R13 was admitted to the facility on [DATE] with diagnoses of Diffuse Traumatic Brain Injury, Obesity, Major Depressive Disorder, Anxiety Disorder, Bipolar Disorder, and Schizoaffective Disorder. R13 is her own person.
R13's Annual Minimum Data Set (MDS) dated [DATE] documents R13's Brief Interview for Mental Status (BIMS) score of 15, indicating R13 is cognitively intact for daily decision making. R13 is independent for all activities of daily living (ADLS). The MDS also documents that bathing did not occur for R13. R13 feels it is very important to the question of: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath.
Surveyor reviewed R13's comprehensive care plan which documents the focused problem of self care deficit due to decreased mobility, and generalized weakness.
Initiated 9/13/20
Intervention initiated on 9/3/20 documents R13 requires assistance of 1 for ADLs.
R13 is scheduled for a shower on Friday on PM shift.
Surveyor requested R13's shower sheets for September, October, November of 2021. Surveyor was provided the following:
September-no documentation of showers
October- no completed shower sheets and treatment administration record(TAR) indicate R13 received 1 shower for the month-10/23/21
November- completed shower sheet for 11/12/21 and treatment administration record(TAR) indicate R13 received 2 showers for the month-11/5/21,11/12/21
On 12/1/21 at 9:13 AM, R13 informed Surveyor that R13 is pissed off about the change from 2 showers a week to 1 shower per week. R13 stated it feels like R13 has gone months without a shower.
3) R18 was admitted to the facility on [DATE] with diagnoses of Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, Major Depressive Disorder, and Anxiety Disorder. R18 is his own person.
R18's Annual MDS dated [DATE] documents R18's BIMS score of 14, indicating R18 is cognitively intact for daily decision making. R18's MDS documents R18 is independent with ADLS and bathing did not occur. R18 feels it is very important to the question of: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath.
Surveyor reviewed R18's comprehensive care plan which documents the focused problem of self care deficit due to decreased mobility, and generalized weakness.
Initiated 1/12/20
Intervention initiated on 5/5/20 documents R18 requires assistance of 1 for ADLs.
R18 is scheduled for a shower on Monday on AM shift.
Surveyor requested R18's shower sheets for September, October, November of 2021. Surveyor was provided the following:
September-1 completed shower sheet-9/21/21
October- no completed shower sheets and treatment administration record(TAR) indicate R18 received 2 showers for the month-10/23/21,10/30/21
November- no completed shower sheet and treatment administration record(TAR) indicate R18 received 1 shower for the month-11/29/21
On 12/1/21 at 9:13 AM, R18 informed Surveyor R18 last had a shower about 3 wks ago. R18 stated R18 feels grubby and when R18 gets a shower R18 feels exhilarated and wants to do something for the day.
4) R23 was admitted to the facility on [DATE] with diagnoses of Paraplegia, Other Psychoactive Substance Use, and Anxiety Disorder. R23 is her own person.
R23's Annual Minimum Data Set (MDS) dated [DATE] documents R23's Brief Interview for Mental Status (BIMS) score of 15, indicating R23 is cognitively intact for daily decision making. R23's MDS also documents R23 requires limited assistance for bed mobility and transfers. R23 requires supervision for dressing and extensive assistance for toileting. R23's MDS documents R23 needs physical help.
R23's Annual MDS dated [DATE] documents R23 feels it is very important to the question of: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath.
Surveyor reviewed R23's comprehensive care plan and notes R23's ADL status and bathing are not documented.
R23 is scheduled for a shower on Thursday on PM shift.
Surveyor requested R23's shower sheets for September, October, November of 2021. Surveyor was provided the following:
September-no documentation of showers
October- completed shower sheets for 10/1/21, 10/8/21 and treatment administration record (TAR) indicate R23 received 1 showers for the month-10/4/21
November-no completed shower sheets and treatment administration record(TAR) indicate R23 received 0 showers for the month
On 11/29/21 at 10:31 AM, R23 informed Surveyor that R23 used to receive 2 showers a week but it was changed to 1 shower per week. R23 stated the day and time switched for R23's shower. R23 stated R23 would prefer a shower 2x per week. R23 stated, I feel yucky without a shower. I'm young and want more showers.
5) R96 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Peripheral Vascular Disease, Delusional Disorders, Major Depressive Disorder, and Shared Psychotic Disorder. R96 is his own person.
R96's Annual MDS dated [DATE] documents R96's BIMS score of 15 meaning R96 is cognitively intact for daily decision making. The MDS also documents R96 requires extensive assistance for bed mobility, dressing, personal hygien and total dependence for transfers. R96 requires physical help with 1 staff for bathing. R96 feels it is somewhat important to the question of: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath.
Surveyor reviewed R96's comprehensive care plan which documents the focused problem of self care performance deficit due to limited range of motion limited mobility, and musculosketal impairment
Initiated 6/9/16
Intervention initiated on 1/18/19 documents R96 is to be given showers on Wednesday evening and Sunday morning.
R96 is scheduled for a shower on Thursday on AM shift.
Surveyor requested R96's shower sheets for September, October, November of 2021. Surveyor was provided the following:
September-no documentation of showers
October- completed shower sheets for 10/4/2, and treatment administration record(TAR) indicate R96 received 2 showers for the month-10/10/21 and 10/24/21
November- completed shower sheet for 11/11/21 which states that the shower could not be given due to no linen and treatment administration record(TAR) indicate R96 received 1 shower for the month-11/25/21
On 11/29/21 at 2:41 PM, R96 informed Surveyor that R96 has not been getting showers 2x per week anymore and now its only 1x per week. R96 stated R96 would prefer 2x per week and stated R96 does not feel clean when R96 goes without a shower.
6) On 12/1/21 at 9:13 AM, Resident Council group informed Surveyor that showers went down from 2x to 1x a wk in October and all Residents are not happy. The 5 Residents in attendance (R18, R91, R1, R20 and R13) further stated that the days the showers are given were switched and do not know what day or shift the shower was switched to. All Residents in attendance stated they would prefer to receive 2 showers a week.
Surveyor reviewed the Resident Council Minutes and notes on 10/26/21, Administrator(NHA-A) informed Residents of the new shower schedule of going to 1 shower a week.
On 12/1/21 at 8:46 AM, Surveyor asked NHA-A, did you tell Residents they would only be getting 1 shower a week due to staff issues? NHA-A confirmed this statement and stated NHA-A informed the Residents at Resident council meeting.
On 12/2/21 at 3:16 PM, Surveyor shared the concern with Administrator(NHA-A), Director of Nursing(DON-B), and Regional Nurse Consultant(RNC-C) about R1, R13, R18, R23, R96 not getting showers, not even 1x per week. RNC-C confirmed that the shower sheets should be completed by Certified Nursing Assistants everytime a Resident gets a shower.
7) R87 was admitted to the facility on [DATE] with diagnosis that included Dementia. R87's admission Minimum Data Set (MDS) dated [DATE] indicated R87 requires 1 person physical assist with part of bathing. The MDS indicates R87 requires extensive assistance of 1 staff member for bed mobility, transferring, dressing, toilet use, and personal hygiene.
On 11/29/21 at 2:00 PM R87 was observed in his wheelchair in his room with hair growth observed on his face.
On 11/30/21 at 10:00 AM R87 was observed in his wheelchair in his room with hair growth observed on his face that was longer than 11/29/21.
On 12/1/21 at 1:00 PM R87 was observed in his wheelchair in his room with hair growth observed on his face that was longer than the day before. R87 indicated he would like to be shaved and would not say no if someone offered to shave him.
On 12/1/21 R87's shower records were reviewed and indicated R87 should receive a shower every week. No documentation could be found that R87 received showers for the week of 10/3/21, 10/10/21, 11/15/21 and 11/22/21.
On 12/1/21 at 3:00 PM Corporate Consultant-C was interviewed and indicated no further documentation could be found to prove R87 received his scheduled showers.
On 12/2/21 at 10:00 AM R87 was observed in his wheelchair clean shaven.
The above information was shared with the Administrator and Director of Nurses on 12/1/21 at 3:00 PM. Additional information was requested if available. None was provided.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not provide treatment and services, consistent with profess...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not provide treatment and services, consistent with professional standards of practice, to promote healing of pressure injuries for 7 (R43, R98, R117, R70, R28, R80, and R97) of 8 residents reviewed with pressure injuries.
R43 developed an Unstageable pressure injury to the left heel on [DATE]. No treatment was put in place until [DATE]. Assessments of the wound base did not equal 100% of the tissue type. Treatments were not consistently signed out on the Treatment Administration Record.
R98 was admitted with a Stage 2 pressure injury to the ball of the right foot, a Stage 3 pressure injury to the right heel, and an Unstageable pressure injury to the sacrum that, once it was able to be staged, was a Stage 4 pressure injury. The pressure injury to the ball of the foot was not documented on when the area healed. The pressure injuries to the right heel and sacrum were not comprehensively assessed weekly and the treatments were not always signed out as being completed on the Treatment Administration Record.
R117 developed an Unstageable pressure injury to the coccyx on [DATE] that was determined to be a Stage 3 pressure injury on [DATE]. R117 was admitted to hospice services on [DATE]. R117 did not have comprehensive weekly assessments documented in the medical record of a Stage 3 pressure injury to the coccyx after [DATE]; R117 died on [DATE] on hospice services while a resident at the facility.
F70 was admitted with a Stage 3 pressure injury to the right gluteal fold/buttock that developed into a Stage 4 pressure injury and a Stage 4 pressure injury to the sacrum. The pressure injuries were not comprehensively assessed weekly, percentages of the wound base did not equal 100%, and treatments were not always signed out as being completed on the Treatment Administration Record.
R28 was readmitted from the hospital on [DATE] with an Unstageable pressure injury to the right heel. The pressure injury was not comprehensively assessed on readmission on [DATE], percentages of the wound base did not equal 100%, and the Care Plan was not implemented or revised when the pressure injury was discovered.
R80 was observed during the survey process to have heels not floated as care planned due to risk of pressure injury development.
R97 was observed during the survey process to have heel boots not in place as care planned with presence of pressure injury to the heel.
Findings:
1. R43 was admitted to the facility on [DATE] after fusion of the cervical spine. R43 had diagnoses of myelodysplastic syndrome, coronary artery disease, myelopathy, and anemia. R43 had limited mobility due to wearing a cervical collar at all times post cervical spine fusion. R43's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R43 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 12 and coded R43 needing extensive assistance with bed mobility, hygiene and bathing. R43 did not have any pressure injuries on admission to the facility.
R43's Impaired Skin Integrity Care Plan was created on [DATE] with an initiation date of [DATE]. The following interventions were put in place on [DATE]:
-Encourage to float heels when in bed
-Pressure redistribution mattress
-Assist to reposition approximately every 2-3 hours and as needed
-Apply cushion to wheelchair
-Barrier cream after each incontinent episode and as needed
-Compete Braden scale upon admission, weekly times four, quarterly, with significant change of condition, and as needed
-Lotion skin with cares
-Weekly skin assessment
-Monitor skin with all cares; report an changes to nurse
-Update physician as needed
-Refer to dietician as needed
-Refer to therapy as needed
LEFT AND RIGHT BUTTOCKS
On [DATE] on the Weekly Skin Check, a Stage 2 pressure injury was found on the left buttock measuring 3.0 cm x 3.0 cm and a Stage 2 pressure injury to the right buttock measuring 3.5 cm x 3.5 cm. The physician was notified and a treatment for zinc oxide was initiated.
R43's Impaired Skin Integrity Care Plan was revised on [DATE] with the intervention of an alternating pressure mattress.
On [DATE], the left and right buttock Stage 2 pressure injuries had healed.
LEFT HEEL
On [DATE] on the Admit/Readmit Assessment form, nursing documented R43 had a corn on the left heel. No other descriptors or measurements of the area were documented.
On [DATE] on the Initial Wound Assessment form, nursing documented R43 had an Unstageable pressure injury to the left heel measuring 1.7 cm x 3.5 cm with no depth. The wound base was 100% eschar. On the treatment section of the form, nursing documented an APM (alternating pressure mattress) ordered, float heels while in bed. Resident is in cervical collar due to compressed vertebrae. Unable to move bilateral feet and has impaired mobility. The form indicated the physician and wound physician had been notified of the new area on [DATE] at 2:00 PM. No treatment order was obtained.
On [DATE] on the Treatment Administration Record (TAR), an order was initiated for the left heel pressure injury: apply betadine to eschar every day and evening shift. The left heel pressure injury did not have a treatment in place for two days after discovery. The wound treatment was not signed out on the TAR by nursing staff indicating the treatment had been completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], seven times.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 2.1 cm x 3.82 cm with no depth with a wound base of 100% eschar. The wound was assessed by the wound physician.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 2.4 cm x 4.1 cm with no depth with the wound base of 100% eschar.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 3.4 cm x 4.2 cm with no depth with 1% granulation, 27% slough, 40% eschar, and 4% epithelialization. The total percentage of the tissue in the wound base should equal 100%; 72% of the wound base was accounted for.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 3.4 cm x 4.0 cm x 0.1 cm with 1% granulation, 4% slough, and 95% eschar.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 1.7 cm x 2.1 cm x 0.1 cm with 19% granulation, 68% eschar, and 9% epithelialization. The total percentage of the wound base assessed was 96%.
The left heel Unstageable pressure injury was comprehensively assessed weekly from [DATE] through the time of the survey.
On [DATE] at 1:36 PM, Surveyor observed R43 in R43's room in a wheelchair. R43 had just transferred into the wheelchair and therapy staff was helping R43 put heel boots on.
On [DATE] at 10:05 AM, Surveyor observed Licensed Practical Nurse (LPN)-S complete the treatment to R43's left heel. R43 was observed to be in bed on an air mattress with heel boots on both feet. LPN-S removed the left heel boot and applied betadine to the left heel pressure wound. The wound measured approximately 1.5 cm x 2.5 cm with black eschar covering 100% of the wound. The betadine was left open to air to dry and then the heel boot was replaced. R43 stated there was no pain to the left heel.
In an interview on [DATE] at 12:40 PM, Surveyor met with Director of Nursing (DON)-B and Regional Nurse Consultant-C to discuss the concern with R43's Unstageable pressure injury to the left heel. Surveyor shared no treatment was put in place on [DATE] when the pressure injury was first discovered; the treatment was not initiated until [DATE], two days later. Surveyor shared the wound base percentages did not equal 100% on [DATE] and [DATE]. Surveyor shared the treatments in the TAR were not consistently signed out by nursing staff as completing the wound treatment. Regional Nurse Consultant-C agreed the treatment to the left heel wound should have been initiated when the wound was discovered on [DATE] and the percentages of the wound base descriptors should equal 100%. Regional Nurse Consultant-C stated the wound physician uses a program when assessing the wounds and the nurse uses the percentages from that program; the program does not give percentages that equal 100% and Regional Nurse Consultant-C stated the nurse should discuss with the wound physician to determine what the wound base is so the total would be 100%. Regional Nurse Consultant-C stated the nurses should be signing out all treatments in the TAR. No further information was given at that time.
2. R98 was admitted to the facility on [DATE] with diagnoses of toxic encephalopathy, diabetes, intellectual disabilities, and pressure ulcers. R98's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R98 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and coded R98 as needing extensive assistance with all activities of daily living including bed mobility, toilet use, and hygiene. The Pressure Ulcer Care Area Assessment for that MDS assessment stated R98 was admitted with three pressure ulcers, see initial wound assessment for more details. Plan of care with treatment to be developed with goal that ulcers heal without complication.
R98's Actual Impaired Skin Integrity Care Plan was initiated on [DATE] on admission with the following interventions:
-Wound physician consult
-assist to reposition approximately every 2-3 hours and as needed
-Apply cushion to wheelchair
-Barrier cream after each incontinent episode and as needed
-Complete Braden scale upon admission, weekly times four, quarterly, with significant change of condition and as needed
-Specialty mattress
-Avoid friction/shearing while repositioning; if resident is unable to assist use at least two staff members, use lift sheet, bed should be as flat as possible while lifting
-Monitor skin with all cares; report any changes to nurse
-Update physician as needed
-Refer to dietician as needed
-Refer to therapy as needed
RIGHT BALL OF FOOT
On [DATE] on the Initial Wound Assessment form, nursing documented R98 was admitted with a Stage 2 pressure injury to the ball of the right foot that measured 1.2 cm x 1.8 cm with no depth and appeared as a flattened blister. The physician was notified at that time.
No assessments were documented after the initial assessment on [DATE].
In an interview on [DATE] at 12:30 PM, Regional Nurse Consultant-C stated the wound on the ball of the right foot had healed the next time the foot was looked at after the initial wound assessment. Regional Nurse Consultant-C stated the nurse should have documented the area had healed.
RIGHT HEEL
On [DATE] on the Initial Wound Assessment form, nursing documented R98 was admitted with a Stage 3 pressure injury to the right heel that measured 1.8 cm x 3.6 cm x 0.1 cm with 90% granulation and 10% slough. The physician was notified at that time.
No treatment to the right heel was initiated on [DATE].
On [DATE] on the Treatment Administration Record (TAR), an order was initiated to the right heel wound: clean with normal saline, dab dry, apply derma blue foam followed by bordered gauze then apply rolled gauze around the foot and place in foam boot daily.
R98's Actual Impaired Skin Integrity Care Plan was revised on [DATE] with the following intervention: treatment as ordered.
R98's Actual Impaired Skin Integrity Care Plan was revised on [DATE] with the following intervention: both heels to float while in bed.
On [DATE] on the TAR, the treatment was changed to cleanse right heel with half-strength Dakins, pat dry, apply skin prep and bordered foam every Tuesday, Thursday, and Saturday.
No documentation was found in R98's medical record of a comprehensive assessment from [DATE] until [DATE], 19 days.
On [DATE] on the Weekly Wound Assessment form, nursing documented R98's right heel Stage 3 pressure injury measured 1.28 cm x 3.03 cm x 0.1 cm with 100% granulation.
The right heel Stage 3 pressure injury was comprehensively assessed weekly from [DATE] until [DATE] when the wound healed.
The treatment to the right heel was not signed out by the nurse indicating the treatment was completed on [DATE].
SACRUM
On [DATE] on the Initial Wound Assessment form, nursing documented R98 was admitted with an Unstageable pressure injury to the sacrum measuring 4.0 cm x 5.6 cm x 1.5 cm with 50% granulation and 50% slough. The physician was notified at that time. A treatment was started at that time with a wound vac and an alternate treatment if the wound vac was unavailable or not functional.
No documentation was found in R98's medical record of a comprehensive assessment from [DATE] until [DATE], 19 days.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 3.65 cm x 4.22 cm x 2.2 cm with 90% granulation and 10% slough. The definition of Unstageable pressure injury is a wound that has the majority of the wound base covered by slough and therefore unable to determine the extent of the wound. With the wound having 90% granulation tissue, the wound should have had enough exposed base in order to stage the wound.
On [DATE], ProSource 30 ml twice daily were ordered to increase protein intake.
The Unstageable pressure injury was comprehensively assessed weekly from [DATE] through [DATE].
R98's Actual Impaired Skin Integrity Care Plan was revised on [DATE] with the following intervention: turn and reposition every 1-2 hours and as needed.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 3.0 cm x 2.4 cm x 1.9 cm with 60% granulation and 40% slough with undermining of 3 cm from 7 o'clock to 5 o'clock. R98's wound was assessed weekly by the wound physician.
R98 was hospitalized from [DATE] until [DATE]. The hospital Discharge summary dated [DATE] indicated the sacral wound was surgically debrided while in the hospital due to an abscess.
On readmission on [DATE], ProSource was not ordered as prior to hospitalization.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 4 pressure injury measured 11.2 cm x 14.6 cm x 3.3 cm with 80% granulation, 10% slough, 5% eschar, and 15% epithelialization, totaling 110%. Tunneling was present measuring 13 cm in length.
The Stage 4 pressure injury was comprehensively assessed weekly from [DATE] until the time of the survey.
R98's Actual Impaired Skin Integrity Care Plan was revised on [DATE] with the following intervention: new order for wound vac to sacrum.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 4 pressure injury measured 9.4 cm x 10.3 cm x 3.1 cm with 98% granulation, 1% eschar, and 1% epithelialization with tunneling of 2.1 cm from 7 o'clock to 8 o'clock.
The wound treatment was changed as the wound progressed as assessed by the wound physician. The treatment was not signed out on the TAR as being completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], a total of 7 treatments.
On [DATE] at 10:11 AM, R98 was observed to be in bed with an air mattress in place. R98 was lying on the left side and did not respond verbally when interacted with by Surveyor.
In the daily exit meeting with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, and Regional Nurse Consultant-C on [DATE] at 3:04 PM, Surveyor requested to observe R98's wound care the following day. Regional Nurse Consultant-C stated R98 has a wound vac and was not sure what days the dressing change was done and would get back to Surveyor to arrange a day and time.
On [DATE] at 10:35 AM, Regional Nurse Consultant-C stated R98's wound vac was due to be changed that day, but the wound vac had malfunctioned and was changed on the previous night shift and was not due to be changed until [DATE]. Surveyor was unable to observe R98's wound treatment.
In an interview on [DATE] at 12:30 PM, Surveyor shared with DON-B and Regional Nurse Consultant-C the concerns with R98's pressure injuries: no documentation was found from [DATE] through [DATE] and treatments were not always signed out as being completed by nursing staff. Regional Nurse Consultant-C stated the Unstageable pressure injury to the sacrum on admission was a Stage 4 at that time and should have been documented that way. Regional Nurse Consultant-C agreed there was no documentation in R98's medical record for those dates and treatments should have been signed out when the treatment was completed. No further information was provided at that time.
3. R117 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, post polio syndrome, diabetes, coronary artery disease, and peripheral vascular disease. R117 admission Minimum Data Set (MDS) assessment dated [DATE] indicated R117 had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 4 and coded R117 needing extensive assistance with bed mobility and hygiene and frequently incontinent of bladder and always incontinent of bowel.
R117's Impaired Skin Integrity Care Plan was initiated on [DATE] with the following interventions:
-Pressure redistribution mattress
-Complete Braden scale upon admission, weekly times four, quarterly, with significant change of condition and as needed
-Weekly skin assessment
-Monitor skin with all cares; report any changes to the nurse
-Update physician as needed
-Refer to dietician as needed
-Refer to therapy as needed
On [DATE] on the Initial Wound Assessment form, nursing documented R117 had an Unstageable pressure injury to the coccyx that measured 1.0 cm x 1.0 cm with 100% slough. No depth was documented. In the comments section nursing charted: Resident cannot express need to be turned. Staff encourages resident to lay on side and staff assists resident to turn, but resident moves onto his back. Staff will re-approach every 2 hours and PRN (as needed) to assist resident with proper positioning. The Nurse Practitioner was notified of the new area. A treatment was started at that time.
On [DATE] at 10:29 AM in the progress notes, nursing charted a consent was sent to R117's Power of Attorney (POA) for R117 to be seen by the wound physician.
R117's Impaired Skin Integrity Care Plan was revised on [DATE] with the following intervention: specialty air mattress; monitor for inflation every shift.
R117's Impaired Skin Integrity Care Plan was revised on [DATE] with the following intervention: assist to reposition approximately every 2-3 hours and as needed.
R117's Impaired Skin Integrity Care Plan was on [DATE] with the following intervention: consult with wound physician.
R117's Impaired Skin Integrity Care Plan was revised on [DATE] with the following intervention: treatments as ordered.
R117's Impaired Skin Integrity Care Plan was revised on [DATE] with the following intervention: bed rest.
The Unstageable pressure injury was comprehensively assessed weekly from [DATE] through [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 1.53 cm x 1.19 cm x 0.3 cm with 100% slough.
On [DATE] on the Weekly Wound Assessment form, nursing documented the pressure injury was a Stage 3 that measured 1.52 cm x 0.47 cm x 0.1 cm with 90% granulation and 10% slough.
The Stage 3 pressure injury was comprehensively assessed weekly from [DATE] through [DATE].
On [DATE] at 10:49 AM in the progress notes, nursing charted R117's POA had given verbal consent for R117 to have hospice provide services.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 3 pressure injury measured 1.1 cm x 0.62 cm x 0.1 cm with 75% granulation and 25% slough.
No wound documentation was found in R117's medical record after [DATE]. Review of hospice documentation indicated the wound was being followed by facility staff.
R117 passed away on hospice care at the facility on [DATE].
In an interview on [DATE] at 12:32 PM, Surveyor shared the concern with Director of Nursing (DON)-B and Regional Nurse Consultant-C no documentation of R117's Stage 3 pressure injury to the coccyx was found in R117's medical record after [DATE]. Surveyor asked DON-B and Regional Nurse Consultant-C if the facility had a policy that stated wounds were not assessed after the election of hospice services. Regional Nurse Consultant-C stated the nursing staff should have continued to assess and treat the pressure injury and document the comprehensive assessment in the medical record. No further information was provided at that time.
4. R70 was admitted to the facility on [DATE] with diagnoses of paraplegia, chronic obstructive pulmonary disease, osteomyelitis, and heart failure. R70's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R70 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and coded R70 needing extensive assistance with bed mobility. R70 had an indwelling urinary catheter and a colostomy.
R70's Impaired Skin Integrity Care Plan was initiated on [DATE] with the following interventions:
-Complete Braden scale upon admission, weekly times four, quarterly, with significant change of condition and as needed
-Encourage to float heels in bed
-Encourage to turn and reposition every 2-3 hours
-Measure area weekly
-Monitor for signs/symptoms of infection
-Monitor for signs/symptoms of worsening skin tissue
-Monitor pain and offer analgesic as needed as ordered
-Monitor skin with all cares; report any changes to nurse/physician
-Refer to dietician as needed
-Soft boots on in bed
-Specialty air mattress; monitor for inflation every shift
-Weekly skin assessment
-Wound doctor to evaluate and treat
-Wound team to follow
-Treatment as ordered
-Update physician with changes in wound status as needed
R70's Impaired Skin Integrity Care Plan was revised on the following dates with interventions:
-[DATE]: ensure ROHO cushion is inflated and bring to therapy if not, and R70 to be up in chair a maximum of 1.5 hours.
-[DATE]: resident was seen by the wound physician.
-[DATE]: treatment changed to right buttock, bed rest for one week, and labs to be drawn.
-[DATE]: may be up in chair twice per week for one hour.
-[DATE]: discontinue peripherally inserted central catheter (PICC) line, wound vac order changed.
On [DATE] on admission, R70 had a Stage 3 pressure injury to the right gluteal fold/buttock and a Stage 4 pressure injury to the sacrum.
RIGHT GLUTEAL FOLD/BUTTOCK
On [DATE] on the Initial Wound Assessment form, nursing documented R70 had a Stage 3 pressure injury to the right gluteal fold that measured 1.5 cm x 1.0 cm x 0.1 cm with 60% granulation and 40% slough. The physician and wound physician were notified.
The Stage 3 pressure injury was comprehensively assessed and documented weekly from [DATE] through [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 0.9 cm x 1.4 cm x 0.1 cm with 80% granulation and 20% epithelialization. The definition of an Unstageable pressure injury is the majority of the wound bed is covered with slough and the wound base is unable to be observed; the wound had a visible wound bed and should have been staged.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Unstageable pressure injury measured 0.9 cm x 1.4 cm x 0.1 cm with 80% granulation and 20% epithelialization. The wound had a visible wound bed and should have been staged.
On [DATE] on the Weekly Wound Assessment form, nursing documented the wound was measured on [DATE] and had the same measurements that had been documented on the [DATE] Weekly Wound Assessment form: 0.9 cm x 1.4 cm x 0.1 cm. The wound bed had the following percentages: 0% granulation and 0% epithelialization. No other tissue types were documented. The assessment was not comprehensive and the date indicated the measurements were not current.
No documentation was found in R70's medical record of a weekly comprehensive assessment from [DATE] through [DATE], for 28 days.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 3 pressure injury measured 1.6 cm x 1.5 cm x 0.1 cm with 90% granulation. No other tissue type was documented.
The Stage 3 pressure injury was comprehensively assessed and documented weekly from [DATE] through [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 3 pressure injury measured 1.33 cm x 1.32 cm x 0.3 cm with 75% granulation and 25% slough.
No documentation was found in R70's medical record of a weekly comprehensive assessment on [DATE].
The Stage 3 pressure injury was comprehensively assessed and documented on weekly from [DATE] through [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 3 pressure injury measured 2.7 cm x 2.1 cm x 0.3 cm with 80% granulation and 20% slough.
No documentation was found in R70's medical record of a weekly comprehensive assessment from [DATE] through [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the pressure injury was now a Stage 4 that measured 2.9 cm x 2.8 cm x 3.2 cm with 53% granulation, 2% slough, 6% eschar, and 28% epithelialization, totaling 89% of the wound bed. The wound was assessed weekly by the wound physician.
The Stage 4 pressure injury was comprehensively assessed and documented on weekly from [DATE] through the time of the survey.
Treatments to the right gluteal fold/buttocks were not initialed on the Treatment Administration Record as being administered on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], 7 treatments.
SACRUM
On admission [DATE] on the Initial Wound Assessment form, nursing documented R70 had a Stage 4 pressure injury to the sacrum that measured 8.8 cm x 10.4 cm x 0.8 cm with 9% granulation and 10% eschar. The documentation described 19% of the wound base; 100% of the wound base should have been described. The physician and wound physician were notified.
The Stage 4 pressure injury was comprehensively assessed on [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 4 pressure injury measured 11.5 cm x 12.3 cm x 1.0 cm with 30% granulation, 14% slough, and 46% epithelialization. The documentation described 90% of the wound base.
The Stage 4 pressure injury was comprehensively assessed weekly from [DATE] through [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 4 pressure injury measured 8.9 cm x 9.2 cm x 0.3 cm with 90% granulation and 10% slough.
No documentation was found in R70's medical record of a weekly comprehensive assessment from [DATE] through [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 4 pressure injury measured 8.9 cm x 8.8 cm x 0.1 cm with 47% granulation and 53% epithelialization.
The Stage 4 pressure injury was comprehensively assessed on [DATE].
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 4 pressure injury measured 7.6 cm x 8.2 cm x 0.1 cm with 10% granulation, 11% eschar, and 70% epithelialization. The documentation described 90% of the wound base.
On [DATE] on the Weekly Wound Assessment form, Regional Nurse Consultant-C documented the Stage 4 pressure injury measured 7.7 cm x 9.1 cm x 0.2 cm with 1100% granulation. Regional Nurse Consultant-C stated in an interview on [DATE] at 12:35 PM the percentage of wound tissue was in error; the form should have stated 100% granulation tissue.
On [DATE] on the Weekly Wound Assessment form, nursing documented the Stage 4 pressure injury measured 7.8 cm x 8.1 cm with 100% granulation. No depth was documented.
The Stage 4 pressure injury was comprehensively assessed from [DATE] through the time of the survey.
Treatments to the sacrum were not initialed on the Treatment Administration Record as being administered on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], 8 treatments.
On [DATE] at 12:54 PM, Surveyor observed Licensed Practical Nurse (LPN)-M administer the wound treatment to R70's sacral wound. R70 was in bed with an air mattress in place. LPN-M stated R70 has a wound to the right buttock that was changed yesterday and not due to be changed that day. LPN-M stated R70 also had a wound to the sacrum that had a daily treatment ordered. Surveyor observed the wound vac in place and functioning to the left gluteal fold/buttock wound. Surveyor observed the sacral wound to be approximately 7 cm x 7 cm with a white/yellow film to the wound bed with undermining. The wound was cleansed with half-strength Dakins followed by normal saline. Skin prep was applied around the wound with bloody drainage noted to be on the pad. Hydrofera blue was cut into the shape of the wound and applied to the wound base and the area was covered with a bordered dressing. LPN-M stated the wound physician thought the wound was infected at one time, but the wound culture came back with no conclusive growth; the following day R70's lower leg got red and the wound physician determined cellulitis to the leg was what the infective process was.
On [DATE] at 12:36 PM, Surveyor met with Director of Nursing (DON)-B and Regional Nurse Consultant-C to share the concerns with R70's right gluteal fold/buttock and sacral pressure injuries. Surveyor shared the assessments that had wound base descriptions that did not equal 100%, the wounds were not assessed comprehensively on a weekly basis, and treatments were not signed out on the TAR as being administered as ordered. Surveyor shared the concern the right gluteal fold/buttock pressure injury progressed from a Stage 3 to a Stage 4. Regional Nurse Consultant-C stated the wound on admission should have been staged at a Stage 4; Regional Nurse Consultant-C thought the wound had always been a Stage 4 wound. Surveyor asked if the wound physician did not come to the facility for one week, who would be responsible for doing the weekly wound assessment. Regional Nurse Consultant-C stated the wound team would be expected to do the assessment even if the wound physician was not there. Regional Nurse Consultant-C did not know why the wounds were not documented on in the medical record weekly. No further information was provided at that time.
5. R28 was admitted to the facility on [DATE] with diagnoses of diabetes, chronic obstructive pulmonary disease, heart failure, and chronic kidney disease. R28's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R28 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 13 and coded R28 as needing extensive assistance with bed mobility.
R28's Diabetic Care Plan was initiated on [DATE] with the following interventions:
-Inspect feet daily for open areas, sores, pressure areas, blisters, edema or redness.
-Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails.
R28 was admitted to the hospital [DATE] and was readmitted to the facility on [DATE]. R28 retu[TRUNCATED]
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 5 (R7, R49, R66, R77, & R113) of 5 residents reviewed were...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that 5 (R7, R49, R66, R77, & R113) of 5 residents reviewed were provided medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Based on resident council minutes and group interview conducted 12/1/21, Residents are in agreement that medically-related social services have not been provided.
*A self-report submitted to the state agency on 9/24/21 documents R7 was involved in a Resident/Resident altercation. The summary documented the social worker would meet with R7 weekly to follow-up on concerns. R7 received no psychosocial follow-up.
*A self-report submitted to the state agency on 9/24/21 documents R49 was involved in a Resident/Resident altercation. The summary documented the social worker would meet with R49 weekly to follow-up on concerns. R49 received no psychosocial follow-up.
*A self-report submitted to the state agency on 10/7/21 documents R66 was involved in a Resident/Resident altercation. The summary documented the social worker would follow-up to ensure R66's psychosocial needs are met. R66 received no psychosocial follow-up.
*A self-report submitted to the state agency on 10/19/21 documents R77 reported an allegation of abuse. The summary documented the social worker would meet with R77 weekly to follow-up on concerns. R77 received no psychosocial follow-up.
*A self-report submitted to the state agency on 10/7/21 documents R113 was involved in a Resident/Resident altercation. The summary documented the social worker would follow-up to ensure R113's psychosocial needs are met. R113 received no psychosocial follow-up.
Findings Include:
Per facility Social Services policy and procedure revised October 2010 the following is required in order to provide medically-related social services to assure that each Resident can maintain his/her highest practicable physical, mental, or psychosocial well-being:
2. Medically-related social services is provided to maintain or improve each Resident's ability to control everyday physical needs, and mental and psychosocial needs.
4. The social services department is responsible for:
a. Obtaining pertinent social data about personal and family problems related to the Resident's illness and care
b. Identifying individual social and emotional needs
c. Assisting in providing corrective action for the Resident's needs by developing and maintaining individualized social service care plans
d. Maintaining regular progress and follow-up notes indicating the Resident's response to the plan and adjustment to the institutional setting,
e. Compiling and maintaining up-to-date information about community health and service agencies available for Resident referrals
f. Making referrals to social service agencies as necessary or appropriate
g. Maintaining appropriate documentation of referrals and providing social service data summaries to such agencies
h. Maintaining contact with the Resident's family members, involving them in the Resident's total plan of care
i. Making supportive visits to Residents and performing needed services
j. Informing the Resident or representative of the Resident's personal and property rights as well as serving on the group council to assure that complaints and grievances are promptly answered/resolved
k. Working with individuals and groups in developing supportive services for Residents according to their individual needs and interests
l. Participating in interdisciplinary staff conferences, providing social services information to ensure treatment of the social and emotional needs of the Resident as a part of the total plan of care
m. Participating in the planning of the Resident's admission, return to home and community, or transfer to another facility by assessing the impact of these changes and making arrangements for social and emotional support
n. Developing and participating in in-service training programs and classes
1.) R7 was admitted to the facility on [DATE] with diagnoses of Vascular Dementia with Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder, Type 2 Diabetes Mellitus, and Other Sequelae of Cerebral Infarction. R7 has a legal guardian.
R7's Annual Minimum Data Set (MDS) dated [DATE] documented R7 has a Brief Interview for Mental Status (BIMS) score of 10, meaning R7 demonstrates moderately impaired skills for daily decision making. R7 Had a Patient Health Questionnaire (PHQ-9) score of 6, meaning R7 has mild depression and verbal behavior was documented, occurring 1-3 days.
R7's Quarterly MDS dated [DATE] documents no mood or behavior issues.
Surveyor reviewed R7's comprehensive care plan and notes that R7 has a history of Resident to Resident altercations-6/19/21, 9/18/21,&11/4/21. R7's care plan also documents R7 takes Lorazepam due to anxiety disorder and Citalopram for depression.
Surveyor reviewed a self-report submitted to the state agency on 9/24/21 which documents R7 was involved in a Resident/Resident altercation. The summary documented the social worker would meet with R7 weekly to follow-up on concerns.
Surveyor reviewed R7's electronic medical record (EMR) and noted there were no documented social service follow-up.
2) R49 was admitted to the facility on [DATE] with diagnoses of Quadriplegia. R49 is his own person.
R49's Quarterly MDS dated [DATE] documents R49's BIMS score of 15, meaning R49 is cognitively intact for daily decision making. R49's PHQ-9 score of 4 reflects minimal depression and R49 demonstrated verbal behaviors 1-3 days.
Surveyor reviewed R49's comprehensive care plan and notes R49's care plan was updated on 9/21/21 to reflect a psychosocial well-being problem due to peer to peer altercation.
Intervention applicable initiated on 9/21/21 is to allow to share thoughts and feelings. Off support through listening in 1:1 situation,
Surveyor reviewed a self-report submitted to the state agency on 9/24/21 which documents R49 was involved in a Resident/Resident altercation. The summary documented the social worker would meet with R49 weekly to follow-up on concerns.
Surveyor reviewed R49's electronic medical record(EMR) and notes there was no documented social service follow-up.
3) R66 was admitted to the facility on [DATE] with diagnoses of Morbid Obesity, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. R66 is his own person.
R66's Quarterly MDS dated [DATE] documents R66's BIMS score of 10 indicating R66 demonstrates moderately impaired skills for daily decision making. R66's PHQ-9 score of 7 indicates mild depression and R66 had rejection of care 1-3 days.
R66's admission MDS dated [DATE] documents R66 had a PHQ-9 score of 4 and verbal behaviors 1-3 days.
Surveyor reviewed R66's comprehensive care plan and notes that R66 has a focused mood state problem due to repetitive verbalizations, persistent anger with self or others, manipulative behaviors, swearing and making racial slurs towards staff. Initiated 8/7/21.
R66's focused problem was updated on 10/7/21 to reflect Resident to Resident altercation that occurred 10/1/21.
Intervention applicable was initiated 8/7/21 and documents to arrange for consult with social services or other counseling services.
Surveyor reviewed R66's self-report submitted to the state agency on 10/7/21 which documents R66 was involved in a Resident/Resident altercation. The summary documented the social worker would follow-up to ensure R66's psychosocial needs are met.
Surveyor reviewed R66's electronic medical record(EMR) and notes there was no documented social service follow-up.
4) R77 was admitted to the facility on [DATE] with diagnoses of Major Depressive Disorder, Acute and Chronic Respiratory Failure, and Type 2 Diabetes. R77 is her own person.
R77's admission MDS dated [DATE] documents R77's BIMS score to be a 15, meaning R77's cognitive skills are intact. R77's PHQ-9 score is a 7 indicating mild depression.
Surveyor reviewed R77's comprehensive care plan and notes that R77 has been prescribed an antidepressant for a persistent diagnosis of depression initiated 10/28/21.
Surveyor reviewed a self-report submitted to the state agency on 10/19/21 which documents R77 reported an allegation of abuse. The summary documented the social worker would meet with R77 weekly to follow-up on concerns.
Surveyor reviewed R77's electronic medical record(EMR) and notes there was no documented social service follow-up.
5) R113 was admitted to the facility on [DATE] with diagnoses of Alcohol Dependence with Withdrawal Delirium and Hepatic Failure. R113 has an activated Health Care Power of Attorney(HCPOA). R113 discharged from the facility on 11/8/21.
R113's Quarterly MDS dated [DATE] documents R113 has a BIMS score of 13, meaning R113 is cognitively intact, and a PHQ-9 score of 7 meaning R113 has mild depression. No behaviors are documented.
R113's admission MDS dated [DATE] documents R113 PHQ-9 score to be 0.
Surveyor reviewed R113's comprehensive care plan and notes there was no applicable focused problem addressing R113's psychosocial needs.
Surveyor reviewed R113's self-report submitted to the state agency on 10/7/21 which documents R113 was involved in a Resident/Resident altercation. The summary documented the social worker would follow-up to ensure R113's psychosocial needs are met.
Surveyor reviewed R113's electronic medical record(EMR) and notes there was no documented social service follow-up.
Surveyor reviewed Resident council minutes and noted Residents had communicated concern about social services not being available and lack of concerns being addressed and resolved.
May 24, 2021-suggestion for a locked box by social services door so Residents could communicate when social worker was not in or to leave information Resident need follow-ups on.
June 29,2021-has not seen anyone from Social Services
July 27, 2021-do we even have Social Services
October 26, 2021-concerns discharge planning and setting up for ancillary services was not getting followed up on
On 12/1/21 at 9:13 AM, Surveyor conducted a Resident Council meeting. All Residents were in agreement that sufficient and appropriate social services were not being provided to Residents at the facility. Surveyor was informed Residents keep getting told 2 people are available but no one is following up on concerns. Surveyor was also informed that social services is very unavailable and not helping with anything.
On 12/6/21 at 9:50 AM, Surveyor shared the concern with Administrator(NHA-A) that medically related social services has not been provided to Residents at the facility in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each Resident. NHA-A acknowledged the concern and no further information was provided at this time.
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** 3. R43 was admitted to the facility on [DATE] with diagnoses of Fusion of Spine, Cervical Region, Unspecified Osteoartritis, Mye...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R43 was admitted to the facility on [DATE] with diagnoses of Fusion of Spine, Cervical Region, Unspecified Osteoartritis, Myelodysplastic Syndrome, Unspecified Dementia, and Major Depressive Disorder. R43 has an activated Health Care Power of Attorney(HCPOA).
R43's admission Minimum Data Set (MDS) dated [DATE] documents R43's Brief Interview for Mental Status (BIMS) score to be a 12, meaning R43 demonstrates moderately impaired skills for daily decision making. R43's MDS also documents R43 requires extensive assistance for bed mobility and eating, total dependence for transfers and toileting. R43's MDS documents R43 has a Foley catheter.
Surveyor reviewed R43's comprehensive care plan and notes that there is a focused problem for the indwelling catheter post surgical initiated on 9/24/21.
Intervention applicable initiated on 9/28/21 stated to follow physician orders and policy protocol.
Surveyor notes the current physician orders for R43's Foley catheter include to flush the Foley with 60cc of sterile water every 8 hours an needed
On 11/29/21 at 11:16 AM, Surveyor observed R43 in bed. Surveyor was able to see the uncovered Foley catheter bag from the doorway. The Foley catheter bag was hanging on the left side of R43's bed. Surveyor also notes the Foley catheter bag was touching the ground.
On 11/30/21 at 8:05 AM, Surveyor observed R43 in bed, the Foley catheter bag uncovered, can be seen from the doorway, and touching the ground.
On 12/2/21 at 10:10 AM, Surveyor observed R43 in bed, the Foley catheter bag uncovered, can be seen from the doorway, and touching the ground.
Surveyor reviewed the policy and procedure, Emptying a Urinary Drainage Bag revised October 2010 provided by the facility and noted the following:
9. Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage.
On 12/3/21 3:15 PM, Surveyor communicated the concern to Administrator (NHA-A), Director of Nursing(DON-B), and Regional Nurse Consultant (RNC-C) of R43's Foley catheter bag being observed to be uncovered, seen from the doorway, and touching the ground. RNC-C stated that all Foley catheter bags should be covered and not laying on the ground.
staff not wearing PPE correctly
nurse touching med when splitting pill
catheter on floor and uncovered
[NAME] based on - and determine scope
Resident #43
Pressure Ulcer/Injury
12/01/21 09:28 AM [NAME] Resident # 43 RESDIENT NOTES
9/21/21 Entry
no sig change
9/28/21 Admit MDS - BIMS 12, PHQ9 10, behaviors none
bed mobility 3/3
transfer 4/3
walk 8/8
dressing 2/2
eating 3/2
toilet use 4/3
hygiene 2/2
bathing 4/3
impairment 0/0, catheter, always incontinent bowel, occasional pain 09, no falls, 58 136 #, mechanically altered therapeutic diet, surgical wound, AD x7, opioid x2, ST, OT, PT
CAAs
COGNITIVE -
VISUAL -
ADL -
URINARY -
PSYCHOSOCIAL -
MOOD -
FALLS -
NUTRITIONAL -
DEHYDRATION -
DENTAL -
PRESSURE - Risk for impaired skin integrity as evidence by limited mobility and incontinece
PSYCHOTROPIC -
PAIN -
11/29/21 01:36 PM 407-B [NAME] (complaint) agreed to have watch treatment, res in wheelchair being helped by staff to put boots on
10/1/21 new areas found Weekly Skin Check
32) Left buttock -
3cm round OA to inner buttock
31) Right buttock - 3.5cm round OA to inner buttock
10/2/21 new areas found Weekly Skin Check
32) Left buttock -
3.0 round OA to inner buttock reported 10/2
31) Right buttock - 3.5 round OA in inner buttock reported 10/2
11) Left scapula -
5.5 cm round excoriation to left scapula discovered this date
10) Right scapula - 3.0 cm round excoriated area to right scapula
10/4/21 new area found Initial Wound Assessment
Left Heel
LEFT BUTTOCK pressure Stage 2
10/1/2021
Zinc oxide tx started 10/1/2021
10/12/2021 - healed
RIGHT BUTTOCK pressure Stage 2
10/1/2021
Zinc oxide tx started 10/1/2021
10/12/2021 - healed
RIGHT SCAPULA trauma
10/2/2021
10/12/2021 - healed
LEFT SCAPULA trauma
10/2/2021
weekly 10/12/2021 until 11/16/2021 - healed
LEFT HEEL pressure Unstageable
10/4/2021
treatment started 10/6/2021
10/12/21 Unstageable 2.1 x 3.82 x 0, 100% eschar, followed by wound team and wound doctor, continue treatment as ordered
10/19/21 Unstageable 2.4 x 4.1 x 0, 100% eschar
10/26/21 Unstageable 3.4 x 4.2 x 0, 1% granulation, 27% slough, 40% eschar, 4% epithelialization (72%)
11/2/21 Unstageable 3.4 x 4 x 0.1, 1% granulation, 4% slough, 95% eschar
11/9/21 Unstageable 1.7 x 2.2 x 0.1, 19% granulation, 68% eschar, 9% epithelialization (96%)
11/16/21 Unstageable 1.7 x 2.1 x 0.1, 25% granulation, 75% eschar
11/23/21 Unstageable 1.5 x 2.1, 100% eschar
BRADEN
11/15/21 score 14
ORDERS
RN TO INSPECT open areas to Bilateral Buttocks Q Shift with cares every shift
-Start Date10/01/2021 2300
-D/C Date10/05/2021 1536
Supplement 2.0 three times a day 120ml
-Start Date09/24/2021 1700
-D/C Date10/12/2021 1645
Supplement 2.0 with meals 240ml
-Start Date10/12/2021 1700
Monitoring OA to bilateral scapulas every shift
-Start Date10/02/2021 1500
-D/C Date10/26/2021 2051
MEPILEX Tx to Bilateral Scapulas every other day and PRN every evening shift every 2 day(s)
-Start Date10/02/2021 1500
-D/C Date10/05/2021 1543
Left scapula Apply Betadine to scab every day and evening shift for wound care
-Start Date10/06/2021 0700
-D/C Date10/18/2021 1022
Left scapula CLEANSE with dakins, pat dry, apply SKIN PREP to wound edges and surrounding skin, apply SANTYL to wound base and cover with bordered gauze every evening shift for wound care
-Start Date10/18/2021 1500
-D/C Date10/26/2021 2040
Cleanse wound to left scapula with saline, Protect periwound with Skin Prep, Cover wound with Foam, Change Tues/Thur/Sat and PRN every day shift every Tue, Thu, Sat
-Start Date10/28/2021 0700
-D/C Date11/09/2021 1349
Right scapula cleanse w/ NS, pat dry, apply skin prep to peri wound and apply hydrocolloid every evening shift every 3 day(s) for wound care
-Start Date10/06/2021 1500
-D/C Date10/26/2021 2030
ZINC OXIDE to OPEN AREAS discovered 10/1 bilateral buttocks every shift
-Start Date10/01/2021 2300
-D/C Date10/05/2021 1544
LEFT BUTTOCK Cleanse with normal saline, pat dry, apply skin prep to peri-wound and apply hydrocolloid every evening shift every other day for wound care
-Start Date10/06/2021 1500
-D/C Date10/26/2021 2032
RIGHT BUTTOCK Cleanse area with normal saline, pat dry, f/b skin prep to peri-wound and surrounding skin and apply hydrocolloid every evening shift every other day for wound care
-Start Date10/06/2021 1500
-D/C Date10/26/2021 2032
LEFT HEEL apply betadine to eschar every day and evening shift for wound care
-Start Date10/06/2021 0700
Skin Integrity Care Plan initiated 9/21/21 and created on 10/7/21
12/01/21 10:05 AM [NAME] LPN
CRAB precautions for wound
splints in place to both hands, neck collar on, signs on wall for schedule of when to wear splints and collar
heel boots on, no pain, air mattress
left heel 1.5 x 2.5 black escar, betadine applied and left open to air
LPN - will get catheter bag cover - cath bag on floor
trauma to scapula was from the sling in wheelchair.
treatments not signed out
No RN assessment of skin on admit. Who assessed on 10/4/21??? - LPN and RN signed off
12/06/21 12:40 PM
Based on observation, record review and staff interviews, the facility did not ensure staff utilized PPE (personal protective equipment) effectively, handled medication in a sanitary manner, or maintained personal medical devices, to prevent the spread of infection, such as COVID-19.
The incorrect PPE application was observed on 3 of 6 units/hallways potentially affecting 65 residents (300 unit has 24 residents, 400 unit has 21 residents, and the 600 unit has 20 residents). Licensed Practical Nurse (LPN) -J, Medication Techinician (MT) - I, and Registered Nurse (RN) - H were observed on resident units without facial masks covering their nose and mouth.
The medication was observed with 1 of 1 Medication Technicians observed preparing medication, and 1 (R43) of 2 residents observed with Foley catheters.
Medication Tech-I was observed handling a medication tablet for R63 with her bare hands and R43 was observed several times to have their Foley catheter bag exposed and resting on the floor.
Findings include:
The facility's policy and procedure for Infection Control, revised October 2018, was reviewed by Surveyor. The policy indicates the facility, through policies and practices, intend to facilitate a safe, sanitary and comfortable environment to help prevent and manage transmission of diseases and infections.
1. On 11/29/21 at 08:52 AM Surveyor observed LPN-J administer medications on the 600 unit. LPN-J's facial mask was not covering her nose. LPN-J indicated the facial mask falls off her nose. LPN-J indicated the facial mask doesn't cover her nose because she can't see otherwise.
On 11/29/21 at 10:17 AM Surveyor observed MT-I on the 400 unit in the hallway passing medications. MT-I was observed wearing her facial mask under her nose. MT-I did not verbalize a reason why her facial mask was not covering her nose.
On 11/29/21 at 11:01 AM Surveyor observed RN-H at the Nurses Station for both the 300/400 unit. RN-H did not have PPE on to cover their mouth, nose and eyes. When Surveyor approached RN-H they then placed a surgical mask on over their nose and mouth with a face shield. RN-H indicated they don't keep their face mask on because their eyeglasses fog up.
On 12/01/21 at 09:00 AM Surveyor reviewed the facility's Infection Control program with RNC -C (Regional Nurse Consultant and DON-B (Director of Nurses). They indicated they will alert staff to wear PPE appropriately in the facility. This means eye protection with facial masks. The facility does have adequate supplies of PPE available. They did not know why staff was not utilizing it appropriately.
2. On 11/29/21 at 10:17 AM Surveyor observed MT (Medication Technician)-I administer medication to R63. MT-I pushed out medication from its individual pharmacy packaging into a dose cup.
R63 had a Zoloft 50 mg tablet that required to be 25 mg. MT-I used their bare hands to place the tablet in a pill splitter from the medication cart. MT-I did not perform hand hygiene, or utilize gloves with tablet handling. MT-I then split the tablet in the pill splitter and threw the other half of tablet in the garbage
On 11/30/21 at 3:07 PM at the facility exit meeting. Surveyor shared the concerns with medication handling. There was no further information provided.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, record review and staff interview, the facility did not ensure the required Nurse Staffing information was displayed daily and maintained for the past 18 months. This had the pot...
Read full inspector narrative →
Based on observation, record review and staff interview, the facility did not ensure the required Nurse Staffing information was displayed daily and maintained for the past 18 months. This had the potential to effect all residents and visitors.
The facility did not have the Nurse Staffing posted, nor the last 18 months readily available for review.
Findings include:
On 11/30/21 at 08:36 AM Surveyor spoke with Administrator-A regarding the Nurse Staffing information that was not observed posted in the facility. Administrator-A indicated they will find out who oversees Nurse Staff postings. This has not been observed posted in the lobby/entrance area.
On 11/30/21 at 09:44 AM Surveyor spoke with Scheduler-E who is in charge of the Nurse Staff posting. Scheduler-E indicated they were busy this morning and just posted it. Scheduler-E shared it is in a standing hard plastic frame at the receptionist desk. Scheduler-E indicated they will provide 18 months of staffing and indicated the PM staffing for nurses needs to be changed for today due to a call-in.
On 11/30/21 at 02:38 PM Surveyor spoke with Scheduler-E in their office. Surveyor had not yet received the 18 months of Nurse Staff posting's. Scheduler-E indicated they are also the Social Worker and will be getting more training. They have been doing resident discharge's. Scheduler-E shared they do not have Nurse Staff Posting's for 2021 and was filling them out now. Scheduler-E was filling out Nurse Staff forms from 2020 and was starting on 2021's.
There was no daily information regarding nurse/staff postings to review regarding staffing accuracy in the facility.
On 11/30/21 at 3:07 PM at the facility exit meeting. Surveyor shared the concerns with the Staff Posting availability. There was no further information provided.
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?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 7 life-threatening violation(s), Special Focus Facility, 4 harm violation(s), $437,569 in fines, Payment denial on record. Review inspection reports carefully.
- • 112 deficiencies on record, including 7 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $437,569 in fines. Extremely high, among the most fined facilities in Wisconsin. 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.
✓ Report will be sent to your email
About This Facility
What is Burlington Center's CMS Rating?
CMS assigns BURLINGTON HEALTH AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Wisconsin, 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 Burlington Center Staffed?
CMS rates BURLINGTON HEALTH AND REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 69%, which is 23 percentage points above the Wisconsin average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Burlington Center?
State health inspectors documented 112 deficiencies at BURLINGTON HEALTH AND REHABILITATION CENTER during 2021 to 2025. These included: 7 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, 100 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 Burlington Center?
BURLINGTON HEALTH AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CHAMPION CARE, a chain that manages multiple nursing homes. With 123 certified beds and approximately 86 residents (about 70% occupancy), it is a mid-sized facility located in BURLINGTON, Wisconsin.
How Does Burlington Center Compare to Other Wisconsin Nursing Homes?
Compared to the 100 nursing homes in Wisconsin, BURLINGTON HEALTH AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (69%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Burlington Center?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is Burlington Center Safe?
Based on CMS inspection data, BURLINGTON HEALTH AND REHABILITATION CENTER 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 7 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 Wisconsin. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Burlington Center Stick Around?
Staff turnover at BURLINGTON HEALTH AND REHABILITATION CENTER is high. At 69%, the facility is 23 percentage points above the Wisconsin average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Burlington Center Ever Fined?
BURLINGTON HEALTH AND REHABILITATION CENTER has been fined $437,569 across 4 penalty actions. This is 11.7x the Wisconsin average of $37,455. 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 Burlington Center on Any Federal Watch List?
BURLINGTON HEALTH AND REHABILITATION CENTER 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.