Avina of Milwaukee
Non profit - Corporation
108 Beds
ASCENSION LIVING
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#259 of 321 in WI
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Avina of Milwaukee has a Trust Grade of F, indicating poor conditions and significant concerns about care quality. It ranks #259 out of 321 nursing homes in Wisconsin, placing it in the bottom half of facilities statewide, and #20 out of 32 in Milwaukee County, meaning only a few local options are worse. The facility's trend is improving, as the number of reported issues has decreased from 34 in 2024 to 7 in 2025. Staffing is average with a rating of 3 out of 5 stars and a turnover rate of 55%, which is close to the state average. However, the facility has racked up concerning fines of $90,921, higher than 78% of Wisconsin facilities, suggesting ongoing compliance issues. Specific incidents include a critical failure to obtain necessary lab work for a resident, leading to a severe health decline, and serious oversights in preventing pressure injuries for residents, which were not addressed promptly. Additionally, the facility has not provided adequate supervision to prevent falls, resulting in injuries for multiple residents. While there are some improvements in the facility's trend, these serious deficiencies highlight significant areas for concern regarding resident safety and care.
- Trust Score
- F
- In Wisconsin
- #259/321
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $90,921 in fines. Higher than 56% of Wisconsin facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 60 minutes of Registered Nurse (RN) attention daily — more than 97% of Wisconsin nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 50 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 20%
Review needed
34 → 7 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 34 issues
2025: 7 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: 55%
Near Wisconsin avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $90,921
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: ASCENSION LIVING
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (55%)
7 points above Wisconsin average of 48%
The Ugly 50 deficiencies on record
1 life-threatening 3 actual harm
Jul 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not report to the State survey agency and/or Law Enforcement in a timely ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not report to the State survey agency and/or Law Enforcement in a timely manner timely for 1 (R2) of 1, abuse allegations reviewed.* On 6/2/2025, R2 reported an incident to Physical Therapy (PT)-D of inappropriate touching from R1. Staff did not report the allegation to Nursing Home Administrator (NHA)-A until 6/3/25.Findings include:The facility's policy, titled Abuse Investigation and Reporting, dated as last approved 12/2024, documents:Reporting:A. Alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property will be reported to the administrator or designee. B. Alleged violations involving abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported: 1. Abuse or serious bodily harm - Immediately but no later than 2 hours. R2 was admitted to the facility on [DATE] with diagnoses of Falls, Pneumonia, Heart Failure and Atrial Fibrillation.R2's Discharge Minimum Data Set (MDS), dated [DATE], documented a brief interview mental status (BIMS) score of 15, indicating R2's cognition was intact. The MDS also documented that R2was understood and understands others.The facility's self-reported incident dated 6/3/2025 documented: The following is a summation of the investigation regarding R1 and R2. R2 reported that R1 put her hands down R2's pants. Administrator notified 6/3/25 at 11:00 AM; Initial self-report submitted to the state on 6/3/25 at 11:37 AM. Initial Intervention/Response to Allegation: Residents were separated, alleged victim moved to assisted living facility. The facility's self-report included a statement from R2 which documented: Can you tell me what happened? This resident (R1) wanted to latch onto me (R2) always walking at me. At lunch yesterday (6/2), she came over to me and put her (R1) hand on my left leg.Who did you report this incident to? Physical Therapy. Surveyor reviewed the Facility Investigative Summary, which documented, that the affected resident reported the event to a member of the therapy team, who wrote the information on a stop and watch form.The Stop and Watch Early Warning Tool written by Physical Therapist (PT)-D and dated 6/2/25 at 6:45 PM documents: The patient (R2) reported that while in the dining room for lunch, R1 put a hand inside his (R2)shorts- He (R2) told R1 to stop which R1 did and then reported the incident to the nurse on R2's unit. Surveyor noted that NHA-A was notified of the incident on 6/3/25 at 11:00 AM, while the incident occurred, and staff was aware on 6/2/25 at 6:45 PM. Surveyor noted there was at least a twelve-hour delay in facility staff reporting the potential sexual abuse incident to NHA-A.On 7/9/2025, at 10:03 AM, Surveyor interviewed PT-D, the therapist that filled out the Stop and Watch form. PT-D stated that PT-D notified the Nurse (RN)-C, on the unit and gave the Stop and Watch form to RN-C. The form was dated 6/2/2025. PT-D stated, R2 reported another resident in the lunchroom touched R2's leg and moved up and put R1's hand in R2's shorts. R2 told R1 to stop and R2 removed himself from the table.On 7/9/2025, at 11:40 AM, Surveyor interviewed RN-C, who stated that RN-C remembers working on 6/2/2025, and remembers receiving the Stop and Watch form from PT-D. RN-C indicated that, he didn't update anyone. RN-C informed surveyor that RN-C talked to R2, about the allegations and R2 stated nothing happened. RN-C stated, I don't know why they're making a big deal of this, because the resident denied it, so I wouldn't need to report it.Surveyor noted that NHA-A was notified of the incident on 6/3/25 at 11:00 AM, while the incident occurred, and staff was aware on 6/2/25 at 6:45 PM. Surveyor noted there was at least a twelve-hour delay in facility staff reporting the potential sexual abuse incident to NHA-A.On 7/9/2025, at 12:18 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Clinical Services (DCS)-B, NHA-A stated the Stop and Watch form should not be used for reporting abuse. NHA-A indicated that RN-C should report abuse right away to NHA-A. NHA-A stated this is why we did the plan of correction, because of the late reporting. Surveyor stated still having concern with reporting, as RN-C, during an interview with surveyor stated that RN-C did not need to report that incident.On 7/28/25 at 2:37 PM, Surveyor interviewed NHA-A regarding the above incident. Surveyor asked NHA-A if the above incident should have been reported immediately to NHA-A. NHA-A informed Surveyor that RN-C and PT-D should have reported the above incident immediately and not utilized the Stop and Watch form to report abuse.No additional information was provided as to why facility did not ensure that R2's allegation of abuse was not reported in a timely manner to NHA-A.
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 interview and record review, the facility did not ensure residents received the necessary behavioral health care and se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents received the necessary behavioral health care and services to maintain the highest practicable mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 (R1) of 1 resident reviewed for related to the residents emotional and mental well-being.*Surveyor reviewed a facility self-report from 6/13/2025, which pertained to behaviors of inappropriate touching with R1 being the aggressor. Nurse Practitioner (NP)-E, stated that currently R2's, psychiatric services are being managed by NP-E. NP-E indicated not being updated regarding alleged behaviors of R1's hands going inside of R2's shorts. There was no documentation that R1's POA was contacted in attempt to obtain consent for psychiatric services. Findings include:R1 was admitted to the facility on [DATE] with diagnoses of dementia and depression.R1's quarterly Minimum Data Set (MDS), dated [DATE], documented a brief interview of mental status (BIMS) score of 1, indicating severe cognitive impairment, is sometimes understood and sometimes understands others. Surveyor noted a care plan was not initiated to address R1's depression including how depression was manifested for R1 or interventions to address those manifestations.Surveyor reviewed a document titled, Psychiatric Consult, dated 1/13/2025, documented: Case discussed with staff at BMC (Behavior Management Consult) meeting. They report that Resident has been tearful latterly for unknown reasons. Would recommend increasing the Depakote back to 250mg BID (twice a day).Crying and anxiety appear to be related to her dementia and Depakote will assist stabilizing the mood to assist in treating her current symptoms. Will plan to follow up in 1 month once she (R1) has had to time to adjust. Staff encouraged to notify BSI (Behavioral Solutions) with any concerns. R1 had discontinued services in February 2025, due to services no longer being available from that provider. The facility had the NP (nurse practitioner)-E take over care for Psychiatric care until they can get a new consent form signed by R2's Power of Attorney (POA). However, Surveyor could not locate any documentation that NP-E was actively being notified of R1's behaviors. Surveyor reviewed facility's self-reported incident dated 6/3/2025 documented: The following is a summation of the investigation regarding R1 and R2. R2 reported that R1 put her hands down R2's pants. Administrator notified 6/3/25 at 11:00 AM; Initial self-report submitted to the state on 6/3/25 at 11:37 AM. Initial Intervention/Response to Allegation: Residents were separated, alleged victim moved to assisted living facility. The facility's self-report included a statement from R2 which documented: Can you tell me what happened? This resident (R1) wanted to latch onto me (R2) always walking at me. At lunch yesterday (6/2), she came over to me and put her (R1) hand on my left leg.Who did you report this incident to? Physical Therapy. Surveyor reviewed the Facility Investigative Summary, which documented, the affected resident reported the event to a member of the therapy team, who wrote the information on a stop and watch form.The Stop and Watch Early Warning Tool written by Physical Therapist (PT)-D and dated 6/2/25 at 6:45 PM documents: The patient (R2) reported that while in the dining room for lunch, R1 put a hand inside his (R2)shorts- He (R2) told R1 to stop which R1 did and then reported the incident to the nurse on R2's unit. Surveyor noted that NHA-A was notified of the incident on 6/3/25 at 11:00 AM, while the incident occurred, and staff was aware on 6/2/25 at 6:45 PM.Surveyor reviewed R1's medical record and could not locate any documentation that R1's psychiatric provider was notified of R1's behavior on 6/2/25. Surveyor could not locate any documentation that R1 received medically related social services to debrief and evaluate R1's behaviors on 6/2/25. Surveyor could not locate any documentation that NP-E was notified of R1's behaviors on 6/2/25.On 7/9/2025, at 12:18 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A and Director of Clinical Services (DCS)-B. Surveyor asked for documentation of the POA being reached out to for psych services. NHA-A indicated there was no documentation showing the POA was contacted or how many times the facility reached out to the POA.At the end of the day meeting, Surveyor informed both NHA-A and DCS-B of concern that R1 had behaviors that were not reported to the medical professional that was overseeing R1's psychiatric services. There was no documentation that R1's POA was informed or received a request for R1 to receive psychiatric services after 1/13/25 or that staff contacted NP-E after R1's behavior on 6/2/25. No additional information was provided as to why the facility did not ensure that R1 received medically related social services after 1/13/25 and after 6/2/25.
Mar 2025
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on interviews, record review, and facility policy review, the facility failed to notify the resident representative of a fall for one of three residents (Resident (R) 7) reviewed for notificatio...
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Based on interviews, record review, and facility policy review, the facility failed to notify the resident representative of a fall for one of three residents (Resident (R) 7) reviewed for notification out of a total sample of 17. This has the potential to cause family members to not have the opportunity to be involved in the resident's care.
Findings include:
Review of the facility's policy titled, Change in a Resident's Condition or Status, revised 02/2022, indicated that the community . shall promptly notify the resident, his or her health care provider, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Unless otherwise instructed by the resident, a nurse will notify the resident's representative, consistent with his or her authority, when . The resident is involved in any accident or incident that results in an injury including injuries of an unknown source .
Review of R7's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/18/24 and provided by the facility revealed the resident had a Brief Interview for Mental Status (BIMS) score of five out of 15, which indicated the resident was severely cognitively impaired. It was recorded that R7 had diagnoses that included diabetes mellitus, hyperlipidemia, thyroid disorder, osteoporosis, hip fracture, and seizure disorder.
Review of R7's Interdisciplinary Notes, dated 11/22/24 and provided by the facility, indicated that R7 experienced an unwitnessed fall at 3:20 PM. R7 was found lying down on the floor, alert, giggling, and with a pillow under her head. R7 stated that she did not know how she got to the floor.
During an interview on 03/20/25 at 9:00 AM, the Administrator and Director of Nursing (DON) were requested to provide documentation of notification to R7's representative of the fall on 11/22/24.
During an interview on 03/20/25 at 4:00 PM, Medical Records (MR) stated that representative notification could not be located.
During an interview on 03/20/25 at 5:30 PM, the Administrator stated that her expectation was that family representatives, case workers and physicians be notified of any falls.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interview, the facility failed to ensure the right to be free from verbal...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interview, the facility failed to ensure the right to be free from verbal and potential sexual abuse for two residents (Residents (R) 3 and R12) of four residents reviewed for abuse/neglect out of a total sample of 17. The facility failed to ensure R3 was protected from verbal abuse by Certified Nursing Assistant (CNA1). The facility failed to protect R12 from potential sexual abuse from R13. These failures had the potential to cause physical harm, pain, or mental anguish.
Findings include:
Review of a facility policy titled, Abuse Prevention, dated 08/2024, indicated, . The community's goal is to achieve and maintain an abuse-free environment. As part of the resident abuse prevention program, the administration will provide a safe resident environment and protect the residents from abuse by anyone including community associates, other residents, consultants, volunteers, associates from other agencies, family members, legal representatives, friends, visitors, or any other individual . This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Sexual abuse is non-consensual sexual contact of any type with a resident . Generally, sexual contact is non-consensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent .
1. Review of a document provided by the facility titled, Profile Face Sheet indicated R3 was
admitted to the facility on [DATE] with diagnoses that included polyneuropathy, rheumatoid arthritis, depression, and anxiety.
Review of R3's quarterly Minimum Data Set (MDS), provided by the facility and with an admission Reference Date (ARD) of 02/10/25, recorded R3 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact.
Review of a Facility Related Incident (FRI), provided by the State of Wisconsin, indicated that R3 was verbally abused by Certified Nursing Assistant (CNA1). Review of a Facility investigation revealed that on 12/05/24 at 2:00 PM, the Administrator was answering a call light and walked into R3's room. R3 was in her wheelchair crying. She reported that CNA1 had hit her hand in the dining room after she had spilled her food and plate on the floor. R3 also stated that CNA1 came into her room and told her I'll be watching you. R3 stated that made her fearful. The schedule was reviewed and CNA1 had worked that evening. CNA1 was suspended from work pending investigation. An x-ray was ordered on R3's hand that resulted in no fractures. Staff were interviewed and no one witnessed CNA1 hitting the resident on her hand. Witnesses at the time stated that CNA1 yelled at R3. Skin assessments were completed with no negative outcome.
Interview with R3 on 03/19/25 at 1:33 PM revealed, [CNA1] got mad at me because I spilled my food on the floor. She hit my hand and yelled at me. R3 became upset and the questioning was stopped. R3 stated she is happy in the facility and feels safe now that the CNA is no longer there.
A review of CNA1's personnel file revealed that she was terminated on 12/18/24. She had previous incidents where she was confrontational with staff and had been counseled.
During an interview with the Administrator on 03/20/25 at 5:26 PM, the Administrator stated, This facility will not tolerate abuse of any kind. The police will be called and if substantiated, then the employee will be terminated.
2. Review of R12's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/12/24 and provided by the facility, indicated R12 was admitted to the facility on [DATE] and had diagnoses of dementia, gastroesophageal reflux disease without esophagitis, and osteoarthritis. It was recorded that R12 did not have a Brief Interview for Mental Status (BIMS) score for cognitive status.
Review of R12's Care Plan, dated 12/24/24 and provided by the facility, indicated R12 had memory problems, impaired decision-making skills, and impaired ability to comprehend dementia.
Review of R13's quarterly MDS with an ARD of 12/11/24 and provided by the facility indicated that R13 was readmitted to the facility on [DATE] with diagnoses of cancer, coronary artery disease, heart failure, colitis, renal insufficiency, diabetes mellitus, hyperlipidemia, dementia, and depression. It was recorded R13's BIMS score was 10, which indicated R13 was moderately cognitively impaired.
Review of the facility's Incident Investigation Summary, dated 03/02/25 and provided by the facility, indicated that R13's guardian reported that R13 attempted to get into bed with R12. The investigation revealed the resident fell while trying to get it in the bed. After the incident R12 was moved to a different unit, psychiatric services were ordered, and behavior monitoring for R13 was being conducted.
In an interview on 03/18/25 at 2:25 PM, R13 stated that he missed his lady friend who is now living downstairs. When asked what happened, R13 stated that R12 asked him to sleep with her. R13 stated that when he got into R12's bed he knew they were not aligned in the bed properly. When asked if R12 was awake, R13 did not respond. R13 stated that R12 was ok with him getting in bed with her and that they were both dressed for sleep.
In an interview on 03/20/25 at 5:30 PM, the Administrator stated that R13's friendship with R12 was known by staff. The Administrator stated that the expectation was for all known resident relationships to be communicated to the interdisciplinary team so that assessments and interventions will be initiated and implemented.
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, record review, and review of facility policy, the facility failed to ensure that allegations of injury of un...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy, the facility failed to ensure that allegations of injury of unknown origin, verbal abuse, and neglect were reported to the State Survey Agency (SSA) in a timely manner for three residents (Resident (R) 2, R3, and R5) reviewed in a total sample of 15 residents. Specifically, the facility failed to report timely an allegation of injury of unknown origin involving R2; an allegation of verbal abuse involving R3; and an allegation of neglect involving R5. This failure had the potential for other allegations to not be reported in a timely manner.
Findings include:
Review of the facility's policy titled Abuse Investigation and Reporting, dated 12/2024 indicated, . Alleged violations involving abuse, neglect, exploitation or mistreatment will be reported immediately but not later than two hours .
1. Review of R2's Profile Face Sheet indicated R2 was admitted to the facility on [DATE] with diagnoses of Alzheimer's, congestive heart failure, and chronic kidney disease.
Review of a Facility Related Incident (FRI) provided by the State of Wisconsin indicated that R2 had an injury of unknown origin resulting in skin tears to her little and middle fingers of the right hand. The incident occurred on 10/20/24 and was not reported to the SSA until 12/09/24.
2. Review of R3'sProfile Face Sheet indicated R3 was admitted to the facility on [DATE] with a diagnoses of polyneuropathy, rheumatoid arthritis, depression, and anxiety.
Review of an FRI provided by the State of Wisconsin indicated that R3 was verbally abused by Certified Nursing Assistant (CNA1). This verbal abuse was reported by the resident on 12/05/24 and not reported to the SSA until 12/12/24.
3. Review of R5'sProfile Face Sheet indicated R5 was admitted to the facility on [DATE] with diagnoses of fracture of lower end of femur, contracture of right knee, and lymphedema.
Review of a FRI provided by the State of Wisconsin indicated that R5 was neglected by the facility for not providing care. This incident took place on 12/26/24 and was not reported to the SSA until 01/03/25.
4. Review of a FRI provided by the State of Wisconsin indicated misappropriation of property (Drug Diversion). The incident was found while watching a video tape on 12/19/24 of a Registered nurse (RN1) taking drugs from the narcotic destruction box. This incident was not reported to the SSA until 12/20/24.
During an interview on 03/20/25 at 5:26 PM, the Administrator revealed My expectations are that reporting needs to be immediate for abuse, neglect, and injuries of unknown origin. Then the investigation has to be completed within five days or notify the SSA of why it is not complete and send in what you have.
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 on review of facility policy, record review, and interview, the facility failed to ensure two resident (Resident (R) 3 and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, record review, and interview, the facility failed to ensure two resident (Resident (R) 3 and R5) out of a sample of three residents reviewed for abuse allegations, had a thorough investigation completed for R5 and the five-day report was not submitted timely to the State Agency (SA) for R3. This failure had the potential to lead to continued episodes of abuse.
Findings include:
Review of the facility's policy titled Abuse Investigation and Reporting, dated 12/2024, .The Administrator will monitor that any further potential abuse, neglect, exploitation, or mistreatment is prevented while the investigation is in progress .Review the resident's medical record to determine events leading up to the incident .Interview the person reporting the incident, any witnesses, staff on all shifts who had contact with the resident, the resident's roommate, family members, and visitors. Interview other residents to whom the accused employee provides care or services, and review camera footage if available .Alleged violations involving abuse, neglect, exploitation or mistreatment will be reported immediately but not later than two hours .The Administrator or designee, will provide the appropriate agencies with a written report of the findings of the investigation within five working days of the occurrence of the incident.
1. Review of a document provided by the facility titled Profile Face Sheet indicated R3 was
admitted to the facility on [DATE] with a diagnoses of polyneuropathy, rheumatoid arthritis, depression, and anxiety.
Review of a Facility Related Incident (FRI) provided by the State of Wisconsin indicated that R3 was verbally abused by Certified Nursing Assistant (CNA1). This verbal abuse was substantiated. Further review of the FRI revealed that the facility failed to submit in the five-day reporting to the State Agency (SA) the outcome of CNA1.
2. Review of a document provided by the facility titled Profile Face Sheet indicated R5 was admitted to the facility on [DATE] with diagnoses of fracture of lower end of femur, contracture of right knee, and lymphedema.
Review of a FRI provided by the State of Wisconsin indicated that R5 was neglected by the facility for not providing care. Further review of the FRI revealed that the facility failed to interview other residents on the night in question.
During an interview with the Administrator on 03/20/25 at 5:26 PM, the Administrator stated, My expectation is that a complete investigation will take place with interviews of witnesses and staff, record review, and the investigation should tell a story, a complete story.
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 F0602
(Tag F0602)
Could have caused harm · This affected multiple residents
Based on observation, document review, interview and facility policy review, the facility failed to prevent misappropriation of resident property for five of five sampled residents (Resident (R) 9, R1...
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Based on observation, document review, interview and facility policy review, the facility failed to prevent misappropriation of resident property for five of five sampled residents (Resident (R) 9, R10, R11, R16, and R17). The facility failed to ensure security resulting in narcotic drug diversion by one of one staff (Registered Nurse 1). Failure to protect residents' property has the potential to affect the residents mental, emotional and financial status.
Findings include:
Review of facility's policy titled, Personal Property revised on 12/19 indicated that residents are permitted to retain and use personal possessions and appropriate clothing as space permits. A representative of the admitting office will advise the resident, prior to or upon admission, as to the types and amount of personal clothing and possessions that the resident may keep in his or her room.
1. Review of facility's Investigation Summary Folder indicated that on 01/31/25 the former Social Services Director (FSSD) notified the Administrator that R11's envelope containing her wallet, $283.00 in cash, credit card, debit card, driver's license and a Foodshare card were missing from the locked closet in the SSD office.
The Administrator and Business Office Manager (BOM) inspected and reconciled all Valuable Envelopes found in the SSD's closet. The audit revealed that R9 was missing $352.00; R10 was missing $90.00; R16 was missing $1.00; and R17 was missing $15.00.
Review of the facility's Investigative Summary dated 02/07/25 indicated that R9 and R10's money would be reimbursed.
Review of R9's Check Request Form dated 02/14/25 indicated a request to submit $352.00 reimbursement to R9's trust fund.
Review of the facility's Investigation Summary Folder indicated that there was no documentation of receipt for actual reimbursement to R9 for $352.00, R10 for $90.00, R16 for $1.00 and R17 for $15.00.
Review of the facility's Investigation Summary Folder provided by the facility indicated that there was no documentation of a receipt for actual reimbursement to R11 for driver's license replacement.
In an interview on 03/20/25 at 9:00 AM documentation was requested for reimbursements from the Administrator. No additional documentation was provided by the facility.
In an interview on 03/20/25 at 2:30 PM the SSD stated that he was aware of the process for handling resident valuables. The SSD stated that Social Services is not involved in the process and does not keep valuables in the SSD office. The SSD stated that residents' valuables kept in a locked box in the medication room and maintained by nursing staff who have keys to the medication room.
Observation on 03/20/25 at 2:45 PM, Licensed Practical Nurse (LPN)2 unlocked the medication room door. Observation of a large black box on top of the counter, locked with a binder notebook next to it.
In an interview on 03/20/25 at 5:30 PM the Administrator stated that going forward her expectation is that the new system will remain secure, that residents and staff are educated on a continual basis, and that the facility's Quality Assessment Performance Improvement (QAPI) committee will continue to monitor the process.
2. Review of the undated facility's policy titled, Controlled Medication Management; Suspected Diversion, revealed, . audit of all narcotics for correct medication and counts; staff with access to the controlled medication lock box will be sent for drug testing and background checks reviewed; MD [physician] notified along with the Medical Director and police department .storage cabinet for controlled substances for destruction is to be fixed and not moveable; slot large enough to put medications in, small enough that no one can put an arm in it or other item to retrieve controlled substances for destruction; deep enough that medications cannot be retrieved .
Review of a Facility Related Incident (FRI) provided by the State of Wisconsin indicated that the facility identified that a diabetic injection pen was missing that was supposed to have been delivered by the pharmacy. Both floor nurses stated that they had not received the medication. Video footage from 12/10/24 was reviewed by the Assistant Director of Nursing (ADON) and the issue was resolved. Upon review of the video, RN1 was seen removing drugs with a coat hanger from the third-floor narcotic destruction box. RN1 put the pills in her pockets. The Director of Nursing (DON) was notified and reviewed the video footage. The Administrator was notified and RN1 was removed from the floor and brought to the Administrators office. A urine drug test was completed and was negative. The police were called and could not come to the facility due to a snowstorm. RN1 was suspended and never came back to the facility. RN1 was an agency nurse who had been employed by the facility for two years.
Interview on 03/19/25 at 2:19 PM, the Staffing Coordinator (SC) stated, I do not know why I do not have RN1's background check. I have checked my emails, and I do not have one from Prime Med Staffing. The agency sends one to us before hire. RN1 was hired on 09/16/22 and left on 12/19/24. When asked why she did not call and get one on RN1, SC stated I do not know.
During an interview on 03/19/24 at 2:28 PM with the Director of Nursing Prime Med (DPM) revealed Background checks are sent to the facility by email. I have no idea if I sent one or not. My email does not go back that far. RN1 was eligible for work on 07/01/22 when I checked her license. An incident took place involving RN1 and a resident credit card from a different facility and her license was suspended on 11/03/22. RN1 was working for Alexian Village at the time of her suspension. We are not notified of suspended licenses.
Interview on 03/19/25 at 3:40 PM, the police department stated that it was an ongoing investigation and no further details were given.
During an interview with the Regional Clinical Nurse (RCN) on 03/19/25 at 4:46 PM revealed, The facility called me about this incident, and I requested to see the video. RN1 took medications out of the narcotic destruction box. I told the facility to call the police, do a urine test on RN1, complete education on drug diversion, and complete an audit of all medications. I had a verbal communication with the DON that all had been completed.
A receipt was provided to the survey team for a new destruction box that is waist high and bolted to the floor on the second floor. Pharmacy records were reviewed for a medication audit of both medication carts and storage rooms, along with the Cubex that stores emergency drugs and the destruction box. The facility provided an in-house audit of all drugs, and no other drugs were missing. Drug diversion training was provided for all staff and sign-in sheets were reviewed. Human Resources provided a list of all new hires for 2025 to 03/20/25, and all background checks had been completed.
The contract for Prime Med Staffing was reviewed. The contract was dated 03/15/21 and stated Nurse Qualifications as follows: Caregiver Background Check Process; Wisconsin Nurse Aide Training and Registry Information; WI Caregiver Misconduct Registry.
Review of RN1's background check provided by Prime Med Staffing revealed On 01/25/21, RN1 had an incident involving a fentanyl patch. The facility at the time concluded that the patch was never given to the resident and a verbal warning and training was provided to RN1. However, RN1 was terminated on 04/12/21. On 05/08/22, RN1 was now working in a different facility, and an incident took place of a credit card taken from a resident and used. RN1 was terminated from that facility on 05/18/22. For a period of at least two years, agency shall provide a copy of this Order immediately to supervisory personnel at all settings where RN1 works as a caregiver. On 12/08/22, the Wisconsin Board of Nursing issued a Final Decision and Order limiting RN1's license to practice as a registered nurse with certain terms and conditions. Pursuant to the Order, Respondent's license may be suspended, without hearing, for substantial or repeated violation of any provision. Information has been received that demonstrates RN1 is in violation of the terms of the Order. As a result, the following is entered: 1.) RN1's professional nursing license is hereby suspended until further notice. 2.) This order is effective at the date of its signing. Signed 01/23/25, Wisconsin Board of Nursing.
Dec 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility did not ensure 1 (R38) of 1 sampled resident's potential allegation of misappropriation of property was reported to the State Survey Agency or the Nur...
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Based on interview and record review the facility did not ensure 1 (R38) of 1 sampled resident's potential allegation of misappropriation of property was reported to the State Survey Agency or the Nursing Home Administrator within 24 hours.
*R38's family reported a missing necklace on 11/29/24 to a facility staff member. R38's missing gold necklace was not reported to the Nursing Home Administrator until 12/2/24. The investigation into R38's missing gold necklace did not start until 12/2/24.
Finding include:
The facility policy entitled Abuse Investigation and Reporting revised on 11/2023 documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, ., and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the [Facility Name] Abuse Prevention policy.
R38's current admission was on 10/21/23.
On 12/2/24, at 8:30 AM, Surveyor noted, during record review, a nurses note dated 11/29/24. Licensed Practical Nurse (LPN)-E charted; Client's family and son at bedside today reporting client was missing gold necklace chain which they noticed she did not have since Wednesday 11/27. Room checked and item not located. Attempt made to update social worker on reported item was unsuccessful. Call placed to administrator NHA (Nursing Home Administrator)-A, voice message left. Family updated that social worker will be in contact to follow up.
On 12/2/24, at 11:53 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A. Surveyor asked, what the facility's procedure, and what actions were implemented around R38's reported missing necklace. NHA-A informed Surveyor NHA-A was not made aware of R38's missing necklace. NHA-A read LPN-E's chart entry dated 11/29/24 regarding R38's missing necklace. NHA-A informed Surveyor NHA-A was in the building and NHA-A was not informed about R38's missing necklace. NHA-A informed Surveyor NHA-A would have reported it and started an investigation right away. Surveyor asked if that was the facility's normal procedure in cases of missing items such as jewelry. NHA-A replied, yes. NHA-A informed Surveyor, we have a lot of agency staff, they may not have informed me, I know that's not an excuse but its what I have. NHA-A told Surveyor, If I (NHA-A) was informed, I (NHA-A) would have reported it right away and started the investigation that day.
On 12/3/24, at 8:10 AM, Surveyor interviewed LPN-E, LPN-E informed the Surveyor, that LPN-E left a message on NHA-A's voicemail right after R38's family reported the necklace missing. LPN-E left a note on the social worker's desk informing the social worker of R38's missing gold necklace. R38's family told LPN-E that it was noticed missing by them on 11/27/24. LPN-E told Surveyor, R38's missing necklace was not that surprising to the family, because R38 plays with it constantly. LPN-E informed Surveyor, that LPN-E told R38's family that the missing necklace still had to be investigated, and that NHA-A had to be notified right away. LPN-E said, they did leave a voicemail about R38's missing necklace right away for NHA-A.
On 12/3/24, at 11:33 AM, Surveyor interviewed Executive Director-B. Surveyor inquired what is the facility's procedure and actions with reported missing jewelry items. Executive Director-B informed Surveyor, that the Social Worker should be informed, and the grievance officer should be informed right away. Surveyor inquired who the grievance officer is. Executive Director-B informed the Surveyor, that it would be NHA-A. Executive Director-B explained to Surveyor, NHA-A and the social worker would make sure the item was not in safe keeping with the facility. NHA-A would make the decision to report to the state agency and or start an investigation; based on whether the facility had the item or if the item could be located right away. Executive Director-B explained, after we verify, we do not have the item in question, we will do the 24-hour report to the state agency and investigate. Surveyor asked what should have been done in the case of R38's missing gold necklace. Executive Director-B informed Surveyor, the facility process of reporting and investigation should have started immediately.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** UNCORRECTED AT REVISIT
Based on record review and interviews, the facility did not ensure they thoroughly investigated and attem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** UNCORRECTED AT REVISIT
Based on record review and interviews, the facility did not ensure they thoroughly investigated and attempted to find the root cause of a fall for 1 (R361) of 3 residents reviewed for being at risk for falls. R361 experienced an unwitnessed fall in her room on 11/12/24. When family entered the room, the wardrobe/dresser was observed to be on top of R361 who was lying on the floor of her room. R361 stated that she lost her balance while attempting to ambulate to the bathroom by herself after calling for help from staff with no response.
Post fall, the facility did not review the wardrobe dressers utilized by facility residents to ensure they were safely secured to prevent other residents from having the wardrobe/dresser fall over creating a safety concern.
The deficient practice has the potential to effect a pattern of the 76 residents currently residing in the facility with the same wardrobes/dressers.
Findings include;
Falls Policy:
The facility policy, entitled, Falls dated revised, 7/2023, states (in part)
.Policy statement: The purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall.
*Policy Detail: Direct care associates shall evaluate the area where the fall occurred for possible contributors.
The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates. The falls should be reviewed at the Daily Stand-up meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls.
An incident report shall be completed for the resident falls by a licensed nurse after the fall occurs.
R361 was admitted to the facility on [DATE] for rehabilitation due to shortness of breath from Pneumonia. R361 was responsible for self and did not have an Activated Power of Attorney for Healthcare.
According to the admission Minimum Data Set (MDS), dated [DATE], R361 is occasionally incontinent of bowel and bladder and there is no toileting plan in place for either. R361 has a Brief Interview for Mental Status (BIMS) score of 15 indicating R361 is cognitively intact. R361 has not had any falls at the facility since her admission.
On 11/3/24, the facility conducted a falls assessment and determined R361 is at moderate risk for falls.
A review of the plan of care indicated that R361 has potential for falls related to recent admission to community. Interventions included to keep pathways clear and provide adequate lighting. The plan of care for Activities of Daily Living documents that R361 needs extensive assist with 1 staff person support to pivot transfer with assistive device. R361 also needs extensive assistance with 1 person for support for toileting.
The Certified Nursing Assistant (CNA) care card indicates that R361 needs extensive assistance with 1 staff person support for toileting and does not use any bowel/ bladder appliances. R361 is continent of bladder and incontinent of bowel. R361 also needs extensive assistance with 1 person staff support for transferring and ambulation.
A Nursing Note dated 11/14/27 at 10:37 a.m. documents, late entry fall on 11/12/24 at 7:00 p.m. Staff was alerted by family that [R361] had a fall. Family stated when she walked in the room the wardrobe was on her [R361] and she flipped it off her. [R361] states she had to go to the bathroom and was walking to the bathroom when she fell. Vital signs and range of motion within normal limits. Head to toe assessment completed and no injury noted. Initially [R361] had no complaints of pain but then stated her right knee was hurting. 911 called and transferred [R361] to the hospital. Per follow-up on 11/13/24 at 7:00 a.m., hospital nurse stated [R361] had no injuries, and all testing was within normal limits.
R361 had not returned to the facility following the transport to the hospital on [DATE].
On 12/2/24, Surveyor requested to review the falls investigation for R361 from 11/12/24. Nursing Home Administrator (NHA)- A provided Surveyor with the Fall Scene Investigation Form, for the fall on 11/12/24 that happened at 7:00 p.m. The form documents that R361 was in her room, and incontinent of feces. R361's statement, I needed to go to the bathroom, and no one was coming so I was walking to the bathroom. The fall was unwitnessed and R361 was observed sitting on the floor. The call light was not activated at the time of the fall. It was unknown if R361 hit her head. The factors noted related to the fall were that R361 was ambulating independently and R361 is to ambulate with the assist of 1 person and her walker. Environmental factors observed was that the wardrobe was face down on the floor. The investigation indicates that the last time R361 was visually observed was 6:40 p.m. on 11/12/24. R361 had gripper socks on and needed items were in reach and R361 was incontinent of bowel.
Surveyor reviewed the Nurse follow-up responsibilities post fall form dated 11/12/24. Task # 6 states to use a Hoyer lift to get resident off the floor. Written documentation stated that emergency medical services (EMS) got R361 off the floor.
Surveyor reviewed written statements from staff members that were included in the facility's investigation. The following was noted:
CNA- J documented that he worked both units on the 2nd shift on 11/12/24. CNA- J stated that he observed R361 in her chair in her room as he was passing out the dinner meal trays and this was approximately 6:40 p.m CNA- J did not document that he had provided any cares to R361 during his shift on 11/12/24 prior to the fall.
Licensed Practical Nurse (LPN)-F documented that he observed R361 at 6:35 p.m., on 11/12/24, sitting on the Broda chair when staff was making rounds and passing medications to other residents. At 7:05 p.m., R361's family was heard yelling loudly that R361 was on the floor and claimed she pushed the board (sic) off of R361. LPN- F documented he called EMS immediately.
CNA- G documented that she was assisting other residents on 11/12/24 when she heard yelling from R361's room. R361's family stated that the dresser was on top of R361 when she came into the room, and she pushed it off her. CNA- G did not indicate she had provided any cares to R361 prior to the fall.
Acting Director of Nursing (ADON)-C documented that she was in the office on 11/12/24 when she heard a loud thump and then seconds later heard yelling coming from a woman. When ADON- C arrived, R361's family member was screaming at staff stating that the dresser was on top of R361. ADON- C observed R361 laying on her back leaning toward her right side with the family member behind her trying to lift R361 up. The floor nurse dialed 911 as well as R361's family member called 911. R361's family member had asked why staff had not done rounds and ADON- C explained that R361 was last checked on at 6:30 p.m. by nursing staff and stated R361 was sitting in her recliner with the call light in reach. R361 had stated that she had called for help to go to the bathroom, nobody came so she tried to go to the bathroom herself and fell on the ground. Surveyor noted there are conflicting statements about where R361 was seated during observations prior to their fall. Surveyor noted staff identified R361 being seated in a Broda chair and others state a recliner. This would be relevant information to know as part of the investigation of the fall.
Registered Nurse (RN)-H documented that she had heard the yelling coming from the C- Unit at 7:00 p.m. and went to make sure all residents were safe. RN- H observed R361 sitting on her buttock on the floor with her legs stretched forward facing the door. The dresser was lying on the floor adjacent to R361. RN- H assessed R361 for injuries. No signs of apparent injuries and denied pain. R361 was incontinent of stool at the time of the assessment. No walker or wheelchair nearby. The call light was not on. At 6:30 p.m., RN-H stated she was in R361's room administering medications and R361 was eating supper. The CNA assigned to R361 was entering room to assist R361 with supper.
Surveyor noted that after reviewing the written statements included in the fall's investigation, no staff member had provided a time that they provided cares for R361. There is no information as to when R361 was last toileted or if anyone had heard R361 requesting help to go to the bathroom.
On 12/2/24 at 1:50 p.m., Surveyor interviewed NHA-A regarding the 11/12/24 fall investigation for R361. NHA-A confirmed that no one had witnessed R361's fall. NHA-A stated that is was right after R361's family member-K arrived to the unit and then entered the resident's room that she (family member-K) began yelling loudly regarding the dresser being on top of R361. NHA-A stated that family member-K would not allow R361 respond to questions about what had happened and how the dresser fell to the ground. NHA-A stated that there was no possible way that the dresser had fallen on R361 and that maybe family member-K had pushed it to the floor. NHA-A stated that staff were trying to calm family member-K down and that staff and family member-K had separately called 911. NHA-A stated that Maintenance staff came into room after the incident and tried to re-enact the fall and see how the dresser ended up on the ground. It was said that nobody could believe that R361 could have knocked over the dresser when she fell as it was a heavy piece of furniture. NHA- A was asked who was assigned to care for R361 on 2nd shift 11/12/24. NHA-A stated she was not aware and would have to follow-up. Surveyor asked why the investigation did not include information about the last time R361 was assisted with toileting because R361 claimed she had been waiting for a long time for help to go to the bathroom and that is when she decided to take herself, resulting in the fall. NHA-A stated that the focus of the investigation became about the dresser and if it had really fallen on R361. NHA-A stated that the dresser was removed from R361's room right away and was replaced. It did not appear that there was anything structurally wrong with the dresser that would have caused it to fall to the ground.
Surveyor conducted a review of the staff schedule for 11/12/24. It was noted that not all of the staff that were working on the 2nd shift on 11/12/24 and may have had knowledge about the fall, were interviewed as part of the investigation into R361's fall.
On 12/3/24 at 8:32 a.m., Surveyor spoke with Scheduler- D who provided an explanation of the schedule and how the assignments were made. Scheduler- D stated that on the 2nd shift on 11/12/24, the nurse would have made the assignments for what CNA was responsible for caring for what residents. Scheduler- D was unable to confirm what CNA was assigned to provide cares for R361 on 2nd shift on 11/12/24. As of the time of exit from the survey, NHA-A also was not able to provide confirmation who was responsible for providing cares to R361 on 11/12/24 on 2nd shift.
On 12/3/24 at 10:03 a.m., Surveyor interviewed Plant Operations Director (POD)- I regarding R361's fall and the allegation that the dresser had fallen on top of her. POD- I stated that the wardrobe was full of R361's belongings at the time of the fall and staff had observed the wardrobe on the ground. The dresser/ wardrobe was put upright and back in place in R361's room after she was transported out. POD- I stated that they had tried to move the dresser to determine how the dresser fell and it proved to be very difficult for Maintenance staff to get the dresser to tip and rock back and forth. POD-I stated that the same dresser is still in place in the room that R361 resided and there was no damage to the dresser and all drawers, and the doors were functioning properly. POD- I stated that they did not check the condition of any of the other dressers/ wardrobes in other resident rooms and there have not been any other incidents involving falls and furniture.
The facility conducted a falls investigation with the primary focus being on the dresser and if it had actually fallen on R361 the night of 11/12/24. The facility's investigation did not include a root cause analysis regarding the actual fall itself and why R361 attempted to toilet herself after requesting assistance and not receiving it. In addition, the facility did not assure that all dressers/ wardrobes were secured/safe and in good repair.
Oct 2024
12 deficiencies
2 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents at risk for pressure injuries received...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and to promote healing for 2 of 2 residents (R5 and R48) reviewed for pressure injuries.
* On 4/16/2024, R5 was noted to have an area of concern that was not comprehensively assessed and R5's pressure injury care plan was not revised until two days later on 4/18/2024. The area was then staged as an unstageable wound to R5's sacrum. Surveyor made observations on 10/1/2024 and 10/2/2024 of R5's care plan not being followed.
* R48's air mattress, which was in place to reduce pressure and prevent pressure injuries, was observed not working appropriately on 10/1/2024 and 10/2/2024 and staff were initialing each shift that R48's mattress was checked and functioning properly.
Findings include:
The facility policy entitled Pressure Injury Assessment/Treatment last revised on 7/2024 documents: The purpose of this procedure is to provide guidelines for a consistent method of identification of and for the initial care of identified pressure injuries, alterations in skin integrity, and the prevention of acquiring additional pressure injuries.
General Guidelines .
A. The pressure injury treatment program should focus on the following strategies: .
3. Resolution of current pressure injuries and prevention of additional pressure injuries.
6. Education and quality improvement.
Documentation- The following information should be recorded in the resident's medical record, treatment sheet, or designated wound form: .
B. Wound appearance, including wound bed, edges, presence of drainage.
E. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound.
1.) R5 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, vascular dementia without behaviors/psych/mood, hemiplegia following cerebral infarction affecting left nondominant side, peripheral vascular disease, dysphagia, history of a sacral stage 4 pressure injury (1/9/2023 - 6/18/2023) and contracture of the left wrist/hand/and muscle.
R5's quarterly minimum data set (MDS) dated [DATE] indicated R5 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R5 needing extensive assist with 2 staff assistance for toileting/personal hygiene, repositioning, and transferred using a Hoyer lift. Per the MDS, R5 is always incontinent of bowel and bladder and wore adult briefs for protection. The facility assessed R5 on 10/3/2024 to be a high risk for developing pressure injuries with a Braden scale score of 12.
R5's Pressure ulcers/Skin prevention care plan was initiated on 11/2/2022 with the following interventions:
(R5) is at risk for skin breakdown due to bowel and bladder incontinence, DM (Diabetes Mellitus), hemiparesis, and impaired mobility.
- Provide peri-care after each incontinence episode and apply skin protectant.
- Monitor for signs and/or symptoms of breakdown.
- Use the following positioning/pressure reducing devices: wheelchair cushion and air mattress. Validate [sic]
- Monitor skin under Left hand splint and tubi grips. Staff to assist to don left hand/wrist splint daily with AM cares and remove with PM cares.
- Encourage and assist to elevate heels when in bed (May not comply).
- Apply lotion to resident's feet during HS (bedtime) cares.
- Apply lotion to arms and legs as needed.
- Reposition off of right buttock at regular intervals and prn (as needed) when in bed.
On 4/16/2024 at 14:58 (2:58 PM), R5's progress notes nursing documents resident's coccyx noted to be reopened, 3.0 cm X 0.4 cm X 0.1 cm (length X width X depth), washed with NS (normal saline), skin prep to surrounding skin, covered with foam dressing. NP (nurse practitioner), family, assistant director of nursing (ADON) notified, and order put in for wound treatment.
Surveyor noted that there was not a comprehensive assessment done on the newly observed area to R5's coccyx describing what the area looked like or staging the area. Surveyor also noted there were no revisions made to R5's care plan.
On 4/18/2024, at 12:15 PM Wound Nurse- H documented:
- Full thickness wound, unstageable pressure injury
- 3.0 X 2.0 X 0.1, oval shaped, 80% slough, 20% granulation tissue, moderate serosanguineous drainage.
- Clean with NS or wound cleanser, skin prep to surrounding tissue, apply medihoney and cover with foam dressing, change daily and prn.
- R5 was seen by wound care team: at present R5 gets up in the morning and stays up all day. R5 is agreeable to getting back in bed after dinner and staying in bed until lunch the next day.
Surveyor noted R5's pressure injury care plan was revised on 4/18/2024 with the following interventions:
- Provide treatment as ordered.
- Provide pain management prior to dressing changes.
- Wound consult.
- Dietary consult.
- Pressure relieving cushion to wheelchair.
- APM (Air pressure mattress) check settings, functioning, and inflation every shift.
- Provide pericare after each incontinence episode and apply skin protectant.
- Monitor labs as ordered and notify MD/NP (Medical doctor/ nurse practitioner) of all values.
- Assist with repositioning every hour. Assist of ii [sic] using draw sheet to minimize friction and shearing.
- Assess and evaluate wound size, depth, color, and drainage weekly with wound rounds.
R5's wound continues to be assessed weekly with the following assessments:
4/25/2024:
-Full thickness PI, Stage 3
- 2.6 X 1.4 X 0.1, 25% epithelial, 75% granulation, mod serosanguineous
- Cleanse with NS or wound cleanser, skin prep surrounding tissue, apply collagen powder and cover with foam dressing. change 3x/week and PRN
- wounds significantly improved
5/2/2024:
- Full thickness wound, PI, stage 3
- 2.4 X 1.2 X 0.3, 100% granular, mod serosanguineous
- cleanse with NS or wound cleanser, skin prep surrounding tissue, apply collagen powder and cover with foam dressing, change daily and PRN
- improved
5/8/2024
- 2.1 X 1.2 X 0.4, 100% granulation, mod serosanguineous
5/16/2024
- 2.0 X 1.8 X 0.5, 100% granular, mod serosanguineous
- up for lunch through dinner and then back to bed, strict side lying only
5/23/2024
- 3.0 X 1.0 X 0.4, 50% slough, 50% granulation, mod serosanguineous
- unstageable
5/30/2024
- 2.5 X 0.8 X 0.7, 50% granulation, 50% slough
6/6/2024
- Full thickness PI, stage 3
- 2.5 X 1.2 X 0.6, 90% granulation, 10% slough, mod serosanguineous
- cleanse with NS and wound cleanser, skin surrounding tissue, apply santyl ointment to wound base and cover with bordered dressing. change daily and PRN
-stable
Surveyor noted that R5's pressure injury care plan was revised 6/8/2024 with the following intervention:
-Resident to stay in bed for breakfast and may get up for lunch and dinner as tolerated.
6/13/2024
- full thickness PI, stage 3
- 2.5 X 1.0 X 0.5, 100% granulation, mod serosanguineous
- cleanse with NS and wound cleanser, skin prep surrounding tissue. apply collagen to wound base and cover with bordered dressing. change 3X weekly and PRN
6/20/2024
- full thickness PI, stage 3
- 3.0 X 0.9 X 0.5, 100% granulation, mod serosanguineous
- improved, edges of wound scraped up to promote healing
6/27/2024
- 2.9 X 1.3 X 0.5, 100% granulation. mod serosanguineous
- stable
7/3/2024
- full thickness PI stage 3
- 2.9 X 0.8 X 0.5, 100% granulation, mod serosanguineous
7/10/2024 (DON)
- full thickness PI, stage 3
- 2.5 X 0.8 X 0.5, 100% granulation, mod serosanguineous
7/11/2024 (RN)
- full thickness PI, stage 3
- 2.9 X 1.1 X 0.4, 100% granulation, mod serosanguineous
7/18/2024
- full thickness PI, Stage 3
- 2.7 X 0.9 X 0.4, 100% granulation, serosanguineous
7/25/2024
- full thickness PI, stage 3
- 2.8 X 0.9 X 0.4, 100% granulation, serosanguineous
- Seen by wound team. No new orders at this time. Will continue with current plan of care.
8/1/2024
- full thickness PI, Stage 3
- 2.5 X 0.8 X 0.4, 100% granulation, serosanguineous
-improved
8/8/2024
- full thickness PI, stage 3
- 2.3 X 0.8 X 0.3, 100% granulation, serosanguineous
-improved
8/15/2024
- Full thickness, stage 3
- 2.4 X 0.8 X 0.3, 100% granulation, serosanguineous
-stable
8/22/2024
- 2.0 X 0.7 X 0.3, 100% granulation, serosanguineous
-improved
8/29/2024
- 2.0 X 0.6 X 0.3, 100% granulation, mod serosanguineous
-improved
9/5/2024
- 1.7 X 0.5 X 0.1, 100% granulation, mod serosanguineous
9/12/2024
- 1.6 X 0.4 X 0.1, 100% granulation, mod serosanguineous
-improved
9/19/2024
- 1.5 X 0.4 X 0.1, 100% granulation, mod serosanguineous
- improved
9/26/2024
- 1.5 X 0.4 X 0.1, 100% granulation, serosanguineous
-stable
10/3/2024
- 1.5 X 0.2 X 0.1, 100% granulation, mod serosanguineous
- stable, improving slowly due to the scar tissue- harder to heal- wound NP has been doing little debridement or scratching of edged to increase wound healing- has been working
On 10/1/2024 at 11:06 AM, Surveyor observed R5 in the dining room sitting in a Broda wheelchair reading a book. Surveyor asked R5 if R5 just got up for the day. R5 stated that R5 has been up all morning and was waiting for lunch. Surveyor asked R5 if R5 has been sitting in the Broda wheelchair all morning or if just got into the Broda wheelchair. R5 stated R5 was sitting in the Broda wheelchair all morning. Surveyor asked R5 if R5 has been repositioned in the Broda wheelchair or laid down in bed after breakfast. R5 replied No.
On 10/2/2024 at 1:27 PM, Surveyor observed R5 in the dining room sitting in a Broda wheelchair finishing lunch.
On 10/2/2024 at 3:21 PM, Surveyor observed R5 sitting in a Broda chair in the dining room, Surveyor asked if R5 had been lain down in R5's be at all since the morning. R5 replied no.
On 10/2/2024 at 7:46 AM, Surveyor observed R5 sitting in the dining room in a Broda wheelchair. R5 stated R5 has been up in the chair for a while and was waiting for breakfast.
On 10/2/2024 at 1:24 PM, Surveyor observed R5 sitting in a Broda wheelchair. Surveyor asked R5 if R5 laid down after lunch or had been repositioned in R5's wheelchair. R5 replied no.
On 10/2/2024 at 3:15 PM, Surveyor shared concerns with Director of Nursing (DON)-B that Surveyor had observations 10/1/2024 and 10/2/2024 of R5 sitting in R5's Broda wheelchair all morning and afternoon and that R5's care plan intervention is that R5 is to be up for lunch and dinner meals as tolerated and in bed for breakfast for pressure injury healing. DON-B stated DON-B would have to look into it and talk with staff.
On 10/3/2024 at 7:35 AM, Surveyor interviewed Wound Nurse- H who stated it was important for R5 to stay off R5's bottom area because of having a history of a pressure injury in the same spot as the one R5 has now and a lot of scar tissue was in the area, so it makes it hard for R5's current pressure injury to heal.
On 10/3/2024 at 3:04 PM, Surveyor shared concerns with ADON-M, Executive Director-C, and Nursing Home Administrator (NHA)-A that R5's pressure injury that was first observed on 4/18/2024 did not have a comprehensive assessment or care plan revisions until two days later on 4/18/2024 when R5's pressure injury was staged as unstageable and then staged as a stage 3 on 4/25/2024. Surveyor also shared observations on 10/1/2024 and 10/2/2024 of R5's care plan not being followed and R5 was observed in R5's Broda wheelchair from morning until evening and that R5's care plan is to be up in wheelchair for lunch and dinner then in bed for pressure injury healing.
No additional information was provided as to why the facility did not ensure that R5 received necessary treatment and services consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing.
2.) R48 was readmitted to the facility on [DATE] with a diagnoses that include malignant pleural effusion, hydronephrosis, protein-calorie malnutrition, and atrial fibrillation.
R48's significant change minimum data set (MDS) dated [DATE] indicated R48 had intact cognition with a brief interview for mental status (BIMS) score of 15 and the facility assessed R48 requiring total assistance with 1 staff member for all activities of daily living (ADL's). the facility assessed R48 on 9/12/2024 as being a moderate risk for pressure injury development with a Braden risk score of 14.
R48's Pressure Ulcer/Skin Condition care plan was initiated on 9/12/2024 with the following interventions:
- Braden scale to be completed.
- Keep bed linens wrinkle free and do not use excess pads.
- Observe skin for redness and breakdown during routine care.
- Use pressure relieving devices, cushion in wheelchair, and off heels [sic], as indicated.
- Follow community skin care protocol.
- Treatments as indicated, see physician orders.
- Pressure reducing mattress on bed, check function, and setting every shift. Set at 2.
On 10/1/2024 at 9:51 AM, Surveyor observed R48 lying on R48's back in bed. Surveyor noted R48's air mattress to be off. Surveyor asked R48 if R48 was comfortable and if staff came in to help R48 reposition. R48 stated R48 was comfortable, and staff was just in to reposition R48 so R48 could eat breakfast.
On 10/1/2024 at 3:16 PM, Surveyor observed R48 lying in bed sleeping. Surveyor noted R48's air mattress was off and not working.
On 10/2/2024 at 7:50 AM, Surveyor observed R48 lying in bed on R48's back and air mattress was not on.
On 10/2/2024 at 1:39 PM, Surveyor observed R48 sitting in a wheelchair. Surveyor noted that R48's air mattress was off.
On 10/2/2024 at 3:15 PM, Surveyor showed DON-B R48's air mattress. DON-B looked at R48's air mattress and noted that the plug was not pushed in to the outlet all the way. DON-B pushed the plug in, and the air mattress started to work and inflated. Surveyor asked DON-B how DON-B can verify that staff is looking at R48's air mattress to make sure it is working appropriately and knows how to operate his air mattress. DON-B replied that it would be an order and on R48's medication/treatment administration record (MAR/TAR) to sign off on when done.
On 10/2/2024, Surveyor reviewed R48's September and October 2024 MAR/TAR record and noted an order that was initiated on 9/12/2024 that states:
-air mattress to bed. Check for proper inflation, function, and setting every shift.
Surveyor noted that staff was initialing on 10/1/2024 and 10/2/2024 every shift that R48's air mattress was functioning properly.
On 10/3/2024 at 3:04 PM, Surveyor shared concerns with ADON-M, Executive Director-C, and Nursing Home Administrator (NHA)-A that R48's air mattress was observed not working appropriately on 10/1/2024 and 10/2/2024 and staff were initialing each shift that R48's mattress was checked and functioning properly.
No additional information was provided as to why R48 did not received the necessary treatment and services consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing.
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
Accident Prevention
(Tag F0689)
A resident was harmed · 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 4 residents reviewed (R38, R29, and R43) re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure 3 of 4 residents reviewed (R38, R29, and R43) received adequate supervision and assistance, and that interventions were in place to prevent accidents.
R38 sustained multiple falls resulting in injuries. A thorough investigation after every fall was not completed to determine root cause analysis. R38's care plan was not revised with recommended fall prevention interventions.
R29 had a fall in their room on 9/24/24. Fall interventions were not in place at the time of the fall.
R43's fall on 9/9/24 was not thoroughly investigated to determine the root cause.
Findings include:
The facility policy titled Falls Prevention dated revised, 7/2023, states (in part)
.The intent of this policy is to provide and environment that is free from accident hazards, over which there is control, and provide supervision and intervention to residents to prevent avoidable accidents .
II. Fall Risk Intervention. The Interdisciplinary Team shall identify individualized interventions to reduce the risk of falls.
1. Falling Star Program .
C. If falling recurs despite initial interventions, associate shall implement additional, different interventions or indicate reason the current approach remains relevant. This documentation should be maintained in the clinical record.
The facility policy, entitled, Falls dated revised, 7/2023, states (in part)
.Policy statement: The purpose of this procedure is to provide guidelines for evaluation of a resident in the event a fall occurred and to assist associates in identification of potential causes of the fall.
Policy Detail: Direct care associates shall evaluate the area where the fall occurred for possible contributors.
The documentation of the identified interventions should be maintained in the resident clinical record and available to the direct care associates.
The falls should be reviewed at the Daily Stand-up meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls.
An incident report shall be completed for the resident falls by a licensed nurse after the fall occurs.
R38 was readmitted to facility on 10/21/23 with diagnoses that include Alzheimer's disease, unspecified protein-calorie malnutrition, and hip fracture that occurred as a result of a fall at the facility on 10/10/23.
R38's quarterly MDS (Minimum Data Set) dated 6/8/24 documents R38 required partial to moderate assist for transfer.
R38's quarterly MDS dated [DATE] indicates a BIMS (Brief Interview for Mental Status) score of 0, indicating severe cognitive impairment and also documents R38 is occasionally incontinent of bowel and bladder.
R38's ID (Interdisciplinary Notes) indicate falls occurred on 10/10/23, 1/16/24, 4/24/24, 4/25/24, 5/4/24, 7/23/24, and 8/20/24.
R38's Care Plan dated 7/5/23, prior to R38's first fall on 10/10/23, documents:
Potential for falls related to recent admission to community, recent fall, generalized weakness, confusion. Interventions include:
-keep pathways clear/adequate lighting
-keep bed at the appropriate height
-keep personal items within reach
-orient to room and call light
-soft touch call light
-bed against wall
-body pillow when in bed to be aware of boundaries
-floor strips next to bed and in front of toilet and recliner.
-dump seat wheelchair with auto lock brakes
-Falling Star program
-Call don't fall signs in room
-encourage to stay in areas of high visibility
-activity assessment
-educate family to notify staff of residents return from outings and of family departure
-educate family to notify staff and to use call light when resident is in need of assistance
-PT (Physical Therapy) to provide education regarding safe transfers
-Transfer resident with a 1 assist stand by
-Keep residents bed at transfer height
-scoop mattress
-bilateral grab bars
-Make sure foot pedals are only on when being pushed
-Assess for bleeding if resident falls due to use of anticoagulant
Review of R38's medical record identify no falls documented prior to 10/10/23. Surveyor asked for all of R38's fall investigations.
The facility Fall Investigation dated 10/10/23 documents: R38 was found on the floor in her room at 6:45 PM. A thorough investigation was completed, and care plan interventions were in place at the time of the fall. R38 sustained a hip fracture as a result and was admitted to the hospital.
R38 was readmitted to the facility on [DATE] with a diagnosis of a hip fracture. The care plan was revised on 10/23/24 to include encourage to wear gripper socks if not wearing her shoes.
R38's medical record documents an interdisciplinary (ID) note dated 1/16/24, indicating R38 sustained a fall on 1/16/24 at 3:30 AM. The ID note documents: Last seen prior to Fall: Not documented. Last Toileted: Not documented. Location of Fall: Room/self-transferring to bathroom. Who witnessed Fall: Unwitnessed. Hit Head: Yes. Neuros completed: Yes. Injury: Right elbow pain, right knee pain and back pain. Staff Statements: Not completed. Nurse Post Fall: Not completed. CNA (Certified Nursing Assistant) Post Fall: Not completed. hospitalized : Yes. Falls Risk assessment: Yes. Root Cause Analysis: Not completed.
Interdisciplinary note dated 1/16/24 at 8:51 PM documents: Intervention: Bed commode since resident is always transferring self to bathroom.
Surveyor was informed the facility does not have a fall investigation for R38's fall on 1/16/24. Surveyor notes the fall prevention intervention of bed commode was not added to R38's care plan.
On 4/24/24, R38's medical record documents R38 had a fall at 9:30 AM. The facility's falls investigation documents R38 was last seen at 9:00 AM. Last Toileted: Not documented. Call light not used. Location of Fall: Room/fell out of wheelchair, trying to get up. Unwitnessed.
Hit head, neurological checks completed. Pain, left elbow. R38 was transferred to the hospital for evaluation, no injuries. New interventions implemented: Get up in morning/offer to lay down after meals. Reeducated resident on not to self-transfer and education on call light use.
Surveyor notes a thorough investigation of the fall was not completed to identify the root cause. There was no documentation as to when R38 was last toileted. The recommended intervention to get up in morning/offer to lay down after meals was not added to R38's care plan. In addition, education on call light use was not an appropriate intervention as R38 is assessed to have severe cognitive impairment.
On 4/25/24, R38's medical record documents R38 had a fall at 4:35 PM in the dining room. The facility's falls investigation documents: Last toileted - unknown. Resident was unable to specify what caused the fall. New recommended intervention: Every one-hour checks during shift, 2 to toilet during shift.
Surveyor notes the facility did not complete a thorough investigation to identify the root cause of the fall. R38's care plan was not revised to include every one-hour checks during shift and a 2-person toilet transfer as documented as the new fall prevention interventions.
On 5/4/24, R38's medical record documents R38 had a fall at 11:30 AM. The facility's falls investigation documents:
Unwitnessed - Fell out of recliner trying to get into bed.
The facility did not complete a thorough investigation to identify the root cause of the fall or if care plan interventions were in place at the time of the fall. There was no documentation of when R38 was last seen or toileted. IDT (Interdisciplinary Team) Root cause determination: Continue monitoring, reeducated on call light use.
Surveyor noted no new interventions were implemented to prevent falls. Reeducation on call light use was not appropriate as R38 is assessed to have severe cognitive impairment.
On 7/23/24 at 3:00 AM, R38 sustained her 6th fall. The fall investigation documents:
Unwitnessed, found on floor. Skin tear left elbow. Appears resident was self-transferring without calling. Last seen prior to Fall: 2:30 AM - 2:45 AM. Last Toileted 12:00 AM.
Footwear: Socks only. Footwear: Gripper socks.
Surveyor noted the fall investigation did not indicate if care plan interventions were in place at the time of the fall (ie: body pillow for positioning). The investigation also is not clear as to R38's footwear at the time of the fall. Surveyor noted R38's care plan was revised with new fall interventions: Low bed and floor mats placed during HS (hour of sleep). Transfer height and grip strips during AM/PM. Resident needs floor mat and transfer height during bedtime. During AM/PM resident needs transfer height and only grip strips. Remove floor mat during AM/PM for fall preventions - implemented 7/25/24.
As a result of the fall on 7/23/24, R38 was sent to the hospital for evaluation. She returned to the facility the same day.
The hospital After Visit Summary dated 7/23/24 documents: X-ray wrist 3 or more views right. Findings: Acute, comminuted and impacted transverse distal radial metaphyseal fracture. Mildly displaced dorsal fracture fragments. Minimally displaced ulnar styloid process fracture. Impression: Acute distal radial and ulnar styloid process fractures.
On 8/20/24, R38's medical record documents R38 had a fall at 11:30 AM. The investigation did not include a root cause analysis of the fall. There was no documentation of when R38 was last seen or toileted. The resident sustained no injuries. Surveyor noted R38's care plan was not revised, and no new interventions were implemented.
On 10/1/24 at 9:50 AM, Surveyor interviewed RN (Registered Nurse)-G who stated R38 had multiple falls and pointed out the Call, don't fall signs throughout R38's room.
On 10/1/24 at 9:45 AM, Surveyor observed R38's room noting fall interventions in place of a low bed, floor mat, non-skid strips on floor by bed, recliner, and bathroom, body pillows, call don't fall signs, and a soft touch call light.
On 10/7/24 at 1:50 PM, Surveyor informed Executive Director-C and NHA (Nursing Home Administrator)-A of concerns regarding R38's falls: R38 sustained a fall on 10/10/23 resulting in a hip fracture. R38 sustained 6 subsequent falls, one of which occurred on 7/23/24 resulted in a wrist fracture. The facility did not complete thorough investigations to determine the root cause following every fall, and recommended interventions were not added to R38's care plan. In addition, recommended interventions to include reeducation on use of call light was not appropriate as R38 has a BIMS score of 0 indicating severe cognitive impairment. NHA-A reported going forward she plans to review all residents' fall interventions. No additional information provided.
3) R43 was admitted to the facility on [DATE] and has diagnoses that include cerebral infarction affecting the left dominant side, left foot drop, repeated falls, wedge compression FX (fracture) to lumbar back, major depressive disorder, and congestive heart failure.
R43's quarterly minimum data set (MDS) dated [DATE] indicates R43 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 9 and the facility assessed R43 needing extensive assist with one staff member for bed mobility and requiring a Hoyer lift with 2 staff members for transferring. R43 is occasionally incontinent of bowel and bladder and uses a wheelchair in which R43 self-propels to places. R43 has a history of falls and the facility last assessed R43 on 7/11/2024 as being at moderate risk for falls with a fall risk score of 23.
On 9/9/24 at 7:14 AM, R43's medical record documents R43 had an unwitnessed fall.
The investigation summary documents R43 was observed by housekeeping staff sitting with R43's back against the bed yelling for help. R43 stated they rolled out of bed.
Surveyor noted the facility's fall investigation does not include staff interviews regarding when R43 was last checked on or toileted, if objects such a call light were in reach of R43. The investigation does not state what R43 may have been reaching for or if R43's call light was activated at the time of the fall. The fall investigation does not state if immediate interventions were put in place and R43's Fall care plan was not revised.
On 10/3/2024 at 10:51 AM, Surveyor observed R43 in the hallway in R43's wheelchair. Surveyor asked R43 if R43 has had any falls out of bed recently. R43 stated R43 could not recall if they had any falls recently.
On 10/3/2024 at 3:04 PM, Surveyor shared concerns with Assistant Director of Nursing (ADON)-M, Executive Director-C, and Nursing Home Administrator (NHA)-A regarding R43's fall investigation on 9/9/2024 not being thorough as it did not identify the root cause of the fall, when R43 was seen and/or assisted by the staff or identify fall prevention interventions implemented to address the root cause of the fall. Surveyor requested if any other information pertaining to the fall could be located regarding staff interviews, how R43 was prior to the fall and when last checked on or toileted, what interventions were put in place and any revisions made to R43's fall care plan. Executive Director-C stated she would look into it and get any further information.
No further information was provided to Surveyor.
2.) On 10/01/24 at 10:46 AM, Surveyor observed R29 sitting in a recliner in their room. R29 wheelchair was next to the recliner.
R29's medical record was reviewed by Surveyor. The (interdisciplinary notes) IDT documents a fall on 9/3/24. R29 had a fall while self transferring. R29 did not have any injury. The fall was assessed with a new intervention identified to keep the wheelchair by the bedside. R29 is able to self transfer and did not have their wheelchair next to their bed at the time of the fall.
R29's medical record documents a fall on 9/23/24. R29 was self transferring from their bed. The Fall Investigation documents the wheelchair was across the room. R29 did not have any injury. Surveyor noted R29's fall prevention intervention of having the wheelchair next to the bed was not followed.
R29's Fall plan of care due to a potential for falls related to recent admission to the community, history of recurrent falls, generalized weakness, poor safety awareness. Has right lower extremity deformity and prefers to wear their personal slippers instead of non-skid socks. This has a start date of 4/19/24. This includes the 9/3/24 fall prevention intervention to keep the wheelchair by bedside.
On 10/02/24 at 11:00 AM, Surveyor observed R29 in a recliner in their room. R29's wheelchair was next to the recliner.
On 10/02/24 at 1:02 PM, Surveyor interviewed (Director of Nurses) DON-B. DON-B stated R29 is aware they are supposed to ask for help. DON-B stated the wheelchair was not next to the bed on 9/23/24 at the time of the fall. DON-B stated they did talk to staff about following the plan of care. R29 does have care plan interventions to have their wheelchair next to the bedside.
On 10/3/24 at 3:03 PM, at the facility exit meeting with (Executive Director) ED-C, Surveyor shared R29's fall intervention concerns. No further information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 report 3 (R5, R111, R45) of 5 allegation to the State Survey Agency, N...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not report 3 (R5, R111, R45) of 5 allegation to the State Survey Agency, Nursing Home Administrator, or local law enforcement during the required timeframe.
R5 had an allegation of abuse and it was not reported to the Nursing Home Administrator until two days later, the alleged employee continued to work at the facility during those two days, and law enforcement was not contacted about R5's potential abuse allegation.
R111's family members had a physical altercation in front of R111 and other resident's in the facility main dining room during meal service. Local law enforcement was notified and removed 1 of the individuals involved. The Nursing Home Administrator was not notified about the altercation until two days later at which time it was reported to the State Agency.
R45's allegation of abuse was not reported timely.
Findings include:
The facility policy entitled Abuse Prevention revised on 8/2024 documents . Reporting/Response:
A. The community will immediately, but no later than 2 (two) hours after the allegation is made, if the events that cause the allegation involve abuse of [sic] result in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in mistreatment, including injuries of unknown source and misappropriation of property, to the administrator and/or designee, State agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames.
The facility policy entitled Abuse Investigation and Reporting revised on 11/2023 documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, ., and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the [Facility Name] Abuse Prevention policy.
Reporting:
A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies:
1. The State licensing/certification agency responsible for surveying/licensing the community.
2. Other officials in accordance with State Law, including the Adult Protective Services where state law provides for jurisdiction in long term care facilities.
B. Alleged violations involving abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported:
1. Abuse or serious bodily harm- Immediately but no later than 2 hours. *If the alleged violation involves abuse or results in serious bodily injury.
2. No serious bodily injury- As soon as practical, but no later than 24 hours*. If the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; does not result in serious bodily injury.
1) R5 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, vascular dementia without behaviors/psych/mood, hemiplegia following cerebral infarction affecting left nondominated side, type 2 diabetes with peripheral angioplasty/diabetic neuropathy/diabetic chronic kidney disease, peripheral vascular disease, major depressive disorder, weakness, heart failure, cognitive communication deficit, dysphagia, and contracture of the left wrist/hand/and muscle. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R5 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R5 needing extensive assist with 2 staff assistance for toileting/personal hygiene, repositioning, and transferred using a Hoyer lift. R5 is always incontinent of bowel and bladder and wore adult briefs for protection. The facility assessed R5 to not have any behavior concerns.
Surveyor reviewed the facility self- report for R5. The summary report for the allegation documents an allegation of possible retaliation to R5 on 7/8/2024, at approximately 8:00 PM when certified nursing assistant (CNA)-F came out of R5's room and stated R5 scratched her. Licensed Practical Nurse (LPN)-E documented R5's left side of her face appeared to be red and swollen upon assessment. On 7/10/2024, LPN-E notified the Social Services Director (SSD) of LPN-E's concern that CNA-F possibly retaliated on R5 for scratching CNA-F during cares. SSD reported the concern to the Nursing Home Administrator (previous NHA)-D. The initial report was submitted to the State survey agency on 7/10/2024, at 5:22 PM, 2 days after the accusation of CNA-F possibly retaliating against R5 on 7/8/2024.
On 10/3/2024, at 12:12 PM, Surveyor interviewed LPN-E who stated LPN-E noted CNA-F coming out of R5's room and CNA-F stated R5 scratched CNA-F on the neck and CNA-F did not want to work with R5 anymore. LPN-E directed CNA-F to report it to the charge nurse on duty, Registered Nurse (RN)-G. LPN-E stated LPN-E went into R5's room and observed R5's face to be slightly red and appeared to be a little swollen. LPN-E stated LPN-E reported it to RN-G who stated R5's face is always like that. LPN-E stated when LPN-E returned back to work on 7/10/2024, LPN-E noted CNA-F was still working and went to SSD to report concern that R5 may have been retaliated on when R5 scratched CNA-F on the neck on 7/8/2024. Surveyor asked LPN-E if LPN-E reported the concern to anyone or notified police. LPN-E stated LPN-E thought RN-G was going to take care of it.
On 10/3/2024, at 12:23 PM, Surveyor interviewed previous NHA-D who stated, it was reported that R5's face is slightly reddened and swollen due to R5's history of having a stroke. When NHA-D interviewed R5, R5 would not respond to NHA-D. NHA-D stated CNA-F documented R5 scratched her when providing cares for R5 and that CNA-F was reassigned to another unit. NHA-D stated R5 scratched CNA-F, so police did not need to be contacted. Surveyor shared the concern with NHA-D that there was an allegation of possible retaliation made against CNA-F to R5 and it was not reported to NHA-D, to the State Agency or law enforcement agency timely. No further information was provided to Surveyor at this time.
2) R111 was admitted to the facility on [DATE] and has diagnoses that include cerebral infarction, type 2 diabetes mellitus with chronic kidney disease, cognitive communication deficit, and mild cognitive impairment. R111's admission MDS (Minimum Data Set) assessment dated [DATE] indicates R111 has moderately impaired cognition with a BIMS (Brief Interview of Mental Status) score of 8. The facility assessed R111 to not have any behavior concerns.
Surveyor reviewed the facility self-report for R111. The summary of the report documents that on 6/22/2024 approximately around 5:00 PM/dinner time in the main dining room R111's wife and daughter were involved in a verbal altercation that escalated to physical altercation of hair pulling and clenched fists striking each other. Facility staff broke up the altercation, police were contacted. Local law enforcement removed one of the visitors. R111 and other residents were witness to the incident. The altercation was not reported to NHA-D until 6/24/2024, 2 days after the altercation happened. NHA-D submitted the initial report on 6/24/2024, at 5:43 PM.
Surveyor noted RN (Registered Nurse)-E reported the altercation to the clinical on call staff member- Director of Quality Management (DQM)-I who did not report it any further.
On 10/3/2024, at 11:55 AM, Surveyor interviewed DQM-I who stated DQM-I did not think it needed to be reported to the State Agency because the altercation did not include any resident's and no residents were harmed in the altercation.
On 10/3/2024, at 12:23 PM, Surveyor interviewed NHA-D who stated NHA-D was made aware of the situation in the morning stand up meeting a couple days after the altercation and started an investigation right away. No further information was provided at this time.
2) R45 admitted to the facility on [DATE] to a room on the 3rd floor and has resided in the same room since admission.
On 10/1/24, at 9:38 AM, R45 advised Surveyor that on 6/17/24 he reported to the facility that he was held down and changed against his will. R45 reported he had a leg cramp, so he slid his leg out of bed, and the right leg went with it, so he was half on/half off the bed with his feet on the floor and his butt on the bed. R45 put his call light on and when the nurse came in and saw his position, she left to get a Certified Nursing Assistant (CNA) to help. R45 reported they lifted his legs back in bed and the nurse said he needed to be changed. R45 reported he said no, adding he has an enlarged prostate and just dribbles urine, and because in a half hour he would let the next shift change him, as he was only damp and there was no need to be changed right now. R45 reported he explained all of this to the nurse, but she kept insisting. R45 could not recall the nurses name, except that she was from Nicaragua. R45 reported he kept saying no and that the nurse told the aide to hold him down. R45 stated: I was lying flat, and the aide was pressing down on each of my shoulders, holding me down. So now I'm fighting with her, trying to get up because she's holding me down and I'm saying no so many times. In the meantime, the nurse is changing me while the aid was holding me down. R45 reported he told the nurse that he wanted to talk to someone to report what happened.
On 10/3/24, at 11:06 AM, Surveyor spoke with Previous NHA (Nursing Home Administrator)-D, NHA-A and Executive Director-C regarding the abuse allegation involving R45.
Surveyor asked Previous NHA-D when the abuse allegation was reported to the State Agency. Previous NHA-D stated: I'm sure I reported it right away, I usually do. Executive Director-C looked at the computer and advised Surveyor it was reported on 6/19/24 and the 5 day was submitted on 6/25/24. Previous NHA-D stated: OK, so I reported it on the 19th. Surveyor advised Previous NHA-D of concern he was made aware of the abuse allegation on 6/17/24 and it was not reported until 2 days later on 6/19/24. Previous NHA-D stated: Well, I'm not sure that abuse even happened. If you're held down by your shoulders, you would have some evidence of it, some marks or something.
Review of the Facility Self Report documented Previous NHA (Nursing Home Administrator)-D was notified of the allegation of abuse on 6/17/24. The abuse was not reported to the State Agency until 6/19/24. In addition, the CNA (Certified Nursing Assistant) statement documented R45 reported the abuse allegation to her on 6/15/24. The CNA did not report the allegation of abuse because he complains about everything.
On 10/7/24, at 10:49 AM, Surveyor advised NHA-A of concerns regarding the Facility not reporting of R45's abuse allegation timely to the State Agency. NHA-A reported she was present when Surveyor was interviewing Previous NHA-D and understands. No additional information was provided.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
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 all allegations involving potential abuse, neglect, and misapp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure all allegations involving potential abuse, neglect, and misappropriation of resident property were thoroughly investigated for 3 (R5, R111, R45) of 5 Facility self-reports reviewed.
R5's allegation of abuse reported on 7/8/2024 was not thoroughly investigated and residents were not protected from potential abuse during the abuse investigation.
R111's family's verbal and physical altercation which occurred in the main dining room during meal time was reported on 6/22/2024 and was not thoroughly investigated.
R45's allegation of abuse reported on 6/17/2024 was not thoroughly investigated.
Findings include:
The facility policy entitled Abuse Prevention revised on 8/2024 documents: . The objective of the abuse policy is to comply with the seven-step approach to abuse and neglect detection and prevention. Injury of Unknown Source is defined as an injury that meets both of the following conditions:
1. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident.
2. The injury is suspicious because of:
a. the extent of the injury.
b. the location of the injury.
c. generally vulnerable or trauma.
TRAINING: .
3. Reporting abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources, and to whom and when associate and others must report their knowledge related to any alleged violation without fear of reprisal.
IDENTIFICATION: .
B. Associates or person affiliated with this community who has witnessed or who believes that a resident has been a victim of mistreatment, abuse, neglect, or any other criminal offense shall immediately report suspected abuse or incidents of abuse to the administrator or designee.
The facility policy entitled Abuse Investigation and Reporting revised on 11/2023 documents: All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, ., and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the [Facility Name] Abuse Prevention policy.
POLICY INTERPRETATION AND IMPLEMENTATION
Role of the Administrator or designee: .
D. The Administrator or designee will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation.
Role of the Investigator:
A. The individual conducting the investigation will, at a minimum: .
3. Interview the person(s)reporting the incident.
4. Interview any witnesses to the incident.
5. Interview the resident (if medically appropriate).
7. Interview associates members (on all shifts) who have had contact with the resident during the period of the alleged incident.
9. Interview other residents to whom the accused employee provides cares or services.
11. Review use of community camera/video footage of incident if available.
1) R5 was admitted to the facility on [DATE] and has diagnoses that include Alzheimer's disease, vascular dementia without behaviors/psych/mood, hemiplegia following cerebral infarction affecting left nondominated side, type 2 diabetes with peripheral angioplasty/diabetic neuropathy/diabetic chronic kidney disease, peripheral vascular disease, major depressive disorder, weakness, heart failure, cognitive communication deficit, dysphagia, and contracture of the left wrist/hand/and muscle.
R5's quarterly Minimum Data Set (MDS) dated [DATE] indicated R5 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R5 needing extensive assist with 2 staff assistance for toileting/personal hygiene, repositioning, and transferred using a Hoyer lift. R5 is always incontinent of bowel and bladder and wore adult briefs for protection. The facility assessed R5 to not have any behavior concerns.
Surveyor reviewed the facility self-report for R5. The summary report for the allegation documents an allegation of possible retaliation to R5 on 7/8/2024 at approximately 8:00 PM when Certified Nursing Assistant (CNA)-F came out of R5's room and stated R5 scratched her. Licensed Practical Nurse (LPN)-E documented R5's left side of her face appeared to be red and swollen upon assessment. On 7/10/2024, LPN-E notified the Social Services Director (SSD) of LPN-E's concern that CNA-F possibly retaliated against R5 for scratching CNA-F during cares. SSD reported the concern to the Nursing Home Administrator (previous NHA)-D. The initial report was submitted to the State survey agency on 7/10/2024 at 5:22 PM, 2 days after the alleged incident occurred.
Surveyor noted CNA-F continued to care for other residents including R5, law enforcement was not notified regarding the allegation of possible retaliation against R5, CNA-F was not following the care plan for R5 and was assisting R5 alone versus 2 staff members per R5's care plan, and education was not provided to all staff member in the facility.
On 10/1/2024, at 3:14 PM, Surveyor observed R5 sitting in a Broda wheelchair in the dining room alone. Surveyor asked R5 if R5 felt safe and if there were any concerns with staff. R5 replied R5 was doing well and liked all the staff and the facility. Surveyor asked R5 if R5 was scared of any staff or was injured by any staff. R5 replied they had no concerns and did not recall having been injured by any staff.
On 10/3/2024, at 9:18 AM Surveyor interviewed CNA-F who stated CNA-F was assisting R5 alone and did not have another staff member in the room when providing care for R5. CNA-F stated the rest of the shift CNA-F has another staff member present with R5's when care is provided. Surveyor asked CNA-F if CNA-F received education related to the incident with R5. CNA-F stated CNA-F was talked to about following the resident care cards.
On 10/3/2024, at 12:12 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-E who stated LPN-E reported concerns to the Social Services Director (SSD) on 7/10/2024 when LPN-E came into work next and found out CNA-F was still on the schedule to work. Surveyor asked LPN-E if LPN-E received education regarding reporting such concerns. LPN-E stated LPN-E received education on reporting abuse.
On 10/3/2024, at 12:23 PM, Surveyor interviewed previous NHA- D who stated CNA-F was taken off the schedule on 7/10/2024 when NHA-D heard about the concern that occurred with R5 on 7/8/2024. Surveyor asked NHA-D if law enforcement was contacted. NHA-D stated law enforcement was not contacted because CNA-F stated CNA-F was fine. Surveyor asked if law enforcement was contacted for the concern of possible retaliation against R5. NHA-D stated when NHA-D went to talk with R5, R5 did not talk with NHA-D and CNA-F denied retaliation against R5 and CNA-F walked out of the room after R5 scratched CNA-F. NHA-D stated there was not a need for law enforcement. Surveyor asked NHA-D if education was provided to staff regarding reporting abuse. NHA-D stated education was given to LPN-E and Registered Nurse (RN)-G regarding reporting abuse. Surveyor asked NHA-D how other staff was educated about abuse prevention and reporting and how is NHA-D aware other staff know the policy/protocols for reporting abuse. NHA-D replied NHA-D often goes onto the units and talks with staff and DON-B does monthly education with staff but not sure what DON-B covers. Surveyor requested the last time staff was educated on reporting/preventing abuse and CNA-F punch card times for the weekend of 7/8/2024 - 7/10/2024.
Surveyor received CNA-F's punch cards and noted CNA-F was listed as working in the facility on:
7/8/2024: 2:29PM - 10:30 PM, 10:30 PM - 6:30 AM into 7/9/2024 (CNA-F worked a double shift)
7/10/2024: 2:37 PM - 10:32 PM
Surveyor noted CNA-F worked a full shift with residents on 7/10/2024 when NHA-D was aware of the allegation of possible retaliation against R5 and during the time the investigation was in progress.
Surveyor was unable to interview NHA-D further due to NHA-D's term being up at the facility and leaving.
On 10/3/2024, at 3:04 PM, Surveyor shared concerns with Assistant Director of Nursing (ADON)-M, Executive Director- C, and Nursing Home Administrator (NHA)-A regarding the Facility Reported Incident not being investigated thoroughly, CNA-F was allowed to continue to work with residents when an allegation was made for possible retaliation against R5, CNA-F was not following R5's care plan and assisted R5 with cares alone instead of 2 staff members, education was not provided to staff. No further information was provided at this time.
2) R111 was admitted to the facility on [DATE] and has diagnoses that include cerebral infarction, type 2 diabetes mellitus with chronic kidney disease, cognitive communication deficit, and mild cognitive impairment. R111's admission MDS (Minimum Data Set) assessment dated [DATE] indicates R111 has moderately impaired cognition with a BIMS (Brief Interview of Mental Status) score of 8. The facility assessed R111 to not have any behavior concerns.
Surveyor reviewed the facility self-report for R111. The summary of the report documents on 6/22/2024 approximately around 6:00 PM/dinner time. R111's wife and daughter were involved in a verbal altercation that escalated to a physical altercation in the main dining room with residents present. Facility staff intervened, law enforcement was contacted and did escort 1 family member out of the building.
Surveyor noted all staff with knowledge of the incident were not interviewed regarding the altercation between R111's family members.
On 10/3/2024, at 12:23 PM, Surveyor interviewed previous NHA-D who stated the facility obtained a staff statement regarded the whole incident, so NHA-D did not feel the need to talk to other staff members regarding the situation. Surveyor asked NHA-D how other staff were provided educating about abuse prevention and how NHA-D aware other staff know the policy/protocols for reporting abuse. NHA-D replied NHA-D often goes onto the units and talks with staff and DON-B does monthly education with staff but not sure what DON-B covers.
On 10/3/2024, at 3:04 PM, surveyor shared concerns with Assistant Director of Nursing (ADON)-M, Executive Director- C, and Nursing Home Administrator (NHA)-A regarding the facility reported incident not being investigated thoroughly, staff that observed or had knowledge of the altercation did not provide statements and education was not provided to staff to ensure they were aware of abuse reporting and need for a thorough investigation.
2.) R45 admitted to the facility on [DATE] to room [ROOM NUMBER] on the 3rd floor and has resided in the same room since admission.
On 10/1/24, at 9:38 AM, R45 advised Surveyor that on 6/17/24 he reported to the facility that he was held down and changed against his will. R45 reported he had a leg cramp, so he slid his leg out of bed, and the right leg went with it, so he was half on/half off the bed with his feet on the floor and his butt on the bed. R45 reported he put his call light on and when the nurse came in and saw his position, she left to get a Certified Nursing Assistant (CNA) to help. R45 reported they lifted his legs back in bed and the nurse said he needed to be changed. R45 reported he said no (adding he has an enlarged prostate and just dribbles urine) and he told her no because in a half hour he would let the next shift change him, as he was only damp and there was no need to be changed right now. R45 reported he explained all of this to the nurse, but she kept insisting he needed to be changed. R45 reported he could not recall the nurses name, except that she was from Nicaragua. R45 reported he kept saying no and the nurse told the aide to hold him down. R45 stated: I was lying flat, and the aide was pressing down on each of my shoulders, holding me down. So now I'm fighting with her, trying to get up because she's holding me down and I'm saying no so many times. In the meantime, the nurse is changing me while the aid was holding me down. R45 reported he told the nurse he wanted to talk to someone to report what happened. R45 reported the allegation of abuse to Previous NHA (Nursing Home Administrator)-D. R45 reported he has been using Oxycodone and Bengay for shoulder pain ever since and has been going to therapy. R45 reported the therapist thinks it is a torn rotator cuff and he has an ortho appointment on 10/4/24.
On 10/2/24, at 10:25 AM, Surveyor spoke with RN (Registered Nurse)-G who reported she is familiar with R45 but doesn't work with him very often. Surveyor asked RN-G to tell me about R45. RN-G stated: He once said he wants me to go back to Nigeria. He has a hard time understanding some of us sometimes and gets angry, he reports everything he gets mad about, like he don't want to be changed, even when his brief is wet, he says it's his right to not be changed. Surveyor asked if she has ever had an altercation or incident with R45. RN-G stated: No, but I heard about one time a few months ago, he was falling out of bed, and they repositioned him and changed him and he was mad because he didn't want to be changed. So now we don't change him if he don't want to. Surveyor asked RN-G if she knew what staff were involved with the alleged incident. RN-G stated: No, not really. I just heard about it, you know, with people talking.
On 10/2/24, at 3:42 PM, Surveyor spoke with OTA (Occupational Therapy Assistant)-R who reported she has been seeing R45 for right should pain since 8/20/24. Surveyor confirmed OT (Occupational Therapy) Plan of Care started care on 8/20/24. Surveyor asked if she had any knowledge regarding the origin of his shoulder pain. OTA-R stated: He told me he was pinned down while they were forcibly changing him and he was fighting back, that's how he injured his shoulder.
Surveyor review of R45's medical record revealed no documentation of pain or increased pain to his shoulder prior to 8/13/24 when progress notes documented: Reporting right shoulder pain with movement. NP (Nurse Practitioner) notified. Order for 2 view shoulder x-rays ordered.
On 8/14/24, a 2 view x-ray shoulder: The right shoulder is normal. There is no erosion or osteophyte formation. There is no dislocation. The mineralization is normal. There are no fractures. The clavicle is normal. Impression: Normal right shoulder.
On 8/28/24 NP note documents: Reports worsening pain within right shoulder and decreased movement right arm. Denies numbness or tingling. Reports thinks [sic] his rotator cuff is bad. No reported injuries or overuse, just worsening achy pain. Reportedly leans on shoulder quite a bit in bed, as it is his favorite position.
On 10/4/24 Ortho consult: Right RC (rotator cuff) tear. Very high risk, no surgical option. Offered CSI (corticosteroid injection). Aggressive therapy right shoulder.
Surveyor reviewed R45's facility abuse investigation. The manilla envelope included handwritten notes on each side by Previous Nursing Home Administrator (NHA)-D. The investigation documented: On 6/17/24, at approximately 11:17 AM, received an email from (Dir Quality Mgmt/IP) that (R45) wanted to speak with the Administrator. Arrived to room at approximately 11:25 AM. (R45) reported the other evening (believed that it was the prior Saturday) sometime before 10 PM (thought but was not sure) 2 CNA's proceed to change him without his permission. NHA asked Social Service Director to speak with (R45) as a second interview to see if the two interviews were consistent.
Surveyor noted the facility abuse investigation included only 5 staff statements, one of which was the Social Worker (who did not provide care).
Social Worker statement dated 6/17/24, at 4:03 PM: Stated he had an issue with a 3rd shift aid, female, short and big boned, could not recall name. On Saturday, June 15 early morning, he was in bed and caught a leg cramp and was half on the bed and half off the bed as a result. Stated he turned on call light, this female aide came and helped him back in bed but insisted on wanting to change him, stating he was wet. Resident told aid no I'm not wet and I don't need to be changed. Aid said, but I have to change you now. Aid left room and came back with another aid. Stated this aid was female, could not recall a description. Stated the aid and other aid held him down, where he was unable to move his shoulders and then they changed him anyway against his will. Stated he was calling them every bad name you could think of while they were changing him. He said to writer - this aid needs to go back to Nigeria, we don't need that import here.
Pool CNA interview/statement (not dated): During the weekend of 6/14, 15 and 16th did you provide any care to resident? Stated she did not remember taking care of (R45) on those dates. She had not worked the A cluster on those dates or for many months. At this point the interview ended, it was obvious that this CNA did not know (R45) nor had she provided any care to him on the dates in question.
RN-G interview/statement (not dated): During the weekend of 6/14, 15 and 16th did you provide any care to resident? Stated she did not provide any care to resident on these dates. Receive any complaint from resident on these dates? NO.
Surveyor noted RN-G was not on the schedule for 6/15/24.
Pool CNA interview/statement (not dated): During the weekend of 6/14, 15 and 16th did you provide any care to resident? Yes, on 6/15/24 worked the 3rd floor on noc (night) shift. Did not get to floor until about 11:15 PM. Shortly after, making rounds, went into residents' room. I recall that he was extremely wet, so I changed him and his bedding. While I was working with him, he mentioned that one of the other girls from the prior shift had come in several times to do a check and change. (R45) said she kept insisting that he need to be changed and he kept telling her no that he was not wet and that it could wait. He said that she is some girl from [NAME] and can't understand her half of the time. He said that eventually this aid came back with another aid and changed him without his permission. I asked if she reported this to anyone, she stated No, because he complains about everything.
Surveyor noted the CNA statement alleges the incident occurred on the previous shift, however the facility did not interview all staff on the previous shift.
Pool CNA interview/statement (not dated): During the weekend of 6/14, 15 and 16th did you provide any care to resident? Stated she did not remember taking care of resident on those dates. NHA concluded as it was very apparent that this CNA did not know (R45).
On 10/3/24, at 1:22 PM, Surveyor spoke with Scheduler-S and asked to explain the schedule and how units and resident rooms are assigned. Surveyor was advised the rooms are assigned as Clusters. Nurses for A/E rooms 50-57, B 60-68, C/D 70-87B
CNAs: A/E 50-57, C/E 70-78, 90, 92 and 94, B/E 60-68, 93 and 95, D/E 80-87 and 91.
Surveyor noted the schedule on 6/15/24 documented 8 staff assigned to the 3rd floor on first shift. The abuse investigation included only 1 staff statement from this shift and there were no statements from the staff specifically assigned to R45's room (cluster).
Surveyor noted the schedule on 6/15/24 documented 9 staff assigned to the 3rd floor on second shift. The abuse investigation included only 2 staff statements from this shift and there were no statements from staff specifically assigned to R45's room (cluster).
Surveyor noted the schedule on 6/15/24 documented 6 staff assigned to the 3rd floor on third shift. The abuse investigation included only 1 staff statement from this shift. The CNA assigned to R45's room provided a statement that indicated R45 reported the incident occurred the previous shift. Surveyor notes this was not reported, and no staff were interviewed.
On 10/3/24, at 10:31 AM Surveyor spoke with Dir Quality Mgmt/IP-I about R45's allegation of abuse. Dir Quality Mgmt/IP reported R45 said that he had something serious to report to someone above him. He did not ask details because he didn't want R45 to have to explain it twice and because he said it was serious, he wanted the NHA to hear it first-hand. Dir Quality Mgmt/IP reported he immediately told the Previous NHA-D that R45 had something serious to report.
On 10/3/24, at 11:06 AM, Surveyor spoke with Previous NHA-D, NHA-A and Executive Director-C regarding R45's abuse allegation. Previous NHA-D stated: Let me start by saying (R45) does complain and it often has nothing to do with cares or anything, he's just prejudiced against color. He wasn't able to provide a name and we weren't able to determine which staff he was referring to in the allegation. Surveyor asked when he was notified of the allegation of abuse. Previous NHA-D reported the Social Worker was doing rounds and R45 told him about it, he immediately reported it to (Previous NHA-D) and he went to R45's room to interview him. Surveyor asked what the Social Worker reported. Previous NHA-D stated: That (R45) said he was held down and changed against his will. Surveyor advised Previous NHA-D that the investigation documents that he was advised by Dir Quality Mgmt/IP-I. Previous NHA-D stated: OK, then maybe it was (him), whoever I wrote down is the person that told me. Previous NHA-D stated: (R45)'s story changed so many times regarding the date and shift that it happened, between 2nd and 3rd shift - he kept saying something different. I reviewed the schedule for those aides assigned to him and interviewed them. They said they were in there 4-5 times to do cares, but he refused. Surveyor advised this information was not on the CNA's statements. Previous NHA-D stated: Maybe I forgot to write it down.
Surveyor advised Previous NHA-D there are only 4 interviews of staff assigned to the 3rd floor that had potential to provide care to R45, and that 1 staff interview documented R45 reported the incident occurred on the previous shift, but she did not report it. Surveyor asked why there were only 4 staff interviewed regarding R45's allegation of abuse. Previous NHA-D stated: Because I determined those were the staff that were assigned to (R45). Surveyor advised they were not the only staff assigned to the 3rd floor. Previous NHA stated: No, but I determined they were the only ones assigned to (R45). Surveyor asked if it is the expectation if call lights are on, or residents need help - would all staff to tend to all residents. Previous NHA-D stated: Of course. Surveyor advised Previous NHA-D of the fact that all staff working the floor have potential to have contact with, or provide cares, is there a reason statements were not obtained of all staff working. Previous NHA-D stated: I didn't think it was necessary adding Well, I'm not sure that abuse even happened. If you're held down by your shoulders, you would have some evidence of it, some marks or something. That was part of my investigation, I asked the DON (Director of Nursing) to do a full body assessment, and nothing was found. Surveyor advised Previous NHA-D the alleged assessment is not included in the investigation. Previous NHA-D stated: Maybe she forgot to write it down. Surveyor asked if camera footage was reviewed as part of the investigation. Previous NHA-D stated: No, I don't see how that would be relevant to the investigation.
Surveyor confirmed with Previous NHA-D he only interviewed selective staff he thought were assigned and provided care to R45. Previous NHA-D stated: Yes, it wasn't necessary to get statements from everyone if they weren't assigned to him. Surveyor asked if the facility provided staff training and education on abuse and reporting related to R45's allegation of abuse. Previous NHA-D stated: Not specifically, but we're doing training all the time on abuse, staff is very aware of abuse and reporting requirements. We try to do training every month when we have a staff meeting. Surveyor asked if it is the expectation the CNA that R45 told about being changed without permission should have been reported. Previous NHA-D stated: Not really, staff says he complains about everything, and he is prejudiced against people of color.
Surveyor advised Previous NHA-D of concern the facility did not complete a thorough investigation of R45's allegation of abuse. Staff working on the date alleged, who may have knowledge of the incident, were not interviewed. In addition abuse education and training was not completed with all staff. Previous NHA-D stated: I don't agree with you. I obtained statements from all staff that worked with (R45) on that date, and we do education on a monthly basis; staff are very well informed of abuse and reporting. Surveyor advised there were only 4 staff statements obtained, 1 of which was not on the schedule and 1 of which R45 reported that the abuse occurred on the previous shift (which was not reported) and no additional staff statements were obtained. Previous NHA-D stated: Again, the staff statements I obtained were the only staff that were assigned to (R45).Surveyor asked how the facility knows that no other staff provided care or have knowledge of the incident if all staff were not interviewed. Previous NHA-D stated: Well, you don't know this resident, we know him well - I sincerely doubt anything happened at all. If it happened the way he alleged, there would be some evidence, redness, bruising, something - there was nothing. Surveyor advised Previous NHA-D there is no evidence an assessment was completed to support this statement and R45 has reported right shoulder pain, has limited range of motion, is receiving therapy and has an ortho appointment for a suspected rotator cuff tear. Previous NHA-D stated: I'd be very surprised if there was any validation to that.
On 10/7/24, at 10:49 AM, Surveyor advised NHA-A of concern R45's allegation of abuse was not thoroughly investigated. NHA-A reported she was present when Surveyor was interviewing Previous NHA-D and understands the concern. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not complete a Preadmission Screening and Resident Review (PASARR) for individuals with a mental disorder for 2 (R4 and R52) of 2 residents reviewed for PASARR screening.
*R4 was admitted [DATE] and the Level I PASARR was completed indicating R4 would be in the skilled nursing facility for less than 30 days. R4 discharged from the facility 2/21/2024. A Level I PASARR was not resubmitted/updated indicating R4 was going to be at the facility longer than the 30 exemption period triggering a Level II PASARR to be completed. R4 was admitted again to the facility on 4/4/2024 and a Level I PASARR was not completed.
*R52 was admitted [DATE] to the facility and the PASARR Level I was not completed accurately to reflect R52's mental illness or psychotropic medications and a Level II PASARR was not completed.
Findings include:
The facility policy and procedure entitled PASARR (Pre admission Screening & Resident Review) dated 1/2023 documents: PROCEDURE: A. Complete Level I screen of the PASAAR [sic] on new admissions. 1. Readmits do not require a PASAAR [sic] to be completed. 3. Those residents whose attending physician has certified, before admission to the community that the individual is likely to require less than 30 days of nursing facility services, do not require a PASAAR [sic] to be completed. B. The resident or resident representative will receive a written notice (copy of Level I screen) if the resident is suspected of having a serious mental illness or a developmental disability, and therefore will require a Level II Screen. C. Update the resident representative that the Level II Screen will determine if the resident does have a serious mental illness or developmental disability, as defined by federal regulation, and if so, if the resident is appropriate for risking community placement and if the resident needs specialized services or specialized psychiatric rehabilitative services to address his/her disability needs. F. A copy of the PASARR screens will be kept in the resident's medical records.
1.) R4 was admitted to the facility on [DATE] with a diagnosis of depression and was receiving the antidepressant medication Duloxetine. The PASARR Level I screen was completed on 12/29/2023 documenting R4 had a hospital discharge exemption of not requiring to be at the facility for greater than 30 days.
R4 was sent to the hospital on 1/28/2024 and returned to the facility on 1/31/2024 as a readmission and a continuation of the initial stay. A PASARR Level I screen was not submitted at that time, after the initial 30 days from admission had lapsed. R4 discharged from the facility on 2/21/2024.
On 4/4/2024, R4 was admitted to the facility from the community. R4 had diagnoses of depression and anxiety. R4 was receiving Buspirone for anxiety and Duloxetine and Trazodone for depression. A PASARR Level I was not found in R4's medical record for the new admission.
On 10/2/2024, at 3:00 PM, Surveyor requested from Previous Nursing Home Administrator (NHA)-D, Director of Nursing (DON)-B and interim Assistant DON (ADON)-M copies of R4's PASARR Level I and Level II screenings.
On 10/3/2024, at 9:03 AM, the facility provided a copy of R4's PASARR Level I screen from 12/29/2023 with the 30-day exemption and no other PASARR screens were provided.
On 10/3/2024, at 3:02 PM, during the daily exit, Surveyor clarified with Executive Director (ED)-C, interim ADON-M, and NHA-A that R4 did not have any other PASARR screens in the medical record besides the Level I screen that was completed 12/29/2023. ED-C stated that one screen was the only PASARR they found in R4's record. Surveyor shared the concern with ED-C, interim ADON-M and NHA-A R4 was admitted [DATE] with a PASARR having a 30-day exemption and R4 stayed longer than those 30 days and a revised Level I was not completed and submitted for a level 2 screening as well as no PASARR was completed on admission 4/4/2024 with diagnoses of depression and anxiety with psychotropic medications prescribed.
In a phone interview on 10/7/2024, at 11:11 AM, Surveyor asked admission Director (AD)-K what the facility process was for completing the PASARR Level I for new admissions. AD-K stated the PASARR screening was completed by AD-K until 1/2024 when Admissions-L took over completing the PASARR Level I screenings. AD-K stated AD-K would review the referral sent by the hospital and look for a psych diagnosis as well as medications and if there was a diagnosis and a psychotropic medication, then it was a positive PASARR Level I and it would be submitted for a Level II to be completed. AD-K stated if there was a diagnosis and no psychotropic medication or a psychotropic medication and no diagnosis, then it was a negative PASARR Level I and a Level II would not have to be done. AD-K stated if the resident was not expected to be in the facility for 30 days, then a Level II would not have to be completed, either. Surveyor asked AD-K if a resident had a 30-day exemption on the Level I screen but then stayed longer, who would be responsible to complete a revised PASARR Level I screen. AD-K stated the social worker would take over the responsibility of ensuring that was completed. Surveyor shared with AD-K the concern R4 had a 30-day exemption on the initial admission on [DATE] and was not discharged until 2/21/2024 with no follow up PASARR Level I screen. AD-K stated the social worker at that time should have completed a new PASARR Level I screen. Surveyor noted that social worker was no longer employed at the facility and unavailable for interview. Surveyor shared with AD-K the concern R4 was admitted on [DATE] and no Level I screen was completed or found in R4's medical record. AD-K stated Admissions-L should have that information.
In an interview on 10/7/2024, at 11:21 AM, Surveyor asked Admissions-L who completed the Level I PASARR screens for new admissions. Admissions-L stated Admissions-L completes the Level I screens. Surveyor asked Admissions-L if R4 had a Level I screen completed on admission 4/4/2024. Admissions-L reviewed the file in the computer where Admissions-L keeps admission records. Admissions-L showed Surveyor the file of names that Admissions-L had gathered admission information for such as immunization history and a copy of admission documents that had been signed on admission. Admissions-L stated R4 was not even on the list that Admissions-L had looked in to for any admission information including the Level I PASARR. Admissions-L stated Admissions-L had been on vacation at the time R4 was admitted and it appeared to Admissions-L that no one had entered any admission information into R4's medical record. Surveyor shared with Admissions-L that R4 was admitted from the Assisted Living side and not from the hospital. Admissions-L stated that may have added to the lack of admission information that had been gathered, but all of that information should have been gotten at that time including a PASARR Level I screen. Admissions-L stated Admissions-L would complete the PASARR Level I screen now and submit it as required. No further information was provided at that time.
2) R52 admitted to the facility on [DATE] and has diagnoses that include Schizophrenia and Dementia.
R52 currently receives Risperdal 0.5 mg (milligrams) by mouth twice daily for Schizophrenia, Lorazepam 0.5 mg three times daily for anxiety/agitation and Buspar 5 mg three times daily for anxiety.
R52's Hospital Discharge summary dated [DATE] includes diagnoses of Schizophrenia and Dementia.
Review of R52's medical record revealed a Pasarr level 1 screen completed 10/11/23. Surveyor noted a check mark next to The resident is not suspected of having a serious mental illness or a developmental disability. Signature of staff member completing this screen: admission Director-K.
On 10/3/24, at 9:21 AM, Surveyor spoke with admission Director-K. Surveyor reviewed the Pasarr level 1, noting R52 is checked for not suspected of having a serious mental illness or a developmental disability. Surveyor advised admission Director-K that R52 has a diagnosis of Schizophrenia and asked why a Pasarr level 2 was not completed. admission Director-K stated: I must've made a mistake and checked that in error. Surveyor confirmed because that box was checked, a Pasarr level 2 was not completed. admission Director-K stated: Yes, I made a mistake, she should have had a level 2 completed.
On 10/3/24, at 3:00 PM, the facility was advised of the above concern. No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure residents had an individualized comprehensive pla...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure residents had an individualized comprehensive plan of care. This was observed with 3 (R48, R55, and R57) of 17 resident comprehensive care plan reviews.
* R48 did not have a comprehensive care plan for R48's oxygen/respiratory monitoring/needs.
* R55 did not have a comprehensive care plan for bowel monitoring.
* R57 did not have a comprehensive care plan for bowel or bladder incontinence.
Findings include:
The facility policy entitled, Care Planning- Interdisciplinary Team, last approved on 1/2024 documents: Our community's Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.
Policy Interpretation and Implementation
A. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident comprehensive assessment (MDS).
B. The care plan is based on the resident's comprehensive assessment and is developed by the Interdisciplinary team
1.) R48 was readmitted on [DATE] and has a diagnoses that includes malignant pleural effusion, and atrial fibrillation.
R48's significant change minimum data set (MDS) dated [DATE] indicated R48 had intact cognition with a brief interview for mental status (BIMS) score of 15.
R48's significant change MDS assessment dated [DATE] documented R48 was on continuous oxygen.
Surveyor noted there was not a care plan initiated for respiratory/ oxygen needs.
On 10/2/2024 at 3:15 PM, Surveyor interviewed director of nursing (DON)-B who stated a care plan should have been initiated if R48 was prescribed oxygen. Surveyor asked who usually initiated the care plans. DON-B stated the IDT team does and/or nursing when it is needed.
On 10/3/2024 at 3:04 PM, Surveyor shared concern with assistant DON (ADON)-M, executive director- C, and nursing home administrator (NHA)-A that R48 did not have a care plan for R48's oxygen/respiratory needs.
On 10/7/2024 at approximately 3:05 PM, Surveyor interviewed MDS coordinator-J who stated not sure why R48 would not have a care plan for R48's oxygen/respiratory needs, it must have been overlooked. MDS coordinator-J stated information is obtained from the residents' charts and asking questions to staff if needed. Surveyor shared concern that a respiratory/oxygen care plan was not initiated for R48.
Crossreference with F695 regarding respiratory/ oxygen monitoring for R48.
No additional information was provided.
2.) R55 was admitted to the facility on [DATE] with a diagnoses that includes chronic pain, unspecified abdominal pain, cognitive communication deficit, major depressive disorder, alcoholic cirrhosis of the liver, and history of infectious and parasitic disease.
R55's quarterly MDS (Minimum Data Set) dated 7/3/2024 indicated R55 had intact cognition with a BIMS score of 15 and the facility assessed R55 needing supervision assistance with toileting and personal hygiene and was assessed always continent of bowel.
On 10/1/2024, at 11:59 AM Surveyor observed R55 in the hallway self- propelling in a wheelchair. Surveyor asked how R55 was doing. R55 stated R55 was having issues with R55's bowels. R55 stated that the doctor was working with R55 to determine why R55 was having abdominal pain and issues with constipation/ diarrhea. R55 stated it has been going on for many years.
Surveyor reviewed R55's care plan and noted that there was not a bowel monitoring care plan for R55. Surveyor also noted that R55 was receiving several medications for R55's bowel.
Crossreference with F684 for bowel monitoring for R55.
On 10/2/2024 at 3:15 PM, Surveyor interviewed director of nursing (DON)-B who stated a care plan should have been initiated for R55 due to the concerns with R55's bowels. Surveyor asked who usually initiated the care plans. DON-B stated the IDT team does and/or nursing when it is needed.
On 10/3/2024 at 3:04 PM, Surveyor shared concern with assistant DON (ADON)-M, executive director- C, and nursing home administrator (NHA)-A that R55 did not have a care plan for R55's bowel management/concerns.
On 10/7/2024 at approximately 3:05 PM, Surveyor interviewed MDS coordinator-J who stated not sure why R55 would not have a care plan for R55's bowel management/concerns, it must have been overlooked. MDS coordinator-J stated information is obtained from the residents' charts and asking questions to staff if needed.
No additional information was provided.
3.) R57 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, congestive heart failure, diabetes, morbid obesity, and anemia. R57's admission Minimum Data Set (MDS) assessment dated [DATE] documented R57 was frequently incontinent of bladder and continent of bowel. The MDS documented a trial of a toileting program had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. The Urinary Care Area Assessment (CAA) documented R57's Urinary Incontinence CAA triggered secondary to the level of assistance needed with toileting needs and actual incontinent episodes. Contributing factors included weakness, impaired mobility, and cognitive loss. Risk factors included skin breakdown, falls, and urinary tract infection. The CAA documented the care plan would be initiated/reviewed to improve/maintain current toileting skills and ability to transfer to the toilet, continence status, decrease fall and pressure ulcer risk, and decrease risk for urinary tract infections.
No bowel or bladder care plan was initiated at that time.
R57's Significant Change MDS assessment dated [DATE] documented R57 was occasionally incontinent of bladder and always incontinent of bowel. The MDS documented a trial of a toileting program had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. The Urinary CAA documented R57's Urinary Incontinence CAA triggered secondary to always incontinent of bowel and bladder and dependence of staff for incontinent care. Contributing factors included weakness, impaired mobility, and cognitive loss. Risk factors included skin breakdown, falls, and urinary tract infections. The CAA documented the care plan would be continued to manage incontinence, reduce pressure injury and fall risk, and reduce the risk for urinary tract infections.
No bowel or bladder care plan was initiated at that time.
On 10/1/2024 at 10:35 AM, Surveyor met with R57. R57 stated staff on third shift used to come and change the incontinent brief at midnight, 2:00 AM, and 4:00 AM on a schedule, which R57 liked. R57 stated now the staff wait until R57 puts on the light to have them come and change R57's brief.
On 10/3/2024 at 3:25 PM, Surveyor shared with interim Assistant Director of Nursing (ADON)-M the concern R57 was incontinent of bowel and bladder and R57 did not have a care plan to manage toileting. Interim ADON-M stated interim ADON-M would look into the concern.
In an interview on 10/7/2024 at 9:07 AM, Certified Nursing Assistant (CNA)-N stated R57 does not have anything written down as to when R57 needs to have incontinence care completed. CNA-N stated R57 is a 2-person transfer and with working with other CNAs, CNA-N knows they do incontinence care before they get R57 up out of bed and after R57 is laid down. CNA-N reiterated nothing was written down in a care plan or care card that says how often cares need to be completed.
In an interview on 10/7/2024 at 10:26 AM, Surveyor asked MDS Coordinator-J who puts in a care plan for bowel and bladder. MDS Coordinator-J stated the MDS nurses creates the care plan after the MDS cycle is complete. Surveyor shared with MDS Coordinator-J the concern R57 is incontinent of bowel and bladder and no care plan is in place for incontinence care. MDS Coordinator-J stated R57 was in and out of the hospital multiple times so maybe that is why nothing was done after the MDS assessment.
Interim ADON-M did not provide any additional information after the discussion with Surveyor on 10/3/2024.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**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 profe...
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**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 1 (R55) of 2 residents reviewed.
* R55 had concerns with feelings of abdominal pain and bloating and is on several bowel medications for management of constipation and diarrhea. The facility was not assessing or monitoring or assessing R55's bowel regimen.
Findings include:
The facility policy entitled Restorative Nursing- Toileting Program last approved 5.2023 documents: . Procedure: . B. Resident continence is assessed on admission, with significant change, and quarterly:
1. Check resident approximately hourly and document in the resident's medical record as continent, incontinent or soiled and level of assistance.
3. After 3 days analyze data:
a. Complete the bowel and bladder evaluation in the resident medical record, to determine type of incontinence and most appropriate program.
b. Determine patterns in frequency, volume, duration, and time of day.
c. If resident is generally correct regarding wet/dry status, consider scheduled or prompted toileting.
1.) R55 was admitted to the facility on [DATE] and has diagnoses that include chronic pain, unspecified abdominal pain, cognitive communication deficit, major depressive disorder, alcoholic cirrhosis of the liver, and history of infectious and parasitic disease.
R55's quarterly MDS (minimum data set) dated 7/3/2024 indicated R55 had intact cognition with a BIMS score of 15 and the facility assessed R55 needing supervision assistance with toileting and personal hygiene and was assessed always continent of bowel.
On 10/1/2024 at 11:59 AM, Surveyor observed R55 in the hallway self- propelling in a wheelchair. Surveyor asked how R55 was doing. R55 stated R55 was having issues with R55's bowels. R55 stated that the doctor was working with R55 to determine why R55 was having abdominal pain and issues with constipation/ diarrhea. R55 stated it has been going on for many years. Surveyor asked R55 if R55 was able to use the bathroom themselves or needed assistance. R55 replied that R55 wears protection if R55 can not make it in time to use the bathroom. R55 replied R55 can tell at times when R55 needs to use the bathroom.
Surveyor reviewed R55's medical record and noted R55 is ordered the following scheduled medications for bowel:
- MiraLAX powder 17 grams- one scoops in 8oz water daily for bowels- 17grams per dose for constipation.
- Senna plus 8.6mg -50mg tablet- take 2 tablets PO (by mouth) every morning for constipation.
- Simethicone 80mg chewable tablet by mouth three times a day after each meal for GI (gastrointestinal)
- Linzess 145 mcg capsule- 1 capsule by mouth every day for gastropathy colonic polyp, evening shift.
R55 was ordered the following as needed medications for R55's bowel:
- Dulcolax 10mg rectal suppository every day as needed for constipation.
- Lactulose 20grams/30 ml oral solution every 12 hours as needed for constipation. (Surveyor noted R55 last requested on 9/2/2024, 9/4/2024, and 9/9/2024.
Surveyor reviewed R55's medication/treatment administration records (MAR/TARs) for September and October 2024 and noted there is not indication that staff is monitoring R55's bowel and if R55 is going every day or if scheduled and as needed medications were effective or not.
Surveyor reviewed R55's care plan and noted R55 did not have a care plan for bowel monitoring. Cross reference F656.
Surveyor reviewed R55's ADL care plan initiated on 2/7/2024 and indicated:
Toileting- I (R55) am incontinent of bladder and incontinent of bowel. I use pullups.
Surveyor reviewed R55's certified nursing assistant (CNA) worksheet and noted the following information for R55's toileting needs:
- Limited assist with 1 person staff support.
- Continent of bladder and continent of bowel. Use pullups.
On 10/7/2024 at 9:03 AM, Surveyor interviewed registered nurse (RN)-G who stated R55 uses the bathroom by himself, and staff ask R55 if R55 has had a bowel movement that day. Surveyor asked if staff document the information anywhere. RN-G stated RN-G has a sheet that gets checked off. Surveyor asked RN-G if the assessments get documented in R55 medical record anywhere. RN-G stated it does but could not remember where at the moment. Surveyor asked where RN-G would look to see when R55 last had a bowel movement.
RN-G stated RN-G would ask R55 or look in the assessment in which RN-G was unable to locate at the moment. Surveyor asked RN-G if R55 had concerns or issues with his bowels. RN-G stated that R55 is fixated on R55's bowels and states concern all the time and talks with psych about it. RN- G also stated that R55 has had a lot of workups on R55's bowels and no concerns are noted at this time.
On 10/7/202, at 9:15 AM, Surveyor shared concerns with executive director- C and Nursing Home Administrator (NHA)-A that R55 bowel regimen is not being monitored consistently with receiving several medications for R55's bowels and complaints of abdominal discomfort and bloating. Surveyor also shared that R55's ADL care plan does not match R55's CNA worksheet to determine if R55 is continent in bowel or incontinent in bowel.
No additional information was provided as to why the facility did not ensure that R55 received treatment and care in accordance with professional standards of practice for his bowl and abdominal concerns.
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 interview and record review, the facility did not ensure residents with urinary incontinence were comprehensively asses...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents with urinary incontinence were comprehensively assessed to receive appropriate treatment and services to prevent complications and restore continence to the extent possible for 1 (R57) of 2 residents reviewed for incontinence.
*R57's admission, quarterly, and significant change Minimum Data Set (MDS) assessments documented R57 was incontinent of bowel and bladder. No comprehensive bowel or bladder assessments were completed to determine a toileting program to decrease incontinence and no care plan was initiated to provide incontinence care on a scheduled basis.
Findings include:
The facility policy and procedure entitled Clinical Protocol: Urinary Continence and Incontinence - Assessment and Management dated 1/2024 documents: Policy Interpretation and Implementation:
A. As part of the initial and ongoing assessments, the nursing staff and physician will screen for information related to urinary continence.
C. 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 the Minimum Data Set (MDS) .
D. As part of its assessment, nursing staff will seek and document details related to continence. Relevant details include: 1. Voiding patterns (frequency, volume, nighttime or daytime, quality of stream, etc.); 2. Associated pain or discomfort (dysuria); and 3. Types of incontinence: a. Stress . b. Urge . c. Mixed . d. Overflow . e. Transient . f. Functional .
E. The nursing staff and physician will identify risk factors for becoming incontinent or for worsening of current incontinence .
F. The evaluation will include a review for medications that might affect continence .
G. The staff and physician will summarize an individual's continence status. For residents deemed incontinent, this includes categorizing incontinence as urge, stress, overflow, mixed, or functional; and relevant causes, risk factors, and complications.
H. The staff and physician will identify individuals with complications of existing incontinence, or who are at risk for such complications (e.g., skin maceration or breakdown, or perineal dermatitis).
I. The physician will consider a more detailed assessment if new incontinence is identified or risk factors and reversible causes have not yet been sought or identified. The review should focus especially on possibly treatable causes such as medication side effects, severe constipation, or urinary tract infections (distinguished from asymptomatic bacteriuria).
P. The physician and staff will address treatable causes or contributing factors related to urinary incontinence, including: 1. Tapering, stopping, or changing medications that may be causing or exacerbating incontinence; 2. Managing pain and/or providing adaptive equipment to help mobilize individuals suffering from arthritis, contractures, neurological impairments, etc.; 3. Incorporating environmental interventions and assistive devices (e.g., grab bars, raised toilet seats, bedside commodes, urinals, bed rails, restraints, and/or walkers) to facilitate toileting; 4. Treating underlying conditions that may impair continence (e.g., delirium causing urinary incontinence related to acute confusion); and 5. Implementing a fluid and/or bowel management program to meet assessed needs.
R. As indicated, and if the individual remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. 1. As appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence. 2. If the individual requires assistance from more than one person to transfer to the toilet, Staff will address his or her mobility problems before attempting a toileting assistance trial. 3. Incontinence care should be individualized at night in order to maintain comfort and skin integrity, and minimize sleep disruption.
S. The staff will document the results of the toileting trial in the resident's medical record. 1. If the resident responds well, the toileting program will be continued. 2. If the resident does not respond and does not try to toilet, or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. 3. A check and change strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin.
1.) R57 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, congestive heart failure, diabetes, morbid obesity, and anemia.
R57's admission Minimum Data Set (MDS) assessment dated [DATE] documented R57 was frequently incontinent of bladder and continent of bowel. The MDS documented a trial of a toileting program had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. R57 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. R57 did not have any pressure injuries on admission. The Urinary Care Area Assessment (CAA) documented R57's Urinary Incontinence CAA was triggered secondary to the level of assistance needed with toileting needs and actual incontinent episodes. Contributing factors included weakness, impaired mobility, and cognitive loss. Risk factors included skin breakdown, falls, and urinary tract infection. The CAA documented the care plan would be initiated/reviewed to improve/maintain current toileting skills and ability to transfer to the toilet, continence status, decrease fall and pressure ulcer risk, and decrease risk for urinary tract infections. No bowel or bladder care plan was initiated at that time.
R57's current Activities of Daily Living (ADL) Care Plan has the following toileting interventions:
- R57 needs extensive assistance with 2 person staff support; R57 uses a Hoyer lift.
- R57 does not use any bowel/bladder appliances.
- R57 is incontinent of bladder and bowel; R57 uses briefs.
Surveyor noted R57 did not have a schedule for the frequency of incontinence care.
On 6/29/2024, R57 was admitted to the hospital and readmitted to the facility on [DATE] with a Stage 3 pressure injury to the coccyx.
No incontinence care revisions were made to R57's care plan and no assessment of voiding pattern was completed or development of a toileting schedule.
R57's Quarterly MDS assessment dated [DATE] documented R57 was always incontinent of bladder and continent of bowel. The MDS documented a trial of a toileting program had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. R57 was cognitively intact with a BIMS score of 15. Surveyor noted R57 had increased urinary incontinence compared to the admission MDS on 5/28/2024 and no revision was made to R57's ADL Care Plan to address the increased incontinence of the bladder. No bowel or bladder care plan was initiated at that time.
R57's Significant Change MDS assessment dated [DATE] documented R57 was occasionally incontinent of bladder and always incontinent of bowel. The MDS documented a trial of a toileting program had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. R57 was cognitively intact with a BIMS score of 15. The Urinary CAA documented R57's Urinary Incontinence CAA triggered secondary to always incontinent of bowel and bladder and dependence of staff for incontinent care. Contributing factors included weakness, impaired mobility, and cognitive loss. Risk factors included skin breakdown, falls, and urinary tract infections. The CAA documented the care plan would be continued to manage incontinence, reduce pressure injury and fall risk, and reduce the risk for urinary tract infections. Surveyor noted R57 was now incontinent of bowel which R57 had not been on the Quarterly MDS assessment on 7/14/2024 and no revision was made to R57's ADL Care Plan to address the incontinence of the bowel. No bowel or bladder care plan was initiated at that time.
On 9/6/2024, R57 was admitted to the hospital and readmitted to the facility on [DATE]. R57's Stage 3 pressure injury had healed while in the hospital.
R57 had a history of excoriation to the coccyx due to incontinence while in the facility. R57 had no skin breakdown at the time of the survey.
R57's Quarterly MDS assessment dated [DATE] documented R57 was always incontinent of bladder and always incontinent of bowel. The MDS documented a trial of a toileting program had not been attempted on admission/reentry or since urinary incontinence was noted in the facility. R57 was cognitively intact with a BIMS score of 15. Surveyor noted R57 had increased urinary incontinence compared to the Significant Change MDS on 8/21/2024 and no revision was made to R57's ADL Care Plan to address the increased incontinence of the bladder. No bowel or bladder care plan was initiated at that time.
On 10/1/2024 at 10:35 AM, Surveyor met with R57. R57 stated staff on third shift used to come and change the incontinent brief at midnight, 2:00 AM, and 4:00 AM on a schedule, which R57 liked. R57 stated now the staff wait until R57 puts on the light to have them come and change R57's brief.
On 10/3/2024 at 3:25 PM, Surveyor shared with interim Assistant Director of Nursing (ADON)-M the concern R57 was incontinent of bowel and bladder, Surveyor was unable to find a comprehensive incontinence assessment such as a bowel and bladder diary, and R57 did not have a care plan to manage toileting. Interim ADON-M had started working at the facility the previous week so was not sure what the process was for developing a toileting schedule and stated interim ADON-M would look into the concern.
Surveyor reviewed R57's CNA Worksheet for 10/3/2024. The information regarding toileting was the same as on the ADL Care Plan.
On 10/7/2024 at 9:07 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-N whom stated R57 was incontinent of both bowel and bladder and the CNAs usually check and change R57 every two hours but knows R57 does not get up out of bed until after breakfast. R57 had been observed to be lying in bed at that time. CNA-N stated R57 is checked and changed at the beginning of the shift, before R57 gets out of bed after breakfast, and then in the afternoon after lunch when R57 is put back to bed. CNA-N stated R57 does not have anything written down as to when R57 needs to have incontinence care completed. CNA-N stated R57 is a 2-person transfer and with working with other CNAs, CNA-N knows they do incontinence care before they get R57 up out of bed and after R57 is laid down. CNA-N reiterated nothing was written down in a care plan or care card that says how often cares need to be completed.
On 10/7/2024 at 10:26 AM, Surveyor asked MDS Coordinator-J how a resident's incontinence status was determined. MDS Coordinator-J stated a bowel and bladder assessment is completed within three days of admission on every shift. Surveyor asked MDS Coordinator-J where that information was documented. MDS Coordinator-J stated the CNAs may have a form but was not sure. Surveyor asked MDS Coordinator-J where the data comes from to complete Section H (Bladder and Bowel) of the MDS. MDS Coordinator-J stated MDS Coordinator-J looks at the CNA charting or will go to the unit and ask staff if there is no documentation by the CNAs on continence status. Surveyor asked MDS Coordinator-J who puts in a care plan for bowel and bladder. MDS Coordinator-J stated the MDS nurses creates the care plan after the MDS cycle is complete. Surveyor shared with MDS Coordinator-J the concerns R57 is incontinent of bowel and bladder and no care plan is in place for incontinence care, no comprehensive bowel or bladder assessment was documented, R57's incontinence status per the MDS assessments have shown a decline in continence, and R57 has a history of skin breakdown attributed to incontinence with no interventions to address the frequency of incontinence care. MDS Coordinator-J stated R57 was in and out of the hospital multiple times so maybe that is why nothing was done after the MDS assessment. Surveyor asked MDS Coordinator-J if R57 had a trial toileting program at any time. MDS Coordinator-J was not sure and would let Surveyor know.
Interim ADON-M did not provide any further information after the discussion with Surveyor on 10/3/2024. MDS Coordinator-J did not provide any further information after the discussion with Surveyor on 10/7/2024.
No additional information was provided.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that residents maintained acceptable parameters of nutritional ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight for 1 of 2 (R40) residents reviewed for weight loss.
* R40 sustained weight loss which was not identified by the facility and the Dietician was not notified.
Findings Include:
The facility policy, entitled Weight Monitoring dated revised 1/2023 documents (in part) .
. It is the policy of (facility) that appropriate nutritional care shall be provided to residents who have a significant weight change. A significant weight change is identified as a weight loss or gain of 5% in 30 days, 7.5% in 90 days or 10% in 180 days.
Policy interpretation and implementation states:
A report should be generated from the electronic medical record (EMR) system to identify all residents with a significant weight change in 30 days, 90 days, and/or 180 days.
At the weekly Resident at Risk Review huddle, the IDT (Interdisciplinary Team) should discuss residents who trigger for a significant weight loss and who lose more than 5 lbs (pounds) since the last weight.
The RD (Registered Dietician) should make recommendations for nutritional interventions based on the information obtained from the weekly Resident at Risk Review huddle meetings. RD recommendations should be reviewed and initiated by nursing associates.
A nursing or nutrition associate should notify the health care provider of any significant weight change that is unexplainable or in which the RD has requested a nutritional evaluation.
The facility policy entitled Dialysis dated revised 12/2019, documents (in part) .
.It is the policy of this community to provide coordination of care with the resident's dialysis provider.
Policy interpretation and implementation states:
The community will coordinate care with the dialysis provider in developing an appropriate plan of care to include but not limited to, fluid restriction and weights as ordered by MD (Medical Doctor)/NP (Nurse Practitioner) and a communication tool is utilized to receive a report on the resident to the community after each dialysis session. A verbal report is accepted, and the licensed nurse will document this in the resident's medical record.
1.) R40 was admitted to the facility on [DATE] with a diagnosis of encephalopathy, end stage renal disease, heart and kidney failure, dependence on renal dialysis, type 2 diabetes and kidney disease.
R40's Quarterly MDS (Minimum Data Set) dated 9/11/24, indicated a BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment. Section K documented no to both questions if R40 had a loss or gain of 5% in last month or 10% in last 6 months.
R40's Care Plan dated 9/11/24, documents: Will have nutritional needs met and will not have an unplanned significant weight change over the next review period. Interventions include, offered diet as prescribed, monitor weight on dialysis days (Tuesday, Thursday, Saturday). Monitor for signs and symptoms of hypo/hyperglycemia, encourage healthy snacks and DO NOT GIVE POTATO CHIPS, provide Mrs. Dash with meals, encourage only one healthy snack per day, provide education on healthy eating habits, fluid breakdown: 10 oz (ounces) breakfast, 10 oz lunch, 10 oz dinner, and 4 oz at each medication pass.
R40's Physician Orders document: Weight to be completed on dialysis days - ordered 8/11/24. Communication form to take and complete before dialysis, and return and complete from dialysis - ordered 8/22/24.
Surveyor review of R40's weights in the EHR (electronic medical record) document weights in pounds documented:
5/23/24 = 319.6
5/25/24 = 300 Surveyor noted a weight loss of 19.6 lbs/6.13%.
6/1/24 = 258.3 Surveyor noted a weight loss of 41.7 lbs/13.9%.
6/29/24 = 287 Surveyor noted a weight gain of 28.7 lbs/11.11%.
7/2/24 = 254.2 Surveyor noted a weight loss of 32.8 lbs/11.43%.
Subsequent weights were stable through September 2024.
Review of R40's medical record revealed no evidence the Physician or Dietician was notified regarding R40's weight loss and/or gain on the above dates.
R40's dialysis communication forms were reviewed revealing the form was not consistently completed as evidenced by 22 missing forms over a 3-month period.
On 10/3/24 at 10:19 AM, Surveyor interviewed Registered Dietician (RD)-T who stated the dialysis facility weighs residents for the pre and post weights. RD-T was not sure what the form is called but it should be recorded on a form. Once the form is completed, it is scanned into the EHR. RD-T reported she reviews the forms on each resident's dialysis days during the normal work week and coordinates with the Dialysis Dietician at least monthly, or more often if there is a drastic change. The Director of Nursing (DON) or the ADON (Assistant) then notifies RD-T of significant weight gain or loss daily during the Monday through Friday stand down afternoon meeting. If there is a significant change over the weekend, RD-T is notified Monday morning by the DON or ADON. If there is a significant change, RD-T talks to resident to determine if supplement is needed or to see if other adjustments to menu are needed.
On 10/3/24 at 11:41 AM, Surveyor interviewed RD-T to address R40's weight loss/gain entered in the EHR and asked if she was notified of these significant losses/gains. RD-T stated she was hired sometime in June but was a contract employee before that and doesn't recall anything specifically. She will research any actions taken during this time and get back to Surveyor.
On 10/3/24 at 1:46 PM, RD-T provided Surveyor Dialysis Communication forms for the period of 5/25/24 through 7/2/24 and indicated weights did not have significant gain or loss, therefore no changes or interventions were needed.
Surveyor noted the facility weights entered in R40's EHR differ significantly compared to the weights entered on the Dialysis Communication Forms. Surveyor review of the forms provided document:
5/25/24 dialysis form: Weight before - 263.2, after - 259.5. Weight in EHR 300.
6/1/24 no dialysis form: Weight in EHR 258.3.
6/29/24 dialysis form: Weight before - 259, after 255.8. Weight in EHR 287.
7/2/24 dialysis form: Weight before 257.3, after 255.3. Weight in EHR 254.
On 10/7/24 at 10:55 AM, Surveyor interviewed RD-T who reported she started looking at the dialysis communication forms about 6 weeks ago and anyone not on dialysis she looks at the EHR weights.
On 10/7/24 at 1:50 PM Surveyor advised Executive Director-C and Nursing Home Administrator-A of concerns regarding R40's weight loss. R40's medical record included documented weights that indicated significant loss and/or gain with no evidence the Physician or Dietician was notified. Executive Director-C reported the facility believed those weights entered were not correct. Surveyor advised there was no documentation indicating staff questioned the weights after noting a significant loss/gain from previous weight entered.
No additional information was provided as to why the facility did not ensure that R40 maintained acceptable parameters of nutritional status.
CONCERN
(D)
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 in observation, interview, and record review the facility did not ensure the necessary services to provide respiratory car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based in observation, interview, and record review the facility did not ensure the necessary services to provide respiratory care were consistent with professional standards of practice for 1 (R48) of 1 resident reviewed for respiratory care.
* R48's oxygen tubing and humidification were not labeled and dated. On 10/1/2024, R48's humidification was below the line/tubing so R48 was unable to benefit from humidification while R48's oxygen was running, R48's oxygen was set for 3 L (liters)/minute (Liters per minute) during survey and R48 order was for 2L/minute, and R48 did not have orders in place for care of oxygen supplies.
Findings include:
The facility policy, entitled Oxygen Administration last approved on 12/2022, documents: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation:
A. Verify that there is a physician's order for this procedure. Review the physician's orders or community protocol for oxygen administration.
Steps on the procedure: .
K. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.
L. Label and date the humidifier bottle and oxygen tubing.
N. Periodically re-check water level in humidifying jar.
Documentation:
After completing oxygen setup or adjustment, the following information should be recorded in the resident's medical chart.
A. The date and time that the procedure was performed.
C. The rate of oxygen flow, route, and rationale.
E. The reason for PRN (as needed) administration.
F. Assessment data obtained before, during, and after the procedure.
1.) R48 was readmitted to the facility on [DATE] with a diagnoses that includes malignant pleural effusion, and atrial fibrillation.
R48's significant change minimum data set (MDS) dated [DATE] indicated R48 had intact cognition with a brief interview for mental status (BIMS) score of 15 and the facility assessed R48 needing total assistance with all activities of daily living (ADL's) with 1 staff member.
On 10/1/2024 at 9:48 AM, Surveyor observed R48 lying in bed with oxygen via nasal canula (N/C) running at 3 L/min and the humidification water had a water level that was lower than the tubing, so the water was not bubbling indicating R48 was not getting humidification with R48's oxygen. The tubing and humidification bottle were not labeled and dated to when it was changed or put on. Surveyor asked R48 if R48 was on oxygen at all times. R48 stated he did have oxygen on all the time. Surveyor asked R48 if R48 knew when the tubing and humidification bottle got changed or filled, R48 was not sure when the tubing and humidification bottle got changed or filled.
On 10/1/2024 at 3:16 PM, Surveyor observed R48 lying in bed. R48's oxygen was set at 3L/min and the water level in the humidification chamber was still lower than the tubing. The tubing and humidification also were not labeled.
On 10/2/2024 at 7:50 AM, Surveyor observed R48 lying in bed. R48's oxygen was set at 3L/min and the tubing and humidification chamber were not labeled.
Surveyor reviewed R48's physician orders and noted the following physician order:
1. Oxygen at 2 liters/minute per N/C to keep sats (saturations) above 90% as needed.
(Ordered: 9/12/2024)
Surveyor noted that R48's oxygen order is for as needed and to be set at 2L/min. R48 currently had R48's oxygen running at 3L/min.
On 10/2/2024 at 3:15 PM, Surveyor showed director of nursing (DON)-B Surveyors concerns that R48's oxygen tubing and humidification are not labeled, the humidification was running below water line on 10/1/2024, and R48's order is for 2L/min as needed to keep sats above 90% but could not locate documentation for R48 requiring oxygen all the time and at 3L/min. DON-B stated that 3rd shift should be changing and labeling tubing and humidification and staff sign it out on the medication/treatment administration records (MARs/TARs). DON-B stated DON-B would look into R48 oxygen order and talk with staff.
Surveyor reviewed R48's September 2024 and October 2024 MAR/TAR. Surveyor noted that the MAR/TAR did not have a place to indicate what R48's vital signs are such as R48's pulse oximetry (PO2) or respirations. Surveyor also noted that there are no orders for R48's tubing and humidification to be changed, labeled, and dated or to fill R48's humidification bottle.
Surveyor did not see documentation regarding R48's requiring the need for R48's PRN oxygen or vital signs that would indicate R48's oxygen level was below 90% to require the oxygen per R48's physician order. Surveyor did not see documentation regarding an increased need in oxygen for R48 to need 3 liters versus the ordered 2 liters of oxygen.
Crossreference to F656 regarding R48 not having a respiratory/oxygen care plan in place.
On 10/3/2024 at 3:04 PM, Surveyor shared concerns with assistant director of nursing (ADON)-M, executive director-C, and nursing home administrator (NHA)-A Surveyors concerns that R48's oxygen tubing and humidification are not being labeled/dated or monitored, R48's sats are not being monitored/documented, and R48's oxygen needs do not correlate with the physician order.
On 10/7/2024 at 8:03 AM, Surveyor observed R48 lying in bed. R48's oxygen was running at 3L/min, and the water was almost below the water line for R48's humidification. R48's oxygen tubing and humidification were still not labeled and dated. Surveyor noted that R48 did not have orders to monitor R48's vital signs such as PO2 and respirations to indicate an increased need for oxygen per R48's oxygen order.
No additional information was provided.
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** The facility policy entitled Catheter Care, Urinary last approved in 1/2024 documents: The Purpose of this procedure is to preve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility policy entitled Catheter Care, Urinary last approved in 1/2024 documents: The Purpose of this procedure is to prevent catheter-associated urinary tract infections.
Infection Control .
B. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.
2. Be sure the catheter tubing and drainage bag are kept off the floor.
2.) R48 was readmitted to the facility on [DATE] with a diagnoses that includes malignant pleural effusion, hydronephrosis, benign prostatic hyperplasia, urine retention, obstructive and reflux uropathy.
R48's significant change minimum data set (MDS) dated [DATE] indicated R48 had intact cognition with a brief interview for mental status (BIMS) score of 15 and that the facility assessed R48 to need total assistance with all activities of daily living (ADL's) with 1 staff member. R48 had a suprapubic catheter in place and was continent of bowel.
On 10/2/2024 at 7:49 AM, Surveyor observed R48 lying in bed. R48's catheter bag was on the right side of R48's bed lying on the floor, the catheter bag had about 100 ml of urine in the catheter bag. Surveyor asked R48 when the aide was last in the room to check on R48. R48 could not remember when the aide was into check on R48.
On 10/2/2024 at 1:41 PM, Surveyor observed R48 sitting up in a wheelchair. Surveyor asked R48 when R48 was assisted into the wheelchair. R48 stated R48 was assisted into the wheelchair before noon meal around 11:30 AM. Surveyor asked if anyone came into R48's room before that to take care of R48's catheter or pick it up off the floor. R48 stated R48 did not believe anyone came into the room to assist R48 until they got R48 up before no one meal.
On 10/2/2024 at 3:15 PM, Surveyor shared concern with director of nursing (DON)-B regarding Surveyors observation on R48's catheter bag being on the floor in the morning and R48's statement that R48's catheter bag was left on the floor until noon mealtime. DON-B stated expectation is for staff to check and make sure catheter bags to not fall onto the floor and will talk with and reeducate staff.
No additional information was provided.
Based on observations, interviews, and record review the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 (R24, R44, R48 and R60) residents reviewed for infection control.
* The shared glucometer on Medication Cart A & D was not cleaned between residents' use.
* R48's catheter bag was observed lying on floor on 10/2/2024.
Findings include:
The facility policy and procedure titled Obtaining a Fingerstick Glucose Level documents (in part) .
. The following equipment and supplies will be necessary when performing this procedure.
A. Disinfected blood glucose meter (glucometer) with sterile lancet; or single-resident use spring loaded device or automatic or safety type lancet.
Steps in the procedure:
A. Place the equipment on a clean field.
C. Always ensure that blood glucose meters intended for reused are cleaned and disinfected between resident uses.
Q. Clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice.
Caviwipes disinfecting towelettes label documents (in part) .
.Caviwipes are effective against the following microorganisms on hard, non-porous surfaces when used as directed:
Mycobacterium, Bacteria, Pathogenic Fungi, Drug-Resistant Bacteria, Enveloped Viruses.
For use as a disinfectant - contact time: Use 1 towelette to visibly wet the surface. Repeated use of the product may be required to ensure that the surface remains visibly wet for 1 minute.
1.) On 10/2/24 at 8:13 AM, Surveyor observed Licensed Practical Nurse (LPN)-P prepare medications for R44. LPN-P removed the glucometer, lancet and alcohol wipe from the top drawer of the medication cart. LPN-P applied gloves and proceeded to poke R44's finger to obtain a blood sample. After obtaining R44's blood sugar, LPN-P placed the glucometer on R44's dresser with no barrier underneath. LPN-P removed his gloves, picked up the glucometer, placed it on the top of the medication cart and sanitized his hands.
Surveyor asked LPN-P if he had any other resident blood sugars to do. LPN-P stated: No, she was my last one. Surveyor asked how many other residents on the unit get their blood sugars taken. LPN-P stated: Maybe 3 or 4 altogether. Surveyor asked if residents have their own glucometers or if the same glucometer is shared between residents.
LPN-P stated: Upstairs I think some residents have their own, but on this floor we use one for everyone. Surveyor asked LPN-P if this was the same glucometer he used to check all residents blood sugars this morning. LPN-P stated: Yes, I don't have anyone left to do. Surveyor noted the glucometer remained on top of the medication cart and asked LPN-P if he cleans the glucometer. LPN-P stated: Every morning before I start, I wipe the med (medication) cart and everything down. LPN-P showed Surveyor a container of Cavi disinfecting wipes. Surveyor asked LPN-P if he cleans the glucometer. LPN-P stated: I wipe that down every morning too, with the Cavi wipe. Surveyor asked LPN-P if he cleans the glucometer with the Cavi wipe between residents' use. LPN-P stated: No, I give it a good wipe down before I start passing meds in the morning.
On 10/2/24 at 10:57 AM, Surveyor asked DON (Director of Nursing)-B what is the expectation for cleaning of the glucometers. DON-B stated: Cavi wipes. Surveyor advised DON-B of observation and interview the shared glucometer used on med cart A&D was not cleaned after and between residents' use. Surveyor asked for a list of residents on the unit requiring blood sugar testing.
On 10/2/24 at 12:41 PM, DON-B advised Surveyor he did education with all staff on glucometer cleaning and the facility policy. DON-B reported he will also be providing extra glucometers for the 2nd floor, so the glucometer does not need to be shared.
Surveyor review of residents utilizing the shared glucometer from med cart A&D identified R24, R44 and R60. Surveyor review of the residents' medical records revealed no communicable disease.
On 10/3/24 at 8:38 AM, during observation of the 2nd floor med cart A&D, Surveyor noted there was not a Cavi wipe disinfecting container in or on the med cart. Surveyor observed a glucometer in a black pouch in the top drawer of the med cart. Surveyor observed LPN (Licensed Practical Nurse)-Q walk to the med cart and place a silver glucometer on the top of the cart. Surveyor asked LPN-Q if she had any other blood sugars to do. LPN-Q stated: Yes, I just checked (R60) just now, I have one more person to do. Surveyor asked what other residents she had checked blood sugars. LPN-Q stated: (R24) in room [ROOM NUMBER], I just did (R60) and now I have (R44).
LPN-Q picked obtained a lancet and several alcohol wipes from the med cart. LPN-Q picked up the silver glucometer from the top of the med cart. (Surveyor noted the glucometer had not been cleaned with a Cavi wipe). LPN-Q entered R44's room, washed her hands and applied gloves. LPN-Q wiped the glucometer with an alcohol wipe for 15 seconds. LPN-Q poked R44's finger and obtained the blood sample. After obtaining the blood sugar, LPN-Q placed the glucometer on the bedside table without a barrier underneath, removed her gloves and then placed the glucometer in her pocket. LPN-Q then sanitized her hands and proceeded to walk down the hall. While walking, LPN-Q removed the glucometer from her pocket and when she reached the med cart, she placed the glucometer on top of the med cart. Surveyor confirmed LPN-Q had no other resident blood sugars to do. Surveyor asked if residents have their own glucometers or if they are shared between residents. LPN-Q stated: I think this cart we have to share. Surveyor confirmed with LPN-Q she used the same glucometer for all 3 residents (R24, R44 and R60). Surveyor asked what the process was for cleaning the glucometer. LPN-Q stated: I clean it with an alcohol wipe between residents, I usually wipe it down for about 30 seconds.
On 10/3/24 at 1:53 PM, Surveyor spoke with Executive Director-C and shared observations and concerns the shared glucometer was not cleaned between residents use. Executive Director-C reported she will address the concern right away.
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 record review, the facility did not store and prepare food in accordance with professional ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not store and prepare food in accordance with professional standards for food service safety potentially affecting 65 of the 66 residents in the facility.
*Observations were made in the main kitchen of food open to air in the freezer, boxes of food stored on the floor, milk in the refrigerator past the expiration date, the dishwasher was in disrepair, and staff not wearing beard coverings while working in the kitchen preparing food.
Findings include:
The facility policy and procedure entitled Food Purchasing and Storage dated 1/2023 documents: Policy Interpretation and Implementation: . H. Foods stored in walk in-refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate cleaning. J. Food must be date marked if it is prepared on site and refrigerated, or commercially processed after the original container is opened. Food shall be dated with the current date and be used or discarded per State Food Code regulations.
1.) On 10/1/2024 at 8:36 AM, Surveyor did a preliminary walk through of the facility kitchen with Kitchen Manager (KM)-O. The walk in freezer had unopened full boxes of food stored on the floor of the freezer. A box of hamburger patties with a plastic bag lining the box was open to the air. A bag of shredded cheese had a hole in the corner of the bag exposing the cheese to the air. KM-O stated there should not be boxes on the floor and KM-O was not aware the bag of cheese had a hole in it. KM-O stated it looked like someone had grabbed something next to the bag of cheese and accidentally caused a hole in the bag. KM-O removed the cheese from the freezer and discarded. The walk in refrigerator that KM-O called the bread and milk refrigerator had an over-filled crate of individual whole milk cartons that had expired on 9/26/2024. KM-O removed the crate of milk from the refrigerator and stated KM-O would discard all the milk cartons. KM-O brought Surveyor to the prep area of the kitchen and stated the prep tables had to be moved because there were pipes in the ceiling above that leaked all over the prep tables. KM-O stated this occurred about six weeks prior and the pipes were fixed, but the ceiling still had two large openings that were covered with plastic. Surveyor observed the two openings in the ceiling that measured approximately 10 feet by 5 feet and 4 feet by 2 feet. The plastic covering the holes were gapped and air was continually blowing causing the plastic to [NAME].
Surveyor observed the prep tables to the side of the ceiling openings with the air blowing in the direction of the prep tables. KM-O brought Surveyor to the dish washing area and explained the dish machine continually leaked onto the floor causing approximately one inch of standing water. Surveyor observed a kitchen staff member using a squeegee to push standing water into a drain in the corner of the room. The floor was slippery to walk on. The dish machine rollers that enable the dish racks to slide into the dishwasher were corroded with most of the rollers in a pile at the end of the dishwashing station. The rollers were unusable making the task of washing dishes difficult. KM-O showed Surveyor the log for cleaning the ice machine for 2024. Not all the months had initials and KM-O stated the ice machine should be cleaned monthly and the log indicated that had not been done consistently.
On 10/1/2024 at 2:58 PM, Surveyor shared with Previous Nursing Home Administrator (NHA)-D, Director of Nursing (DON)-B and interim Assistant DON (ADON)-M the observations in the kitchen and the concerns those observations brought. Previous NHA-D did not have any knowledge of the kitchen ceiling having large openings or who was responsible to fix the ceiling. Previous NHA-D was not aware the dish machine was leaking or in disrepair.
On 10/3/2024 at 10:08 AM, Surveyor observed four male kitchen staff members in the kitchen with beards that did not have beard covers on. Surveyor observed a bin of flour with the scoop in the bin and a bin of all-purpose flour with a bowl in the bin. Surveyor shared these observations with KM-O and KM-O showed Surveyor the flour bin with the scoop in the flour had a hook on the inside top of the bin where the scoop should hang but thought the scoop may have been bumped and landed in the flour or someone may have put the scoop directly in the flour in the bin. KM-O did not know why there was a bowl in the all-purpose flour bin. Surveyor observed unbaked formed cookie dough in the freezer that was open to the air.
On 10/3/2024 at 3:02 PM, Surveyor shared with Executive Director (ED)-C, interim ADON-M, and NHA-A the observations in the kitchen regarding no beard nets on male staff members with beards, a scoop and a bowl in the flour bins, and unbaked formed cookie dough open to the air in the freezer.
No additional information was provided as to why the facility did not store and prepare food in accordance with professional standards for food service safety.
Jul 2024
19 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
Quality of Care
(Tag F0684)
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 did not ensure that based on the comprehensive assessment of a resident, resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that based on the comprehensive assessment of a resident, residents (R4, R1, and R3) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and residents' choices.
*R4 admitted to the facility on [DATE] and was to have admission lab work completed on [DATE] to get a baseline and because his labs on [DATE] at the hospital had some significant results. The facility did not obtain this lab work until [DATE]. The after hours Nurse Practitioner (NP) was notified of the lab results on [DATE] and ordered a repeat a CBC (complete blood count) on [DATE]. On the afternoon of [DATE], R4 fell in the parking lot while working with therapy and complained of hip pain after he was brought to his room. R4 had a change in condition with lethargy and pallor and became unresponsive with agonal breathing. EMS transported R4 to 2 hospitals where he was hypotensive (low blood pressure) and required emergency blood transfusions. R4 admitted with multiple organ failure and passed away at the hospital on [DATE].
The State of Wisconsin Nurse Practice Act section N 6.03 Standards of practice for registered nurses states:
(1) General nursing procedures. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention and evaluation. This standard is met through performance of each of the following steps of the nursing process:
(a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis.
(b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis.
(c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants.
(d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis.
The facility's failure to provide treatment and care in accordance of professional standards for R4 by failing to obtain labs when ordered, failing to consult with R4's physician when lab results demonstrated a change of condition, failing to monitor edema by obtaining daily weights as ordered, and failing to arrange a follow up nephrology appointment as ordered resulted in a significant decline in R4's health, and the need to be transferred to the ICU with multiple organ failure resulting in R4's death.
This created a finding of Immediate Jeopardy (IJ), which began on [DATE]. Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B were notified of the immediate jeopardy on [DATE], at 3:53 P.M. The immediate jeopardy was removed on [DATE], however, the deficient practice continues at a severity/scope level of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor its action plan as evidenced by:
*R1 had a BNP (B-Type Natriuretic Peptide) and BMP (basic metabolic panel) drawn on [DATE] related to R1's bilateral lower extremity edema. The facility did not monitor R1's bilateral lower edema and a care plan for edema was not implemented.
*Only one of three stool ordered samples were obtained for R3 and a colonoscopy was not scheduled.
Findings include:
The facility's policy entitled Laboratory, Radiology, and other Diagnostic Test Results dated 12/2016 and last revised 12/2017 documents:
Policy Statement
The resident's Attending Physician will be notified of the results of laboratory, radiology, and other diagnostic tests.
Policy Interpretation and Implementation
A. Results of laboratory, radiological, and diagnostic tests shall be reported in writing to the Resident's Attending Physician or to the community.
B. Should the test results be provided to the community, the Attending Physician shall be promptly notified of the results.
C. The Director of Nursing Services, or Charge Nurse receiving the test results, shall be responsible for notifying the Physician of such test results.
D. Signed and dated reports of all diagnostic services shall be made a part of the Resident's medical record .
R4 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Stage 3, Chronic Diastolic Heart Failure, Anemia in Chronic Kidney Disease, Type 2 Diabetes Mellitus, Repeated Falls, and Hyperlipidemia. R4 was his own person while at the facility.
R4's admission Minimum Data Set (MDS) completed on [DATE] documents R4 had a Brief Interview for Mental Status (BIMS) score of 13, indicating R4 was cognitively intact for daily decision making. R4 had no mood or behavior concerns documented. R4's MDS documents a range of motion impairment on both sides of the upper extremities and impairment on 1 side of the lower extremity. R4 requires supervision for rolling left to right, lying to sitting, chair/bed-to-chair transfers, and toilet transfers. R4 required partial/moderate assistance for sit to lying and sit to stand.
R4's care plan, dated [DATE] with a target date of [DATE] documents:
R4 has potential complications from chronic kidney disease. Interventions include:
-monitor for increased fatigue or weakness
-monitor urine for color, odor, and amount, and maintain intake and output if indicated
-monitor for weight gain or loss, or edema, inform physician of concerns
-monitor labs as ordered and inform physician of results
Surveyor reviewed R4's hospital discharge paperwork dated [DATE] which documents on [DATE], R4 was admitted to the hospital with diagnoses of multiple falls, head injury, atrial fibrillation, recurrent gastrointestinal (GI) bleeds, anemia, hypertension, and chronic kidney disease, stage 3. R4 had fallen at home, which resulted in a left femoral neck fracture.
R4's hospital Discharge summary dated [DATE] also documents R4 is noted to have chronic edema, however, on presentation, edema was greater than baseline therefore diuresis was pursued but unfortunately this resulted in a rise in creatine. Later in R4's stay, nephrology was consulted. Creatinine trended down prior to discharge but was not quite to baseline. R4 was cleared for discharge by nephrology with plans to hold diuretics for 2 days, then resume, hold angiotensin reception blockers (ARBs) and plan to follow up with R4's nephrologist in next 2-4 weeks. Discharge instructions document R4 to have labs checked, follow up with nephrology, do not take diuretics, Lasix for next 2 days, and resume on [DATE].
R4 was to have lab work completed on [DATE] to gain a baseline for admission and to recheck the labs after significant values were recorded in the hospital on [DATE].
R4's physician orders document Lasix was initiated on [DATE], 40 mg 2 times a per week and 60 mg 5 times a week.
R4's physician orders also document R4 was to have daily weights initiated on [DATE]. Surveyor reviewed R4's documented weights. The facility did not obtain a weight on [DATE], day of admission. There are no weights documented for R4 on 4/5, 4/6, 4/7, 4/8, or [DATE].
Surveyor reviewed Nurse Practitioner (NP)-H's progress notes for R4.
NP-H's visit progress note dated [DATE] documents: monitor labs closely and to follow up with R4's nephrologist. NP-H documents pending admission lab [results].
On [DATE], NP-H documents pending admission lab [DATE] and again for follow-up with nephrology.
On [DATE], NP-H documents pending admission lab for today and again to follow up with nephrology.
Surveyor was unable to locate documentation that a follow up nephrology appointment was made for R4.
On [DATE], at 10:59 AM, Health Information Management (HIM)-F confirmed HIM-F is responsible for making sure follow up appointments are made. HIM-F confirmed that no follow up nephrology appointment was made for R4 prior to being discharged to the hospital on [DATE].
R4's medical record contained documentation of a laboratory order request dated [DATE] which documents R4 was to have labs drawn weekly on Mondays for 4 weeks effective [DATE]. There were no labs drawn for Monday 4/1 or Monday [DATE]. Surveyor notes R4 did not have labs drawn until [DATE].
On [DATE], at 10:24 PM, R4's medical record documents the after hours Advanced Practice Nurse Practitioner (APNP)-Q was notified of the lab results. Registered Nurse (RN)-R documents at 11:19 PM, an order to repeat the CBC (complete blood count) on [DATE] in the morning.
Surveyor notes R4's medical record does not contain documentation that labs were completed the morning of [DATE] as ordered.
Surveyor reviewed R4's labs and the following are of significance:
[DATE] (morning before discharge from the hospital) [DATE] Reference Interval
Sodium 147 Sodium 150 136-145 High
Chloride 113 Chloride 115 98-107 High
Blood Urea Nitrogen 108 Blood Urea Nitrogen 93 6-23 High
Creatinine 2.68 Creatinine 2.26 .70-1.30 High
RBC 2.2 RBC 2.71 4.4-5.9 Low
Hemoglobin 8.9 Hemoglobin 7.1 13.7-17.5 Low
Hematocrit 29.3 Hematocrit 24 40-51 Low
MCV 108.1 MCV 111 79-98 High
MCH 32.8 MCH 32.4 25.7-32.2 High
MCHC 30.4 MCHC 29 32-36 Low
Platelet Count 160 Platelet Count 132 165-366 Low
Surveyor notes there is no documentation R4's attending physician was notified and reviewed R4's [DATE] lab values.
On [DATE], at 3:00 PM, R4's medical record documents R4 had a fall in the parking lot. Therapy was working on a car transfer at the time with R4. R4 was brought back to his room.
On [DATE], at 3:58 PM, R4's medical record documents Assistant Director of Nursing (ADON)-C was called to R4's room due to his complaints of hip pain. ADON-C documents that upon entering R4's room, R4 appeared lethargic and pale. Blood Pressure 62/49. Heart Rate 75. Blood Pressure verified with manual cuff 56/48. Emergency Medical Services (EMS) contacted.
On [DATE], at 4:10 PM, R4 became unresponsive with agonal breathing and pallor. R4 positioned in supine position on floor. Emergency equipment at bedside. EMS arrived for hand off and transported to the hospital.
Hospital records dated [DATE] document upon arrival to the hospital, EMS reported that R4 was hypotensive and did not improve with 800 cc (cubic centimeters) of normal saline. R4 presented with a small scalp hematoma. R4 required emergent transfusion and was ordered 2 units of uncross matched blood. R4's computed tomography (CT) of the chest, abdomen, and pelvis demonstrated large bilateral flank and lateral abdominal wall subcutaneous heterogeneous fluid collections suggesting the possibility of bilateral flank hematoma's of indeterminate age. Another hospital was contacted for an intensive care unit bed and accepted. After the acceptance, R4 again became hypotensive despite norepinephrine, 2 additional units of packed red blood cells (PRBCs) were ordered. R4's blood pressure did improve with the 3rd unit of PRBCs and 4th unit was given to the EMS crew to transport R4 to the ICU with norepinephrine running at 10 mcg/minute. R4's hemoglobin was rapidly identified to be anemic at 5.6. Chest x-ray with questionable left lower lobe infiltrate versus effusion was identified. R4 was admitted to ICU.
On [DATE], at 10:35 AM, Surveyor interviewed R4's Family (FAM)-S. FAM-S stated FAM-S was informed by the ICU that R4's labs were bad and was admitted with multiple organ failure and never recovered. R4 expired on [DATE].
On [DATE], at 11:19 AM, Surveyor interviewed NP-H. NP-H stated R4 needed to be monitored due to stage 3 kidney disease and the facility should have completed the weights as ordered. NP-H stated the expectation is if daily weights are ordered, it should have been done to monitor R4's edema. NP-H stated NP-H ordered labs to be completed and recognized on [DATE] and [DATE] the labs had not been completed by the facility. NP-H stated sometimes it doesn't get done. Surveyor asked NP-H if that is right and NP-H stated, No, it is not, it should have been done.
On [DATE], at 12:33 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C. ADON-C does not recall why R4's labs were not completed upon admission as ordered.
On [DATE], at 2:38 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B that R4's daily weights had not been completed, R4's follow up with nephrology had not been scheduled, and R4 did not have labs completed until 10 days after admission leading to a change in condition and the need for R4 to be transferred to the hospital.
On [DATE], at 9:37 AM, ADON-C explained the facility process and procedure for obtaining labs for residents. ADON-C stated every new admission has labs ordered every week for 4 weeks and as needed. ADON-C stated the lab company comes every day and lab draws are always done in the morning. ADON-C stated when a resident is admitted , the expectation is the lab draw is completed the next morning. ADON-C cannot answer why R4's labs were not completed the day after admission. ADON-C stated, can't speak to the delay in obtaining the labs for R4. ADON-C stated the unit nurse is responsible for monitoring the residents' labs. The after hours, on call NP (NP-Q) does not know the residents so abnormal labs like R4's would be reviewed with NP-H, however, there is no documentation in R4's medical record this was completed.
On [DATE], at 12:30 PM, Surveyor interviewed NP-H in regard to R4's abnormal labs. NP-H confirmed they had reviewed R4's medical record and noted the labs had not been completed for R4 and it was critical to get them done. NP-H stated that is why NP-H kept documenting pending admission labs [results]. NP-H stated they give verbal orders to the nursing staff to get labs completed. NP-H compared R4's lab values from [DATE] and [DATE] and confirmed R4's labs on [DATE] were concerning. NP-H would have expected the labs to be repeated as ordered by NP-Q on [DATE] in the morning to make sure R4 did not need to go out for a blood transfusion. NP-H stated they would be concerned with hypernatremia and dehydration based on R4's labs. NP-H agreed it is very concerning R4's labs were not repeated the next day as expected given R4's lab value changes noted between the results from [DATE] and [DATE]. NP-H stated, It was not completed and should have been completed.
On [DATE], at 2:17 PM, Surveyor had follow-up questions for NP-H and interviewed NP-H via phone. NP-H can not confirm if therapy should have attempted a car transfer in the parking lot based on R4's critical labs. NP-H stated R4 did not have complaints of dizziness and does not know how it would have impacted working with therapy. However, there is no documentation of R4's condition prior to the attempted car transfer. NP-H stated based on R4's lab values it appears R4 was losing blood from somewhere. NP-H did agree that labs not being completed as needed or expected provided no monitoring of R4 and perhaps the change in condition could have been caught and R4 sent out earlier to the hospital.
On [DATE], at 2:30 PM, Surveyor communicated to NHA-A and DON-B the serious concern of the facility failing to get R4's labs completed as ordered by the nurse practitioner resulting in R4 becoming unresponsive, being sent to the emergency room and requiring emergent transfusion, being admitted to ICU with multiple organ failure, and consequently expiring.
The facility's failure to obtain labs when ordered, consult with R4's physician when lab results demonstrated a change in condition, monitor R4's edema by obtaining ordered daily weights, and to arrange a follow-up appointment with nephrology as ordered resulted in a significant decline in R4's health and his subsequent hospitalization and death thus leading to a finding of immediate jeopardy. The facility removed the jeopardy on [DATE] when the facility implemented the following:
-Designee will do a facility-wide lab audit in order to identify any Residents who had lab orders that did not receive the proper follow up.
-Residents identified will have lab order results verified with the provider and appropriate action taken.
-Designee will audit all lab orders for two weeks, then weekly for one month to ensure that labs are completed and are completed to the provider.
-Audit results will be reviewed at the QA committee until the QA committee has determined that substantial compliance has been achieved.
-Direct care licensed nurses will be re-educated on the proper procedures for placing lab orders, ensuring that the lab draws occur per provider's orders and that lab results are reported to the providers in a timely manner.
The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as evidenced by the following:
2.) R1 was admitted to the facility on [DATE] with diagnoses which includes right femur fracture, dementia, and anxiety.
The facility developed the following care plans:
* [R1's first name] is at risk for impaired communication related to change in environment. Dated [DATE].
* [R1's first name] needs assistance with daily ADL (activity daily living) care. Dated [DATE].
* [R1's first name] is at risk for psychosocial well-being concern related to COVID-19 and/or other infections. Dated [DATE].
* [R1's first name] is at risk for changed activity and preferences due to new environment. Short stay, dementia. Dated [DATE].
* [R1's first name] has potential for falls related to recent admission to community. Dated [DATE].
* [R1's first name] is at low risk for impaired nutrition. Dated [DATE].
* [R1's first name] is at risk for pressure ulcers and other skin related injuries. Dated [DATE].
* [R1's first name] rates pain a <0|1|2|3|4|5|6|7|8|9|10>. Dated [DATE].
* [R1's first name] does not plan to make the community a long term home. Dated [DATE].
* [R1's first name] will have advance directives reviewed upon admission, full code. Initiated [DATE].
* [R1's first name] is at risk for < increased behavioral expressions||altered mood||elopement||impaired adjustment ability to new environment>. Dated [DATE].
* Level 1 PASRR (preadmission screening and resident review) is negative. Dated [DATE].
* [R1's first name] has diseases and conditions which are treated with medication. Dated [DATE].
* [R1's first name] has memory problems, impaired decision making skills and impaired ability to comprehend, confused and forgetful, own person, dx (diagnosis) dementia. Dated [DATE].
* [R1's first name] need enhanced barrier precaution d/t (due to) indwelling medical device, wound/s or MDRO (multidrug resistant organisms) or contained infection. Dated [DATE].
The nurses note dated [DATE] PM (evening) documents Per DON (Director of Nursing) sleep study initiated. New lab orders for 6/6 BNP (B-Type Natriuretic Peptide) and BMP (basic metabolic panel) r/t (related to) BLE (bilateral lower extremity) edema.
Surveyor was unable to locate any monitoring of R1's bilateral lower extremity edema and a care plan for edema was not implemented.
On [DATE], at 10:00 a.m., Surveyor observed R1 sitting in a wheelchair wearing socks and sneakers. Surveyor observed R1's feet are resting on the floor, there are no leg rests on R1's wheelchair and R1's legs are not elevated.
On [DATE], at 10:45 a.m., Surveyor observed R1 continues to be sitting in a wheelchair in the room with R1's feet on the floor. R1's legs are not elevated.
On [DATE], at 1:20 p.m., Surveyor observed R1 sitting in a wheelchair in the room with her daughter. R1's feet are resting on the floor.
On [DATE], at 3:27 p.m., Surveyor observed R1 sitting in a wheelchair in the room with her feet resting on the floor. R1's daughter is sitting on R1's bed talking with R1. R1 does not have her legs elevated.
On [DATE], at 7:54 a.m., Surveyor observed R1 wheeling herself out the the room. R1 informed Surveyor she had gotten up too early and went back to bed. Surveyor observed there are no leg rests on R1's wheelchair to elevate her legs.
On [DATE], at 8:05 a.m., Surveyor observed R1 sitting in a wheelchair with her feet on the floor in the dining room eating cereal.
On [DATE], at 9:55 a.m., Surveyor observed R1 sitting in a wheelchair with her feet on the floor. R1's son is sitting in a chair in the room.
On [DATE], at 11:16 a.m., Surveyor observed R1 sitting in a wheelchair with her feet on the floor in the bathroom. Surveyor asked R1 what she was doing. R1 replied, I think I was turning the light off.
On [DATE], at 12:03 p.m., Surveyor asked ADON (Assistant Director of Nursing)-C if there are any issues with R1 having edema. ADON-C informed Surveyor R1 has chronic edema in her legs, not excessive by any means, more of dependent edema due to sitting in a chair and having her legs in a low position. Surveyor asked ADON-C if R1's legs should be elevated. ADON-C informed Surveyor she did suggest this to the family. Surveyor asked about staff interventions. ADON-C informed Surveyor she suggested to the unit nurse to have R1's legs elevated. ADON-C informed Surveyor this should be on the CNA (Certified Nursing Assistant) assignment sheet and could add it to the care plan then it will cross over to the CNA worksheet. Surveyor informed ADON-C Surveyor was not able to locate any evidence staff was monitoring R1's edema and a care plan was not developed for the edema.
On [DATE], at 2:38 p.m., Surveyor informed NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and ADON-C of labs drawn on [DATE] for R1's bilateral extremity edema. Surveyor was unable to locate any evidence staff was monitoring R1's edema and a care plan for edema was not developed.
3.) R3's diagnoses includes hypertension, atrial fibrillation, and diabetes mellitus.
On the BMP (basic metabolic panel) laboratory report with a collection date of [DATE], there is a handwritten notation dated [DATE] which documents, Collect 3 stool samples for occult blood.
The nurses note dated [DATE] at 0530 (5:30 a.m.) documents, 97.6 72 16 92% Monitoring stool for occult blood. No active bleeding or reports of a stool this shift. Without acute distress. In the bed resting. Will monitor.
The nurses note dated [DATE] at 1100 (11:00 a.m.) documents, without stool obtained.
The nurses note dated [DATE] at AM (morning), Stool collection completed.
APNP-H's note dated [DATE] under assessment and plan for decreased weight loss includes documentation of EGD (esophagogastroduodenoscopy) (an endoscopic procedure that includes visualization of the oropharynx, esophagus, stomach and proximal duodenum) on [DATE]. Pending stool sample for FGOT (fecal guaiac occult blood test).
The nurses note dated [DATE], AM, documents Stool spec (specimen) obtained. 1st one. Sent to lab 0915 (9:15 a.m.).
The nurses note dated [DATE], PM (evening), documents No stool sample this shift. Surveyor was unable to locate any further nurses notes regarding stool collection after this date.
The occult blood, fecal screen lab report verified on [DATE] documents for value not detected. There is a handwritten notation on this laboratory report dated [DATE] which documents Schedule colonoscopy.
Surveyor was only able to locate one occult blood, fecal screen and did not note any documentation regarding the colonoscopy being scheduled.
On [DATE], at 10:19 a.m., Surveyor asked HIM (Health Information Management)-F who is responsible for setting up outside appointments. HIM-F informed Surveyor herself and Receptionist-I work together. Surveyor inquired if R3's colonoscopy appointment had been set up. Surveyor informed HIM-F Surveyor noted a notation on lab report dated [DATE] documenting 3 stool samples for occult blood. Surveyor was able to locate one of the three and asked HIM-F if the other two samples were collected. HIM-F informed Surveyor she will get back to Surveyor.
On [DATE], at 11:00 a.m., HIM-F informed Surveyor R3 was suppose to have a EGD but this appointment was rescheduled for [DATE]. HIM-F informed Surveyor they were going to go from there if a colonoscopy was needed. Surveyor asked HIM-F if she was able to locate any more stool samples. HIM-F informed Surveyor there was only one done. Surveyor asked HIM-F if there was a unit manager Surveyor could speak with. HIM-F informed Surveyor they don't have unit manager. HIM-F informed Surveyor there is first name of DON (Director of Nursing)-B, first name of ADON (Assistant Director of Nursing)-C, first name of RN (Registered Nurse)/Quality Management-E, and the floor nurses. HIM-F suggested Surveyor speak with ADON-C.
On [DATE], at 11:26 a.m., Surveyor asked APNP-H if a colonoscopy was suppose to be scheduled for R3. APNP-H replied yes. Surveyor asked APNP-H if she wrote an order. APNP-H replied I believe so and explained there should be a paper copy. APNP-H informed Surveyor if she was in the building she would have written a paper order and in some cases if she receives a call she gives a verbal order. Surveyor informed APNP-H Surveyor had noted her progress note dated [DATE] which documents stool samples pending. Surveyor inquired if these stool samples were completed. APNP-H informed Surveyor so far she's heard back one was done which was negative. Surveyor asked APNP-H if three stool samples should have been obtained. APNP-H replied yes. Surveyor asked APNP-H if she knows why they weren't done. APNP-H replied no. Surveyor asked APNP-H if anyone informed her the stool samples weren't obtained. APNP-H replied no. APNP-H informed Surveyor she ordered the stool samples for weight loss and colonoscopy for cancer.
On [DATE], at 11:43 a.m., Surveyor asked ADON-C if she knew why the stool specimens for occult blood were not obtained. ADON-C replied I do not and explained she wrote this on their board numerous times, put the tubes to collect the blood there and despite her doing this only one was collected. ADON-C informed Surveyor R3 does not eat very much and does not stool a lot. Surveyor inquired about a colonoscopy being scheduled. ADON-C informed Surveyor APNP-H asked an EGD be scheduled. ADON-C indicated while they are going down they could do the other end and go up. Surveyor inquired if anyone communicated this to the GI (gastrointestinal) doctors about doing the colonoscopy at the same time. ADON-C replied not to my knowledge. Surveyor asked ADON-C if an order for the colonoscopy had been written. ADON-C replied I did not see an order for colonoscopy and explained APNP-H may have given the order to floor nurse.
On [DATE], at 2:38 p.m., Surveyor informed NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and ADON-C three stool specimens for occult blood and a colonoscopy was not scheduled for R3. No additional information was provided to Surveyor as to why this was not done.
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 interviews, the Facility did not ensure that an allegation of abuse involving 1 (R5) of 3 Residents r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the Facility did not ensure that an allegation of abuse involving 1 (R5) of 3 Residents reviewed for allegations of abuse were reported immediately to the Nursing Home Administrator and State Survey Agency.
*On 4/19/24 R5 informed the facility of an allegation of abuse involving Certified Nursing Assistant (CNA)-M. The facility did not report the allegation of abuse to the State Survey Agency until 4/22/24. The Nursing Home Administrator was not notified of the allegation until 4/22/24.
Findings Include:
The facility's policy entitled, Abuse Prevention, dated 9/2017 and last revised on 6/2020 documents:
. Investigation
A. The community will investigate and report any allegations of abuse within timeframe's as required by federal, state, and local requirements.
Protection
A. The community will protect Residents from further potential abuse, neglect and exploitation, or mistreatment while abuse investigations are in progress;
1. Respond immediately to protect the alleged victim and integrity of the investigation.
2. Make room or staffing changes, if necessary, to protect the Resident(s) from the alleged perpetrator.
3. Provide protection from retaliation; and
B. Provide emotional support and counseling to the Resident during and after the investigation, as needed.
Reporting/Response
A. The community will immediately, but no 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 no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of property, to the Administrator and/or designee, State Agency, adult protective services and to all other required agencies(law enforcement when applicable) within specified time frames;
B. Assure that reporters are free from retaliation or reprisal;
C. Report to the State nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for services;
D. Implement interventions as a result of the investigation .
The facility's policy entitled, Abuse Investigation and Reporting, dated 9/2017 and last revised on 11/2023 documents:
. Reporting
A. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Administrator or designee and to the following other officials or agencies:
1. The State licensing/certification agency responsible for surveying/licensing the community;
2. Other officials in accordance with State Law, including Adult Protective Services where state law provides for jurisdiction in long term care facilities;
3. The Resident's Representative;
4. The Resident's Attending Physician;
5. The community Medical Director
B. Alleged violations involving abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of Resident property) will be reported:
1. Abuse or Serious Bodily Harm-Immediately but no later than 2 hours. *If the alleged violation involves abuse or results in serious bodily injury.
2. No Serious Bodily Injury-As soon as practical, but not later than 24 hours. *If the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of Resident property; does not result in serious bodily injury.
R5 was admitted to the facility on [DATE] with diagnoses of Hypertensive Chronic Kidney Disease, Stage 3, Hyperlipidemia, Pulmonary Hypertension, and Pleural Effusion. R5 is currently her own person.
R5's Annual Minimum Data Set (MDS) completed on 4/10/24 documents R5's Brief Interview for Mental Status (BIMS) score as 14, indicating R5 is cognitively intact for daily decision making; R5 has range of motion impairment of upper extremity on one side. R5 requires partial/moderate assistance with upper and lower body dressing. Substantial to maximum assistance for sit to lying, and lying to sitting. R5 requires supervision for transfers and mobility.
The facility was informed by R5 on 4/19/24 that R5 requested assistance from Certified Nursing Assistant (CNA)-M. R5 stated that CNA-M responded in a rude and aggressive manner. R5 expressed R5 felt disrespected and mistreated by CNA-M's behavior. R5 reported this to Registered Nurse (RN)-N, Certified Nursing Assistant (CNA)-O, and Registered Nurse (RN)-P.
On 6/18/24, at 1:39 PM, Surveyor received the facility's self-report file from the facility and noted the initial report, 'Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report' is dated 4/22/24. The initial report documents R5's allegation was discovered at 6:40 PM, on 4/19/24. The initial report then documents that the State Agency was notified on 4/22/24, at 4:27 PM.
Surveyor reviewed a statement provided by Registered Nurse (RN)-P. The statement indicates that RN-P identified CNA-M as the employee that R5 was alleging to be mistreated by. RN-P documents that RN-P and CNA-M then went to R5's room to apologize to R5. R5 refused to accept the apology. RN-P's statement then states that CNA-M left at 8:25 PM due to an emergency, leaving six Residents on assignment unattended to.
Surveyor has concerns that residents were not safeguarded immediately at 6:40 PM, when R5's allegation first became known, CNA-M was allowed to have contact with R5 after the allegation and then remained in the building in contact with other Residents before choosing to leave due to an emergency. Surveyor notes that leaving 6 Residents unattended to would meet the definition of neglect, however, the facility did not initiate a self report and investigation for that issue.
On 6/18/24, at 2:30 PM, Nursing Home Administrator (NHA)-A informed Surveyor that NHA-A is responsible for submitting all allegations of abuse, neglect, and misappropriation investigations to the State Agency. NHA-A stated NHA-A gets a statement from the Resident because NHA-A likes to be clear on what the issue is. NHA-A stated NHA-A did not complete R5's investigation, RN/Quality Management Director (QMD)-E completed the investigation.
On 6/18/24, at 3:07 PM, Surveyor interviewed QMD-E who informed Surveyor that QMD-E typically does not do the self-reports or complete the investigation when there is an allegation of abuse or neglect. QMD-E stated the NHA-A was brand new to the facility so QMD-E completed the investigation and forwarded it to NHA-A.
On 6/19/24, at 1:50 PM, NHA-A informed Surveyor that NHA-A is unable to answer any questions in regards to R5's allegation because NHA-A did not complete this investigation. NHA-A stated NHA-A is not sure why there was a delay in reporting. Surveyor shared the concern with NHA-A that the initial report of R5's allegation was not submitted to the State Agency until 3 days after the allegation. NHA-A acknowledged the concern.
On 6/19/24, at 2:38 PM, Surveyor shared the concern with NHA-A and Director of Nursing(DON-B) that CNA-M was not removed from resident contact immediately at 6:40 PM, when R5's allegation first became known, was allowed to have contact with R5 after the allegation and then remained in the building in contact with other Residents before choosing to leave due to an emergency. Surveyor shared the concern that there was no self-report initiated for the 6 Residents who were left unattended to rule out abuse/neglect.
On 6/19/24, at 9:56 AM, additional information was provided by QMD-E. QMD-E stated that the problem was the allegation occurred on Friday evening and then there was the weekend. QMD-E notified NHA-A on 4/22/24, the following Monday of R5's allegation. QMD-E agrees that CNA-M should not have been allowed to remain in the facility when R5 reported the allegation.
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** 3.) R5 was admitted to the facility on [DATE] with diagnoses of Hypertensive Chronic Kidney Disease, Stage 3, Hyperlipidemia, Pu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.) R5 was admitted to the facility on [DATE] with diagnoses of Hypertensive Chronic Kidney Disease, Stage 3, Hyperlipidemia, Pulmonary Hypertension, and Pleural Effusion. R5 is currently her own person.
R5's Annual Minimum Data Set(MDS) completed on 4/10/24 documents R5's Brief Interview for Mental Status(BIMS) score of 14, indicating R5 is cognitively intact for daily decision making. R5's MDS also documents that R5 has range of motion impairment of upper extremity on one side. R5 requires partial/moderate assistance with upper and lower body dressing. Substantial to maximum assistance for sit to lying, and lying to sitting. R5 requires supervision for transfers and mobility.
The facility was informed by R5 on 4/19/24 that R5 requested assistance from Certified Nursing Assistant (CNA)-M. R5 stated that CNA-M responded in a rude and aggressive manner. R5 expressed R5 felt disrespected and mistreated by CNA-M's behavior. R5 reported this to Registered Nurse (RN)-N, Certified Nursing Assistant (CNA)-O, and Registered Nurse (RN)-P.
On 6/18/24, at 1:39 PM, Surveyor received the facility's self-report file and notes there was one staff statement and no other Resident statements. There is no statement with details from R5.
Surveyor reviewed a statement provided by Registered Nurse(RN)-P. The statement indicates that RN-P identified CNA-M as the employee that R5 was alleging to be mistreated by. RN-P documents that RN-P and CNA-M then went to R5's room to apologize to R5. R5 refused to accept the apology. RN-P's statement then states that CNA-M left at 8:25 PM due to an emergency, leaving six Residents on assignment unattended to.
Surveyor noted there is no investigation involving the 6 Residents who were unattended to.
On 6/18/24, at 1:49 PM, Social Services Director (SSD)-D stated that SSD-D's responsibility is to interview other Residents. Staff reports to SSD-D and then the obtained information is forwarded to Nursing Home Administrator (NHA)-A and NHA-A submits the final report. Administration and nursing get staff statements. SSD-D informed Surveyor that SSD-D will need to look for any written statements.
On 6/18/24, at 2:30 PM, NHA-A informed Surveyor that NHA-A gets a statement from the Resident because NHA-A likes to be clear on what the issue is. Social Services get involved for the 2nd interview from the Resident. NHA-A would get interviews from staff and then go to 5 or 6 Residents to see if any other Residents were involved. All statements would be part of the self-report file. NHA-A stated NHA-A did not complete R5's investigation, RN/Quality Management Director(QMD)-E completed the investigation.
On 6/18/24, at 3:07 PM, Surveyor interviewed QMD-E who informed Surveyor that QMD-E typically does not do the self-reports or complete the investigation when there is an allegation of abuse of neglect. QMD-E stated the NHA-A was brand new to the facility so QMD-E completed the investigation and forwarded it to NHA-A. QMD-E stated QMD-E is usually not involved with getting staff statements.
On 6/18/24, at 3:39 PM, SSD-D was not notified until the following Monday morning of the allegation from R5 and informed Surveyor that there should be staff statements as part of the investigation.
On 6/19/24, at 8:20 AM, SSD-D is not able to tell Surveyor why statements were not included in the facility investigation. SSD-D does not have Resident specific interviews from other Residents that may have been affected by CNA-M. SSD-D's statement from R5 does not match what is in the self-report's summary written by QMD-E.
On 6/19/24, at 1:50 PM, NHA-A informed Surveyor that NHA-A is unable to answer any questions in regards to R5's allegation because NHA-A did not complete this investigation. Surveyor shared there is only one staff statement, and no other Resident statements possibly affected by CNA-M's behavior is not part of the investigation. Surveyor also shared that CNA-M was not suspended immediately, had contact with R5 and other Residents. Those Residents on CNA-M's assignment were not interviewed. NHA-A acknowledges the concern.
On 6/19/24, at 2:38 PM, Surveyor shared the concern with NHA-A and Director of Nursing(DON-B) the concern that R5's allegation was not thoroughly investigated. At this time, no additional information was provided by the facility in regards to why a thorough investigation was not completed in regards to R5's allegation.
On 6/19/24, at 9:56 AM, additional information was provided by QMD-E who stated QMD-E took statements and combined it into one for the summary but is not able to locate any individual statements from RN-N, CNA-O, and RN-P. QMD-E stated that the issue was, it was the weekend.
Based on interview and record review the Facility did not have evidence all alleged violations of misappropriation, neglect, & mistreatment were thoroughly investigated for 3 (R6, R3, & R5) of 3 residents facility report incidents reviewed.
* On 6/9/24 R6 reported $20.00 missing. The Facility did not conduct a thorough investigation as the police were not notified and other residents residing on the unit were not interviewed.
* On 5/28/24 R3's gown was full of feces and allegedly a CNA stated oh no I'm not dealing with that and walked out. During the investigation it was revealed the CNA assigned to R3 was unaware she was assigned to R3 and did not provide any cares to R3. The facility did not investigate why no cares were provided to R3 on 5/28/24.
* R5's allegation of mistreatment on 4/19/24 was not thoroughly investigated.
Findings include:
The facility's policy titled, Abuse Investigation and Reporting and last reviewed 11/2023 under policy statement documents All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing, and other imaging of residents, and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by community management. Conclusions of investigations will also be reported, as defined by the [Name] Abuse Prevention policy.
Under Policy Interpretation and Implementation for the Role of the Investigator documents
A. The individual conducting the investigation will, at a minimum:
1. Review the completed documentation forms;
2. Review the resident's medical record to determine events leading up to the incident;
3. Interview the person(s) reporting the incident;
4. Interview any witnesses to the incident;
5. Interview the resident (as medically appropriate);
6. Interview the resident's attending physician as needed to determine the resident's current level of cognitive function and medical condition;
7. Interview associates members (on all shifts) who have had contact with the resident during the period of the
alleged incident;
8. Interview the resident's roommate, family members, and visitors;
9. Interview other residents to whom the accused employee provides care or services; and
10. Review events leading up to the alleged incident.
11. Review use of community camera/video footage of incident if available.
1.) R6 was admitted to the facility on [DATE]. R6 has a guardian.
The admission MDS (minimum data set) with an assessment reference date of 5/12/24 has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact.
On 6/18/24, at 10:16 a.m., Surveyor observed R6 sitting in a wheelchair in her room. Surveyor asked R6 how staff treats her. R6 replied alright. Surveyor asked R6 if she has had any money missing. R6 replied yup. R6 explained on she had gotten $160 from her granddaughter. On Friday night she went to bed and when got up Saturday she was missing $20.00. R6 informed Surveyor she knew someone had been in her purse because her doctors cards were not put back right. Surveyor asked R6 if she told anyone about her missing money. R6 informed Surveyor she told one of the CNAs (Certified Nursing Assistants), she told first name of SSD (Social Services Director)-D and SSD-D came and spoke with her. R6 informed Surveyor she now has a lock box and her money is in the front office.
On 6/18/24, at 1:30 p.m., Surveyor reviewed the facility's report incident for R6's allegation of misappropriation for $20.00 missing on 6/9/24.
The initial report, alleged nursing home resident mistreatment, neglect, and abuse report (F-62617) to the state agency, under brief summary of incident includes documentation of .The resident was asked if she wanted the police contacted to make out a report. She stated, no she just wanted her money back.
RN (Registered Nurse)-G interview with R6 dated 6/9/24 for question #3 Do you want police called? documents Yes I don't care.
The misconduct incident report (F62447) submitted 6/14/24 under section 5. Law enforcement involvement: no is answered for question was law enforcement contacted or involved.
During review of R6's investigation, Surveyor was unable to locate any Resident interview, other than R6, to determine if there are other Residents who have missing money & may not have reported it.
On 6/18/24, at 1:49 p.m., Surveyor asked SSD (Social Services Director)-D if he is involved with investigating Resident's allegations. SSD-D informed Surveyor he takes the resident statement and interviews other residents. Surveyor asked SSD-D how he becomes aware of an allegation. SSD-D informed Surveyor from the Administrator or staff reports to him and then he will go to the DON (Director of Nursing) & Administrator as the Administrator is the grievance officer. Surveyor asked SSD-D after he interviews the resident or other residents where does this information go. SSD-D replied back to the Administrator since they are the grievance officer. Surveyor asked who makes the decision if the police are called. SSD-D replied Administration. Surveyor asked SSD-D if he was involved with R6's investigation regarding $20.00 missing on 6/9/24. SSD-D informed Surveyor he will have to check and let Surveyor know.
On 6/19/24, at 8:15 a.m., Surveyor asked SSD-D if he has any information during R6's investigation regarding missing $20.00 were any other residents interviewed. SSD-D informed Surveyor he was off and NHA (Nursing Home Administrator)-A will talk with Surveyor today.
On 6/19/24, at 1:39 p.m., Surveyor met with NHA-A to discuss R6's investigation regarding the allegation of $20.00 missing. Surveyor asked NHA-A if the information provided to Surveyor is the complete investigation. NHA-A replied I assume if you took it out of the file it is, that's all I have. Surveyor inquired why the police were not notified. NHA-A informed Surveyor he asked R6 if she wanted the police called and she said no she didn't want the police contacted, she wanted her money back. Surveyor informed NHA-A the facility still has the obligation to notify the police. NHA-A informed Surveyor he will do this from now on and explained to Surveyor he has always done the wishes of the resident. Surveyor informed NHA-A Surveyor didn't note any other resident interviews. NHA-A informed Surveyor he didn't think other residents needed to be interviewed and stated I do it when I feel it is necessary. NHA-A stated If I feel money is missing I do a 360. NHA-A explained a 360 is when 4-6 residents on the same unit are questioned.
2.) R3 was admitted to the facility on [DATE].
The quarterly MDS (minimum data set) with an assessment reference date of 5/9/24 has a BIMS (brief interview mental status) score of 12 which is moderate cognitive impairment.
On 6/19/24, at 10:22 a.m., Surveyor reviewed the facility's reported incident regarding R3's allegation of neglect on 5/28/24 when R3 had an incontinence episode, CNA said she was not going to deal with this and walked out without providing cares.
On 6/19/24, at 11:53 a.m., Surveyor asked ADON (Assistant Director of Nursing)-C if she was involved with investigating R3's allegation of neglect on 5/28/24. ADON-C explained she was coming out of a care conference and 2nd shift CNA (Certified Nursing Assistant) came out of R3's room wearing a gown & gloves and told her she needed to go into the room. ADON-C informed Surveyor R3's gown was full of stool and asked R3 what was going on as there were tissues with stool on the bedside table. R3 informed ADON-C someone had walked in and said I'm not going to deal with this and walked out. ADON-C informed Surveyor R3's breakfast tray was sitting there, this was 2:15 in the afternoon and wondered where is the lunch tray and why is the breakfast tray still sitting there. ADON-C informed Surveyor she looked at the schedule to try to figure out who the CNA was that was assigned to R3 and called DON (Director of Nursing)-B. DON-B informed her to suspend the CNA assigned to R3. ADON-C informed Surveyor she asked the unit nurse if she saw the CNA and she informed her she hadn't. ADON-C informed Surveyor she called the CNA assigned to R3 who informed her she wasn't aware she had R3, didn't know how the schedule worked and didn't know who had R3. ADON-C informed Surveyor it didn't seem that anyone had R3. ADON-C informed Surveyor she had the 2nd shift CNA write a statement which she gave to DON-B and told the PM nurse to write a statement ADON-C informed Surveyor this was her part of the investigation.
On 6/19/24, at 1:50 p.m., Surveyor met with NHA (Nursing Home Administrator)-A to discuss R3's investigation. NHA-A informed Surveyor ADON-C brought to his attention while she making rounds the CNA on the 2nd shift informed her of a fecal situation with R3. NHA-A informed Surveyor ADON-C was suppose to give a statement and will need to ask. Surveyor informed NHA-A while speaking with ADON-C, ADON-C informed Surveyor in the afternoon the breakfast tray was still there, no evidence the lunch tray had been delivered and the CNA was unaware she was assigned to R3 & had not provided any cares to R3. Surveyor inquired why the facility didn't investigate why R3 hadn't received cares for approximately seven hours, when was R3 seen, had she been repositioned, any continence cares provided, etc. NHA-A informed Surveyor he believes he asked for documentation from ADON-C and if he had received it he would of look into it. NHA-A informed Surveyor there was a lot going on with the cyber issue at the time and this was all the information he had.
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 F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the Facility did not ensure proper foot care for 1 (R3) of 3 Residents.
R3's toenails were very long and in need of trimming.
Findings include:
R3's ...
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Based on observation, interview, and record review the Facility did not ensure proper foot care for 1 (R3) of 3 Residents.
R3's toenails were very long and in need of trimming.
Findings include:
R3's diagnoses includes hypertension, atrial fibrillation and diabetes mellitus.
The quarterly MDS (minimum data set) with an assessment reference date of 5/9/24 has a BIMS (brief interview mental status) score of 12, indicating R3 has moderate cognitive impairment. R3 is assessed as being dependent for putting on/taking off footwear: The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility including fasteners if applicable.
On 6/19/24 at 9:33 a.m. Surveyor observed R3 sitting in a wheelchair in her room with a breakfast tray on an over bed table in front of R3. R3 is wearing gripper socks on her feet. Surveyor asked R3 if Surveyor could look at her feet later. R3 shook her head yes.
On 6/19/24 at 9:34 a.m. Surveyor informed CNA (Certified Nursing Assistant)-J Surveyor had observed R3 still has her breakfast tray in front of her and inquired when Surveyor could look at R3's feet with her. CNA-J informed Surveyor R3 doesn't eat very much and indicated Surveyor could look at R3's feet now. Surveyor & CNA-J entered R3's room. CNA-J placed gloves on and removed R3's right gripper sock. Surveyor observed the toe nails on R3's right foot are very long. CNA-J placed the gripper sock back on R3's right foot and then removed the gripper sock from R3's left foot. Surveyor observed R3's toe nails on her left foot are very long. Surveyor noted R3's toe nails are in need of trimming. After CNA-J placed R3's gripper sock on the left foot, Surveyor asked CNA-J who is responsible for cutting resident's toe nails. CNA-J replied I think she is a diabetic, she goes out.
Surveyor reviewed R3's medical record and was unable to locate when R3 was examined by a podiatrist.
On 6/19/24, at 12:05 p.m., Surveyor asked ADON-C when the last time R3 was examined by a podiatrist as Surveyor observed R3's toe nails to be very long. ADON-C informed Surveyor it's her understanding the podiatrist puts their notes under the consult section of the medical record. Surveyor asked ADON-C how the podiatrist knows who they are to see. ADON-C informed Surveyor SSD (Social Service Director)-D puts the resident on their list.
On 6/19/24, at 12:58 p.m., ADON-C informed Surveyor she found out R3 goes out to the podiatrist per family request. Surveyor asked ADON-C when was the last time R3 saw the podiatrist. ADON-C informed Surveyor she will check and let Surveyor know.
On 6/19/24, at 2:38 p.m., NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and ADON-C were informed of R3's toe nails being very long and staff was unable to provide Surveyor with the last time R3 was examined by a podiatrist.
On 6/20/24 at 8:10 a.m. Surveyor asked SSD-D where Surveyor would be able to locate podiatrist consult for R3. SSD-D informed Surveyor it would be under the attachment for consults. SSD-D looked in R3's medical record and was unable to locate a podiatrist consult.
On 6/20/24 at 8:48 a.m. HIM (Health Information Management)-F informed Surveyor she was unable to locate any podiatrist consultations for R3.
On 6/20/24 at 9:27 a.m. ADON-C informed Surveyor has an appointment to see the podiatrist on 7/8/24.
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 electronic medical record(EMR) review, and interview, the facility did not ensure adequate supervision and assistance d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on electronic medical record(EMR) review, and interview, the facility did not ensure adequate supervision and assistance devices, or ensure the environment remained free of accident hazards to prevent accidents for 1 (R4) of 2 Residents reviewed for falls.
*R4 had a fall on 4/11/24 where the root cause of the fall was not determined, the facility did not complete documentation of the fall including witness statements and a registered nurse (RN) assessment and interventions were not not reviewed or initiated.
Findings Include:
The facility's Fall policy dated 12/2017 and last revised 7/2023 documents:
.The licensed nurse shall document the fall in the Resident's clinical record.
The documentation of the identified interventions should be maintained in the Resident clinical record and available to the direct care associates.
The falls should be reviewed at the Daily Stand-up Meeting following the fall for identification of any additional individualized interventions to reduce the risk of falls.
An incident report shall be completed for Resident falls by a Licensed Nurse after the fall occurs.
R4 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease, Stage 3, Chronic Diastolic Heart Failure, Anemia in Chronic Kidney Disease, Type 2 Diabetes Mellitus, Repeated Falls, and Hyperlipidemia.
R4's admission Minimum Data Set (MDS) completed on 4/4/24 documents R4 had a Brief Interview for Mental Status (BIMS) score of 13 indicating R4 was cognitively intact for daily decision making. R4 had no mood or behaviors documented on the MDS. R4's MDS documents that R4 has range of motion impairment on both sides of upper extremities and impairment on 1 side of lower extremity. R4 required supervision for rolling left to right, lying to sitting, chair/bed-to-chair transfers, and toilet transfers. R4 required partial/moderate assistance for sit to lying and sit to stand.
R4's fall assessment dated [DATE] documents a score of 35. The fall assessment states 16-35 is moderate risk for falls and 36 and over is high risk for falls.
R4 had an at risk for falls care plan.
R4's EMR documents on 4/11/24, at 3:00 PM, Assistant Director of Nursing(ADON)-C .was called to parking lot by physical therapist to assist with witnessed fall. Upon arrival, R4 was found laying in supine position, legs extended toward hood of car and head toward trunk of car with head on cushion. With assist of four staff and gait belt, R4 was brought to sitting position. With assist of four staff, gait belt, as well as stand by assist of one therapist, R4 assisted back to wheelchair. Escorted inside and back to room.
On 6/19/24, at 1:26 PM, Director of Nursing (DON)-B confirmed that DON-B was unable to locate R4's fall investigation.
On 6/19/24, at 2:38 PM, DON-B explained to Surveyor what needs to be completed when a Resident falls. A nurse should do an assessment. An SBAR (situation, background, assessment, and recommendation) document is completed. DON-B stated that all staff should provide statements and a fall packet with investigation is completed on the Resident. The fall is reviewed for immediate intervention and then the next day the fall is reviewed by the interdisciplinary team to determine if any other interventions need to be initiated. At this time, Surveyor shared with DON-B and Nursing Home Administrator (NHA)-A that R4 fell on 4/11/24 and there is no fall investigation with documentation that a nurse assessment was completed, no staff statements, no root/cause analysis was completed. No additional information was provided by the facility at this time as to why the facility did not complete a fall investigation for R4's fall on 4/11/24.
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, interview, and record review the facility did not ensure 1 (R1) of 1 residents received medically related ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure 1 (R1) of 1 residents received medically related social services to attain or maintain their highest practicable physical, mental and psychosocial well being.
R1 was admitted to the facility on [DATE] with an order for Seroquel. The Facility was not monitoring the effectiveness of multiple medication changes with R1's Seroquel, Buspar & Depakote. The Facility did not determine the root cause of R1's anxiety and did not develop patient center approaches to help R1 with her anxiety.
Findings include:
R1 was admitted to the facility on [DATE] with diagnoses which includes right femur fracture and dementia.
[R1's first name] is at risk for <increased behavioral expressions||altered mood||elopement||impaired adjustment ability to new environment> care plan with a start date of 4/26/24 documents the following approaches:
* Follow community elopement evaluation and monitoring process. Dated 4/26/24.
* Identify current mood and behavioral expressions, monitor for changes. Dated 4/26/24.
* Orient [R1's first name] to community layout, routines, and schedules.
[R1's first name] has memory problems, impaired decision making skills and impaired ability to comprehend, confused and forgetful, own person, dx (diagnosis) severe dementia care plan with a start date of 5/1/24 documents the following approaches:
* Call resident by name. Dated 5/1/24.
* Daily orientation to facility routines and activities schedule. Dated 5/1/24.
* Use environmental cues (e.g. pictures, signs, clocks, calendars, color coding of environment) to stimulate memory and promote appropriate behavior. Dated 5/1/24.
* Provide cues to promote independence and ensure safety. Dated 5/1/24.
* Provide consistent physical environment and daily routine. Dated 5/1/24.
The admission MDS (minimum data set) with an assessment reference date of 4/30/24 has a BIMS (brief interview mental status) score of 3 indicating R1 has severe cognitive impairment. R1 is assessed as not having any behavior and mood score is 00.
The behavioral symptoms CAA (care area assessment) dated 6/11/24 documents Behavioral CAA triggered due to (resistant to care, wanders, yells out). Contributing factors include (Dementia, Disorientation, and decreased ability to understand others). Risk factors include injuring self/others, decreased socialization, social isolation and increased anxiety. Care plan will be reviewed to monitor behavior patterns, decrease agitation and monitor the effectiveness.
The Psychotropic Drug Use CAA dated 6/11/24 documents Psychotropic Drug Use CAA triggered secondary to use of psychotropic med (medication) to manage psychiatric illness/condition. Contributing factors include (depression/psychosis/insomnia). Risk factors include increase falls, impaired balance, and potential for adverse effects of medication. care plan will be reviewed to monitor effectiveness of psychotropic medications.
APNP (Advanced Practice Nurse Prescriber)-H's initial visit note dated 4/30/24 under assessment and plan for F03.90 Dementia documents Advance continue current regimen of Seroquel. Monitor mood and behavior needs frequent reorientation and redirection.
The social services note dated 4/30/24, at 09:28 (9:28 a.m.), documents writer faxed psych referral to [name] solutions, and asked that res (resident) be placed on the next visit list. This nurses note was written by SSD (Social Service Director)-D.
APNP-H's progress note dated 5/1/24 under assessment and plan for F03.90 Dementia documents Advance continue current regimen of Seroquel. She needs frequent reorientation and redirections. Seroquel dose reduce today to 12.5 mg for 1 week then plan to dc (discontinue). Monitor mod sic (mood) and bx (behavior) closely.
The social services note dated 5/1/24, at 11:19 a.m., documents care conference: present: res (resident), writer, [name] therapy, [name] [name] health, [name] DON (Director of Nursing).
full code, own person, dc (discharge) goal: home with son to the community, mood and behavior stable, on Seroquel for anxiety, has psych consult pending for clarification of Seroquel dx (diagnosis), has fall mats, air mattress, bilateral bars to bed, gets pt/ot/st (physical therapy/occupational therapy/speech therapy), has hard time standing, res states she does have pain at times, 2 person assist for transfers, needs a lot of assist with dressing and cares, has right hip area to skin from surgery, care plan and physician orders reviewed, copies given to res, nursing will check with np (nurse practitioner) about scheduling Tylenol for res. [name] stated that he will manage res insurance case, while res is at facility, more progress is expected in therapy. This note was written by SSD-D.
The nurses note dated 5/1/24, at 1514 (3:14 p.m.), documents Resident has N.O. (new order) to decrease Quetipine (Seroquel) 25 mg (milligrams) to 12.5 mg x (times) 1 week and then D/C. No s/s (signs/symptoms) of distress noted, will continue to monitor. This nurses note was written by LPN (Licensed Practical Nurse)-K.
APNP-H's progress note dated 5/3/24 under assessment and plan for F03.90 Dementia documents Advance continue current regimen of Seroquel. She needs frequent reorientation and redirections, Seroquel dose reduce to 12.5 mg for 1 week then plan to dc on 5/8/24. Monitor mod sic (mood) and bx closely.
The nurses note dated 5/9/24, at 0600-_30 (6:00 a.m.-_30), documents Resident is more confused and constantly need to know why she is here. She is told & redirected but continues to ask. without s/s (signs/symptoms) of distress will continue to monitor. This nurses note was written by LPN-K.
APNP-H's progress note dated 5/10/24 under assessment and plan for F03.90 Dementia documents Advance continue current regimen of Seroquel. She needs frequent reorientation and redirections. Seroquel dose reduce to 12.5 mg for 1 week then plan to dc on 5/8/24. Staff reported that pt is noted anxious at times, however, no ssx (signs/symptoms) of anxiety/distress was noted. Per the staff nurse the mood had improved.
The nurses note dated 5/11/24, at PM (evening), documents Pt (patient) is extremely anxious and concerned about being lost and along. Needs frequent reassurance.
APNP-H's progress note dated 5/14/24 under chief complaint documents fall on 5/12, anxiety. Under subjective documents Patient resting in the WC (wheelchair), working with ST (speech therapy). Denies pain/discomfort during this visit. S/p (status post) fall on 5/10/24 denies injury. Per staff patient was noted and changed on several occasions after discontinuing Seroquel. Patient is started on Buspar 5 mg twice daily, mood and behavior remain stable during this visit. Recent labs reviewed. Under assessment and plan for F03.90 Dementia documents Advance continue current regimen of Seroquel. She needs frequent reorientation and redirections. Seroquel reduced and taper off on 5/8/24. F41.9 Anxiety.
APNP-H's progress note dated 5/17/24 under chief complaint documents fall on 5/12, anxiety. Under subjective documents Patient resting in the WC, per staff pt is anxious at times. Recently started on Buspar. Pending liver panel, plan to start pt on Depakote for persistent perseveration's elicit negative behaviors irritability, agitation. Under assessment and plan for F03.90 Dementia documents Advance continue current regimen of Seroquel. She needs frequent reorientation and redirections. Seroquel reduced and taper off on 5/8/24. F41.9 Anxiety: See above HPI (history present illness), recently started on Buspar. Pending liver panel today, play to start pt on Depakote 125 mg Q HS. Psych referral pending.
The nurses note dated 5/18/24, at 0500 (5:00 a.m.) documents Patient was confused and not sleeping until 0300 (3:00 a.m.). Patient stating she needs help but not able to verbalize what she needed help with. Patient was helped with toileting w/ (with) assist x 2 and then helped into bed. Son stayed at bedside until patient was sleeping. Patient currently in bed @ (at) lowest position. Floor mat next to bed, call light within reach.
The nurses note dated 5/19/24, at NOC (night) shift, documents Resident has a new order for Melatonin 3 mg @ HS (hour sleep) x 7 days. Son/POA (power of attorney) left after resident fell asleep at approx (approximately)0100 (1:00 a.m.), had concerns about his mothers state. [name]/POA stated that resident is ore restless and agitated and would like her to have Buspar increased to TID (three times daily) or re-start on Seroquel, [POA first name] has reservations about starting her on Depakote. Writer will pass on to AM (morning) nurse and leave a note for [APNP-H's first name].
The nurses note dated 5/21/24, at 0930 (9:30 a.m.), Per [APNP-H's name] NP Buspar increased to 7.5 mg po (by mouth) TID. Unit nurse notified. This nurses note was written by ADON (Assistant Director of Nursing)-C.
The nurses note dated 5/25/24, at 2159 (9:59 p.m.), documents Writer was approach by son tonight with concern regarding mother state his mother has been calling him and his sister every night crying stating she wants to leave. Son requested mother to be restarted on her Seroquel. Son stated since the Seroquel has been stopped mother is more agitated. Call was placed out to MD (medical doctor) awaiting return call.
The nurses note dated 5/25/24, at 2210 (10:10 p.m.), documents MD returned call and was updated on resident's status and gave new orders to restart Seroquel in am (morning) and d/c Buspar also gave 1x order for hydroxine 25 mg. Daughter is aware of new orders.
The nurses note dated 5/26/24, at 2100 (9:00 p.m.), documents Resident anxious at times but easily redirected. In bed resting at this time. Son at bedside. Schedule Seroquel given ppoc (per plan of care). Consumed 30% of dinner, 240 cc (cubic centimeters) of ensure.
The nurses note dated 5/29/24, at 1422 (2:22 p.m.), documents Per [name of APNP-H] order to decrease Seroquel to 12.5 mg po q hs (by mouth every hour sleep) x 4 days then discontinue and initiate Depakote 125 mg po q hs. Son made aware. Unit nurse notified. This nurses note was written by ADON-C.
APNP-H's progress note dated 5/31/24 under chief complaint documents anxiety. Under subjective documents Patient is sitting in the WC, noted in pleasant mood. Recently increased Buspar, per family mood and bx are not improving. Pt continues to get anxious. A Depakote option is discussed with the family, POA agreed to initiate a Depakote, plan to start Depakote from 6/2 after dc Seroquel. Patient needs frequent reorientation and redirection. Under assessment and plan for F03.90 Dementia documents She needs frequent redirections and reorientation. POA activated. F41.9 Anxiety documents See above HPI, recently started on Buspar, increased to TID. Plan to start Depakote 125 mg Q HS after tapering and dc Seroquel (6/2).
The nurses note dated 6/2/24, at PM, documents Resident A & O (alert and oriented) denies pain or discomfort. No s/s of respiratory issues. N.O. (new order) r/t (related to) Depakote. No A/R (adverse reactions) noted. Buspar & Seroquel discontinued, no A/R noted. Afebrile.
The nurses note dated 6/3/24, at 2100 (9:00 p.m.), documents after dinner resident became more confused. Hard to redirect. Resident up & down in & out of bed calling for [name] and made several request to call the police. Returned resident back to bed. Resident go (sic) back in wheelchair.
The nurses note dated 6/4/24, at 0700 (7:00 a.m.) documents Con't (continue) to monitor client for discontinuation of Seroquel & Depakote administration. Without adverse reaction noted increased bx (behavior) noted at the beginning of the shift. 1:1 initiated will monitor.
The nurses note dated 6/4/24, at 2012 (8:12 p.m.) documents No adverse reaction to medication change repetitive behaviors noted. Daughter [name] at bedside helping redirect behaviors.
APNP-H's progress note dated 6/5/24 under chief complaint documents anxiety. Under subjective documents Patient noted resting in a wheelchair, requesting to go home. Needs frequent reminders and reorientation. Recent start of Depakote, per staff mood is improving. Pending psych consultation. Under assessment and plan for F03.90 Dementia documents She needs frequent redirections and reorientation. POA activated. Psych consultation pending. F41.9 Anxiety documents. See above HPI, recently started on Buspar, increased to TID. Plan to start Depakote 125 mg Q HS after tapering and dc Seroquel (6/2). Psych consultation pending. See above HPI, improvement in mood reported.
APNP-H's progress note dated 6/5/24 under chief complaint documents anxiety. Under subjective documents Pt is continue to ask when she can return home. No new medical concern reported. Staff to obtain sleep study. Recent dc Buspar and Seroquel. Under assessment and plan for F03.90 dementia documents She needs frequent redirections and reorientation. POA activated. Psych consultation pending. F41.9 Anxiety documents See above HPI, recently started on Buspar, increased to TID. Depakote 125 mg Q HS, Seroquel dcd (6/2). Psych consultation pending. Continue to need frequent reorientation and redirection's. Encourage participation different activities.
The social services note dated 6/18/24, at 11:53 (11:53 a.m.), documents behavior management held, IDT (interdisciplinary team) present, saw psych today, Seroquel was d/c and Buspar was d/c, res only receives scheduled Depakote, res does want to go home, but doesn't have 24 hour care at home per family, sleeping varies, nursing will do a sleep study, will be reviewed in July 2024. This note was written by SSD-D.
During R1's record review, Surveyor was unable to locate monitoring of R1's Seroquel, Buspar, and Depakote for behavior &/or mood nor was Surveyor able to locate the root cause of R1's anxiety or person centered approaches to help decrease R1's anxiety.
On 6/18/24, at 10:00 a.m., Surveyor observed R1 sitting in a wheelchair in her room. Surveyor asked R1 what she is going to do today. R1 informed Surveyor she wants to leave here and go home.
On 6/19/24, at 7:46 a.m., Surveyor asked CNA (Certified Nursing Assistant)-L what she could tell Surveyor about R1. CNA-L informed Surveyor she has dementia, very sweet, calls out a couple times at night asking where she is, and works with therapy. CNA-L informed Surveyor R1 calls out when she needs something and has a lot of visitors. Surveyor asked CNA-L if R1 has any behavior. CNA-L replied no, very sweet.
On 6/19/24, at 11:16 a.m., Surveyor observed R1 sitting in a wheelchair in the bathroom of her room. Surveyor asked R1 what she was doing. R1 replied I think I was turning the light off.
On 6/19/24 at approximately 11:30 a.m. Surveyor asked APNP-H about R1. APNP-H informed Surveyor R1 is every pleasant & forgetful and R1's son is very involved. APNP-H informed Surveyor due to R1's anxiety they have tried several medications. APNP-H explained R1 was admitted with Seroquel but didn't have psych diagnosis . The medication was tapered off and discontinued. R1 has an unstable mood and was started on Depakote, she was previous on Buspar for anxiety but the Buspar wasn't effective. APNP-H informed Surveyor she saw R1 yesterday and thinks she was seen by psych.
On 6/19/24 at 12:03 p.m. Surveyor spoke with ADON-C regarding R1. ADON-C informed Surveyor R1 is very confused and anxious. R1 came in on Seroquel, did not have qualifying diagnosis and the medication was discontinued. ADON-C informed Surveyor the family is very involved and kind of feels they fuel the fire as R1 gets more anxious when the family is there. ADON-C informed Surveyor R1 was started on Depakote which is a good choice as R1 doesn't have agitated behaviors. Surveyor asked ADON-C if the CNAs document regarding R1's anxiety or behavior. ADON-C informed Surveyor they don't document this and they can tell the nurses. The nurses would document and should be documenting if R1 is stable or has behaviors. Surveyor informed ADON-C Surveyor was unable to locate what the root cause of R1's anxiety, approaches to help R1 with her anxiety and monitoring of the effectiveness of the medications ordered for her anxiety.
On 6/19/24 at 2:38 p.m. Surveyor informed NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and ADON-C Surveyor wasn't able to locate how the facility was monitoring the effectiveness of medication R1 was placed on for her anxiety, the root cause of R1's anxiety and approaches the facility had implemented to help R1 with her anxiety.
On 6/20/24 at 7:31 a.m. Surveyor spoke with SSD-D regarding R1. SSD-D informed Surveyor R1's family is very involved. R1 was admitted for short term care but needs twenty four hour care. R1 is confused, her POA is activated and R1 likes to wander around. R1 can be anxious at times, wants to go home. The family would take her home but they don't have 24 hour care for R1. Surveyor asked if R1 has any aggressive behavior or verbal outbursts. SSD-D replied no. Surveyor asked SSD-D how they are monitoring R1's anxiety. SSD-D informed Surveyor it should be through the nurses notes. SSD-D informed Surveyor R1's family says she's anxious & wants to go home but he sees her wandering around.
No additional information was provided to Surveyor why the facility was not monitoring the effectiveness of R1's Seroquel, Buspar or Depakote, what was the root cause of R1's anxiety and approaches implemented to help R1 with her anxiety.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R8 was admitted to the facility on [DATE] with diagnoses of Aphasia Following Cerebral Infarction, Chronic Kidney Disease, S...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R8 was admitted to the facility on [DATE] with diagnoses of Aphasia Following Cerebral Infarction, Chronic Kidney Disease, Stage 3, Unspecified Atrial Fibrillation, Type 2 Diabetes Mellitus, Anorexia, Major Depressive Disorder, and Anxiety Disorder. R8 had an activated Health Care Power of Attorney (HCPOA) while at the facility. R8 expired in the facility on [DATE].
Surveyor reviewed R8's electronic medical record (EMR) and notes that the last nursing progress notes is [DATE].
Surveyor notes the last written nursing progress is dated [DATE], at 5:30 PM, which documents registered nurse was called to R8's room by certified nursing assistant stating that R8 had vomit on gown. Family at bedside and hospice was updated.
Surveyor notes there is no written note when R8 expired and the circumstances of R8's death.
3.) R9 was admitted to the facility on [DATE] with diagnoses of Dysphagia, Oral Phase, Hypertensive Chronic Kidney Disease, Cerebral Palsy, Anemia, and Insomnia. R9 was her own person while at the facility. R9 expired in the facility on [DATE].
Surveyor reviewed R9's electronic medical record (EMR) and notes that the last nursing progress notes is [DATE].
Surveyor notes there is no written progress notes after [DATE] and no written note when R9 expired and the circumstances of R9's death.
On [DATE], at 8:11 AM, HIM-F informed Surveyor that HIM-F is unable to locate any written documentation for R8 and R9 of when and the circumstances of both R8 and R9's death in the facility. Surveyor notes there is no hospice documentation in the facility that documents when both R8 and R9 expired and the circumstances of their death.
On [DATE], at 3:53 PM, Director of Nursing (DON)-B and Nursing Home Administrator (NHA)-A were informed of the concern by Surveyor that the facility is unable to locate written medical records which would have documented R8 and R9's death with details. At this time, no further information was provided by the facility as to the circumstances of the missing medical records of R8 and R9.
Based on interview and record review, the facility did not maintain records that were complete and accurately documented for 3 (R12, R8, & R9) of 6 residents reviewed who expired in the facility.
* R12 expired in the facility on [DATE] and there is no documentation in R12's medical record regarding R12's death.
* R8 expired in the facility on [DATE] and there is no documentation in R8's medical record regarding R8's death.
* R9 expired in the facility on [DATE] and there is no documentation in R9's medical record regarding R9's death.
Findings include:
The facility's policy titled, Guidelines for Charting and Documentation last revised 1/2018 under policy statement documents Services provided to the resident, or changes in the resident's medical or mental condition, shall be documented in the resident's medical record.
Under the section for Purpose documents
The purpose of charting and documentation is to provide:
A. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., and the progress
of the resident's care;
B. Guidance to the physician in prescribing appropriate medications and treatments;
C. The community, as well as other interested parties, with a tool for measuring the quality of care provided to the
resident;
D. Nursing service personnel with a record of the physical and mental status of the resident;
E. Assistance in the development of a Plan of Care for each resident;
F. A legal record that protects the resident, care providers, and the community; and
G. A source for resident charges.
Under General Rules for Charting and Documentation includes documentation of
A. Chart pertinent changes in the resident's condition, reaction to treatments, medication, services performed, etc.,
as well as routine observations.
On [DATE], Surveyors were notified by Health Information Management (HIM)-F starting on [DATE], the facility was involved in a large cyber attack of their medical records. The facility then switched to paper charting and was able to get back on electronic medical record (EMR) as of [DATE].
1.) R12 was admitted to the facility on [DATE] and expired in the facility on [DATE].
Diagnoses includes hemiplegia following cerebral infarction, hypertension, and dementia. R12 received hospice services.
Surveyor reviewed R12's medical record and noted the last nurses note in R12's medical record is dated [DATE] PM (evening) which documents Resident slept throughout most of the shift but woke up briefly and ate about 25% of her supper and drank about 450 cc (cubic centimeters) of fluids in total this shift. Chest congestion noticeable. PRN (as needed) Levsin given continue to monitor.
There is a notice of removal of a human corpse from a facility form dated [DATE] at 12:10 p.m.
On [DATE] at 2:23 p.m. Surveyor informed HIM (Health Information Management)-F R12 expired in the Facility on [DATE] and the last nurses note Surveyor was able to locate was dated [DATE]. Surveyor informed HIM-F Surveyor was unable to locate any documentation regarding R12's death. HIM-F informed Surveyor this was all she could find.
On [DATE] at 4:27 p.m. NHA (Nursing Home Administrator)-A and DON (Director of Nursing)-B were informed Surveyor was unable to locate any information documented in R12's medical record regarding R12's death.
No additional information was provided as to why the facility did not ensure R12 had complete and accurate documentation in their medical record.
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 F0887
(Tag F0887)
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 was offered a COVID 19 immunization for 2 (R6 & ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure each resident was offered a COVID 19 immunization for 2 (R6 & R10) of 11 residents reviewed for their COVID 19 immunization.
Findings include:
The facility's policy titled, Vaccination of Residents (Example: Pneumococcal, Influenza, Covid-19) last revised 7/2023
under policy statement documents:
Residents will be educated about and offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has current up to date vaccine status.
A. Residents will be educated about and offered vaccines in accordance with the CDC (Centers for Disease Control
and prevention) and attending physician recommendations to aid in preventing infectious diseases unless the
vaccine is medically contraindicated or the resident has current up to date vaccine status.
B. Prior to receiving vaccinations, the resident or resident representative will be provided information and education
regarding the benefits and potential side effects of the vaccinations. (See current vaccine information statements
and EUA (emergency use authorizations) Fact Sheets at https://www.cdc.gov/vaccine/hcp/vis/current-vis.html for
educational materials.)
C. Provision of such education shall be documented in the resident's medical record.
D. Residents/resident representatives may sign a consent/refusal form for vaccinations.
E. New residents will be assessed for current vaccination status upon admission.
1.) R6 was admitted to the facility on [DATE]. R6 has a guardian.
The admission MDS (minimum data set) with an assessment reference date of [DATE] has a BIMS (brief interview mental status) score of 13 which indicates cognitively intact.
The nurses note dated [DATE], at 2120 (9:20 p.m.), documents Lab result received and resident tested positive for Coronavirus. NP (Nurse Practitioner) notified, isolation was put in place. Afebrile but cough. Continue to monitor.
The nurses note dated [DATE], at 2115 (9:15 p.m.), documents Resident resident remains in isolation precaution r/t (related to) Covid + (positive). Resident c/o (complained of) throat hurting, chill, afebrile, lung sound clear bilateral. No SOB (shortness of breath), no acute respiratory distress. All cares rendered in residents room.
The nurses note dated [DATE], at 2005 (8:05 p.m.), documents Resident remains in isolation precautions for + Covid. Asymptomatic, afebrile, no respiratory distress or coughing. All cares render in the residents room.
Surveyor reviewed R6's medical record and was unable to locate any evidence where R6 and/or R6's guardian was offered the Covid 19 immunization.
On [DATE], at 10:00 a.m., Surveyor met with RN (Registered Nurse)/Quality Management Director-E to discuss Resident's Covid 19 immunizations. Surveyor inquired about R6 who was admitted on [DATE]. Surveyor informed RN/Quality Management Director-E Surveyor was unable to locate evidence where R6 and/or R6's guardian was offered the Covid 19 immunization. RN/Quality Management Director-E informed Surveyor he was unable to get a consent and their system was down so it was hard to look at R6's past immunization history. RN/Quality Management Director-E informed Surveyor he spoke with R6 today and she declined as she had Covid and didn't want any more needles. RN/Quality Management Director-E informed Surveyor R6's last Covid vaccination was [DATE].
2.) R10 was admitted to the facility on [DATE]. R10 expired in the Facility on [DATE] and was reviewed as a closed record.
R10's POA (power of attorney) for healthcare was activated on [DATE].
On [DATE], at 10:00 a.m., Surveyor met with RN (Registered Nurse)/Quality Management Director-E to discuss Resident's Covid 19 immunizations. Surveyor informed RN/Quality Management Director-E Surveyor was unable to locate evidence where R10 and/or R10's POA was offered the Covid 19 immunization. RN/Quality Management Director-E informed Surveyor R10 had Covid in the fall. RN/Quality Management Director-E explained R10 was missed as he couldn't find the POA to give consent and sometimes the POA sends back the consents a month or two later. RN/Quality Management Director-E informed Surveyor he did receive a consent back. R10's POA signed the consent for R10 to receive the Covid immunization on [DATE]. RN/Quality Management Director-E informed Surveyor at this time to order the Covid vaccine they had to order three packs which was 30 doses so he had to try to get 30 people. The CDC then extended the expiration date to April/May. Now one package of 10 doses can be ordered and vaccine can be refrigerated for a month. RN/Quality Management Director-E informed Surveyor he has to make sure have 10 residents as each dose is $135.00. RN/Quality Management Director-E stated she was just missed.
On [DATE] RN/Quality Management Director-E provided Surveyor with R10's vaccine history and consent form. Surveyor noted R10 had received Covid 19 immunizations on [DATE], [DATE], & [DATE]. Surveyor noted I wish for the above resident to received COVID-19 vaccination if it is determined that he/she does not have adequate protection is circled. This vaccine history and consent form was signed by R10's POA on [DATE].
No additional information was provided as to why the facility did not ensure R6 & R10 was offered and/or received their Covid 19 immunization.
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 F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility did not ensure privacy and confidentiality of personal health information for 9 (R13, R14, R15, R16, R17, R19, R1, R6, & R18) of 9 residents.
On 6/18/2...
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Based on observation and interview, the facility did not ensure privacy and confidentiality of personal health information for 9 (R13, R14, R15, R16, R17, R19, R1, R6, & R18) of 9 residents.
On 6/18/24 Cluster C report sheet for R13, R14, R15, & R16 dated 6/17/24, Cluster D report sheet for R17, R19, R1, R6, & R18 dated 6/17/24 and CNA (Certified Nursing Assistant) worksheet dated 6/12/24 for R6, R18, R14, R17, R19, & R1 were observed on the round table in the dining area located on the D unit during multiple observations. These report sheets and CNA worksheets contained personal resident information.
Findings include:
On 6/18/24, at 10:06 a.m., Surveyor observed on the round table, in the small dining area on the D unit, a C cluster report sheet dated 6/17/24 with R13, R14, R15, & R16's name along with their physician name and if they were their own person. There is also a D cluster report sheet dated 6/17/24 with the same information for R17, R19, R1, R6, & R18. Under the C & D cluster report sheets is a CNA (Certified Nursing Assistant) worksheet for Wednesday 6/12/24. This CNA worksheet dated 6/12/24 includes sections for cognition/behavior & appliances, transfers and ambulation mobility, bathing/hygiene/dressing, diet/special instructions, toileting, and preferences with personal information on care requirements for R6, R18, R14, R17, R19, & R1. Surveyor observed there are no staff in this area.
On 6/18/24, at 10:29 a.m., Surveyor observed the C cluster report sheet dated 6/17/24 with personal information for R13, R14, R15, & R16, the D cluster report sheet dated 6/17/24 with personal information for R17, R19, R1, R6, & R18 and the CNA worksheets dated 6/12/24 with personal information on care requirements for R6, R18, R14, R19, & R1 continued to be on the round table in the small lounge area dining area on the D unit. Surveyor observed there are no staff in this area.
On 6/18/24, at 10:45 a.m., Surveyor observed the C cluster report sheet dated 6/17/24 with personal information for R13, R14, R15, & R16, the D cluster report sheet dated 6/17/24 with personal information for R17, R19, R1, R6, & R18 and the CNA worksheets dated 6/12/24 with personal information on care requirements for R6, R18, R14, R19, & R1 continued to be on the round table in the small lounge area dining area on the D unit. Surveyor observed there are no staff in this area.
On 6/18/24, at 12 47 p.m., Surveyor observed the C cluster report sheet dated 6/17/24 with personal information for R13, R14, R15, & R16, the D cluster report sheet dated 6/17/24 with personal information for R17, R19, R1, R6, & R18 and the CNA worksheets dated 6/12/24 with personal information on care requirements for R6, R18, R14, R19, & R1 continued to be on the round table in the small lounge area dining area on the D unit. Surveyor observed there are no staff in this area.
On 6/18/24, at 3:21 p.m., Surveyor observed the C cluster report sheet dated 6/17/24 with personal information for R13, R14, R15, & R16, the D cluster report sheet dated 6/17/24 with personal information for R17, R19, R1, R6, & R18 and the CNA worksheets dated 6/12/24 with personal information on care requirements for R6, R18, R14, R19, & R1 continued to be on the round table in the small lounge area dining area on the D unit. Surveyor observed there are no staff in this area.
On 6/19/24 at 12:29 p.m. Surveyor asked ADON (Assistant Director of Nursing)-C if the cluster report sheets and CNA worksheets should be left unattended on a table on the unit. ADON-C replied no, absolutely not. Surveyor informed ADON-C of the observations on 6/18/24 of C & D cluster report sheets and CNA worksheets being left on the round table in the dining area.
On 6/19/24, at 2:38 p.m., NHA (Nursing Home Administrator)-A, DON (Director of Nursing)-B and ADON-C were informed of the above.
No additional information was provided to Surveyor as to why personal information for R13, R14, R15, R16, R17, R19, R1, R6, & R18 was left on the round table in the dining area on the D unit for anyone to see.
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 F0940
(Tag F0940)
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 develop, implement, and maintain an effective training program for al...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop, implement, and maintain an effective training program for all facility and contracted staff consistent with their expected roles and based on the facility assessment for 8 of 8 facility staff. (Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W.
The facility does not have an effective training program and does not maintain documentation of staff completing the required training's.
Findings include:
The facility was unable to provide a policy and procedure in regards to the required training's.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics .
The facility's facility assessment does not document all the required training's are provided as required.
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of Physical Therapist (PT)-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that Physical Therapist (PT)-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W received all the required training's since their hire date.
PT-X-date of hire 3/13/18
DIET-Y-date of hire 3/7/01
RN-N-date of hire 11/5/15
CNA-O-date of hire 6/6/23
CNA-T-date of hire 9/29/22
CNA-U-date of hire 11/28/17
CNA-V-date of hire 6/22/21
CNA-W-date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no formal program in place for all required training's to be completed for PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W had all not received the required training's. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no formal effective training program for all required training's. The facility did not provide any additional information in regards to the development of a formal effective training program and the facility has not been maintaining records of staff required training's at this time.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
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 6 direct staff chosen at random received communication tr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure 6 of 6 direct staff chosen at random received communication training. Registered Nurse (RN)-N, Certified Nursing Assistants (CNA) CNA-O, CNA-T, CNA-U, CNA-V and CNA-W did not receive communication training.
This has the potential to affect the 8-10 residents who reside on each unit where RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned.
Findings include:
The facility was unable to provide a policy and procedure in regard to Communication training
The facility's 2023 MyLearning-Required Annual Training Assignment Schedule does not include Communication training as a required training.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics
-Communication-effective communication for direct care staff .
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W received any Communication training since their hire date.
RN-N - date of hire 11/5/2015
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented communication training completed for RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W had not received Communication training. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation Communication training was provided to RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility did not provide any additional information in regards to the direct care staff not receiving Communication training at this time.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual Abuse/Neglect/Exploitation and Dem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual Abuse/Neglect/Exploitation and Dementia training: Dietary (DIET)-Y, Certified Nursing Assistants (CNA), CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect 8-10 residents who reside on each unit where CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned.
The facility did not provide staff with the required annual Abuse/Neglect/Exploitation and Dementia training.
Findings include:
The facility was unable to provide a policy and procedure in regard to Abuse/Neglect/Exploitation and Dementia training.
The facility's 2023 MyLearning-Required Annual Training Assignment Schedule includes Dementia Care: Understanding Alzheimer's Disease and Preventing, Recognizing and Reporting Abuse as a required training.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics
-Abuse, neglect, and exploitation-training that at a minimum educates staff on-(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of Resident Property; (2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of Resident property; and (3) Care/management for persons with dementia and Resident abuse prevention.
The facility's facility assessment does not document Dementia as a training topic.
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of DIET-Y, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that DIET-Y, CNA-T, CNA-U, CNA-V, and CNA-W received any Abuse/neglect/Exploitation and Dementia training since their hire date.
DIET-Y - date of hire 3/7/2001
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented Abuse/Neglect/Exploitation and Dementia training completed for DIET-Y, CNA-T, CNA-U, CNA-V, and CNA-W. Further, CNA-O has no documentation CNA-O completed Dementia training. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that DIET-Y, CNA-T, CNA-U, CNA-V, and CNA-W had not received Abuse/Neglect/Exploitation and Dementia training and CNA-O did not complete Dementia training. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation Abuse/Neglect/Exploitation and Dementia training was provided to DIET-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility did not provide any additional information in regard to the staff not receiving Abuse/Neglect/Exploitation and Dementia training at this time.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure that 5 of 5 CNAs (Certified Nursing Assistants) reviewed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure that 5 of 5 CNAs (Certified Nursing Assistants) reviewed completed the required annual 12 hours of educational training hours. (Certified Nursing Assistants (CNA) (CNA-O, CNA-T, CNA-U, CNA-V and CNA-W did not receive annual 12 hours of educational training.
This has the potential to affect the 8-10 residents who reside on each unit where CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W are typically assigned.
Findings include:
The facility was unable to provide a policy and procedure in regard to CNAs receiving 12 hours of educational training
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics
-Required in-service training for nurse aides. In-service training must:
-Be sufficient to ensure continuing competence of nurse aides, but must be no less than 12 hours per year.
-Include dementia management training and Resident abuse prevention training.
-Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of Residents as determined by the facility staff .
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W received the required 12 hours of educational trainings within the year based on hire date.
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented 12 hours of required educational training's completed for CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W had not received the required 12 hours of educational training. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W completed the required 12 hours of educational training. The facility did not provide any additional information in regard to CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W receiving the required 12 hours of required educational training at this time.
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 F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure Certified Nursing Assistants (CNA) had annual performan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure Certified Nursing Assistants (CNA) had annual performance reviews at least once every 12 months for 5 of 5 CNA staff reviewed (CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W). This had the potential to affect all 72 residents in the facility as staff assignments float throughout the facility.
Findings Include:
The facility was unable to provide a policy and procedure in regard to annual performance reviews.
The facility's 2023 MyLearning-Required Annual Training Assignment Schedule documents that there should be Year End Review (All annual education needs to be done no later than 12/31/23). In-Person Annual Performance Review with follow up training for areas of weakness and special needs of residents.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Required in-service training for nurse aides. In-service training must:
-Be sufficient to ensure continuing competence of nurse aides, but no less than 12 hours per year.
Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that a performance review had been completed on an annual basis from each of the CNAs date of hire. Consequently, there is no performance review of each CNA in order to determine performance review of skills competency, in order to provide regular in-service education based on the outcome.
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented performance reviews completed on CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B agreed with Surveyor that there was no competency review documented for the CNAs in order to provide reeducation as indicated.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation that a competency performance review was completed on CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W and agreed reeducation based on outcome of a competency performance review would be beneficial. Both NHA-A and DON-B understand the concern and provided no additional information at this time of the survey process.
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 F0942
(Tag F0942)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual Resident Rights training: Dietary ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual Resident Rights training: Dietary (DIET)-Y, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility.
The facility did not provide staff with the required annual Resident Rights training.
Findings include:
The facility was unable to provide a policy and procedure in regards to Resident Rights training.
The facility's 2023 MyLearning-Required Annual Training Assignment Schedule includes Protecting Resident Rights in Nursing Facilities as a required training.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics
-Resident rights and facility responsibilities-ensure that staff members are educated on the rights of the Resident and the responsibilities of a facility to properly care for its Residents.
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of Dietary (DIET)-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W received any Resident Rights training since their hire date.
DIET-Y - date of hire 3/7/21
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented Resident Rights training completed for DIET-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that DIET-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W had not received Resident Rights training. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation Resident Rights training was provided to DIET-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility did not provide any additional information in regard to the staff not receiving Resident Rights training at this time.
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 F0944
(Tag F0944)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual QAPI training: Dietary (DIET)-Y, P...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual QAPI training: Dietary (DIET)-Y, Physical Therapist (PT)-X, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility.
The facility did not provide staff with the required annual QAPI training.
Findings include:
The facility was unable to provide a policy and procedure in regards to QAPI training.
The facility's 2023 MyLearning-Required Annual Training Assignment Schedule does not include QAPI as a required training.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics .
QAPI is not listed as a training topic in the facility assessment.
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of Physical Therapist (PT)-X, Dietary (DIET)-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W received any QAPI training since their hire date.
PT-X - date of hire 3/13/18
DIET-Y - date of hire 3/7/21
RN-N - date of hire 11/5/15
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented QAPI training completed for PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W had not received QAPI training. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation QAPI training was provided to PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility did not provide any additional information in regard to the staff not receiving QAPI training at this time.
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 F0945
(Tag F0945)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure all employed staff received annual training on written p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure all employed staff received annual training on written policies and procedures of the facility's Infection Control Program.
Dietary (DIET)-Y, Physical Therapist (PT)-X, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W employee files were reviewed. This practice had the potential to affect all 72 residents in the facility.
The facility did not provide the above staff with the required Infection Control training.
Findings include:
The facility was unable to provide a policy and procedure in regards to Infection Control training.
The facility's 2023 MyLearning-Required Annual Training Assignment Schedule documents Infection Control and Prevention should be completed by all staff with a due date of 2/28/23.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics
Infection Control-a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program.' .
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of Physical Therapist (PT)-X, Dietary (DIET)-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that, PT-X, DIET-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W received any Infection Control training since their hire date.
The employee records documented the following:
PT-X - date of hire 3/13/18
DIET-Y - date of hire 3/7/21
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented Infection Control training completed for PT-X, DIET-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that PT-X, DIET-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W had not received any Infection Control training. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation Infection Control training was provided to PT-X, DIET-Y, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W.
The facility did not provide any additional regarding why the above staff did not receive the required Infection Control training.
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 F0946
(Tag F0946)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual Compliance and Ethics training: Ph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual Compliance and Ethics training: Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants(CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility.
The facility did not provide staff with the required annual Compliance and Ethics training.
Findings include:
The facility was unable to provide a policy and procedure in regards to Compliance and Ethics training.
The facility's 2023 MyLearning-Required Annual Training Assignment Schedule does not include Compliance and Ethics as a required training.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics .
The facility's facility assessment does not document Compliance and Ethics training as required.
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of Physical Therapist (PT)-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that Physical Therapist (PT)-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W received any Compliance and Ethics training since their hire date.
PT-X - date of hire 3/13/18
DIET-Y - date of hire 3/7/01
RN-N - date of hire 11/5/15
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented Compliance and Ethics training completed for PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that PT-X, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W had not received Compliance and Ethics training. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation Compliance and Ethics training was provided to PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility did not provide any additional information in regards to the staff not receiving Compliance and Ethics training at this time.
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 F0949
(Tag F0949)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual Behavioral Health training: Physic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure staff received annual Behavioral Health training: Physical Therapist (PT)-X, Dietary (DIET)-Y, Registered Nurse (RN)-N, Certified Nursing Assistants (CNA), CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. This practice had the potential to affect all 72 residents in the facility.
The facility did not provide staff with the required annual Behavioral Health training.
Findings include:
The facility was unable to provide a policy and procedure in regards to Behavioral Health training.
The facility's 2023 MyLearning-Required Annual Training Assignment Schedule does not include Behavioral Health as a required training.
Surveyor reviewed the facility assessment dated [DATE], and last reviewed/updated 12/28/23, the following is documented under Staff Training/education and competencies:
.Staff receive education through new hire orientation process, via My learning, and during in-services. If additional training is needed, individual in-servicing is provided.
Training Topics .
The facility's facility assessment does not document Behavioral Health training as required.
On 7/1/24, at 12:47 PM, Surveyor reviewed the employee records of Physical Therapist (PT)-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility was unable to provide documentation that Physical Therapist (PT)-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W received any Behavioral Health training since their hire date.
PT-X - date of hire 3/13/18
DIET-Y - date of hire 3/7/01
RN-N - date of hire 11/5/15
CNA-O - date of hire 6/6/23
CNA-T - date of hire 9/29/22
CNA-U - date of hire 11/28/17
CNA-V - date of hire 6/22/21
CNA-W - date of hire 6/11/19
On 7/1/24, at 1:38 PM, Director of Nursing (DON)-B confirmed that the facility has no documented Behavioral Health training completed for PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. DON-B stated that there is no specific education/training coordinator and stated, I guess I'm in charge.
On 7/1/24, at 1:51 PM, Surveyor asked DON-B to confirm that PT-X, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W had not received Behavioral Health training. DON-B stated, If I had anything for them, I would give it to you.
On 7/1/24, at 2:55 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A and DON-B that the facility has no documentation Behavioral Health training was provided to PT-X, DIET-Y, RN-N, CNA-O, CNA-T, CNA-U, CNA-V, and CNA-W. The facility did not provide any additional information in regard to the staff not receiving Behavioral Health training at this time.
Apr 2024
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
Deficiency F0678
(Tag F0678)
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 have a system in place to outline staff response in the event of a res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not have a system in place to outline staff response in the event of a resident requiring cardiopulmonary resuscitation (CPR) and the facility did not have a system in place to maintain records documenting agency staff are qualified to perform CPR. This had the potential to affect 34 of 78 residents residing in the facility who have elected their code status to be full code (receive CPR).
* On [DATE] R1 had a change in condition which led to CPR being performed. Registered Nurse (RN)-D left R1 to get the automated external defibrillator (AED) and other nursing staff were not aware of R1's change in condition and need to receive CPR until emergency medical technician (EMT) staff arrived at the facility. RN-D did not have a up to date CPR certification on file at the facility at the time of R1's event.
Findings include:
The facility policy entitled, Procedure: Cardiopulmonary Resuscitation revised 1/2024 states: 1. PURPOSE: To ensure compliance with state and federal guidelines related to emergency response. 2. POLICY: Licensed staff are required to complete and maintain current CPR certification for healthcare providers on the CPR and basic life support (BLS), including defibrillation. D. If an individual . is found unresponsive and not breathing, staff member who is certified in CPR/BLS shall initiate CPR/BLS prior to the arrival of emergency medical services.
R1 was admitted to the facility on [DATE] and had diagnoses that include bradycardia, Syncope and collapse, heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, legal blindness, atherosclerotic heart disease, and vascular dementia.
R1's admission minimum data set (MDS) assessment dated [DATE] indicated R1 had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R1 needing moderate assist with 1 staff member for toileting hygiene and assist of 2 staff members, gait belt, and walker for transfers. R1 was able to make R1's needs known, was legally blind, and physician orders documents R1's code status as Full code/CPR.
On [DATE] at 10:02 AM, in the progress notes nursing charted writer [RN-D] called to R1's room approximately 0943 (9:43 AM) by certified nursing assistant (CNA) to report R1 had fallen off the toilet. RN-D responded to room immediately to find R1 lying on R1's left lateral side next to toilet completely unresponsive, yet breathing and faint femoral pulse felt. 911 was immediately called and AED (automated external defibrillator) and code cart brought to room. Bp (blood pressure) 95/52, P (pulse) 111, RR (respiratory rate) 18, glucose (blood sugar) measurement 204. AED attached and mentioned no shock advised. EMT/fire department on site at approximately 0951 (9:51 AM). Intravenous line and airway established.
On [DATE], Surveyor requested to review the facility self-report related to R1. Surveyor noted a phone interview summary dated [DATE] with RN-D (RN-D is an agency nurse) that documents RN-D was notified by the CNA that there was a significant fall involving R1. RN-D responded immediately with two CNA's. RN-D began assessing R1 and confirmed presence of a carotid pulse and observed respirations. RN-D instructed one of the CNAs to go get the crash cart and instructed someone to call 911, RN-D then left the room to go get the AED, bp monitor, glucometer and indicated R1 was still breathing and had a pulse when RN-D left the room. RN-D applied the AED and analysis advised No Shock advised, RN-D assessed R1 again indicated a loss of pulse and that is when RN-D initiated CPR until Emergency medical services arrived.
On [DATE] at 11:38 Am, Surveyor called and left a voicemail message with a return phone number for RN-D. RN-D did not return Surveyors phone call.
On [DATE] at 12:09 PM, Surveyor interviewed CNA-F who stated CNA-F assisted CNA-G with taking R1 to the bathroom and seated on the toilet. CNA-F stated CNA-F left the room to tend to other residents. CNA-F stated CNA-G came to get CNA-F and stated R1 fell off the toilet. CNA-F stated on the way back to R1's room they told RN-D, and all went to R1's room. CNA-F stated RN-D told CNA-G to go get the crash cart and medication cart. CNA-F stated CNA-F then went to help the resident across the hall to get back into their room because of the commotion. CNA-F stated when CNA-F got back to R1's room, RN-D had applied the pads to R1's chest. CNA-F stated the AED was saying something but could not remember what it was saying, CNA-F stated R1 was making snoring noises and when R1 stopped making noises RN-D reassessed R1 and then started CPR until the EMTs arrived. Surveyor asked if anyone was alerted to get another nurse to assist RN-D or alert other staff members. CNA-F stated no and they just stayed incase RN-D needed anything else. Surveyor asked if R1 was left alone in the bathroom and any time during the incident. CNA-F stated CNA-F was unsure, CNA-F stated that someone was always in room when CNA-F was in the bathroom. Surveyor asked CNA-F what the process was if staff came upon a resident that was unresponsive. CNA-F responded that CNA-F would get the nurse and stay with the resident if able until someone arrived and then follow direction.
On [DATE] at 12:27 PM, Surveyor interviewed CNA-G who stated CNA-G stayed in R1's bedroom after getting R1 on the toilet. CNA-G stated R1's bathroom door was left open, but R1 liked to have privacy when using the toilet. CNA-G made R1's bed, checked in with R1 and then sat in a chair in R1's bedroom. CNA-G stated R1 pushed R1's call light indicating R1 was done using the toilet. CNA-G stated CNA-G was calling CNA-F to come back and assist R1 off the toilet when CNA-G saw R1 fall forward off the toilet onto the bathroom floor. CNA-G stated CNA-F did not answer the phone, so he went to get CNA-F. CNA-G stated they got RN-D on the way back to R1's room. When RN-D assessed R1 RN-D instructed CNA-G to get the crash cart and the medication cart. CNA-G stated CNA-G was not sure what happened after that but at some point, RN-D started to do CPR until the EMT's arrived. Surveyor asked CNA-G if CNA-G was ever directed to get other staff to assist RN-D with R1. CNA-G said he was only instructed to get the medication cart and crash cart for RN-D. Surveyor asked CNA-G what the policy if staff came upon a resident that was unresponsive. CNA-G stated would call for a nurse or other staff for assistance. Surveyor asked if the resident should be left alone. CNA-G stated the resident should always have someone with them if able. CNA-G stated CNA-G was unable to get staff from the phone, so CNA-G went to get them.
On [DATE] at 12:51 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-H who stated ADON-H was in a meeting and when ADON-H came out of the meeting there were paramedics in the facility. ADON-H directed the paramedics to the elevators and ADON-H took the stairs to see what was going on. Surveyor asked ADON-H if ADON-H was notified of an incident happening with R1. ADON-H stated ADON-H was not aware of any concerns until ADON-H saw the paramedics. ADON-H stated normally staff would call ADON-H's phone, but ADON-H did not have the phone due to being in a meeting. ADON-H stated when ADON-H arrived to R1's bedroom RN-D was in the bathroom with R1 and initiated CPR. ADON-H stated RN-D said R1 had a pulse but was not able to feel it any longer so RN-D started CPR. ADON-H stated ADON-H got the Ambu-bag ready to use until the paramedics were able to get to the room. Surveyor asked ADON-H what the process is if staff came upon a resident that was unresponsive. ADON-H stated the staff member should stay with the resident and call for help and the first nurse to get to the resident should take over the delegating of tasks such as calling 911, getting supplies, or other staff, etc. ADON-H stated at no time should nursing leave the resident in need. Surveyor asked if anyone else was notified regarding R1 on [DATE]. ADON-H was not sure if RN-D delegated anyone to get other staff members. Surveyor asked ADON-H if R1 was left alone. ADON-H stated ADON-H is not sure if R1 was ever left alone, ADON-H stated RN-D was with R1 when they arrived to R1's bedroom.
On [DATE] at 2:07 PM, Surveyor interviewed RN-I who stated RN-I was working on another floor on [DATE] at the time of the incident. RN-I stated RN-I was not aware of anything going on with R1 until later in the day. Surveyor asked RN-I what the process is if a resident is found unresponsive. RN-I stated RN-I would stay with the resident and call out for assistance or use RN-I's phone to call staff. RN-I stated RN-I would delegate staff to get supplies that are needed and to make necessary calls as RN-I tended to the resident. Surveyor asked RN-I how RN-I would know if a code was called in the facility. RN-I stated RN-I would only know if someone came to get RN-I.
On [DATE] at 2:10 PM, Surveyor interviewed RN-J (agency staff) who stated RN-J was in the stairwell at the time ADON-H entered the stairwell to go upstairs. RN-J stated ADON-H directed RN-J to take the EMTs up to R1's bedroom. RN-J stated RN-J was not aware of what was going on until RN-J arrived to R1's bedroom with the EMTs. RN-J did not enter R1's room but stayed outside the door in case RN-J needed to assist with anything. Surveyor asked RN-J what the process is if a resident is found unresponsive. RN-J was unsure if there is a specific code to be called, but RN-J would tell staff to alert other staff for assistance and to get necessary supplies while RN-J stayed with the resident.
On [DATE] at 2:24 PM, Surveyor interviewed RN-K (agency staff) who stated RN-K was working on the same floor as RN-D on [DATE] but was not aware of anything happening until RN-K saw ADON-H come up from the stairs fast and went to R1's bedroom and then saw the EMTs arrive. RN-K stated RN-K went down to R1's room and stayed outside the bedroom in case RN-K was needed. RN-K stated the EMTs were able to get a pulse on R1 again and then took R1 out of the facility to the hospital. RN-K was not aware of anything that happened until after the incident. Surveyor asked RN-K what the process is if a resident is found unresponsive. RN-K stated RN-K would yell out for somebody to assist. RN-K stated that a nurse, if available should always stay with the resident so the nurse can keep assessing the resident and delegate what is needed. RN-K stated usually if someone yells for help then usually everyone heads to that direction to help if needed. RN-K stated that if staff push 0 on the phone they could ask the front desk to overhead page, but not sure if that is policy or what supposed to do.
Surveyor went up to the second floor to observe the distance from the AED unit to R1's bedroom at the time. The AED unit and R1's bedroom at the time is on opposite ends of the hallway. RN-D went all the way down to the hallway to get the AED unit and back. Surveyor also observed the crash cart underneath the AED unit.
On [DATE] at 3:35 PM, Surveyor interviewed Physical Therapy Assistant (PTA)-L who stated RN-D asked PTA-L to call 911. PTA-L called 911 and did not know the answers to the questions the operator was asking so PTA-L went to R1's bedroom and saw RN-D was on the phone with 911 services as well. PTA-L stated PTA-L hung up with 911 services because RN-D was speaking to someone and there were 2 CNAs in the room along with the crash cart. PTA-L went back to the resident's room PTA-L was working with. PTA-L stated PTA-L was not aware of what was going on and was not asked to do anything else. Surveyor asked PTA-L what the process is if staff found a resident that was not responsive. PTA-L stated PTA-L would get nursing and go from there.
On [DATE] at 3:47 PM, Surveyor interviewed Quality Director (QD)-M who stated QD-M put the facility self-report together. Surveyor asked QD-M when RN-D went to get the AED if R1 was left alone in the room. QD-M stated RN-D stated in RN-D's phone interview that a CNA was in the room with R1 when RN-D went to get the AED. Surveyor asked QD-M why RN-D did not send a CNA to get the AED. QD-M was not sure, and the expectation would be for the RN to delegate that task and to stay with the resident. QD-M stated RN-D said that R1 still had a pulse and respirations when RN-D went to get the AED unit.
On [DATE] at 4:30 PM, Surveyor interviewed Director of Nursing (DON)-B who stated DON-B was not in the facility at the time of the incident. Surveyor asked DON-B if there is a process or what expectations are of staff when a resident is found unresponsive. DON-B stated that there is not a formal written process, that the facility just has the CPR/BLS and AED policies, but staff should yell for assistance from other staff and make sure a nurse is there if not already to assess the resident. DON-B stated the first nurse to arrive should be the one to assess and delegate accordingly if needed. DON-B stated there is no overhead paging in the facility and staff should be directed to grab other staff for assistance or us the phone for assistance. DON-B stated ADON-H did an in-service training for a Mock Code Blue with staff on [DATE]. Surveyor reviewed the in-service attendance form and noted only 7 nursing staff were present. Surveyor asked DON-B why other facility staff did not complete the in-service training for the Mock Code Blue. DON-B stated that was the staff present that day and they are working on getting more lined up in the future. Surveyor asked DON-B if the facility had a written process for a Code Blue. DON-B stated there has not been a process written up, but ADON-H continues to educate the staff and DON-B goes over the information during the monthly staffing meetings. Surveyor asked DON-B if agency staff are present during any of the educations in services or monthly meetings. DON-B stated the facility usually has the same agency staff, so they are included in the monthly meetings and in-services.
Surveyor requested to see the CPR/BLS certification for RN-D. Surveyor received RN-D's certification and noted the issue date was [DATE]. Surveyor noted RN-D's CPR/BLS certification was obtained after the [DATE] incident involving R1.
On [DATE] at 10:21 AM, Surveyor requested to see RN-D's CPR/BLS prior certification. Nursing Home Administrator (NHA)-A stated the facility did not have a copy on file of RN-Ds previous certification card.
On [DATE] at 10:23 AM, Surveyor interviewed DON-B who stated when DON-B reviewed the self-report DON-B noted the facility did not have a current CPR/BLS certification for RN-D and asked RN-D to bring it into the facility. Surveyor asked DON-B how the facility assures the staff are CPR certified. DON-B stated all facility nursing staff are to be CPR certified and there is a program that will prevent them from working if their CPR certification is not up to date. DON-B stated not sure what the process is for agency staff and that was something DON-B was not keeping up on.
On [DATE] at 11:22 AM, Surveyor interviewed Scheduler-C who stated that Scheduler-C reaches out to the agencies used by the Facility to get the staff members profile and certifications and Scheduler-C makes sure everything is up to date. Scheduler-C stated a couple months prior to [DATE] Scheduler-C reached out to the agency and notified them Scheduler-C will be needing a CPR renewal for RN-D and that the agency was going to work on it and this was never followed up on. Scheduler-C was unable to locate the previous CPR certification for RN-D. Scheduler-C stated Scheduler-C is keeping up on the agency certifications to make sure all nursing staff that come to the facility are CPR certified.
On [DATE] at 11:35 AM, Surveyor interviewed staffing specialist [for staffing agency] (SS)-E who stated when someone is staffed with the agency one of the credentials is to have CPR certification. SS-E stated RN-D was certified but it had expired before RN-D could get it renewed. SS-E was unable to locate RN-D's previous certification due to the staffing agency switching over to newer systems recently. SS-E confirmed RN-D had an expired CPR certification at the time of the incident on [DATE].
Surveyor reviewed CPR credentials for nursing staff on the schedule for [DATE], RN-D was the only staff member that did not have an active CPR certification. All other nursing staff had active CPR certification on [DATE].
On [DATE] at 4:50 PM, Surveyor expressed concern to Nursing Home Administrator (NHA)-A and DON-B of Surveyors concerns the facility did not have a system in place identifying how staff should respond or what staff should do in the event of a resident requiring cardiopulmonary resuscitation (CPR) and the facility did not have a system in place to maintain records showing that agency staff are qualified to perform CPR. No further information was provided.
Aug 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and provider interview, and record review, the facility did not notify a provider of a significant weight loss fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and provider interview, and record review, the facility did not notify a provider of a significant weight loss for 1 Resident (R) (R67) of 4 residents reviewed for weight loss.
R67 lost a significant amount of weight (defined as 10% loss in 6 months; 7.5% loss in 3 months; 5% loss in 1 month) between 7/5/23 and 7/26/23. R67's provider was not notified of the weight loss.
Findings include:
The facility's Weight Monitoring policy, with an approval date of 1/2023, indicates: .F. A nursing or nutrition associate should notify the health care provider of any significant weight change that is unexplainable or in which the RD (Registered Dietitian) has requested a nutritional intervention.
From 8/8/23 through 8/9/23, Surveyor reviewed R67's medical record. R67 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease, and dementia in other diseases classified elsewhere, unspecified severity with agitation. R67's Minimum Data Set (MDS) assessment, dated 7/26/23, indicated R67 had a significant weight loss not prescribed by a physician. R67's most recent nutritional assessment, dated 7/21/23, documented a score of 7 out of 14 with a 0-7 score indicating malnutrition. R67's nutritional care plan, dated 5/29/23, indicated R67 was at risk for malnutrition related to diagnoses of Alzheimer's disease and dementia and as evidenced by R67's weight, diagnoses, reported significant weight loss, average intake of 50% or less at meals and nutritional assessment score. The care plan contained a goal that indicated R67's nutritional needs will be met and R67 will not have an unplanned significant weight change over the next review period.
R67's medical record contained the following weights:
7/5/23 - 136.80 pounds
7/21/23 - 129.40 pounds (-5.41% loss in 16 days)
7/26/23 - 125.40 pounds (-8.33% loss in 21 days)
No further weights were recorded.
On 8/8/23 at 1:07 PM, Surveyor interviewed RD-E regarding R67's significant weight loss. RD-E indicated RD-E noted R67 lost weight and increased R67's nutritional drink from once per day to twice per day. RD-E indicated RD-E thought RD-E updated Nurse Practitioner (NP)-F of the weight loss in a daily morning meeting, but when RD-E checked with NP-F on 8/8/23 to verify NP-F was updated, NP-F told RD-E that NP-F did not recall being updated.
On 8/9/23 at 9:47 AM, Surveyor interviewed NP-F via telephone. NP-F stated RD-E approached NP-F yesterday (8/8/23) when NP-F was in the facility, and asked whether or not NP-F was aware of R67's weight loss. NP-F told RD-E that NP-F did not recall whether or not RD-E updated NP-F on R67's weight loss. NP-F stated in NP-F's opinion, any resident who has a significant weight loss should be placed on weekly weights, and NP-F should be notified so additional interventions can be put in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
On 8/9/23 at 9:28 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility's process at transfer/discharge is that the nurse prints a transfer notice and sends the notice...
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On 8/9/23 at 9:28 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated the facility's process at transfer/discharge is that the nurse prints a transfer notice and sends the notice with the resident. Social Worker (SW)-D then follows up with notification of the resident's family/Power of Attorney for Health Care (POAHC) regarding the transfer/discharge policy. NHA-A was unable to verify if nurses were completing the process and sending a copy of the transfer notice to residents' representatives. NHA-A reviewed the Monthly Discharge Register to Ombudsman binder and verified the Ombudsman was not notified of R14, R21, and R26's hospital transfers.
On 8/9/23 at 11:22 AM, Surveyor interviewed SW-D regarding the facility's transfer/discharge notification process. SW-D indicated the process is initiated by nursing staff and SW-D follows up with residents' representatives the following day. If residents are private pay or have a 15-day bed hold with Medicaid, SW-D stated verbal notification is given and written transfer notices are not mailed. SW-D stated Ombudsman notification is not done if residents return to the building before midnight. SW-D stated Ombudsman notification is only done if the resident discharges from the facility.
Based on staff interview and record review, the facility did not ensure a written notification of transfer, including the reason for the transfer, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman was provided for 3 Residents (R) (R14, R21, and R26) of 3 residents reviewed for hospitalization.
R14 was not provided a written transfer notice when R14 was transferred to the hospital on 5/9/23.
R21 was not provided a written transfer notice when R21 was transferred to the hospital on 6/18/23.
R26 was not provided a written transfer notice when R26 was transferred to the hospital on 7/23/23.
Findings include:
1. From 8/7/23 through 8/9/23, Surveyor reviewed R14's medical record. R14's medical record did not contain a written notification for R14's hospital transfer on 5/9/23.
2. From 8/7/23 through 8/9/23, Surveyor reviewed R21's medical record. R21's medical record did not contain a written notification for R21's hospital transfer on 6/18/23.
3. From 8/7/23 through 8/9/23, Surveyor reviewed R26's medical record. R26's medical record did not contain a written notification for R26's hospital transfer on 7/23/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
2. From 8/7/23 through 8/9/23, Surveyor reviewed R21's medical record. R21 was transferred to the hospital on 6/18/23 due to a change in condition. R21's medical record did not include a copy of the b...
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2. From 8/7/23 through 8/9/23, Surveyor reviewed R21's medical record. R21 was transferred to the hospital on 6/18/23 due to a change in condition. R21's medical record did not include a copy of the bed hold notice or documentation that R21 was provided a copy of the bed hold notice.
3. From 8/7/23 through 8/9/23, Surveyor reviewed R26's medical record. R26 was transferred to the hospital on 7/23/23 due to a change in condition. R26's medical record did not include a copy of the bed hold notice or documentation that R26 was provided a copy of the bed hold notice.
On 8/9/23 at 9:28 AM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated at transfer/discharge, a nurse prints a bed hold notice and sends the notice with the resident. Social Worker (SW)-D then follows up with notification of the resident's family/Power of Attorney for Health Care (POAHC) regarding the bed hold policy. NHA-A was unable to verify nurses were completing the process and sending a copy to residents' representatives and indicated bed hold notifications were not being mailed.
On 8/9/23 at 11:22 AM, Surveyor interviewed SW-D regarding bed hold notification when a resident is transferred to the hospital. SW-D indicated the process is initiated by nursing staff and SW-D follows up the next day with residents' representatives. SW-D indicated if a resident is private pay or has a 15-day bed hold with Medicaid, verbal notification is given and a form is not mailed.
Based on staff interview and record review, the facility did not ensure 3 Residents (R) (R14, R21, and R26) of 3 residents reviewed for hospitalization received written information regarding the facility's bed hold policy, including the duration of the bed hold, the reserve bed payment policy, and the right to return to the facility.
R14 was transferred to the hospital on 5/9/23 and was not provided a bed hold notice.
R21 was transferred to the hospital on 6/18/23 and was not provided a bed hold notice.
R 26 was transferred to the hospital on 7/23/23 and was not provided a bed hold notice
Findings include:
1. From 8/7/23 through 8/9/23, Surveyor reviewed R14's medical record. R14 was transferred to the hospital on 5/9/23 due to a change in condition. R14's medical record did not include a copy of the bed hold notice for the transfer or documentation that R14 was provided a copy of the bed hold notice.
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 staff interview and record review, the facility did not ensure 1 Resident (R) (R42) of 5 residents reviewed for unneces...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R42) of 5 residents reviewed for unnecessary medications was monitored for adverse reactions to an antipsychotic medication.
R42 was prescribed aripiprazole (an antipsychotic medication). The facility did not complete a tardive diskinesia (TD) (movement disorder characterized by uncontrollable, abnormal, and repetitive movements of the face, torso, and/or other body parts caused by prolonged use of treatments that block dopamine receptors in the brain, such as antipsychotic use) screening assessment to monitor for adverse reactions to the medication.
Findings include:
The facility's Behavioral Assessments, Intervention and Monitoring policy, with an approval date of 1/2022, indicates: .A. Behavioral symptoms will be identified using community-approved behavioral screening tools and the comprehensive assessment .Procedure: 1. The interdisciplinary team will meet to review and discuss the following:
e. AIMS (Abnormal Involuntary Movement Scale) or other findings.
On 8/9/23, Surveyor reviewed R42's medical record. R42 was admitted to the facility on [DATE] and had diagnoses that included bipolar depression (depressive episodes that are part of the mood cycling in bipolar disorder), and schizoaffective disorder (a mental disorder with both schizophrenia and mood disorder symptoms). R42's medical record did not contain a baseline TD assessment.
On 8/9/23 at 2:24 PM, Surveyor interviewed Director of Nursing (DON)-B who verified the facility did not complete a baseline TD assessment for R42. DON-B stated a TD assessment would be completed right away, and education would be provided to nursing staff that TD screenings need to be completed for all residents who receive antipsychotic medication.
CONCERN
(D)
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, staff interview, and record review, the facility did not establish and maintain an infection control progr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection for 2 Residents (R) (R6 and R21) of 7 residents observed during the provision of cares.
During the provision of cares for R6, Licensed Practical Nurse (LPN)-G did not appropriately remove gloves and cleanse hands.
During the provision of cares for R21, Certified Nursing Assistant (CNA)-H did not appropriately remove gloves and cleanse hands.
Findings include:
The facility's Hand Hygiene policy, dated 5/2023, indicates: This community considers hand hygiene the single most important practice to prevent infections and promote resident safety. Evidence based hand hygiene guidance is practiced to reduce the risk of transmission of pathogenic microorganisms to residents, associates, and visitors.
F. Hand hygiene is practiced:
1. Immediately before touching a resident
3. Before moving from work on a soiled body site to a clean body site on the same resident
4. After touching a resident or the resident's immediate environment
5. After contact with blood, body fluids or contaminated surfaces
6. Immediately after glove removal
H. The use of gloves does not replace hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.
1. R6 was admitted to the facility on [DATE] with diagnoses including dementia, adult failure to thrive, and osteoarthritis. R6's MDS (Minimum Data Set) assessment, dated 7/26/23, indicated R6 required extensive assistance with bed mobility, dressing, hygiene, and toileting.
On 8/8/23 at 10:41 AM, Surveyor observed LPN-G provide incontinence and wound care for R6. During the care of R6's sacral wound, LPN-G donned gloves and assisted R6 on R6's left side. Upon turning R6, LPN-G noted R6 was incontinent of stool. LPN-G removed R6's soiled brief and cleansed R6's buttocks with soap and water. With the same soiled gloves, LPN-G touched R6's clean draw sheet and clean brief.
On 8/8/23 at 10:55 AM, Surveyor interviewed LPN-G who verified LPN-G did not remove soiled gloves and cleanse hands after the provision of pericare and prior to applying a clean brief and providing a clean draw sheet.
2. R21 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarct affecting the right dominant side, and neuromuscular dysfunction of the bladder. R21's MDS assessment, dated 7/10/23, indicated R21 required extensive assistance with bed mobility and dressing and was dependent on staff for hygiene and toileting.
On 8/8/23 at 11:22 AM, Surveyor observed CNA-H provide incontinence care for R21 who was incontinent of stool. CNA-H removed R21's soiled brief and provided incontinence care. Without removing gloves and cleansing hands, CNA-H touched R21's clean brief, gown, sheet, basin, towels, and remote control. CNA-H then washed R21's face with a washcloth.
On 8/8/23 at 11:35 AM, Surveyor interviewed CNA-H who verified CNA-H did not remove gloves and cleanse hands after the provision of pericare and prior to touching the aforementioned items.
On 8/9/23 at 1:31 PM, Surveyor interviewed Director of Nursing (DON)-B who verified DON-B expected staff to remove gloves and perform hand hygiene when going from a dirty to clean area during cares.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One of 4 medication carts was observed unlocked an...
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Based on observation and staff interview, the facility did not ensure all drugs and biologicals were stored in accordance with the facility's policy. One of 4 medication carts was observed unlocked and not under direct supervision of the nurse in charge of the cart. This had the potential to affect 14 residents whose medications were stored in the cart.
The third floor medication cart was observed unlocked and against the wall for approximately 2 minutes. During that time, Resident (R) (R32) was observed opening the unlocked draws. The unlocked medication cart was not in direct supervision of the nurse on duty.
Findings include:
The facility's Storage of Medications policy, with an approval date of 12/2021, indicates: The community shall store all drugs and biologicals in a safe, secure, and orderly manner .H. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others .K. Only persons authorized to prepare and administer medications shall have access to the medication room, including any keys.
On 8/8/23 at 3:17 PM, Surveyor noted a medication cart on the third floor that was unlocked and against a wall. Surveyor observed R32 walk over to the unlocked medication cart and begin to open and close the drawers. Surveyor noted keys on top of the medication cart, but no nursing staff in direct sight. Surveyor observed an unidentified staff member alert Registered Nurse (RN)-C that R32 was going through RN-C's medication cart. Surveyor observed RN-C return to the medication cart and ask R32 if needed anything. R32 then walked away.
On 8/8/23 at 3:19 PM, Surveyor interviewed RN-C who verified the medication cart was unlocked and RN-C's keys were on top of the cart. RN-C verified staff should lock medications carts and keep keys on their person.
On 8/8/23 at 3:22 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who verified medication carts should be locked when nurses are away from the carts. Surveyor explained the above observation to NHA-A who verified the cart should have been locked and the keys should have been secured.
On 8/9/23 at 7:16 AM, Director of Nursing (DON)-B requested to speak to Surveyor regarding the unlocked medication cart. DON-B verified the medication cart should have been locked and the keys should have been secured. DON-B stated DON-B spoke to RN-C regarding the concern and started staff education.
Mar 2023
1 deficiency
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 interview and record review, the facility did not ensure that residents with pressure injuries received necessary treat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview 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 for 1 of 3 (R1) residents reviewed for pressure injuries.
R1 had an air mattress ordered for the treatment of a stage 4 pressure injury. R1 moved rooms and the air mattress was not placed on her bed until 1 week later, resulting in a decline in the wound.
Findings include:
R1 admitted to the facility on [DATE] and has diagnoses that include Dementia, Adult Failure to Thrive, Peripheral Vascular Disease, chronic venous insufficiency, osteomyelitis, and anxiety disorder.
R1 admitted to the facility with a stage 4 pressure injury to her sacrum measuring 4.1 x 2.0 x 1.2 cm (centimeters) 100% granulation tissue. R1 has been followed by the wound care physician and appropriate care plan interventions were implemented, which included a low air loss, alternating pressure air mattress. R1's care plan also documented resident at risk for pressure ulcers and other skin related injuries - declines to turn side to side and will only lay on her back.
R1's Quarterly Minimum Data Set, dated [DATE] documented bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed - as extensive 1-person physical assist.
R1's October 2022 APNP (Advance Practice Nurse Practitioner) wound care notes and measurements document:
10/13/22 Sacrum/coccyx - pressure stage 4. Full thickness wound measuring 4.0 x 1.4 x 0.3 cm, 100% granular. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx (signs/symptoms) of infection. Plan - apply collagen powder and cover with bordered super absorbent dressing. Change dressing daily.
10/20/22 Sacrum/coccyx - pressure stage 4. Full thickness wound measuring 3.5 x 1.0 x 1.0 cm, 100% granular. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx (signs/symptoms) of infection. Plan - apply collagen powder and cover with bordered super absorbent dressing. Change dressing daily.
On 10/26/22 facility progress notes document R1 was positive for Covid, and she was moved to a private room on the Covid unit.
10/27/22 (facility skin evaluation form) Sacrum pressure injury stage 4. Full thickness wound measuring 3.4 x 1.0 x 1.0 cm, 100% granulation tissue, beefy red, surrounded by whitish scar tissue. Moderate serosanguineous drainage. Treatment: Cleanse with NS (normal saline) skin prep surrounding tissue, apply collagen powder to wound bed f/b (followed by) bordered dressing. Change daily.
11/3/22 Sacrum/coccyx stage 4. Full thickness wound measuring 6.0 x 3.8 x 1.7 cm, there is undermining from 1-2 o'clock about 2.1 cm. The base is 90% granular and 10% yellow slough covered with palpable bone. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx of infection. Status: decline. Plan: Apply collagen powder and cover with bordered super absorbent dressing. Change dressing daily.
Surveyor noted a significant decline in the sacral pressure injury from 10/27/22 to 11/3/22. Although facility staff completed daily treatment and dressing changes, there was no documentation in facility progress notes that staff recognized a change or decline in the sacral pressure injury from 10/27/22 until the NP identified the significant decline on 11/3/22 during wound rounds. Further review of the APNP note on 11/3/22 documented: Spoke with social worker and bedside RN (Registered Nurse) regarding patient not on specialty mattress.
Subsequent documentation:
11/10/22 Sacrum/coccyx stage 4. Full thickness wound measuring 4.5 x 4.0 x 1.8 cm, there is undermining from 10 o'clock about 2.5 cm. The base is 50% granular and 50% yellow slough covered with palpable bone. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx of infection. Status: improve. Plan: Santyl and cover with bordered super absorbent dressing. Change dressing daily.
11/17/22 Sacrum/coccyx stage 4. Full thickness wound measuring 4.0 x 4.5 x 1.0 cm. The base is 90% granular and 10% yellow slough covered with palpable bone. Moderate serosanguineous drainage. Peri wound is pink and scarred. No s/sx of infection. Status: improve. Plan: Santyl and cover with bordered super absorbent dressing. Change dressing daily.
Current documentation:
Sacrum/coccyx stage 4. Full thickness wound measuring 4.1 x 2.0 x 1.2 cm. The base is 100% granular. Moderate serosanguineous drainage. Wound edges are attached and beginning to appear to be epithelialized. Peri wound is pink and scarred. No s/sx of infection. Status: stable. Plan: Collagen base and cover with bordered foam. Change dressing 3x (times)/wk (week) and PRN (as needed).
On 3/8/23 at 10:40 AM, Surveyor spoke with Social Service Director (SSD)-C. Surveyor asked if he recalled if, when R1 moved rooms, the air mattress was moved with the resident to her new room. SSD stated: To my knowledge, yes.
On 3/8/23 at 10:55 AM, Nursing Home Administrator (NHA)-A came to the conference room to speak with Surveyor. NHA-A reported SSD-C had just told her what we had talked about, and she wanted to speak to Surveyor. NHA-A stated: Yes, we did have a problem in October when we had Covid. We moved R1 to the Covid unit and it was found that some equipment didn't go with the resident. Surveyor asked if the air mattress was moved to the new room, to which NHA-A stated: No, it did not. It was a bad situation. We immediately got it moved to her bed. Surveyor asked how long R1 was without the air mattress. NHA-A reported a couple of days, if I remember.
On 3/8/23 at 2:42 PM, Surveyor spoke with Director of Nursing (DON)-B. DON-B reported on 11/3/22 the NP noticed R1 did not have the air mattress on her bed. DON-B reported the air mattress was immediately replaced and the next day the facility had a meeting to look at the process for moving residents. DON-B reported he spoke to R1's Power of Attorney (POA) the next day and explained what happened and what the facility did to fix it. DON-B reported he does rounds twice weekly to check all air mattresses. Surveyor asked DON-B if he thought R1 having Covid and not having her air mattress for at least 7 days caused decline in the sacral wound. DON-B stated: I would assume that was the reason. It's gotten better already since the air mattress was replaced.
Surveyor noted evidence revealed R1 moved rooms on 10/26/22 and the air mattress did not move with the resident to her new bed/room. This was not identified until 8 days later, on 11/3/22 when the NP notified the facility the air mattress was not on R1's bed. A significant decline in R1's sacral wound was noted at that time with increased size of the wound, undermining, and yellow slough covered with palpable bone. Facility staff performing daily dressing changes did not recognize the decline or that R1 was not receiving care planned interventions post move, to include use of an air mattress.
Surveyor reviewed R1's TAR (Treatment Administration Record) for October and November 2022 which documented:
Air mattress - validate air mattress on correct settings (2), Adjust if necessary. For skin integrity; diagnosis/reason = skin integrity daily. Times to sign out compliance were night shift, day shift, eve (evening) shift.
R1's October 2022 TAR documented the above signed out as completed although evidence shows R1's air mattress was not on her bed: Night shift from 10/26/22 through 10/31/22 was signed out as completed, evening shift on 10/26/22, 10/27/22, 10/29/22 and 10/31/22 was signed out as completed, 10/28/22 and 10/30/22 were blank. Day shift 10/26/22, 10/27/22 and 10/31/22 were signed out as completed, 10/28/22 through 10/30/22 documented (N) which Surveyor verified as no.
R1's November 2022 TAR documented the above signed out as completed although evidence showed R1's air mattress was not on her bed: Night shift, evening shift and day shift from 11/1/22 through 11/3/22 were signed out as completed.
On 3/8/23 at 2:30 PM, Surveyor advised NHA-A of concern R1 moved rooms on 10/26/22 and the ordered air mattress for her stage 4 sacral pressure injury was not put on her bed until 8 days later when identified by the Nurse Practitioner. This resulted in a significant decline in the wound. Surveyor advised of concern facility staff completed daily treatment and dressing changes to R1's sacral pressure injury and did not recognize deterioration of the wound which was identified by the NP on 11/3/22. Surveyor advised R1's TAR indicated staff was to be validating the air mattress settings every shift, which was signed out as having been completed on all shifts, on multiple days from 10/26/22 through 11/3/22 even though the air mattress was not on R1's bed. No additional information was provided.
Apr 2022
2 deficiencies
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 observation, interview, and record review the facility did not ensure that 1 (R35) of 1 residents reviewed received dia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure that 1 (R35) of 1 residents reviewed received dialysis services consistent with professional standards of practice.
* R35 did not have evidence that her dialysis port was assessed for complications.
Findings include:
The facility's policy dated as last approved 01/2022, and titled, Dialysis documents under the Policy Interpretation and Implementation section, The community will co-ordinate care with the dialysis provided in developing an appropriate plan of care to include, but not limited to: Checking thrills/bruit of grafts and fistulas, documented on TAR (Treatment Administration Record); When to remove dressing from the access site placed on the dialysis center; Monitor for sign and symptoms of infection including, but not limited to, fever, redness, tenderness, bleeding at fistula site.
1.) R35 was readmitted to the facility on [DATE], with a diagnosis that include End Stage Renal Disease, Chronic Kidney Disease, Stage 5 and Dependence on Renal Dialysis.
R35's Quarterly MDS (Minimum Data Set), dated 3/22/22, documents a BIMS (Brief Interview for Mental Status) score of 15, indicating that R35 is cognitively intact.
Section O (Special Treatments, Procedures and Programs) documents, R35 is currently receiving dialysis treatments upon admission the facility.
R35's Renal care plan, dated as initiated on 12/18/21, documents under the Goal section, R35 will not experience complications due to renal disease requiring outside medical intervention.
Surveyor was unable to locate any documentation in R35's medical record that facility staff monitored R35's dialysis port on a daily basis or after R35 returned from the dialysis clinic.
On 4/11/22, at 2:08 p.m., Surveyor interviewed Registered Nurse (RN)-C, whom was working on R35's unit, regarding R35's dialysis communication log.
Surveyor asked RN-C how the facility communicates with R35's dialysis clinic and how it monitors R35's dialysis port.
RN-C informed Surveyor that the facility sends outs a communication sheet for the dialysis clinic to complete that includes information on R35's dialysis port.
On 4/11/22, at 3:48 p.m., Surveyor interviewed R35 regarding his dialysis port. Surveyor asked R35 if facility staff change the dressing or monitor his dialysis port. R35 showed Surveyor his dialysis port, located on his chest, and Surveyor noted the dressing not to be labeled with a date, indicating the day the area was assessed and the dressing was changed.
R35 informed Surveyor that facility staff do not change the dressing or monitor his dialysis port and that dressing changes of his dialysis port are completed at the dialysis clinic and not at the facility.
On 4/11/22, at 3:52 p.m., Surveyor informed NHA (Nursing Home Administrator)-A of the above findings. Surveyor asked NHA-A if R35 had a physician order or care plan intervention for the monitoring of his dialysis port, as Surveyor could not locate one in R35's medical record.
NHA-A informed Surveyor she would speak with DON (Director of Nursing)-B and let Surveyor know.
On 4/12/22, at 9:07 a.m., DON-B informed Surveyor that a physician order had been put in place for the daily monitoring of R35's dialysis port.
On 4/12/22, at 2:04 p.m., Surveyor reviewed R35's medical record and noted the following physician order dated 4/12/22, Right Subclavian Dialysis Catheter; Every day monitor and assess dressing to site and ensure it is intact. As needed in the event of soiled or remove dressing to right Subclavian.
No additional information was provided.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on interview and record review, the facility did not have an Infection Preventionist that completed specialized training in infection prevention and control, potentially affecting all 47 residen...
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Based on interview and record review, the facility did not have an Infection Preventionist that completed specialized training in infection prevention and control, potentially affecting all 47 residents in the facility.
Director of Nursing (DON)-B was the designated full-time Infection Preventionist of the facility. DON-B did not complete specialized training in infection prevention and control.
Findings:
In an interview on 4/12/2022, at 10:20 AM, Surveyor interviewed DON-B for the survey infection control task. DON-B identified she was the facility's designated full-time Infection Preventionist. Surveyor asked DON-B if DON-B had taken any infection control courses as required by CMS (Centers for Medicare and Medicaid Services). DON-B stated DON-B was aware of the requirement to have specialized training in Infection Control and had not taken any infection control courses but will be taking the course in the future. DON-B stated the facility is looking to hire an individual who will take over the infection control program for the facility and that person will also be taking the infection control courses that are offered.
No further information was provided at that time.
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?"
- "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: 1 life-threatening violation(s), 3 harm violation(s), $90,921 in fines, Payment denial on record. Review inspection reports carefully.
- • 50 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $90,921 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: Trust Score of 0/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Avina Of Milwaukee's CMS Rating?
CMS assigns Avina of Milwaukee 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 Avina Of Milwaukee Staffed?
CMS rates Avina of Milwaukee's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 55%, which is 9 percentage points above the Wisconsin average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 61%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Avina Of Milwaukee?
State health inspectors documented 50 deficiencies at Avina of Milwaukee during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 46 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Avina Of Milwaukee?
Avina of Milwaukee is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by ASCENSION LIVING, a chain that manages multiple nursing homes. With 108 certified beds and approximately 84 residents (about 78% occupancy), it is a mid-sized facility located in MILWAUKEE, Wisconsin.
How Does Avina Of Milwaukee Compare to Other Wisconsin Nursing Homes?
Compared to the 100 nursing homes in Wisconsin, Avina of Milwaukee's overall rating (1 stars) is below the state average of 3.0, staff turnover (55%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Avina Of Milwaukee?
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?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.
Is Avina Of Milwaukee Safe?
Based on CMS inspection data, Avina of Milwaukee has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Wisconsin. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Avina Of Milwaukee Stick Around?
Staff turnover at Avina of Milwaukee is high. At 55%, the facility is 9 percentage points above the Wisconsin average of 46%. Registered Nurse turnover is particularly concerning at 61%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Avina Of Milwaukee Ever Fined?
Avina of Milwaukee has been fined $90,921 across 2 penalty actions. This is above the Wisconsin average of $33,988. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Avina Of Milwaukee on Any Federal Watch List?
Avina of Milwaukee is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.