Based on observation, interview and record review, for 1 of 40 sampled residents, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident developed a shearing injury related to a Hoyer lift transfer. This will be cited at a Harm level at past non-compliance with a completion date of 3/6/26. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included unspecified fracture of right lower leg, paraplegia, cirrhosis of liver, rhabdomyolysis, and mild protein-calorie malnutrition. On 4/22/26 at 3:04 PM, an interview was conducted with resident 10, who stated that he had been cut on the buttocks during a Hoyer lift transfer by a new Hoyer sling, which had sharper edges than his previous sling. Resident 10 stated that after the initial injury the sling was replaced. Resident 10 stated that the wound had been painful. On 3/12/2026 at 4:18 PM, a nursing progress Event Note documented: Event Description: On 3/6/2026 as the Skilled nurse [SN] was completing a weekly skin assessment, skin breakdown was noted to resident buttocks. SN contacted nurse management and assessment of wound noted. Resident noted to have breakdown on right buttock, and shearing injury related to Hoyer sling being removed by CNA [Certified Nursing Assistant]. Contacted MD [Medical Director] and wound NP [Nurse Practitioner] for orders and to review interventions. The Event Note Template documented that resident 10 was at risk for a breakdown in skin integrity and that it is the determination of the IDT [interdisciplinary team] that improper removal from under the resident of the Hoyer sling caused friction and shearing injury. On 4/22/26 at 3:13 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that two CNAs always performed Hoyer transfers and assisted resident 10 in gently rolling from side to side to remove the Hoyer sling. CNA 2 stated that resident 10 typically tolerated transfers well, but he had recently mentioned an injury sustained during a Hoyer transfer. CNA 2 stated that the facility had recently conducted training on Hoyer transfers, which included the proper technique for rolling the resident side-to-side when placing and removing a Hoyer sling. On 4/22/26 at 4:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the Assistant Director of Nursing (ADON) 1 informed her of resident 10's wound on 3/6/26, and then they telephoned resident 10's physician and Wound Care Provider (WCP) to obtain orders. The DON stated that while the resident and the CNA staff present when the injury occurred were interviewed she did not know if they had documentation of the interviews. The DON stated that through interviews, assessment, and discussions with the WCP, they determined the wound was a shearing injury sustained when staff incorrectly removed a Hoyer sling from under the resident. The DON stated that resident 10's physician ordered Vitamin C and a nutritional supplement, and the WCP provided wound care orders. Additionally, the DON stated that after it was determined that improper removal of the Hoyer sling caused the shearing injury, she collaborated with the CNA Coordinator to train the staff working that day. The DON stated that they later provided an in-service to staff which covered the proper removal of a Hoyer lift sling after use. Additionally, the DON stated that the facility completed Hoyer sling removal skills checks and observation audits with the CNAs. On 4/24/26, the facility provided a timeline of events, a summary of an interview with resident 10 dated 3/6/26, a staff sign in-sheet and in-service documentation, and the completed staff skill checks. The timeline stated the in-service was held on 3/10/26. The in-service covered the following topics: Why Proper Sling Removal Is Important, When to Remove the Sling, Steps for Proper Sling Removal, and Safety Reminders. It should be noted that the recertification survey was conducted from 4/19/26 through 4/27/26. On 4/29/26, the facility provided a Performance Improvement Project (PIP). The PIP documented that the Skin tear was treated and dressed, provider contacted for further orders and an audit was performed and identified 4 residents at risk of being affected d/t (due to) use of the hoyer lift was completed on 3/6/26. The Measures/Systemic Changes listed in the PIP were: providing education to clinical staff on the proper removal of the Hoyer sling to prevent skin injury and obtaining observation competencies from all CNAs to demonstrate removal competence. The PIP documented that these measures were completed on 3/6/26. The PIP's monitoring plan included CNA coordinator will perform randomized observation audits 3 times a week for 12 weeks to ensure continued competency of hoyer sling removal. The projected completion date was 6/10/26. The Hoyer Sling Removal/Observation Audits 3/16/26 through 4/26/26 were provided.
Every finding on record at Crestwood Rehabilitation and Nursing
Ogden, Utah · CCN 465083
25 findings across 6 inspections, in the inspector's own words, 7 of them at actual harm or above.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Inspection of April 27, 2026
19 findingsBased on observation, interview and record review, for 2 of 40 sampled residents, the facility did not ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident's pain medications were decreased after admission and no appointment was made after the resident requested an appointment with the pain clinic. This example will be cited at a harm level. In addition, another resident's pain to her thumb knuckles was not addressed. Resident identifiers: 4 and 8. Findings included: 1. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included stage 4 pressure ulcers, paraplegia, osteomyelitis, spastic hemiplegia and injury of root of cervical spine. On 4/19/26 at 3:27 PM, an interview was conducted with resident 8. Resident 8 stated he was in a lot of pain and when he was admitted the house physician decreased his pain medication. Resident 8 stated he requested to be sent to a pain clinic because his pain medications were decreased when he was admitted . Resident 8 stated he did not have a phone to call his medical providers. Resident 8 stated he asked for telehealth with the pain clinic but that was never scheduled and they finally scheduled him for a pain clinic appointment that he had been asking for since October when he was admitted . Resident 8 was observed to groan when moving. A Nurse Practitioner (NP) note dated 11/4/25 at 2:39 PM revealed, [Resident 8] is a [AGE] year old male presenting for hisotry [sic] and physical. He has a history of neuralgia and neuritis, depression and anxiety, paraplegia, and osteomyelitis. Today he is complaining that his baclofen should be 60 mg [milligrams] 4 times daily. Supervising physician does not want to give that dose currently and I am referring to her for dosing. He is currently at 30 mg 4 times daily which is a total of 120 mg daily. He is actively in discomfort and has asked to see a pain management clinic. No other concerns at this time. Plan: . Continue medications as ordered . Monitor for any change in condition .f/u [follow up] appointments as ordered.A physician's admission note dated 10/31/25 at 11:57 AM revealed, .ROS [review of systems]: quadriplegia, wounds, chronic pain, muscle spasms, depression, anxiety, nausea . Plan: .4. Chronic pain/opioid dependence - will continue current meds 5. Muscle spasms - he says he cannot get a baclofen pump while he has wounds .A care plan initiated on 2/23/26 revealed resident 8 had potential for altercation in health maintenance related to his medical diagnoses. One of the goals was that resident 8 would have symptoms managed for comfort through the review date. Interventions included to monitor for increased pain and notify physician/nurse. A physician's note dated 3/2/26 at 11:00 AM revealed, . ROS : paralysis of LE [lower extremity], wounds, chronic pain, muscle spasms, . 4. Chronic pain/opioid dependence - will continue current meds. He wants more opioids. Staff do not feel this is indicated. Will refer to a pain clinic 5. Muscle spasms - he says he cannot get a baclofen pump while he has wounds.A physician office visit or referral to physician form dated 3/4/26 revealed Botox injection. There were no other notes on the form. A physician's note dated 4/3/26 at 11:49 AM revealed, [Resident 8] continues to report having pain. Nursing staff report his pain appears well controlled. He wants to go to a pain clinic and also wants to see [Name of physician removed] PM&R [Physical Medicine and Rehabilitation].a/p [assessment and plan] 1. Chronic pain - has been referred to pain clinic 2. Spinal cord injury - will refer to [name of physician] Resident 8's Medication Administration record for April 2026 revealed resident complained of pain higher than 6 twenty-one times. A pain scale was 0 for no pain and 10 for excruciating pain. On 4/22/26 at 11:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 8 had gone to a spasticity clinic and provided the form from 3/4/26. On 4/22/26 at 2:23 PM, a follow up interview was conducted with the DON and Regional Nurse Consultant (RNC). The RNC stated when resident 8 was admitted , the physician was not comfortable with the amount of pain medication he was taking. The RNC stated they were not sure when resident 8 was referred to the pain clinic. The RNC stated resident 8 might have had an appointment at the pain clinic but was hospitalized or something. The DON stated the former ADON [Assistant Director of Nursing] knew about resident 8's pain clinic appointments but there was nothing documented. The DON stated there was no documentation that the pain clinic appointment was scheduled after admission. The DON stated prior to admission resident 8 was being seen at a pain clinic. The facility provided a timeline regarding resident 8's pain. On 11/12/25, the physician contacted his rehab physician regarding baclofen and it was concluded it would not be a safe thing to do with his wounds. On 11/25/25, a muscle relaxer was ordered for pain management and on 12/30/25 Baclofen was increased. Resident 8 did not bring up the pain clinic until February 2026, which was when a referral was put in but there was no documentation of when the pain clinic appointment was made. 2. Resident 4 was admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses which included benign neoplasm of cerebral meninges, altered mental status, dementia, bipolar disorder, generalized anxiety disorder, post-traumatic stress disorder and acquired absence of left leg below knee. On 4/19/26 at 10:06 AM, an interview was conducted with resident 4. Resident 4 stated that she had pain in both thumbs and it caused her to lay awake all night. Resident 4's thumbs were observed to be red colored on both knuckles. Resident 4's physician orders revealed the following:a. Gabapentin Oral Tablet, Give 200 milligrams (mg) by mouth two times a day for phantom limb pain. The order was initiated on 3/27/24. b. Tylenol Tablet (Acetaminophen), Give 650 mg by mouth every 6 hours as needed (PRN) for pain. Not to exceed 3 grams in 24 hours. The order was initiated on 2/11/23. c. Monitor pain level every shift using (0-10 or FLACC [Face, Legs, Activity, Cry, and Consolability] scale). Acceptable pain level: 6. Document ALL interventions being utilized for pain management: 0) No intervention indicated d/t [due to] no pain 1) Scheduled pain medication 2) PRN [as needed] pain medication 3) PRN pain medication offered and refused 4) Repositioning 5) Rest 6) Ice/Heat 7) Other (specify in progress notes) 8) Resident refused all non-pharmacological interventions. The order was initiated on 1/12/24. Resident 4's April 2026 Medication Administration Record (MAR) documented Pain scores of 10 out of 10 on 4/7/26, 4/15/26, and 4/19/26 during the day shift (6:00 AM - 6:00 PM). The FLACC scores were documented as a 1 on 4/7/26, a 2 on 4/15/26, and a 0 on 4/19/26. The MAR documented that the interventions provided on all three dates were 1) Scheduled pain medication, 4) Repositioning, and 5) Rest. On 4/15/26 at 8:53 AM, the Tylenol administration note documented that the resident requested the medication. On 4/15/26 at 9:00 AM, the Tylenol progress note documented that the administration was effective and the follow up pain score was 3/10. It should be noted that the follow-up pain assessment was conducted 7 minutes after the medication was administered. On 4/7/26, the pain evaluation documented that resident 4 had occasional pain in the past 5 days and it occasionally impacted the resident's sleep and day-to-day activities. Resident 4 rated the worst pain over the last 5 days was a 6/10 and described it as moderate. Resident 4 described the pain as phantom limb pain of the left below the knee amputation. Resident 4 reported an acceptable level of pain was a 3/10. The resident reported that Tylenol, rest, repositioning, distraction and activities helped alleviate the pain. Resident 4 had a care plan focus area for altered comfort related to generalized pain initiated on 6/23/22. Interventions included to inform if pain medication was effective or monitor for signs and symptoms of effectiveness, monitor pain level using a numerical scale or FLACC scale, and that resident 4 was able to state what increased or alleviated her pain. On 4/27/26 at 9:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated that resident 4 sometimes had complaints of pain and had Tylenol and Gabapentin available. LPN 2 stated that for any reports of 10/10 pain levels she would try non-pharmacological interventions first such as listening to music as a distraction. LPN 2 stated that she would also inform resident 4 that she had Tylenol available. LPN 2 stated that resident 4's mood was hit and miss and she suffered from hallucinations and delusions. LPN 2 stated that resident 4 would often scoff when the Tylenol was offered for pain management. LPN 2 stated that the PRN pain note would document if the pain medication was offered or refused and you should be able to see if the treatment was provided. LPN 2 stated that for reports of 10/10 pain an intervention should be documented as provided or refused. LPN 2 stated that if resident 4 refused the Tylenol it should be documented as a #3 for offered and refused PRN pain medication. LPN 2 stated that #3 should have been documented on 4/7/26 and 4/19/26 if the Tylenol was refused for the pain levels of 10/10. On 4/27/26 at 9:51 AM, an interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC). The DON stated that staff should do a FLACC score along with a numerical pain score when evaluating a resident's pain. The DON stated that staff would provide non-pharmacological interventions for pain management such as redirection and repositioning. The CRN stated that staff reported that redirection worked with resident 4's reports of 10/10 pain. The CRN stated that resident 4 did not understand her pain with her cognitive issues and if non-pharmacological interventions did not work staff would administer PRN pain medication. The CRN stated that on 4/7/26 and 4/19/26 they did not have documentation that the PRN Tylenol was administered or documentation of the effectiveness of the non-pharmacological interventions. The CRN stated that staff should take into consideration what resident 4 reported her pain was along with her cognitive decline and her ability to interpret her pain. The CRN stated staff should determine resident 4's source of the pain, what other circumstances might be contributing to the pain, and if they can resolve it at the moment. The CRN stated that maybe other things contributed to the 10/10 pain score and the staff were able to resolve it at the moment. The CRN stated that the nurses got used to the baseline of the resident and maybe they did not document what was going on fully. The facility Pain Management Policy documented that the facility would Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. The policy further stated that facility staff should observe for nonverbal indicators of pain such as: a. Change in gait (e.g. limping), skin color, vital signs (e.g. increased heart rate, respirations, and/or blood pressure), perspirationb. Loss of function or inability to perform activities of daily living (ADLs) (e.g. rubbing a specific location of the body, or guarding a limb or other body parts)c. Fidgeting, increased or recurring restlessnessd. Facial expressions (e.g. grimacing, frowning, fright, or clenching of the jaw)e. Behaviors such as: resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activitiesf. Difficulty eating or loss of appetiteg. Weight lossh. Difficulty sleeping (insomnia)i. Negative vocalizations (e.g. groaning, crying, whimpering, or screaming)j. Decline in activity levelk. Skin conditions.The policy documented that non-pharmacological interventions included: a. Environmental comfort measures (e.g., adjusting room temperature, smoothing linens, comfortable seating, assistive devices or pressure redistributing mattress and positioning)b. Loosening any constrictive bandage, clothing or devicec. Elevating or supporting limbs (e.g., using a pillow or folded blanket)d. Physical modalities (e.g., cold compress, warm shower/bath, massage, turning and repositioning)e. Exercises to address stiffness and prevent contractures as well as restorative nursing programs to maintain joint mobilityf. Cognitive/behavioral interventions (e.g., music, relaxation techniques, activities, diversions, spiritual and comfort support, teaching the resident coping techniques and education about pain). The policy documented that pharmacological interventions should be specific to each resident who had pain or the potential for pain. The facility should Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain. The policy was last updated in 2025.
Based on observation, interview and record review the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, the facility dish machine was not reaching the required temperature, dirty dishes were loaded from the clean side, gloves were not changed between touching dirty dishes and then clean, there were foods in the refrigerator that had been in there longer than 7 days and there were soiled areas in the kitchen. Findings include: 1. On 4/19/26 at 8:26 AM, an observation was made of the facility kitchen. The following was observed: a. There were 2 sanitizer buckets. Dietary Aide (DA) 1 stated she had changed the sanitizers 15 minutes prior. DA 1 was observed to use chlorine sanitizer testing strips. The white strips did not change color. DA 1 stated she did not know what color the strip should change to. DA 1 stated she used a sanitizer from the 3 compartment sink. An observation was made of the sanitizer and it was labeled Quaternary [Quat] sanitizer. b. [NAME] 1 was observed to place an omelet directly on the trayline counter and then pick it up and put it on the tray on top of other omelets. [NAME] 1 was observed to serve the omelet. c. The drink refrigerator was observed and there were 2 cups of milk with no date. d. The dry storage was observed. There was a brown substance on the pipes on the ceiling. The floor was observed to have a black substance on it. e. The walk in refrigerator was observed. There were 2 large tubes of ground meat dated 4/11/26, a ziplock back of brown gravy dated 4/12/26, 2 chicken drum sticks dated 4/12/26, sliced bologna dated 4/14/26 and 4 cups of fruit with no dates on them. f. The floor in the kitchen had black and brown substances around the outside walls, around the electrical outlet on the floor, and the legs of equipment. g. The dish machine was observed. The washing temperature was 90 degrees Fahrenheit. The rinse temperature was 110 degrees Fahrenheit. The April 2026 dish machine temperature log had the first date of 4/17/26. There were no temperatures written for 4/17/26 and for 4/18/26 there was no dinner temperature recorded and no temperatures recorded for 4/19/26. The log revealed the washing temperature needed to be above 120 Fahrenheit and rinse temperature needed to be above 75 degrees Fahrenheit with the sanitizer above 50 parts per million. 2. On 4/22/26 at 1:20 PM, there was a follow up kitchen tour conducted. The following was observed: a. The floor was soiled with a black substance around the outside walls, equipment legs, and around the electrical box on the floor. b. DA 2 was observed to test the sanitizer solution in a red bucket. DA 2 stated it was changed out every 1 to 2 hours. DA was observed to use the quaternary solution test strips. The strip was observed to change from orange to green. DA 2 stated he honestly dontt know what that means when asked what the colors meant. DA 2 stated he did not test it every time he made the solution. c. There was a mop bucket with black water in it next to where the clean dishes were removed from the dish machine. d. The dish machine log was filled in for all meals from 4/17/26 though 4/22/26 breakfast. The dish machine was observed: [Note: All temperatures were in degrees Fahrenheit.] i. At 1:30 PM, the washing temperature was less than 110. The rinse temperature was 119. A large pan was washed and put away by DA 3. ii. At 1:32 PM, DA 3 was observed to use gloved hands to pull out clean dishes from the dishwasher, use the same gloves to put dirty dishes into the dishmachine, and then use the same gloves to put away clean bases and heating pellets. iii. At 1:35 PM, the washing temperature was 100 and rinse temperature was 110. An interview was immediately conducted with [NAME] 2. [NAME] 2 stated the dish machine needed to be at 120 for the washing and rinsing cycles. [NAME] 2 stated if the temperature was not above 120 then she turned off all the sinks and ran the dish machine continuously until it was above 120. iv. At 1:37 PM, the washing temperature was 110 and the rinse temperature was 120. v. At 1:39 PM, DA 3 was observed to use a gloved hand to touch dirty dishes and then used the same gloved hands to put away a clean pan from the above cycle. DA 3 was then observed to put a washing machine tray on the clean side and push it into the dishmachine with the same gloved hands. vi. At 1:40 PM, the washing temperature was 105 and the rinse temperature was 119. DA 3 was observed to put a basket with dirty dishes on the clean side of the dishmachine and push it into the dishmachine. vii. At 1:42 PM, the washing temperature was 110 and the rinse temperature was 119. On 4/22/26 at 1:44 PM, an interview was conducted with DA 3. DA 3 stated she was provided training on washing dishes, preparing meals, and knowing where everything was. DA 3 stated she was trained to make sure all dishes were scrubbed and the temperature of the dishmachine was above 120. DA 3 stated if the dish machine did not reach 120, then she needed to keep using it until the temperature was above 120. DA 3 stated she was not trained on how to load or unload the dishes. DA 3 stated she was trained to change her gloves when she changed tasks. On 4/22/26 at 1:47 PM, an interview was conducted with the Dietary Manager (DM). The DM stated all dishes needed to be put in the 3 compartment sink since the dishmachine was not reaching the required temperature. The DM stated the dish machine reached the required temperature during breakfast dishes. The DM stated the wash and rinse cycles both needed to be higher than 120 degrees Fahrenheit. The DM stated she did not know why the dishmachine temperature log was not filled out on 4/17/26 when observed on 4/19/26. The DM stated there was a dishmachine log for 4/1/26 though 4/16/26 which was on her desk. The DM provided the dishmachine log from 4/1/26 through 4/15/26. On 4/1/26 at lunch, the temperature was 50 for the wash, 50 for the rinse and 30 for the chlorine sanitizer. The DM stated the floors should be mopped nightly and the pipe with the dried substance in the dry storage should be cleaned. The DM stated staff should know that the sanitizer buckets used Quats sanitizer and it should be between 50 to 150 Parts Per Million.
Based on observation, interview and record review, for 12 of 40 sampled residents, the facility did not provide each resident with food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, the test tray was not palatable or attractive, and there were resident council minutes and grievances with complaints of food quality. Resident identifiers: 1, 8, 10, 33, 50, 52, 54, 63, 66, 76, 78 and 92. Findings included: Resident interviews 1. On 4/19/26 at 9:48 AM, an interview was conducted with resident 10, who stated the food and coffee were usually served cold. Additionally, Resident 10 stated the food tasted awful. 2. On 4/19/26 at 12:44 PM, an interview was conducted with resident 33, who stated he was unable to chew the meat served because it was too tough. 3. On 4/19/26 at 10:43 AM, an interview was conducted with resident 63. Resident 63 stated Oh God, you had to ask when asked about food quality. Resident 63 stated I skip, honestly indicating he skipped meals. Resident 63 stated the cooks were bad and most of the time his food was either under cooked or over cooked with no seasoning. Resident 63 stated the food was tasteless. Resident 63 stated if there was seasoning, then he would start eating it again. Resident 63 stated They are cooking like shit. Resident 63 stated the country fried steak tasted like spam. 4. On 4/19/26 at 11:19 AM, an interview was conducted with resident 92. Resident 92 stated the food had not been good. Resident 92 stated he was served 2 overcooked hotdogs on a plate with no condiments, no bun and no side dishes. Resident 92 stated portions were too small for a person his size. 5. On 4/19/26 at 11:36 AM, an interview was conducted with resident 78. Resident 78 stated the food was terrible and she was always having to fill out alternative menus. Resident 78 stated she needed gluten-free food and was not served gluten-free. Resident 78 stated she used her $45 per month on gluten free food. 6. On 4/19/26 at 11:40 AM, an interview was conducted with resident 66. Resident 66 stated the food was terrible and she was always filling out alternative menus. 7. On 4/19/26 at 3:43 PM, an interview was conducted with resident 52. Resident 52 stated the food was really obnoxious sometimes. 8. On 4/19/26 at 3:24 PM, an interview was conducted with resident 8. Resident 8 stated the food was just terrible. Resident 8 stated he thought there were problems with paying cooks and having to work in a tiny kitchen to serve 80 residents. Resident 8 stated he received 2 slices of bread with a slice of cheese that was not melted and 4 bites of tomato soup. Resident 8 stated he was on a high protein diet for wound healing and that was not enough food. 9. On 4/19/26 at 2:39 PM, an interview was conducted with resident 1. Resident 1 stated that the kitchen did not follow her food preferences. Resident 1 stated that she was not supposed to eat potatoes and the only vegetable she could tolerate was corn. Resident 1 stated that the kitchen kept giving her peas and carrots. Resident 1 stated that she was not supposed to eat fruit because she was a diabetic. Resident 1 stated that she could not eat some of the food because it did not taste good. Resident 1 stated that the kitchen staff did not listen and they should pay attention to the resident diets. 10. On 4/19/26 at 3:51 PM, resident 50 stated that the food at the facility was not good and they have had several cooks rotate through. Resident 50 stated that they served a lot of broccoli, salad, and black beans. 11. On 4/19/26 at 11:28 AM, resident 54 stated he did not eat much of the food because he did not like it and because of this he made his own food. Resident 54 stated that he wanted food that put weight on him. Resident 54 stated that since admission he had lost a lot of weight. Resident 54 stated that he gets too much chicken and fish and he did not like it. 12. On 4/19/26 at 10:47 AM, resident 76 stated that the kitchen had been struggling and they cannot keep staff in the kitchen. Resident 76 stated that there was a lot of food that he could not eat and the facility did not have enough options. Resident 76 stated that alternative food options were a salad and hot dogs. Resident 76 stated that they had a lot of fish at the facility and he could not eat fish. Resident 76 stated that he got chicken every day and he was getting sick of it. Resident 76 stated that the food was not served warm and they microwaved the chicken which made it rubbery. Test tray On 4/21/26 at 12:40 PM, the last tray was placed on the cart and a test tray was requested. At 12:55 PM, the last tray was delivered in the 200 hallway. The test tray was observed to have a slice of pepperoni pizza, a thin slice of bread, and a white cake. The pizza was 142 degrees Fahrenheit. The pizza was tough to chew and unable to be cut. The garlic bread was very thin and crunchy like a cracker. The white cake tasted like white cake with coconut topping. The tray had all brown and white foods on it. There was no color. Resident Council Minutes A review of resident council meeting notes revealed the following: a. On 8/5/25, the notes documented that residents had concerns about meal tickets, specifically the likes/dislikes, not being read.c. On 9/2/25, the Facility Response/Solution to the meal ticket concerns addressed in the previous resident council was documented as much better. Additionally, the notes documented that residents had concerns about dislikes and that the Dietary Manager (DM) would be updated so those dislikes would be on the meal tickets.b. On 4/7/26, the residents had dietary concerns with cold coffee and food. On 4/22/26 at 2:02 PM, an interview was conducted with the Dietary Manager (DM). The DM stated when residents disliked the food, they usually came to her and she fixed the problem. The DM stated there was a lot of new staff in the kitchen because there was high DA [Dietary Aide] turnover. The DM stated residents could also fill out a grievance form regarding food quality. The DM stated food preferences were asked upon admission and in care conferences. The DM stated after admission the residents could come to the kitchen and let her know their preferences and she would relay them to the kitchen staff. The DM stated a new plate warmer was ordered but had not arrived. The DM stated they usually kept the warmers for the 200 hallway. On 4/22/26 at 4:34 PM, an interview was conducted with the Administrator (ADM). The ADM stated the facility had a pellet warmer system ordered. The ADM stated there should be enough pellet warmers for the full facility. The ADM stated he completed audits after the last complaint survey because food palatability was cited. The ADM stated he did not have anything horrible to eat on the test trays. The ADM stated he had been in a lot of skilled nursing facilities and the food was not 5 star food. Grievance Report Form On 5/31/25, the grievance form documented the concern as Resident stated that her bread/roll this morning for breakfast was too hard, and she asked a CNA she believed to be [name omitted] to get her a new one. She stated that he never followed up with her and that she didn't get a new roll. The grievance was confirmed. The corrective action was to encourage the resident to approach the Dietary Manager with concerns. On 7/17/25, the grievance form documented the concern as Resident stated that he continues to get meats he can't chew on his meal trays. Resident does not have any teeth and is unable to chew certain foods. The grievance was confirmed. The corrective action was that staff would check his tray before delivering to the resident. On 8/5/25, the grievance form documented the concern as Residents stated that they continue to receive items on their tray that they dislike. The grievance was confirmed. The corrective action was that Certified Nurse Assistants (CNAs) will double check meal tickets to ensure the residents are getting the right diet and dislikes aren't on the trays. On 9/26/25, the grievance form documented the concern as [Name omitted] stated that she received old lettuce and cucumbers in her salad last night and undercooked chicken a couple weeks ago that she sent back to be cooked longer but never got back. The grievance was confirmed. The corrective action was that the kitchen was to confirm that the food was cooked thoroughly and fresh produce will be utilized, not wilted. On 11/14/25, the grievance form documented the concern as He wants staff to let him know what the menu will be daily so he can choose alternatives if he doesn't like the meal. Also for CNAs to tell them whats on his plate before feeding him. The grievance was confirmed. The corrective action was that staff will take more time to read the menu and explain what was on his meal tray.
Based on observation, interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not 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. Specifically, observations were made of cross-contamination and improper hand hygiene practices during wound care, and Enhanced Barrier Precautions (EBP) was not implemented during wound care. Additionally, multiple observations were made of resident drinks being delivered throughout the facility while uncovered during transport. Resident identifier: 76. Findings included: 1. Resident 76 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included type II diabetes mellitus, morbid obesity, peripheral vascular disease, lymphedema, and atopic dermatitis. On 4/19/26 at 10:41 AM, an interview was conducted with resident 76. Resident 76 stated he had cellulitis on the right leg and an infection on the heel of his foot. Resident 76 stated that he had wound care to the foot 3 times a week and had been receiving wound care as long as he had been at the facility. Resident 76 did not have a sign indicating EBP was required outside the resident's room.On 4/17/26, resident 76's wound orders documented, Wound Care to Bilateral posterior thighs; Clean with wound cleanser, apply small hydrogel sheet on the inferior RIGHT thigh. Apply large hydrogel sheet dressing on BILAT [bilateral] posterior thighs. Change on shower days and PRN [as needed] one time a day every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for poor skin integrity.On 4/17/26, resident 76's wound care orders documented, Wound care- Wounds to bottom of RIGHT foot. Clean with NS or wound cleanser and pat dry ApplyAquaphor/urea to feet, apply collagen SHEET, cover with boarder [sic] sorbact foam, and wrap feet with kerlix. Change every other day and PRN (DO NOT USE COBAN, IT WRAPS TOO TIGHTLY) one time a day every other day. On 4/22/26 at 11:27 AM, an observation and concurrent interview was conducted with Licensed Practical Nurse (LPN) 3 and Assistant Director of Nursing (ADON) 3 during resident 76's wound care. Both staff entered the resident's room and neither donned a gown for the wound care. LPN 3 and ADON 3 donned gloves, but no observation of hand hygiene was made prior to glove application. Resident 76 stood from his motorized wheelchair and LPN 3 placed a chucks pad on the seat of the wheelchair and resident 76 returned to the seat. LPN 3 doffed and donned new gloves. No hand hygiene was performed. LPN 3 stated that the dressing on the right foot was a Kerralite cool dressing. ADON 3 placed normal saline onto a package of 4x4 gauze pads. ADON 3 removed resident 76's sock on the right foot and pulled back the tubigrip. ADON 3 stated that there was not an old dressing present due to the resident having just showered. ADON 3 did not doff the dirty gloves, perform hand hygiene and don new gloves. ADON 3 cleaned the wound bed on the right foot with the normal saline soaked gauze. ADON 3 cleaned the wound bed from the outside inward and then back outwards in a back and forth motion, crossing over the center of the wound bed multiple times. ADON 3 doffed her dirty gloves and donned new gloves. ADON 3 stated that she needed to wash her hands prior to the application of new gloves but LPN 3 stated that she did not need to wash her hands as she was still clean. ADON 3 applied the Kerralite cool dressing over the top of the plantar wound. ADON 3 pulled the tubigrip down over the dressing and the sock was reapplied. ADON 3 did not label and date the new dressing. Resident 76 stated that the other wound was located on his bare butt. Resident 76 stood up from the wheelchair so that LPN 3 could have access to the wound. LPN 3 stated that the wound was to be cleansed with normal saline and then a hydrogel dressing was placed on the wound. LPN 3 opened 2 packages of 4x4 gauze and sprayed normal saline inside the package. LPN 3 opened one package of small hydrogel and 2 packages of the large hydrogel dressings. LPN 3 cleaned the wound bed wiping multiple times over the same site, in a back and forth motion. LPN 3 stated that the left inner thigh had one large wound and the right inner thigh had 2 smaller wounds. LPN 3 applied all packages of the hydrogel dressing to the wounds. The dressings were not secured in place with a cover or adhesive. Resident 76's wound bed was not visualized as access was not possible due to limited space. The wound care was observed from the left lateral side of resident 76. LPN 3 then assisted resident 76 in pulling up his trousers. Resident 76 resumed his seat in the wheelchair.LPN 3 stated that he was going to wash his hands now. LPN 3 stated that with resident 76's wound care he was on EBP and they should have worn gowns. LPN 3 stated that gloves should be changed when moving to a new site, or touching any contaminated surface. LPN 3 stated that hand hygiene should be performed after each doffing and prior to donning of new gloves. LPN 3 stated that he did not want to exit the room to wash his hands during wound care because it would leave the dressing supplies open and exposed to possible contamination. LPN 3 stated that they could have brought Alcohol Based Hand Rub (ABHR) into the room to perform hand hygiene. LPN 3 stated that the process for cleaning a wound bed was to clean from the inside out, to reduce cross contamination and they should not go back and forth over the same site. ADON 3 stated that they did not label the foot dressing. On 4/22/26 at 11:49 AM, an interview was conducted with the Director of Nursing (DON), Regional Nurse Consultant (RNC), and ADON 4. The DON stated that EBP was for any resident that had intravenous (IV) access, a central line, a peripherally inserted central catheter (PICC) line, catheter care, wound care, chronic wounds, pressure ulcers, diabetic foot ulcers and unhealed surgical wounds. The DON stated that in EBP rooms staff should don gloves and gowns during resident care. The DON stated that during wound care they should don gloves at the beginning, after the first cleansing and before they start the next step of wound care. The DON stated that gloves should be doffed, hand hygiene performed and new gloves donned prior to cleansing the wound bed to prevent cross contamination. The ADON 4 stated that the new dressing should contain the date and the initials of the person performing the wound care. ADON 4 stated that staff should clean the wounds from the inside outward ensuring that they did not pass over the center of the wound bed again. ADON 4 stated the center of the wound bed was less contaminated and to reduce the risk of contamination staff should not pass over the same area more than once with the same cleansing wipe. On 4/22/26 at 1:47 PM, a follow-up interview was conducted with LPN 3. LPN 3 stated that he used Kerralite for the wound care because that was what the order was written for. LPN 3 stated that he called the wound nurse prior to the dressing change to clarify the order because they were previously using Kerralite. LPN 3 confirmed that the order was changed prior to resident 76's dressing change. Review of the facility policy for Enhanced Barrier Precautions (EBP) documented that it was an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO] that employs targeted gown and gloves use during high contact resident care activities. The policy documented that EBP were indicated for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO. (Peripheral IVs, continuous glucose monitors, insulin pumps, or ostomies without an associated indwelling medical device are not an indication for EBP.) The policy documented that high contact care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care. The policy was last revised in 2025.2. On 4/19/26 at 12:27 PM, an observation was made of Certified Nursing Assistant (CNA) 3. CNA 3 was observed to pour a cup of coffee into a mug in the dining room and transport it down the hallway uncovered to a resident room. 3. On 4/21/25 at 12:21 PM, an observation was made of staff transporting coffee from the 100 hallway dining room to room [ROOM NUMBER] uncovered. 4. On 4/19/26 at 12:19 PM, an observation was made of the lunch meal service in the 100 hallway. The meal cart was parked between rooms [ROOM NUMBERS]. Meals and drinks were served from this cart.At 12:21 PM, a cup of uncovered coffee was walked down the hallway and delivered to room [ROOM NUMBER]. At 12:24 PM, two cups of uncovered coffee were walked down the hall and delivered to room [ROOM NUMBER]. At 12:26 PM, the meal cart was moved and parked between rooms [ROOM NUMBERS]. A cup of uncovered coffee was walked down the hall to room [ROOM NUMBER].At 12:29 PM, two cups of uncovered coffee were walked down the hall to room [ROOM NUMBER].
Based on interview and record review it was determined, for 1 out of 40 residents sampled, that the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, a resident's urinalysis laboratory report was not located in the medical records. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia, osteomyelitis, anemia, post-traumatic stress disorder, depression, anxiety disorder, and insomnia. On 3/21/26, resident 8's physician ordered a urinalysis to be obtained. No documentation could be found of the laboratory results in resident 8's medical records. On 4/27/26 at approximately 8:00 AM, the Director of Nursing (DON) was asked to provide the results for the urinalysis that was ordered on 3/21/26. On 4/27/26 at 8:40 AM, the Regional Nurse Consultant (RNC) provided via email the laboratory results for the urinalysis. On 4/27/26 at 9:40 AM, the DON stated that resident 8's urinalysis results were obtained from the laboratory. The RNC stated that they had a copy from the laboratory at one point because it was sent to the provider, but she was not sure why it did not make it into resident 8's medical records.
Based on interview and record review it was determined, for 1 of 40 residents sampled, that the facility did not ensure that prompt efforts to resolve grievances made by the residents were completed, tracked through the conclusion with a summary of the findings, and a statement as to whether the grievance was confirmed or not confirmed with any corrective action taken and the date it was completed. Specifically, the facility did not promptly resolve the grievance made by the resident and the grievance did not contain the investigation, summary of findings, or the conclusion of the investigation with dates. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, hypertension, anxiety disorder, major depressive disorder, and post-traumatic stress disorder. On 4/19/26 at 2:44 PM, an interview was conducted with resident 1. Resident 1 stated that she told the Resident Advocate (RA) that a Certified Nurse Assistant (CNA) let the door slam on her finger and it cut her finger causing it to bleed. Resident 1 stated that this incident occurred last week. Resident 1 stated that she filled out a grievance report with the RA. Resident 1 stated that the nursing staff put Neosporin and a bandage on the finger after the incident. Resident 1 stated that she did not know the name of the CNA but she worked the night shift. Resident 1 stated that no one should be treating the residents that way. On 4/10/26 resident 1's grievance documented the concerns as Resident Reported that the CNA [name omitted] (NOC) [night shift], does not hold the smoking door open for her and another resident. She stated that the CNA swings the door open and walks away. The form documented that upon initial interview an allegation of abuse or neglect was not identified. The grievance form did not have any documentation of the steps taken to investigate the grievance, a summary of the findings and conclusion, and if the grievance was confirmed or not. The form did not have a written decision date, resident signature, grievance officer signature, or Administrator signature. On 4/22/26 at 3:48 PM, an interview was conducted with the RA. The RA stated that when resident 1 went outside the CNA did not hold the door open for the resident. The RA stated that resident 1 reported that when she went to grab the door she had a small cut that reopened. The RA stated that she reported the incident to the Administrator (ADM) and Director of Nursing (DON). The RA stated that resident 1 presented the incident to her that when she went to stop the door from closing her cut reopened, but not that it was slammed on her. The RA stated that resident 1 mentioned that she felt like the CNA was in a hurry. The RA stated that resident 1 did not mention that she felt like the CNA was intentional in their actions and that the incident was directed at her purposefully. On 4/22/26 at 4:05 PM. an interview was conducted with the ADM, DON, and Regional Nurse Consultant (RNC). The ADM and DON stated that they were not informed of the incident with resident 1. The ADM stated that they would do an investigation and would check the camera footage. The DON stated that they would assess resident 1 for pain and injury. The ADM stated that they would obtain a statement from resident 1 and the employee. The RNC stated that there was nothing filled out on the back of the grievance form which indicated that it was still in progress. The ADM stated that if the form indicated that it was not an allegation of abuse then it should have been resolved within a couple of days of submission. The ADM stated that with this grievance being initiated on 4/10/26 it should have been resolved by now.
Based on interview and record review it was determined, for 1 of 40 sampled residents, that the facility did not ensure that as needed (PRN) orders for psychotropic drugs were limited to 14 days unless the prescribing practitioner or attending physician documented a rationale in the resident's medical record and indicated the duration for the PRN order. Specifically, a resident's PRN order for Trazodone exceeded 14 days and the resident's medical record did not have a documented indication to extend the use with a duration for the order. Resident identifier: 8. Findings included Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia, post-traumatic stress disorder, depression, anxiety disorder, and insomnia. On 4/8/26, resident 8's physician ordered Trazodone HCL [hydrochloride] Tablet 150 milligram (mg) by mouth every 24 hours as needed for insomnia. The order was discontinued on 4/20/26, and reinstated on the same day. Resident 8's April Medication Administration Record (MAR) documented that the PRN order of Trazodone was administered on 4/10/26 at 1:39 AM, on 4/11/26 at 2:13 AM, 4/15/26 at 11:32 PM, on 4/18/26 at 12:37 AM on 4/19/26 at 1:56 AM and at 10:00 PM, on 4/20/26 at 10:08 PM, on 4/25/26 at 2:38 PM, and on 4/26/26 at 10:34 PM. It should be noted that on 4/19/26 resident 8 was administered the PRN dose of Trazodone 2 times within the 24 hour period and the order was for one PRN dose in 24 hours. On 11/24/25, resident 8's Psychotropic Medication Review did not have documentation for the on-going use of the PRN Trazodone medication. Resident 8's medical records were reviewed and no documentation could be found of the physician rationale to extend the PRN dose past 14 days with a duration of use. On 4/27/26 at 9:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that Trazodone was prescribed for insomnia. The DON stated that they had a psychotropic review that documented that a Gradual Dose Reduction (GDR) was contraindicated but did not document a rationale for the on-going PRN Trazodone order.
Based on interview and record review, the facility did not ensure that allegations of neglect, including events that caused reasonable suspicion of neglect, were reported immediately to the State Survey Agency (SSA). Specifically, for 1 of 40 sampled residents, the facility did not report a resident injury that occurred during a staff-assisted transfer with a mechanical lift to the SSA. Resident Identifier: 10. Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included unspecified fracture of right lower leg, paraplegia, cirrhosis of liver, rhabdomyolysis, and mild protein-calorie malnutrition. On 3/12/26 at 2:18 PM, an Event Note Template documented On 3/6/2026 as the Skilled nurse [SN] was completing a weekly skin assessment, skin breakdown was noted to resident buttocks. SN contacted nurse management and assessment of wound noted. Resident noted to have breakdown on right buttock, and shearing injury related to Hoyer sling being removed by CNA [Certified Nursing Assistant]. Contacted MD [Doctor of Medicine] and wound NP [Nurse Practitioner] for orders and to review interventions. On 04/22/26 at 4:52 PM, an interview was conducted with the administrator, who stated he was unsure if the incident was reported to the SSA. It should be noted that no documentation could be located to determine if the incident was reported to the SSA. [Cross refer to F689]
Based on interview and record review the facility did not provide an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Specifically, for 1 of 40 sampled residents, a resident was not provided discharge planning. Resident identifier: 52. Findings include: Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease, type 2 diabetes mellitus, cerebral infarction, schizophrenia, and history of transient ischemic attack. On 4/19/26 at 3:43 PM, an interview was conducted with resident 52. Resident 52 stated he would like to discharge to his own apartment or maybe an assisted living. Resident 52 stated the staff said he did not make enough money for the New Choice Waiver but he was on Medicaid. A Behavioral Complex Interdisciplinary Team Review on 4/17/26 at 1:09 PM revealed, . Resident has recommendations for specialized services or PASSR[ Pre-admission Screening/Resident Review] Recommendations of Pt[patient] . discharge planning. There was no care plan in resident 52's medical record for discharge planning. On 4/22/26 at 3:48 PM, an interview was conducted with the Resident Advocate (RA). The RA stated resident 52 did not have a discharge plan and was going to need long term care (LTC). The RA stated resident 52 wanted to discharge to another LTC facility but they were full. The RA stated she had asked resident 52 if he wanted to send a referral to another facility and he said no. The RA stated resident 52 had brought up going to assisted living and discussed the new choice waiver with him but was not sure if he had an income. The RA stated she documented the discharge plan in the progress notes. The RA stated the Assistant Director of Nursing (ADON) completed discharge care plans.
Based on interview and record review it was determined, for 1 out of 40 residents, that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice. Specifically, the facility did not provide a resident timely orders and treatments after they sustained a shearing wound. Resident identifier: 10 Findings included: Resident 10 was admitted to the facility on [DATE] with diagnoses which included unspecified fracture of right lower leg, paraplegia, cirrhosis of liver, rhabdomyolysis, and mild protein-calorie malnutrition. On 4/22/26 at 3:04 PM, an interview was conducted with resident 10, who stated that he had been cut on the buttocks during a Hoyer lift transfer by a new sling, which had sharper edges than his previous sling. Resident 10 stated that after the initial injury the sling was replaced. Resident 10 stated that the wound had been painful. On 3/6/26 at 6:30 PM, a Late Entry Progress Note documented Skilled nurse (SN) was completing a weekly skin assessment and noted skin breakdown to resident buttocks. SN contacted nurse management and assessment of wound noted. Resident noted to have breakdown on right buttock due to shearing injury related to Hoyer sling, Contacted MD (Medical Director) and wound NP (Nurse Practitioner) for orders and to review interventions. It should be noted that the creation date was 3/17/26 at 1:56 PM, 11 calendar days after the effective date. A review of Resident 10's medical record revealed that prior progress notes referencing the shearing injury were labeled as Late Entry and were created after 3/9/26. An order for was documented on 3/9/26, WOUND CARE --- Right buttocks --- Cleanse wound with NS [normal saline]. Pat dry. Apply zinc barrier cream layered with collagen powder. Cover with ABD [abdominal] pad to dress the wound. Apply zinc barrier cream to surrounding areas in proximity to the wound with compromised skin concerns. every night shift for Wound Care. It should be noted that the order was documented 3 calendar days after a late entry progress note documented that the shearing injury was discovered and assessed. A review of Resident 10's medical record revealed that the facility did not document any treatment orders or wound care provided for the resident prior to 3/9/26. On 4/22/26 at 3:26 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that because she was a new employee at the facility she was unfamiliar with the history of resident 10's wound. LPN 1 stated that a resident's Treatment Administration Record (TAR) contained any wound care orders and that staff documented all provided wound care in the TAR. On 4/22/26 at 4:52 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that she was informed on 3/6/26 of resident 10's wound by the Assistant Director of Nursing (ADON) 1, and they contacted resident 10's physician and Wound Care Provider (WCP) via phone to receive orders. The DON stated that it was determined the wound was a shearing injury sustained when a Hoyer sling was incorrectly removed from under the resident through interview, assessment, and discussions with the WCP. Furthermore, the DON stated the WCP gave verbal wound care orders and she was unsure why the orders were not entered into resident 10's medical record. The DON stated that when verbal orders are given, the nurse will enter them into the medical record and the provider will then electronically sign the orders. The DON stated that she knew that resident 10 was provided the wound care ordered that night due to the verbal communication she had with ADON 1, despite the order and cares not being documented in the TAR. On 4/27/26 at 11:45 AM, an additional interview was conducted with the DON, who stated that the nursing staff needed to document any events pertaining to each resident in the progress during their shift. The DON stated this incident should have been documented in the progress notes so other staff could refer to the incident if needed and so there was a paper trail and explanation of what happened. On 4/27/26 at 12:06 PM, a telephone interview was conducted with ADON 1, who stated that at the time the incident occurred it was reported to him by a floor nurse. ADON 1 stated he sent a picture of the wound to the wound care provider in order to receive orders. ADON 1 stated he remembered the wound care orders were to use a zinc barrier, collagen powder and use an abdominal dressing to cover the wound but he was not sure if that was the exact order. ADON 1 stated that he, the DON, and the Corporate Resource Nurse all worked on the orders and put them into the medical record. ADON 1 stated he knew the floor nurse provided wound treatment on 3/6/26 and he was unsure why documentation showed that the order was not put into the medical record until 3/9/36. The order wasn't put in until the following Monday. ADON 1 stated that the weekend floor staff would not have received a notification to perform wound care if the order was not in the medical record, and subsequently they would not have known that resident 10 needed wound care. On 4/27/26 at 12:26 PM, a telephone interview was conducted with the WCP, who stated the facility called her in March 2026 to address resident 10's shearing injury. The WCP stated she did give an order for the wound, but she could not recall the specific details. The WCP stated that resident 10 refused to let her do an assessment when she was at the facility. A review of resident 10's medical record revealed that resident 10 refused the WCP's attempts to assess the shearing wound to his buttock on 3/13/26, 3/20/26, and on 3/27/26.
Based on observation, interview and record review it was determined, for 1 of 40 residents sampled, that the facility did not provide each resident the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not demonstrate reasonable attempts to provide or arrange behavioral health services for a resident who was monitored for depressive statements and had tearfully expressed his lack of independence since suffering a stroke. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] with diagnoses which included ischemic cardiomyopathy, unsteadiness on feet, muscle weakness, history of falling, need for assistance with personal care, asthma, chest pain, severe protein-calorie malnutrition, cachexia, contracture of left and right hand, takotsubo syndrome, and portal hypertension. On 4/19/26 at 11:39 AM, an interview was conducted with resident 54. Resident 54 became tearful multiple times during the conversation recounting his physical limitations since his stroke and lack of independence. Resident 54 stated that he did not currently have mental health services. On 9/2/25, resident 54 had a physician order for BEHAVIOR MONITORING: EXPRESSIONS OF SADNESS Q [every] SHIFT (Avoiding eye contact, drooping facial expression, withdrawing from social interaction, etc). On 9/2/25, resident 54 had a physician order for Observation: Behaviors - Observe every shift. If behavioral symptoms are present, attempt non-pharmacologic interventions. A) Relaxation/breathing techniques B) Music or TV of choice C) Offer food/fluids D) Assess for pain E) Offer toileting F) Offer activity or other distraction of choice G) Other (specify in note). Document effectiveness. every shift for Monitoring On 9/2/25, resident 54 had a physician order for Monitor Behaviors: DepressiveStatements Interventions: 1.ONE ON ONE; 2. ACTIVITY; 3. ADJUST ROOMTEMPERATURE; 4.BACK RUB; 5. CHANGE POSITION; 5.OFFER FLUIDS; 7.OFFER FOOD; 8. REDIRECT; 9.REMOVE RESIDENT FROM ENVIRONMENT; 10. TOILET; 11.OTHERS : sertraline every shift Monitoring. The order was discontinued on 3/22/26. The April 2026 Treatment Administration (TAR) documented 4 episodes of expressions of sadness. The Behavior monitoring documented daily non-pharmacological interventions for 36 out of 39 observations. The March 2026 TAR documented 3 episodes of expressions of sadness. The Depressive Statements monitoring documented 4 episodes for the month. The Behavior monitoring documented daily non-pharmacological interventions for 43 out of 62 observations. The February 2026 TAR documented zero episodes of expressions of sadness. The Depressive Statements monitoring documented zero episodes for the month. The Behavior monitoring documented daily non-pharmacological interventions for 43 out of 56 observations. The January 2026 TAR documented 2 episodes of expressions of sadness. The Depressive Statements monitoring documented 2 episodes for the month. The Behavior monitoring documented daily non-pharmacological interventions for 52 out of 62 observations. The December 2025 TAR documented zero episodes of expressions of sadness. The Depressive Statements monitoring documented 1 episode for the month. Behavior monitoring documented daily non-pharmacological interventions for 55 out of 62 observations. On 9/2/25, resident 54's baseline care plan did not have any documentation under social services or any identified psychosocial needs/problems. On 9/10/25, the Minimum Data Set (MDS) admission assessment documented that the Care Area Assessment (CAA) triggered Psychosocial Well-being and the triggering conditions were related to activity preferences. On 9/29/25, resident 54's Psychotropic Meeting Review documented Sertraline 50 milligram daily for Chest pain? Depression. The assessment documented 2 episodes of verbalization of sadness. Non-pharmacological interventions were Resident is encouraged to leave his room and interact with other residents through facility activities. Resident enjoys passing time watching TV and visiting with his roommate. Staff check in on resident and offer active listening often. Staff learn resident's preferences and accommodate them. The form documented that it was unclear why the resident was taking Sertraline and a gradual dose reduction (GDR) was initiated from 50 mg to 25 mg. On 10/11/25, resident 54's Psychosocial Assessment documented, He is alert and oriented x [times] 3. He scored a 12 on his most recent BIMS [Brief Interview for Mental Status] assessment, indicating moderate cognitive impairment. He is able to make his needs known verbally. He is able to understand and is able to be understood. The summary of adjustment to placement was He is adjusting well to placement and understands the situation and routine. He is pleasant and has been participating appropriately overall in the facility. The plan is for him to remain in the facility for long-term care. The behavioral concerns documented that his behavioral status was stable and he was cooperative and compliant with staff and care. The assessment documented that he was living in his truck prior to admission and was working with social services for his economic factors. Additional recommendations were Emotional support, redirection, reassurance, encouragement, validation, socialization and unconditional positive regard. Continue to monitor mood and behavior and notify MD [Medical Doctor] and DON [Director of Nursing] of any changes. Continue to monitor psychosocial well-being and notify LCSW [Licensed Clinical Social Worker] of any changes. On 10/27/25, resident 54's Psychotropic Meeting Review documented that he tolerated his GDR of Sertraline and they discontinued the medication. The form stated that they would monitor the resident again the following month. It should be noted that the resident did not have another Psychotropic review after the discontinuation of the Sertraline in October and further monitoring was not conducted. On 4/21/26 at 8:30 AM, an interview was conducted with the Resident Advocate (RA). The RA stated that resident 54 was seen by a local company who provided mental health services. The RA stated that she would verify how long resident 54 had been on services and how often he was seen by the provider. The RA stated when resident 54 was first admitted he was on an anti-depressant (Sertraline) and he did not have a diagnosis of depression. The RA stated that resident 54 had stated to the previous Assistant Director of Nursing (ADON) 2 that he was feeling depressed that was why he was referred for mental health services. The RA stated that resident 54 had a lot of family issues which caused him to feel lonely. The RA stated that resident 54 had expressed a loss of his independence but she had noticed an improvement in his mental health since he received his power wheelchair. It should be noted that no documentation could be found for mental health services for resident 54. On 4/21/26, the Regional Nurse Consultant (RNC) stated via email that resident 54 was not signed on with mental health services. Per our resident advocate, he has not expressed a desire to be on services. It should be noted that this was a contradiction to the RA's previous interview and statement that resident 54 had told ADON 2 that he was feeling depressed. On 4/22/26 at 8:14 AM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that they monitored resident 54 for expressions of sadness because he had been depressed due to his family not coming around and also about losing weight. LPN 3 stated that resident 54 was not eating and that was why he was being monitored for depression. LPN 3 stated that resident 54's non-pharmacological interventions for depression were music, socializing during smoking breaks, watching old western movies, and encouraging him to attend activities. LPN 3 stated they documented how many episodes of sadness he had that shift and there should be a corresponding non-pharmacological intervention that was provided. On 4/22/26 at 8:22 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that resident 54 did not need to request mental health services to be seen by a provider. The RNC stated that residents were asked during their initial care conference if they were interested in receiving behavioral health services. The RNC stated that the facility staff were good at picking up on resident mood changes and would initiate those services. The RNC stated that some residents refused behavioral health services and in those cases they would consistently ask them again. The RNC stated that staff should inform the Medical Doctor of any residents that needed mental health services and they also informed the RA so she could make the referral. The RNC stated that resident 54 had not voiced that he wanted mental health services and she was not sure if they had a documented refusal for those services. The RNC stated that resident 54 was admitted on Sertraline and there was nothing in the admission paperwork that indicated it was prescribed for depression. The RNC stated that the pharmacy said it could have been prescribed for chest pain and they were not sure what the indication for use was for the medication. The RNC stated that they had mental health services in the building 1-2 times a week and they would make a referral for resident 54 today.
Based on observation and interview it was determined that the facility did not store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys. Specifically, a medication cart was observed unlocked and unattended outside of resident rooms. Findings included: On 4/19/26 at 8:05 AM, an observation was made of the medication cart on the second floor between room [ROOM NUMBER] and 204. The cart was unlocked and unattended by nursing staff. On 4/19/26 at approximately 8:10 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 was observed exiting room [ROOM NUMBER]. RN 1 confirmed that he had left the medication cart unlocked and unattended. On 4/22/26 at 8:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when staff walk away from the medication cart and no other staff were present it should be locked.
Based on interview and record review it was determined, for 1 of 40 residents sampled, that the facility did not obtain laboratory services to meet the needs of its residents. Specifically, the facility did not obtain a Basic Metabolic Panel (BMP) when ordered by the provider. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included paraplegia, osteomyelitis, anemia, post-traumatic stress disorder, depression, anxiety disorder, and insomnia. On 4/15/26, resident 8's physician ordered a BMP to be obtained. No documentation could be found of the laboratory results in resident 8's medical records. On 4/27/26 at approximately 8:00 AM, the Director of Nursing (DON) was asked to provide the results for the BMP that was ordered on 4/15/26. On 4/27/26 at 8:40 AM, the Regional Nurse Consultant (RNC) communicated via email that they were still looking for the results of resident 8's BMP. On 4/27/26 at 9:40 AM, the DON stated that resident 8's BMP was never drawn and they could not find any evidence that the laboratory specimen was obtained. The DON stated that the phlebotomist felt like it was done but the laboratory could not find the results.
Based on observation and interview the facility did not provide a safe, clean, comfortable, and homelike environment. Specifically, for 1 of 40 sampled residents, the facility did not clean a resident's window which was covered in dryer lint. Resident identifier: 63. Findings included: On 4/19/26 at 10:43 AM, an observation was made of resident 63's room. The window was covered in dryer lint. Resident 63 was interviewed. Resident 63 stated general cleaning was getting done but deep cleaning was not happening. Resident 63 stated the window needed to be wiped down. On 4/27/26 at 1:26 PM, an interview was conducted with Housekeeper (HK) 1.HK 1 stated that resident 63's room was deep cleaned last Monday (4/20/26). HK 1 stated that resident 63's window was located next to the dryer vent. HK 1 stated that she did not know when the last time the outside dryer vent was cleaned. HK 1 stated to ask the Housekeeping Manager when the window was cleaned last. On 4/27/26 at approximately 1:30 PM, an observation was made of resident 63's window. The window was completely obscured from view with little light penetrating and was covered in dryer lint on the outside. On 4/27/26 at 1:32 PM, an interview was conducted with the Housekeeping Manager (HM). The HM stated that the outside of the windows were not on the cleaning schedule and he did not know when they were last cleaned. The HM stated that resident 63's window was located near the dryer vent. The HM stated that he ordered replacement parts for the dryer vent last week that included a pipe and elbow attachment. The HM stated that once the new parts were installed the dryer lint would not hit the window anymore. The HM stated that cleaning of the outside windows was his responsibility but he had not cleaned them yet. The HM stated that he started his employment with the facility in November 2025 and the outside window cleaning was on the spring cleaning schedule. The HM stated that the dryer vent had been broken since December 2025. The HM stated that ordering the parts to fix the vent had not been done because it was not a priority.
Based on interview and record review it was determined, for 1 out of 40 sampled residents, that the facility did not file in the resident's clinical record signed and dated reports of radiologic and other diagnostic services. Specifically, the resident's chest x-ray report was not located in the medical records. Resident identifier: 6. Findings included: Resident 6 was admitted on [DATE] and re-admitted on [DATE] with diagnoses that included contracture right and left hand, dysphagia, hypothyroidism, dementia, atrial-fibrillation, pain, hypertension, chronic pain, deformity of left lower leg, peripheral vascular disease, and idiopathic neuropathy. On 4/19/26, resident 6's medical records were reviewed. On 1/10/26 at 9:37 AM, resident 6's progress note documented, Resident has productive cough and crackles bilaterally, MD [Medical Doctor] notified and STAT [immediate] CXR [chest x-ray] ordered.No documentation of the chest x-ray was found in resident 6's medical records. On 4/22/26 at 9:49 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that they tried to obtain stat results within 24 hours of the order being initiated. The DON stated that the appropriate timeframe to scan the report into the resident's medical records would be within 24 hours of receipt of the document during business hours. The DON stated that was the goal, but it did not always happen. On 4/22/26 at 10:39 AM, DON stated that the results came in on Saturday [1/10/26] and the Medical Doctor (MD) reviewed it with the nurse. The DON stated that it was located in a group chat. The DON stated that she did not know why it was not included in resident 6's medical records. The DON stated that they needed to work on their weekend process.
Based on interview and record review it was determined the facility did not employ a full-time, designated person to serve as the director of food and nutrition services. Specifically, the facility did not have a qualified food service director. Findings included: On 4/22/26 at 1:20 PM, an interview was conducted with the Dietary Manager (DM). The DM stated she did not have a certification. The DM stated she had been the DM for 3 years. The DM stated the Registered Dietitian (RD) was at the facility weekly for the nutrition at risk meeting and was available by phone anytime. The DM stated she had registered for the course a few times but then staffing was low in the kitchen and she was pulled to work in the kitchen. On 4/22/26 at 4:05 PM, an interview was conducted with the Administrator. The Administrator stated that he did not know if the DM had a certification. The Administrator stated the RD worked 1 day a week at the facility. (Cross refer to F804 and F812)
Based on interview and record review, for 1 of 40 sampled residents, the facility did not arrange timely services for outside resources that met professional standards and principles that applied to professional providing services. Specifically, a resident was not scheduled for a pain clinic appointment when pain was identified and the resident requested. Additionally, resident records were not secured, left unattended, and visible to any passerby. Resident identifier: 8. Findings included: 1. Resident 8 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included stage 4 pressure ulcers, paraplegia, osteomyelitis, spastic hemiplegia and injury of root of cervical spine. On 4/19/26 at 3:27 PM, an interview was conducted with resident 8. Resident 8 stated he was in a lot of pain and when he was admitted the house physician decreased his pain medication. Resident 8 stated he requested to be sent to a pain clinic because his pain medications were decreased when he was admitted . Resident 8 stated he did not have a phone to call his medical providers. Resident 8 stated he asked for a telehealth appointment with the pain clinic but that was never scheduled and they finally scheduled him for a pain clinic appointment that he had been asking for since October when he was admitted . A Nurse Practitioner (NP) note dated 11/4/25 at 2:39 PM revealed, .Plan: . Continue medications as ordered . Monitor for any change in condition .f/u [follow up] appointments as ordered. A care plan initiated on 2/23/26 revealed resident 8 had potential for altercation in health maintenance related to his medical diagnoses. One of the goals was that resident 8 would have symptoms managed for comfort through the review date. Interventions included to monitor for increased pain and notify physician/nurse. A physician's note dated 3/2/26 at 11:00 AM revealed, . ROS [review of system]: paralysis of LE [lower extremity], wounds, chronic pain, muscle spasms, .4. Chronic pain/opioid dependence - will continue current meds. He wants more opioids. Staff do not feel this is indicated. Will refer to a pain clinic . A physician office visit or referral to physician form dated 3/4/26 revealed Botox injection. There were no other notes on the form. A physician's note dated 4/3/26 at 11:49 AM revealed, [Resident 8] continues to report having pain. Nursing staff report his pain appears well controlled. He wants to go to a pain clinic and also wants to see [Name of physician removed] PM&R [Physical Medicine and Rehabilitation].a/p [assessment and plan] 1. Chronic pain - has been referred to pain clinic 2. Spinal cord injury - will refer to [name of physician]. On 4/22/26 at 11:01 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 8 had gone to a spasticity clinic and provided the form from 3/4/26. On 4/22/26 at 2:23 PM, a follow up interview was conducted with the DON and Regional Nurse Consultant (RNC). The DON stated when a resident needed an appointment outside of the facility, there was a physician's order for the referral. The RNC stated there was an insurance issue, so the facility had trouble making appointments. The RNC stated there should be a trail of documentation regarding when appointments were scheduled. The DON stated there was no documentation that the pain clinic appointment was scheduled after admission. The DON stated prior to admission resident 8 was being seen at a pain clinic. 2. On 4/19/26 at 8:05 AM, an observation was made of the medication cart on the second floor between rooms [ROOM NUMBERS]. The computer was unlocked and open to resident records. The cart contained the nurse's resident roster and report sheet with medical information that was viewable by passersby. On 4/19/26 at approximately 8:10 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 was observed exiting room [ROOM NUMBER]. RN 1 confirmed that he had left the computer open and unattended. On 4/22/26 at 8:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when staff walk away from the medication cart the Medication Administration Record and nurse report sheet should not be visible when staff were not around. The DON stated that staff should always protect resident privacy.
Based on interview and record review, for 1 of 40 sampled residents, the facility did not maintain medical records on each resident that were accurately documented. Specifically, a resident had an order for 12 tablets of an antidepressant when the physician ordered 1 tablet. Additionally, the medication cart had the computer open to resident records and left unattended and a nurse report sheet with resident medical information was visible. Resident identifier: 4. Findings included: 1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included muscle weakness, altered mental status, dementia, bipolar and pulmonary hypertension. A physician's order dated 2/27/25 and discontinued 3/4/25 revealed Wellbutrin XL [extended-release] oral tablet extended release 24 hours 150 milligrams [MG]. The directions were to give 12 tablets by mouth one time a day for depressive symptoms. A nursing progress note dated 2/26/25 at 10:38 AM revealed, .I received new orders and reviewed them with the facility NP [Nurse Practitioner] d/c [discontinued] Namenda and start Wellbutrin XL 150 mg po [orally] daily due to increased depressive symptoms. On 4/21/26 at 10:02 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the Wellbutrin XL should have been 1 tablet and not 12. The RNC stated resident 4 did not get 12 tablets per day. The RNC provided pharmacy orders that revealed resident 4 received 30 tablets before reordering 30 days later. 2. On 4/19/26 at 8:05 AM, an observation was made of the medication cart on the second floor between room [ROOM NUMBER] and 204. The computer on the cart was open to resident records. The cart contained the nurse report sheet with resident medical information that was visible to passerby. The cart was unattended by nursing staff. On 4/19/26 at approximately 8:10 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 was observed exiting room [ROOM NUMBER]. RN 1 confirmed that he had left the medication cart unattended with resident information visible. On 4/22/26 at 8:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when staff walked away from the medication cart medical records should not be visible to protect resident privacy.
Inspection of December 30, 2025
1 findingBased on observation, interview, and record review it was determined, for 3 of 19 sampled residents, the facility did not provide each resident with food that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of food quality, the test tray was not attractive or palatable, and there were complaints in the resident council meetings. Resident identifiers: 2, 16, and 17. Findings include:On 12/29/25 at 11:51 AM, an interview was conducted with resident 17. Resident 17 stated the food tasted like shit. Resident 17 stated They could starve a bird with the food they serve here. Resident 17 stated he was served only a piece of toast and coffee for breakfast yesterday. On 12/29/25 at 1:39 PM, an interview was conducted with resident 2. Resident 2 stated the food was served cold. On 12/30/25 at 11:07 AM, an interview was conducted with resident 16. Resident 16 stated the food was not good and she did not eat lunch on 12/29/25. Resident 16 stated it was popcorn chicken with all breading and it looked horrible. Resident 16 stated she did not eat anything for lunch. On 12/29/25 at 12:27 PM, an observation was made of the trayline during lunch. [NAME] 1 was observed to plate the food and then put a plate into a base. At 12:41 PM, [NAME] 1 was observed to use a hot pellet under a plate. [NAME] 1 stated they were out of bases. At 12:45 PM, the last tray was plated for the 200 hallway. At 12:48 PM, the meal cart was set outside the kitchen with resident meals and the test tray. At 12:58 PM, the last tray was served to residents and the test tray temperatures were obtained. The tray had brussel sprouts that were dark green/brown colored, popcorn chicken was brown, and the rice was white. There was a yellow colored dessert served and a roll in a baggie. The following temperatures were obtained from the test tray: [Note: All temperatures were in degrees Fahrenheit.] a. The popcorn chicken was 97.5 and cold to the taste. It was hard on the outside with lots of breading and hard to chew. b. The rice was 98.6 and cold to the taste.c. The brussel sprouts were 94.1 with a brown/dark green in color with a mushy texture. The brussel sprouts were cold to the taste. d. The dessert was 63.8. The dessert was pineapple with a cinnamon crumble top. The dessert's flavor had a strange combination of flavors. Resident council minutes from 1/7/25, 2/4/25, 3/5/25, and 5/6/25, there were complaints of cold food. On 6/3/25, the concerns being followed up on did not have cold food as a concern. On 12/30/25 at 11:30 AM, an interview was conducted with [NAME] 2. [NAME] 2 stated the plates were warmed and put into the liner with a dome over the top when serving food. [NAME] 2 stated there were not enough liners, so pellets were used when the cooks ran out of the liners. [NAME] 2 stated that pellets were not used with the plastic liners. [NAME] 2 stated the pellets were warmed and got really hot but by the time the pellet was provided to the resident it was cool enough to touch. On 12/30/25 at 12:28 PM, an interview was conducted with the Dietary Supervisor (DS). The DS stated kitchen staff should use a liner/base, then a pellet in the base, the plate, and a dome over the top of it. The DS stated the pellets should not be used without the liner/base. The DS stated there were not enough bases for all the residents in the facility. The DS stated the pellets were used to hold in heat and should be warmed to the point that staff could not touch them. The DS stated there were complaints of cold food but then there was staff turnover in the kitchen and in the last 5 months there have not been as many food complaints.
Inspection of January 29, 2024
1 findingBased on interview and record review it was determined that the facility did not ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, for 1 of 33 residents sampled, the facility did not provide care to a resident who sustained a head laceration after a fall and requested to be sent to the hospital via ambulance for treatment. The deficient practice identified was determined to have occurred at a harm level. Resident identifier 35. Findings included: Resident 35 was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, unsteadiness on feet, adult failure to thrive, muscle weakness, suicidal ideation, malignant neoplasm of larynx, tracheotomy status, presence of artificial larynx, chronic kidney disease, and hypothyroidism. On 1/23/24 at 10:16 AM, resident 35 was observed ambulating independently in the hallway directly outside of his room. On 1/23/24, resident 35's medical records were reviewed. On 10/23/23, the Admission Minimum Data Set (MDS) assessment documented that resident 35 required supervision with touch assistance for ambulation. The assessment documented that resident 35 did not use any mobility devices, and did not have any functional limitations in the upper or lower extremities. On 11/25/23 at 12:48 PM, the skilled nursing note documented that resident 35 used a cane and was independent with bed mobility, transfers and ambulation. Resident 35's progress notes documented the following: a. On 11/27/23 at 6:33 PM, the note documented, Visitor informed nurse that this resident had taken a fall outside. Nurse rushed over and found resident on the concrete outside. Resident was distressed and would not answer further questioning. He did point to the laundry basket that his visitor was holding next to him. Nurse approached the resident who was laying halfway on the grass and halfway on the concrete. Resident had blood dripping from his right eyebrow and blood on his fingers and hand. Nurse asked if the resident was hurt anywhere. The resident shook his head no and began to get up on his hands and knees. Nurse tried to clean up blood from the resident but he began to crawl into the building. Resident refused help from the nurse as well as vitals. Resident requested that an ambulance be called. He would not allow the nurse to complete an assessment and was determined to go to the hospital. Without completing an assessment, the nurse stated that the resident's family member could call the ambulance if they felt necessary. b. On 11/28/23 at 12:31 AM, the note documented, Resident returned to facility at 1955 [7:55 PM] from being seen in ER [emergency room ] at [name of local hospital]. Dx [diagnosis] form fall: upper extremity bruise, facial fracture and head injury with laceration to left eye brow area. New orders to remove sutures in 5 days, keep clean and dry, follow up with [name of provider] for follow up care r/t [related to] facial fracture and oxycodone 7.5/325 mg [milligram] q [every] 6 hours prn [as needed] pain quantity 5 only. Resident alert and oriented x [times] 4, pleasant and cooperative upon arrival. VS [vital signs] 170/90 [blood pressure], 98.6 [temperature], 90 [heart rate], 18 [respirations], 92% [oxygen saturation] on room air. Laceration with dried blood to site. No c/o [complaints of] n/v [nausea and vomiting], dizziness, blurry vision, confusion, memory loss. Mild headache due to incident. New prn pain med given at 2030 [8:30 PM] and eff [effective]. HOB [head of bed] elevated and resting quietly in bed with call light within reach. Checked on q hour. c. On 11/28/23 at 4:46 PM, the note documented, Resident is recovering from fall last night. Resident has stated that he has been in a lot of pain r/t the fall. Managing this pain with routine and PRN [as needed] medications as well as nonpharmaceutical interventions such as rest and repositioning. Resident has been responding well to current treatment. Will continue to monitor. d. On 11/28/23 at 9:20 PM, the Interdisciplinary (IDT) note documented that the Visitor informed nurse that this resident had taken a fall outside. Nurse rushed over and found resident on the concrete outside. The risk factors and root cause that was identified by the IDT was due to the resident carrying multiple items in his hands and the inability to utilize his cane properly to assist with ambulation. The note documented the preventative measures were, Resident has been educated on calling for assistance, Resident has been educated on the proper use of the call light and demonstrated the proper use. The note documented the new interventions were, Resident educated on calling for assistance with ADLs [Activities of Daily Living]. Resident educated on fall prevention and fall precaution. Resident will continue working with PT [Physical Therapy]. Resident educated on proper use of cane while ambulating. e. On 11/29/23 at 12:29 AM, the note documented, Continues on alert charting for unwitnessed fall. Neuro [neurological] checks wnl [within normal limits]. Sutures to left eyebrow area intact and scabbed over. Medicated for pain x [times] 1 and eff [effective]. No c/o n/v, dizziness or headache. Resting quietly with call light in reach. f. On 11/29/23 at 11:15 AM, the note documented, Monitoring resident from recent fall. Bruising to around L [left] eye dark purple and green. Stitches intact without concerns. Denies dizziness, nausea. g. On 11/30/23 at 12:38 AM, the note documented, Resident is being monitored after having a unwitnessed fall. Neuro checks are complete. He has no s/sx [signs and symptoms] of changes in LOC [level of consciousness]. Bruising to the left side of his face had not increased. He reports the site to be tender but he denies concerns. Stitches are in place with no concerns of altered healing. wound edges approximated well with no s/sx of infection at this time. On 11/27/23 at 5:15 PM, the incident report documented that the visitor informed the nurse that the resident had fallen outside. The nurse found resident on the concrete outside, the resident was distressed and would not answer any questions. The report documented a laceration as the injury, and that the resident requested to go to the hospital. The incident report documented that the Medical Director was notified on 11/27/23 at 5:16 PM. On 11/27/23, the hospital report documented a chief complaint of a head injury. The resident reported that he caught his foot on an elevated portion of the concrete and fell forward striking his head on the cement. The computerized tomography (CT) of the face documented the results as a nondisplaced acute fracture through the left orbital floor and extending through the anterior and lateral maxillary walls. The report documented a left brow laceration repair was completed with sutures. The clinical impression upon discharge was an orbital fracture, facial laceration, and head trauma. Resident 35's care plan for at risk for falls was initiated on 11/27/23. Interventions identified were assure the lighting was adequate; ensure the environment was clutter free and free from spills; ensure the bed was in the lowest position; ensure call light was within reach; ensure items were within reach; provide assistive devices as needed; physical therapy to work on balance and gait stability using cane; and remind resident to ask for assistance when carrying items and walking. On 1/25/24 at 12:12 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that she would notify the Medical Director (MD) and family if a resident was transferred out of the facility. RN 2 stated that if the situation was emergent she would call 911. RN 2 stated that she would provide the paramedics or hospital a copy of the resident's facesheet, medication list, copy of Physician Orders for Life Sustaining Treatment (POLST), and a copy of the most recent vital signs. RN 2 stated she would call and give report to the hospital staff and then notify the MD and obtain an order for the transfer. RN 2 stated she would document in a nursing note the reason for the transfer and the specific details of the incident. RN 2 stated that she was not aware of any transfer forms. RN 2 stated that if the resident requested to go to the hospital she would notify the MD and send them. RN 2 stated that she would not tell the resident that their family member could call for the ambulance themselves. On 1/25/24 at 12:46 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated that when they sent a resident to the hospital they would send a facesheet, POLST, medication list, and inform transport. LPN 3 stated that she would call for the ambulance first and then print out the information for the receiving provider. LPN 3 stated she would message the MD and notify them of the situation. LPN 3 stated she would document a nurses note of what was sent to the hospital, reason for transfer, who was notified, situation for transfer, who she gave report to, and any recent vital signs. LPN 3 stated that if a resident was injured and requested to be transferred to the hospital they had that right. LPN 3 stated that she believed the resident had to call 911 themselves. LPN 3 stated that she was training and orienting with LPN 1 when resident 35 had his fall and sustained an injury. LPN 3 stated that LPN 1 told her that resident 35 did not need to go to the hospital, and she did not feel like it was necessary to call 911. LPN 3 stated that LPN 1 told the family member that if they thought it was necessary to go to the hospital they could call for an ambulance. LPN 3 stated that they found the resident outside in front of the building. LPN 3 stated he was on the ground and there was a basket and his cane next to him. LPN 3 stated resident 35 was bleeding from his head. I think above the left eyebrow and there was blood on his wrist. LPN 2 stated that resident 35's watch face was broken from the fall. LPN 3 stated that they obtained resident 35 vital signs, assisted him to a wheelchair, and wheeled him inside. LPN 3 stated she recalled it was really cold outside. LPN 3 stated that she looked at the wound and attempted to clean the wound with gauze. LPN 3 stated that resident 35 became angry, and did not want her to touch him. LPN 3 stated that resident 35 was angry because he was in pain and it hurt when she attempted to clean the wound. LPN 3 stated that resident 35 requested to go to the hospital for treatment. LPN 3 stated that resident 35's family member called the ambulance after LPN 1 informed them that they needed to call for the ambulance themselves. LPN 3 stated that she felt conflicted about this guidance, but she was a new nurse at the time. LPN 3 stated she felt like they should help resident 35 to receive the care at the hospital if he wanted it, and that it was the resident's right. LPN 3 stated that resident 35 returned to the facility after her shift had ended, and she thinks he had something broken, and returned with sutures. LPN 3 was observed to verify via the secured communication text that she notified the MD on the date of the incident, and that resident 35's family member had called 911. On 1/25/24 at 2:41 PM, an interview was conducted with the Director of Nursing (DON) and the Corporate Resource Nurse (CRN). The DON stated that depending on what the transfer was for staff needed to assess the resident's condition, address any injuries first, notify the DON, Administrator (ADM) and MD and then call for an ambulance. The DON stated that staff should provide the receiving provider a copy of the POLST, order summary, and facesheet. The DON stated that staff should call 911 and give report to the hospital. The DON stated that the nurse would enter a discharge order and document a discharge summary in the progress notes. The DON stated that the most current vital signs and reason for transfer was located on the transfer facesheet. The DON stated that if the resident requested a transfer to the hospital then the nurse should call for transport to pick them up. The DON stated that she was not aware of the situation with resident 35's transfer to the hospital on 11/27/23. The DON stated that they were initially under the impression that the family wanted to call the ambulance and not that LPN 1 was refusing to call the ambulance. [Cross-refer F622] On 1/31/24 at 12:46 PM, the facility provided additional information in the form of a timeline for resident 35's treatment after his fall. The facility attached the local fire departments prehospital care report to help construct a timeline for treatment provided by the paramedics. The fire departments care report documented that they were notified on 11/27/23 at 5:19 PM, were at the scene at 5:25 PM, and arrived at the destination of the local hospital at 5:51 PM. Although treatment by the paramedics after resident 35's fall was timely, the facility failed to respond to the residents' request to notify Emergency Medical Services (EMS) in the first place and instead instructed him to call for an ambulance himself. Additionally, the facility stated that resident 35 did not allow the facility nurse to assess him. This contradicts LPN 3's statement of what she observed, which was a visual assessment, and the treatment and services she attempted to provide before resident 35 asked her to stop and call for an ambulance. It should also be noted that LPN 3's statement of obtaining resident 35's vital signs, transferring him to a wheelchair and moving him inside the facility while attempting to clean his head wound contradicts the fire departments care report. The fire department's care report documented that the patient was found sitting on the ground being assessed by the facility staff.
Inspection of April 25, 2022
1 findingBased on observation, interview, and record review it was determined that the facility failed to establish an infection prevention and control program designed to prevent the development and transmission of Coronavirus disease (COVID-19). Specifically, the facility failed to ensure that staff members were screened for COVID-19 prior to entering the facility to work. The facility failed to ensure a symptomatic staff member, who subsequently tested positive for COVID-19, was screened accurately and notification and evaluation was completed per the facility protocol. The failure resulted in 3 residents being exposed to COVID-19. After the staff member tested positive for COVID-19, the facility did not implement the use of additional personal protective equipment (PPE) for staff to decrease the spread of COVID-19. In addition, visitors were not screened for COVID-19 and were not provided PPE prior to entering the facility. In addition, facility staff did not use appropriate PPE when providing aerosol-generating procedures. These examples were cited at an Immediate Jeopardy (IJ) level. Staff members were observed to touch resident medications with bare hands and not perform hand hygiene during medication pass. Resident identifiers: 17, 29, 33, 50 and 53. Findings included: On 4/21/22 at 11:14 AM, an IJ was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prevent the spread of COVID-19. Specifically, the facility failed to ensure employees and visitors were screened for COVID-19, facility staff did not use appropriate PPE during an outbreak, and staff did not use appropriate PPE during transmission based precautions for aerosol generating procedures during an outbreak. This resulted in three residents being exposed to COVID-19. Notice of IJ was given verbally to the Administrator, Director of Nursing (DON), and the Regional Nurse Consultant (RNC) and they were informed of the findings of IJ pertaining to F880. On 4/21/22 at 3:11 PM, the Administrator provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 4/21/22 at 3:11 PM: Immediate Actions Taken to Correct Deficient Practices All employees and visitors currently in the facility have completed COVID-19 screening in accordance with facility policy and expectations. All employees have donned eye protection due to outbreak status as extended use PPE in addition to face mask for use when in resident rooms and resident common areas. 3 residents were identified to use devices that are aerosol generating:. Precaution carts with all necessary PPE for use during aerosol generating procedures have been implemented with visible signage posted communicating the requirement to utilize gloves, gowns, respiratory/N95 mask and eye protection when aerosol generating procedures are occurring. Measure to Ensure the Deficient Practice Does not Recur All employees have been in-serviced regarding requirements for COVID-19 screening of employees and visitors and PPE usage during an outbreak and during aerosol-generating procedures. Administrator has posted visible signage in conspicuous locations throughout the facility reminding employees and visitors of COVID screening requirements and reminding employees of PPE usage requirements. Administrator has scheduled a staff member to supervise the front entrance of the facility to ensure that all staff and visitors during business hours are screened for COVID-19 appropriately and designated the 200 hall nurse as the primary staff member responsible to ensure screening is completed outside of business hours. Administrator has implemented a COVID screening audit tool to be conducted at each shift change (0600 [6:00 AM] 1400 [2:00 PM], 2200 [10:00 PM]) daily x 2 weeks then at each shift change three times weekly x 4 weeks to ensure all employees have been screened for COVID-19 and to confirm that all visitors have been appropriately screened for COVID-19. Director of Nursing has implemented a PPE Usage Audit to be conducted on each shift (0600, 1400, 2200) daily x 2 weeks then at each shift change three times weekly x 4 weeks to ensure that PPE is being utilized in accordance with CDC, CMS and local department of health guidelines. Measure to Monitor and Ensure Corrective Action is Achieved and Sustained QAA [Quality Assurance and Assessment] committee under the director of the administrator will review the findings for COVID screening tool audit as well as the PPE Usage audit monthly until a lesser frequency is determined to be appropriate. Any ongoing problems with COVID screening and PPE usage process will be addressed with modifications to the plan of correction implemented at the direction off the QAA committee. Immediate Jeopardy A. Screening for staff and visitors: On 4/18/22 at 8:30 AM, an observation was made of the COVID-19 screening area at the front entrance. There was a binder with forms for visitor information. The binder had forms filled out and did not have blank forms. Licensed Practical Nurse (LPN) 1 was observed across the dining room. LPN 1 was observed to tell the surveyors to head to the conference room. The surveyors asked if there was anything that needed to be done before allowing the surveyors into the facility. LPN 1 sated oh yeah, sign in but LPN 1 was unable to find blank forms. LPN 1 located a form with columns for a name, time in, time out, and what resident the visitor was visiting. There was no information regarding where to document temperatures or if a visitor had signs or symptoms (s/sx) of COVID-19. LPN 1 was observed to make changes to the form and obtained surveyors temperatures. LPN 1 did not ask surveyors about s/sx of COVID-19. On 4/18/22 at 9:16 AM, an interview was conducted with the Administrator. The Administrator stated Certified Nursing Assistant (CNA) 3 tested positive for COVID-19 on 4/16/22. The Administrator stated that CNA 3 worked the 100 hall graveyard shift on 4/14/22 and 4/16/22. The Administrator stated that she received a text of a positive COVID-19 test from CNA 3 at about 10:30 PM on 4/16/22. The Administrator stated that CNA 3 was sent home. The Administrator stated they contacted the Healthcare Acquired Infection (HAI) team member and there were no residents with signs and symptoms. The Administrator stated CNA 3 had minimal contact because he was working nights so there was a lower risk. The Administrator stated that the HAI team member did not instruct for PPE changes for the staff. The Administrator stated that staff were to continue wearing surgical masks only and 3 residents were tested on [DATE]. On 4/18/22 at 9:56 AM, additional observations were made of the facility's COVID-19 screening area. It was observed that there was no staff member at the front entrance. A sign was observed on the wall by the screening station that listed the symptoms of COVID-19. A second sign was observed that stated, Please make sure to screen yourself BEFORE visiting your loved one. The visitor's log was observed to be on the table. It was observed that on the visitor log sheet, there was a place for visitors to put the date, their name, and their temperature. The binder for COVID-19 screening questionnaires for visitors was observed to be on the table. It was observed that a binder for employee screening was on the table. It was observed that in the binder that each employee had a sheet with their name and two calendars, one for April 2022 and one for May 2022. It was observed that employees were required to record their temperature on the calendar day they worked, and to circle either L for low risk or H for high risk. A flow sheet for COVID-19 screening was observed in the front of the binder that had questions to guide employees to determine if they were a high risk or a low risk for COVID-19. It was observed that surgical masks, face shields, two thermometers, and hand sanitizer were available at the screening table. On 4/18/22 at 11:05 AM, an observation was made of the Maintenance Supervisor (MS). A family member was on the 100 hallway talking to LPN 2, the MS asked a visiting family member of a resident to put a mask on. On 4/18/22 at 11:07 AM, an interview was conducted with the family member (FM). The FM stated she thinks she was supposed to check in when she comes to visit but she did not. The FM stated no one at the facility showed her how to check in and she had not worn a mask when visiting for the 10 days her family member had lived at the facility. On 4/19/22 at 8:15 AM, surveyors entered the facility. The Administrator in Training (AIT) was at the front door. The AIT stated that she did not usually sit at the front entrance because there was usually another staff member that screened visitors and directed them within the facility. The AIT stated that the front entrance staff member recently quit and now the facility was rotating through staff members to sit at the front entrance. The AIT stated the staff members at the front entrance were decided during the morning meeting and she was not sure who covered the front desk when she was not there. The AIT stated she was currently screening people as they came in for COVID-19. The AIT stated there was a visitor screening questionnaire that she filled out when visitors entered and obtained their temperatures. The AIT stated if a visitor answered yes to any question regarding contact or s/sx of COVID-19, then she asked more questions to see where they were at. The AIT stated she would then ask about vaccination status and which resident the visitor was visiting. The AIT stated she understood to not allow a visitor in, if there were any symptoms reported. The AIT stated if a resident had a cough, then she asked more questions. The AIT stated the visitor could also test for COVID-19 at the front entrance. The AIT stated that the name at the bottom of the questionnaire was the person verifying that the screening was done and the visitor was not at risk to enter the facility. The AIT stated if the visitor was unvaccinated, they preferred for them to wear a surgical mask. The AIT stated if the visitor was vaccinated they were able to go without a mask. The AIT stated that employee screening was done in a binder next to the visitor screening. The AIT stated that employees obtained their temperature and wrote it on their specific form in the screening binder. The AIT stated if there were any symptoms then the employee reported to their immediate supervisor or Administrator. The AIT stated that COVID-19 testing was available and the staff member would be quarantined until the test was complete. The AIT stated that COVID-19 testing was completed by the nursing office on the other side of the building. The AIT stated she did not know what the L or H meant on the employee specific form. The AIT stated she did not mark the L or H, because she did not know we were supposed to. The AIT stated if the temperature was in the range then the L or H would be marked. On 4/19/22 at 12:06 PM, an interview was conducted with LPN 1. LPN 1 stated visitors were screened at the front entrance for COVID-19. LPN 1 stated a temperature was obtained and the visitor was asked if they had been out of town or feeling sick. LPN 1 stated that the L or H on the employee screening was determined based on an assessment form. LPN 1 located the assessment form next to the employee screening. LPN 1 stated the L and H were for low or high risk based on the assessment. LPN 1 stated if an employee was at high risk to any questions, the employee would step outside for the nurse to assess. LPN 1 stated a rapid COVID-19 test was completed in the managers office. LPN 1 stated that there was usually a staff member at the front desk from about 9:00 AM to 5:00 PM. On 4/19/22 at 12:13 PM, an interview was conducted with the Director of Rehabilitation (DR). The DR stated when he had screened employees, he asked questions, took their temperature, and made sure their mask was on. The DR stated if the employee had a high temperature or they answered yes to any of the questions, the employee went outside and around the building to have a COVID-19 test. The DR stated that for visitors, he took their temperature, had them fill out the questionnaire form, and encouraged them to wear a mask. The DR stated if a visitor had an elevated temperature, he let them know they should not be in facility. The DR stated he encouraged the visitor to get tested for COVID-19 and once they were negative, to come back to the facility. The DR stated that everyone who came into the facility was screened. The DR stated that there was no one at the front desk on weekends. The DR stated the 200 hall charge nurse kept an eye on the door and screened visitors on weekends. The DR stated contracted employees such as hospice staff should know they need to screen like everyone else. On 4/19/22 at 12:26 PM, an interview was conducted with CNA 5. CNA 5 stated when she entered for her shift she had her temperature checked and wrote the temperature on her specific sheet and them marked if she was low or high risk for COVID-19. CNA 5 stated she had COVID-19 in January 2022 and she came to work and marked she was high risk. CNA 5 stated she was tested at the nurses station and waited in the back room for her test results and was sent home. CNA 5 stated when visitors entered the facility, if their temperature was not higher than 98 degrees they were able to come in. CNA 5 stated if the visitors temperature was higher than 98 degrees they would have to wait until symptoms were gone to come back to visit. CNA 5 stated there were no forms that she filled out for visitor screening. CNA 5 stated that she thought there might be a visitors sign in sheet there at the front. On 4/19/22 at 12:38 PM, an interview was conducted with the Activities Director (AD). The AD stated usually when a visitor came in she asked them COVID-19 screening questions that were on the form and obtained their temperature, had them sanitize their hands, and put on a mask. The AD stated visitors usually filled out the form in the visitor bind. The AD stated the employee that obtained the visitors temperature signed the form at the bottom. The AD stated there was an employees screening form and a flow sheet to determine if a staff member was at low or high risk for COVID-19. The AD stated if the employee was high risk, then someone from the nurse management or the charge nurse did an assessment on the employee. On 4/19/22 at 12:38 PM, an interview was conducted with CNA 8. CNA 8 stated staff were screened for COVID-19 before their shift. CNA 8 stated a temperature was taken and recorded in the staff binder. CNA 8 stated the nursing staff would take the staff members temperatures and if they were not available, another CNA did it. CNA 8 stated the staff member reviewed the list of symptoms to determine if they were a low or high risk. CNA 8 stated if staff were high risk, the nurse was informed, and an evaluation was done. CNA 8 stated if the nurse felt a COVID-19 test was needed, they tested the staff member. On 4/19/22 at 12:41 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that there was an employee or charge nurse that screened other employees for COVID-19. The RA stated that the employee took the other employees temperature and asked questions. The RA stated if the employee was at medium to high risk then a nurse manager was contacted. The RA stated that the nurse manager then asked additional questions to see if the employee was safe to come to work. The RA stated that the employee sanitized their hands, a temperature was obtained, and a mask was put on. The RA stated visitors had a different form to complete. The RA stated that visitors filled out a log, obtained temperatures, filled out a form, and the employee at the front entrance screened each visitor. The RA stated the employee made sure the visitor had a mask on, hands sanitized, and their temperature was okay. The RA stated she was at the front entrance most of the time and there was a receptionist. The RA stated the receptionist was at the front entrance from 9:00 AM to 3:00 PM. The RA stated she covered the front desk from 3:00 PM until 5:00 PM. The RA stated that after 5:00 PM until about 9:00 AM the 200 hall nurse was in charge of screening visitors. The RA stated that the CNAs helped notify the nurse if someone was at the front desk. The RA stated that CNAs were able to notify the nurse through an app or a walkie. The RA stated that there were times that CNAs and nurses were busy in resident rooms and she was not there so she did not know how the visitors were stopped and screened at the front entrance. The RA stated visitors during the day were good at stopping and screening themselves and letting someone know they were there. A binder labeled Visitor log was reviewed on 4/19/22. The log revealed a section for date, name, resident visited, time in, and time out. There was a Visitor Screening Questionnaire for COVID-19 forms in the binder. There were no questionnaires completed from 4/4/22 until 4/19/22. A review of the log and questionnaires revealed they did not match. The log did not have any signatures for visitors on 4/17/22. There were no questionnaires completed for visitors on 4/17/22. [Note: The date 4/17/22, was Easter.] On 4/19/22, there were 13 visitor names on the log and there were 6 Visitor Screening Questionnaire forms completed. The Visitor log further revealed that from 3/28/22 through 4/4/22, 30 visitors signed the visitor's log but did not complete a screening questionnaire for visitors, and 27 visitors completed a screening questionnaire for visitors but did not sign the visitor's log. The records showed that one visitor filled out the visitor's log and completed the screening questionnaire for visitors two times for two separate visits. A binder at the front entrance titled Employee screening revealed the following: 1. The MS did not indicate if he was low or high risk on 4/11, 4/12, 4/18 and 4/19. 2. CNA 9 did not indicate if she was low or high risk on 4/12 and 4/14. 3. The Transportation staff member did not indicate if he was low or high risk on 4/11, 4/12, and 4/13. 4. The DR did not indicate if he was low or high risk on 4/8 and 4/14. 5. CNA 2 did not indicate if she was low or high risk on 4/7 and 4/8. 6. The RNC did not indicate if she was low or high risk on 4/12. 7. CNA 6 did not indicate if she was low or high risk on 4/10, 4/11, 4/12, 4/13, 4/16, 4/17, 4/18 and 4/19. 8. Nurse 1 did not indicate if she was low or high risk on 4/1, 4/2, 4/3, 4/8, 4/9, 4/10, 4/15, 4/16 and 4/17. 9. Nurse 2 did not indicate if he was low or high risk on 4/14 and 4/16. 10. The DON did not indicate if she was low or high risk on 4/5, 4/6, 4/7, 4/8, 4/11, 4/12, 4/13, 4/14, 4/15, 4/17, 4/18 and 4/19. 11. CNA 11 indicated she was high risk on 4/13. It should be noted there was no additional information on the form. 12. The Minimum Data Set (MDS) coordinator did not indicate if she was low or high risk on 4/1, 4/4, 4/5, 4/6, 4/8, 4/11, 4/12, 4/13, 4/14, 4/15, 4/18 and 4/19. 13. The Laundry Service worker had a temperature of 99.1 degrees written on 4/13/22 and did not mark if she was high or low risk on 4/16 and 4/19. 14. The CNA Supervisor did not indicate if she was low or high on 4/7, 4/8, 4/9, 4/11, 4/12, 4/13, 4/14 and 4/16. 15. The AIT did not indicate if she was high or low on 4/14, 4/15, 4/19 and 4/20. It should be noted that the binder was reviewed on 4/19. 16. The RA did not have temperatures documented 4/1 though 4/6. On 4/20/22 at 8:30 AM, a telephone interview was conducted with CNA 3. CNA 3 stated he had worked at the facility for a couple of months, night shift on the 100 hallway. CNA 3 stated that when he arrived at his shift, he entered through the front entrance, got a mask, screened in for COVID-19, but had forgot to screen for a little while for the last couple month. CNA 3 stated that to screen he should have filled out a paper, taken his temperature, and checked for symptoms. CNA 3 stated that on 4/16/22, he was only at the facility for about 20 minutes. CNA 3 stated that on 4/16/22, he went in the front entrance, did not screen, went through the 200 hallway to the elevator, tested himself for COVID-19 at the 100 hall nurses station. CNA 3 stated that he had chills, congestion, muscle aches, but no fever. CNA 3 stated he thought he had a cold. CNA 3 stated that while waiting for his COVID-19 test results he filled up a residents mug in room [ROOM NUMBER] and delivered it to him. CNA 3 stated he did not have contact with any other residents. CNA 3 stated that he texted the CNA Supervisor on 4/15/22, and told her he was not feeling well, she told him to come in and get screened by the nurse. CNA 3 stated that he overslept for his shift on 4/15/22, so he did not work. CNA 3 stated that he worked on 4/14/22, and wore a surgical mask with no other PPE. A time sheet was provided which revealed CNA 3 worked 4/12/22, 4/13/22 and 4/14/22. The time sheet revealed CNA 3 worked on 4/16/22 from 10:00 PM until 10:40 PM. There were no temperatures or screening forms completed on those days for CNA 3. On 4/20/22 at 8:50 AM, a phone interview was conducted with the CNA Supervisor. The CNA supervisor stated if a CNA had s/sx of Covid-19, the CNA was to be assessed by a nurse and tested before starting working. The CNA supervisor stated staff members checked in at the front entrance. The CNA supervisor stated CNA 3 texted her that he was not feeling well and called off for a shift on 4/15/22. The CNA supervisor read CNA 3's text on 4/15/22 at 5:00 PM, I wasn't feeling good last night, anyway that I could get tonight off? The CNA supervisor stated her response was I'm sorry you are sick and let the nurse know so they can assess you and if the nurse could give you a Tylenol at 5:05 PM. The CNA supervisor stated she did not ask about any further symptoms. The CNA supervisor stated the process for screening employees was to enter through the front entrance, someone took temperatures, and the employee completed a screening form. The CNA supervisor stated that there was a form with a calendar with 2 months on it and the employee determined if they were low or high risk. The CNA Supervisor stated that low or high risk was determined by if they had been around people with COVID-19 or if there were s/sx of COVID-19 because those would make an employee high risk. The CNA Supervisor stated that she trained CNA's on how to screen in. The CNA supervisor stated that the visitor screening process consisted of checking in at the front entrance, making sure the visitor had a mask, a form with questions about s/sx was completed, and temperature obtained. On 4/20/22 at 1:11 PM, a follow up phone interview was conducted with the CNA Supervisor. The CNA supervisor stated that 2 to 3 times since January 2022 she had been unable to find a nurse to screen her in. The CNA Supervisor stated she thought she had been circling the L on the form and did not know why she had not completed it for dates listed above. On 4/20/22 at 11:33 AM, and interview was conducted with CNA 5. CNA 5 stated she arrived this morning at 6:00 AM, took her own temperature, and wrote it down in the book. CNA 5 stated she then clocked in and put her stuff away on the unit where she would be working. CNA 5 stated that if she had a fever, she would contact the nurse immediately to be tested for COVID-19. CNA 5 stated that when the nurse arrived, she looked at the temperatures recorded in the book and asked the staff if they had any signs or symptoms of COVID-19 or if they had been in contact with anyone who had COVID-19. On 4/20/22 at 10:24 AM, an interview was conducted with the Administrator. The Administrator stated CNA 3 called in sick on 4/15/22, because he was not feeling well. The Administrator stated she received a picture text from CNA 3 at 10:58 PM on 4/16/22, of a positive COVID-19 test. The Administrator stated that she called CNA 3 and sent CNA 3 home. The Administrator stated that CNA 3 told her that he had symptoms when he worked 4/14/22. The Administrator stated that CNA 3 should have been screening in prior to every shift. The Administrator stated not screening in was grounds for a write up. The Administrator stated that everyone was very aware of the process and when to screen prior to their shift. The Administrator stated that the 200 hallway nurse would have screened him and found he was high risk and then the nurse should have talked to the DON or Administrator, then CNA 3 would have been tested prior to working on 4/14/22. The Administrator stated that there were COVID-19 testing supplies at the nurses station. The Administrator stated if a staff became sick on shift they would test for COVID-19 at the nurses station but otherwise the test was done prior to entering the facility. The Administrator stated they completed contract tracing and determined that CNA 3 only exposed 3 resident on 4/14/22, to COVID-19 so those residents were tested on [DATE]. The Administrator stated CNA 3 was the only CNA working on the 100 hallway on 4/14/22. The Administrator stated that CNA 11 was not tested and no s/sx were reported on 4/14/22, when she marked she was high risk. The Administrator stated that if a staff member marked an H then the nurse assessed and reported to the DON or Administrator. The Administrator stated if suspicious of anything, then COVID-19 testing was completed. The Administrator stated that the flow sheet to determine a staff members COVID-19 risk was great but there needed to be further assessment. The Administrator stated if the staff member tested negative, the staff member would still be able to continue their shift. The Administrator stated if a staff member was high risk because of a COVID-19 exposure, then the staff member wore an N95 mask and eye protection. On 4/21/22 at 5:33 AM, a phone interview was conducted with CNA 10. CNA 10 stated she worked the night shift from 6:00 PM to 6:00 AM. CNA 10 stated that she entered through the front entrance, checked her temperature, signed in a book, and got a mask. CNA 10 stated that the sign in was for her temperature and she was not sure what the L or the H were for on the form. CNA 10 stated there had been a few times that she forgot to do her temperature. CNA 10 stated there were no staff members at the front entrance and she was not aware of the process for screening visitors. CNA 10 stated there were a lot of visitors on 4/17/22, because it was Easter and she was not sure if anyone had signed in or screened. A review of CNA 10's time sheet revealed she worked on 4/12/22. There was no temperature documented on her screening form, nor if she was low or high risk. A review of LPN 3's time sheet revealed she worked on 4/12/22 and 4/16/22. There was no temperature documented on her screening form, nor if she was high or low risk for 4/12/22 and 4/16/22. A review of Housekeeping staff member 2's time sheet revealed she worked on 4/4/22. There was no temperature documented on her screening form, nor if she was high or low risk. On 4/19/22 at 1:42 PM, an interview was conducted with the Administrator. The Administrator stated that visitor and employees entered through the front entrance and had COVID-19 screening books at the front entrance. The Administrator stated that each employee had their own page and when an employee came to work they needed to pull another staff member to obtain their temperature, and ask for s/sx. The Administrator stated that employees were assessed as low, medium, or high risk for COVID-19. The Administrator stated if an employee was medium or high risk then a discussion was done with the employee as to why they were high risk for example allergies. The Administrator stated if an employee was a high risk exposure, then the employee did not work. The Administrator stated the L and H on the employee form were following the CDC check list. The Administrator stated each day employees should assess their risk, temperature, and complete the form. The Administrator stated no one audited the employee or visitor forms. The Administrator stated Ideally the floor nurse should be screening the employee and the DON would be auditing to ensure screening was done. The Administrator stated that there was a visitor binder at the front entrance. The Administrator stated there was a questionnaire and a log. The Administrator stated there was an employee at the front entrance but had recently resigned. The Administrator stated if no one was at the front door there were signs and staff members walking around. The Administrator stated if the visitor was high risk, they were asked not enter the facility. The Administrator stated that the AIT and AD had taken over for the employee at the front entrance to screen visitors as of 4/19/22. The Administrator stated that there were not enough staff to be able to man the front entrance 24 hours per day 7 days a week. The Administrator stated that a majority of traffic was during the day and not in the evening. The Administrator stated if a visitor walked in and did not get a staff member they have all the tools to screen themselves. The Administrator stated there was a check in log and visitors completed the screening questionnaire. It should be noted when surveyors entered on 4/18/22, there were no blank logs or questionnaires in the binder at the front entrance. On 4/20/22 at 10:47 AM, an interview was conducted with the RNC and DON. The DON stated for employees the nurse or someone else screened them for COVID-19. The DON stated that the healthcare passport was used for the screening to determine if staff were lower or higher risk. The DON stated if at any point a staff member was high risk they determined that if there was an explanation for the s/sx, then a decision was made that they were not in the high risk category. The DON stated that screening was completed at the beginning of each shift. The RNC stated the 200 hallway nurse or an administration staff member screened staff as they entered the facility. The RNC stated it did not have to be a designated nurse to screen visitors. The RNC stated that anyone else who was knowledgeable about the screen process could screen visitors. The RNC stated that the visitor screening was the same process. The RNC stated there was visible signage for visitors to wait until screening was completed. The RNC stated there was not a staff member at the front entrance to stop visitors. The RNC stated that some visitors were completing the screening themselves and then a staff member was to review their screening. The RNC stated that the signage was implied that you should not proceed to visit until screening was completed. The RNC stated that in the admission agreement, there was the COVID-19 visitation process and it was reviewed during care conferences. The RNC stated that she had noticed CNA 3 had not been documenting screening since the surveyor asked for information. The RNC stated that they had been very aggressively reminding staff of screening procedures and the visitor screening procedures. On 4/21/22 at 8:31 AM, surveyors entered the facility. The AIT was observed to be at the front entrance. The AIT stated that she changed the screening process so that it was more simple, basic, and effective. The AIT stated she wanted it to be more steam lined with a better process. The AIT had surveyors sign the log and the AIT asked the questions on a questionnaire regarding exposure to COVID-19 and signs and symptoms. B. PPE when the facility was in outbreak status: On 4/18/22 at 8:30 AM, an observation was made of LPN 1. LPN 1 was observed passing medications and was observed to be wearing a surgical mask and no eye protection. On 4/18/22 at 9:45 AM, an observation was made of CNA 1, CNA 4, LPN 2, and the MDS coordinator. The staff members were observed without eye protection on the 100 h [TRUNCATED]
Inspection of March 26, 2018
2 findingsBased on observation, record review, and interview it was determined that, for 3 of 28 sample residents, the facility failed to ensure the environment remained as free of accident hazards as was possible and that each resident received adequate supervision to prevent accidents. Specifically, one resident spilled coffee and sustained a burn to her sternum, two residents eloped from the facility twice and ingested barrier cream, and another resident was observed cleaning a disposable razor with scissors tweezers. The deficient practice identified for resident 35's coffee burn was found to have occurred at a harm level. Residents 2 and 6 were cited at a potential for harm level. Resident identifiers: 2, 6, and 35. Findings include: A. Harm: Resident 35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/20/18, resident 35's medical record was reviewed. 1. A review of resident 35's Event Notes revealed an entry by Registered Nurse (RN) 1 dated 1/3/18 at 8:40 PM, Event: Burn - sternum. Date and Time of Event: 01/03/2018 (at) 12:50. Description and location of skin condition: Area over sternum, skin open, red, measurement not taken, wound nurse notified. What caused skin condition: Hot coffe (sic) . Cognition: A&O (alert and oriented) (times) 1 WNL (within normal limits) . A review of resident 35's physician orders [REDACTED]. A review of resident 35's Treatment Administration Record (TAR) for (MONTH) (YEAR) revealed that wound care for the sternal burn was performed from 1/4/18 through 1/10/18. Resident 35's annual Minimum Data Set (MDS) assessment dated [DATE] was reviewed. Resident 35's MDS revealed that resident 35 had scored a 5 out of 15 on the Brief Interview for Mental Status (BIMS), indicating that she had a severe cognitive impairment. Additionally, resident 35 was assessed as requiring one-person physical assistance with eating. On 3/21/18 at 7:32 AM, RN 1 was interviewed. RN 1 stated that she did not observe the burn occur, but that Certified Nursing Assistant (CNA) 2 reported the burn to her shortly after it had occurred. RN 1 stated that she observed the burn and reported it to the MDS Coordinator who also acted as the Wound Nurse (WN). RN 1 stated that CNA 2 told her that the coffee that morning was too hot. RN 1 stated that it was a good, quick burn so (the coffee) must have been hot. On 3/21/18 at 7:49 AM, CNA 2 was interviewed. CNA 2 stated that she was in the dining room while resident 35 was eating breakfast on 1/3/18. CNA 2 stated that she did not see what caused resident 35 to spill her coffee, but noticed the spill as it happened and took resident 35 to RN 1 to be assessed. CNA 2 stated that she was unaware what the temperature of the coffee was that morning as the kitchen staff were responsible for measuring the temperature. On 3/21/18 at 8:04 AM, the Staff Developer (SD) was interviewed. The SD stated that she was the a acting Director of Nursing (DON) from (MONTH) (YEAR) until (MONTH) (YEAR). The SD stated that the duties of the DON were divided between the Administrator, the MDS Coordinator/WN, and herself. The SD stated that there was not much of an investigation after the burn occurred. The SD stated that she was unaware of any policy or assessment protocol regarding resident consumption of hot beverages. The SD stated that she did not know if the temperature of the coffee was being monitored currently or at the time of the burn. On 3/21/18 at 8:59 AM, an observation was made of the facility coffee and hot water. A mug filled with coffee from a dispenser in the first floor dining room was received. The temperature of the coffee in the mug was measured at 148.6 degrees Fahrenheit. At 9:02 AM, a mug filled with coffee and a mug filled with hot water from dispensers in the second floor dining room was received. The temperature of the coffee was measured at 154.7 degrees Fahrenheit and the temperature of the hot water was measured at 164.4 degrees Fahrenheit. On 3/21/18 at 9:02 AM, the Dietary Manager (DM) was interviewed. The DM stated that the coffee was brewed each morning at 5:00 AM. The DM stated that the coffee was supposed to be delivered to the dining rooms at 7:45 AM. The DM stated that two dispensers of coffee and one dispenser of hot water were delivered to each dining room. The DM stated that the temperature of the coffee was 165 degrees Fahrenheit after it finished brewing. The DM stated she expected the staff to cool the coffee to 145 degrees Fahrenheit before delivering the coffee dispensers to the dining rooms. The DM stated that the coffee was cooled by leaving the lid of the dispenser open or by adding ice to the coffee. The DM stated that prior to the burn on 1/3/18, the temperature of the coffee and the hot water were not measured. The DM stated that following the burn on 1/3/18, the temperature of the coffee was measured until the end of January, but the temperature of the hot water was not measured. The DM stated that in (MONTH) (YEAR), the temperatures of the coffee were measured as a precaution, but were no longer recorded. On 3/21/18 at 9:10 AM, Cook 1 was interviewed. Cook 1 stated that he had worked in the facility as a cook for about one month. Cook 1 stated that he had not checked the temperatures of the coffee or the hot water that morning. Cook 1 stated that checking the temperature of the coffee and hot water were not on his temperature log. On 3/21/18 at approximately 10:30 AM, the WN was interviewed. The WN stated that she observed the sternal burn on 1/3/18. The WN stated that she did not take measurements of the burn or document an assessment as she did not believe the burn was serious. On 3/21/18 at approximately 10:40 AM, the Corporate Resource Nurse (CRN) was interviewed. The CRN stated that the temperature of hot beverages should be 150 degrees Fahrenheit for each resident. The CRN stated that safety is the same across the board regardless of a resident's cognitive status. The CRN further stated that as resident 35 was able to verbalize her wants and needs, she was not concerned about her safety while drinking hot beverages. (Note: As mentioned previously, resident 35's BIMS score of 5 was indicative of severe cognitive impairment and was assessed at the time of the incident as requiring one-person physical assist with eating.) On 3/22/18 at 10:52 AM, the Director of Nursing (DON) was interviewed. The DON stated that the WN looked at resident 35's sternal burn the day after it had occurred. The DON stated that the WN did not document her observation of the burn. The DON stated that the WN should have documented an in-depth description of the burn. 2. A review of resident 35's Event Notes revealed the following incident documented on 1/2/18 at 7:24 PM: Event: General Condition/ingested barrier cream. Date and Time of Event: 01/02/2018 at 17:30 (5:30 PM). Description and cause of symptoms: Resident ingested appx (approximately) 5 cc (cubic centimeters) barrier cream. Cognition: A&O x 1 self WNL . New interventions following event: Keep barrier cream locked up in tx (treatment) cart. Resident 35's TAR for (MONTH) (YEAR) revealed an order to apply barrier cream to redness in groin twice daily until the redness resolved. The barrier cream was administered 3/12/17 through 3/14/18. On 3/21/18 at 7:27 AM, the warning label for a tube of barrier cream was reviewed. The warning label revealed, Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away. On 3/21/18 at 8:04 AM, the SD was interviewed. The SD stated that she was unsure how resident 35 had access to the barrier cream. The SD stated that at the time of the ingestion, the barrier cream was supposed to be kept in a locked treatment cart or locked in the supply room. The SD stated that the incident was reported to her, but that no investigation was completed. On 3/26/18 at 8:55 AM, RN 1 was interviewed. RN 1 stated barrier cream should be locked in the treatment cart or locked in the supply room. RN 1 stated that barrier cream might have been left in a resident's room if that resident was alert and oriented. On 3/26/18 at approximately 10:00 AM, the DON was interviewed. The DON stated that facility staff were expected to lock up and secure the barrier cream. 3. A review of Resident 35's Event Notes revealed the following incidents: a. On 10/8/17 at 3:31 PM, Event: Resident found sitting outside south doors on step by staff. Date and Time of Event: 10/08/2017 (at) 15:00 (3:00 PM). Description and cause of symptoms: Staff reported resident was outside sitting on step, nurse f/u (follow up) with report. Resident stated she was sitting outside because this was the United States of America, when asked. Resident wheeled herself to the south doors and walked through the double doors and sat on the steps . Cognition: Resident is A&O to self . Does resident have a wandergaurd: No . New interventions following event: Close monitoring of resident, resident to be assisted outside as weather permits. Redirect resident to ask staff to go outside for resident safety . b. On 10/9/17 at 7:06 PM, 72 Hour Event Charting. Type of Event: Resident found sitting outside south doors on step by staff. Interventions: . Need to f/u with wandergard (sic). c. On 1/21/18 at 1:03 PM, Event: Resident was found outside on 37th. Date and Time of Event: 01/21/18 at 12:15. Description and cause of symptoms: Sometime between 11:45 and 12:15, residnt (sic) had made (her) way into elevator onto second floor and managed to find her way out the front door. Resident was found on 37th on the south corner of floor 1 entrance. Resident is safe and in fair condition WNL of self . Cognition: A&O x 1 WNL to self . Does resident have a wandergaurd (sic): No . New interventions following event: Wander guard (sic) placed. A review of resident 35's Order Summary Report revealed the following physician orders: a. On 1/21/18, Wandergaurd (sic) in place, check to ensure in place Q shift. Two times a day for elopement risk. b. On 1/21/18, Q Sunday ensure wander guard functioning, change PRN, one time a day every Sun (Sunday) for elopement risk. A review of resident 35's TAR and Medication Administration Record [REDACTED]. A review of resident 35's annual MDS assessment from 11/17/17 revealed that the resident was assessed as requiring one-person extensive assistance with walking and with transferring between bed and wheelchair. On 3/21/18 at 8:04 AM, the SD was interviewed. The SD stated that there were no staff assigned to cover the front desk on the weekend. The SD stated that a Restorative Aide assists at the front desk when needed, but is on shift primarily to complete restorative tasks. (NOTE: Both of resident 35's elopements occurred on a Sunday.) On 3/21/18 at 8:37 AM, the Assistant Director of Nursing (ADON) was interviewed. The ADON stated that resident 35 was not able to walk alone without somebody helping her. She falls. The ADON stated that she was unable to locate the order to check wanderguard functioning on either the TAR or the MAR for resident 35. On 3/21/18 at approximately 9:00 AM, the manufacturer User Instructions for the facility's wanderguard's were reviewed. Under the Warning heading, the instructions revealed: Test each signaling device before using. Thereafter, test the device daily and record the results in the resident's records. On 3/21/18 at 11:21 AM, the DON was interviewed. The DON stated that she would not leave the resident outside unattended as the resident was not safe to be outside alone. The DON stated that the wanderguard was placed because the resident was not safe to be outside alone. The DON stated that the staff were not aware that resident 35 was outside alone when she eloped from the facility on 1/21/18. The DON stated that the order to ensure that the wanderguard was functioning had not been added to the TAR and had not been completed. The DON stated that she was unaware of the manufacturer recommendation to have the wanderguard checked daily, and stated, We will be revising that order. B. Potential for Harm 1. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/26/18, resident 2's medical record was reviewed. A review of resident 2's Event Notes revealed the following incidents: a. On 6/2/17 at 10:41 PM, Event: Left facility unaware to staff. Date and Time of Event: 6-2-17 around 2100 (9:00 PM) . Cognition: Alert to self and confused at all times . New Interventions following event: Wanderguard to be placed on resident . b. On 6/3/17 at 11:37 PM, 72 hour Event Charting: Type of Event: Elopement. Interventions: Monitor res (resident) closely, make sure res has wanderguard (sic) n (sic) at all time (sic) . c. On 6/4/17 at 5:46 PM, 72 hour Event Charting: Type of Event: Elopement. Interventions: Wander guard to be place (sic) on resident . d. On 6/5/17 at 3:24 PM, 72 hour Event Charting: Type of Event: Elopement. Interventions: Resident wandergard (sic) is off d/t (due to) alarm being triggered at times r/t (related to) her room being close to door sensor. Monitor resident closely. A review of resident 2's Nursing Progress Notes revealed the following entry on 7/1/17 at 2:30 PM: Resident went outside and left walker at bottom of outdoor steps and walked up the stairs. Resident found by upstairs aid (sic) buy (sic) postal truck. Resident was out of breath. Returned to downstairs and educated on letting staff know if going somewhere. Rested in bed until lunch. No injuries. A review of resident 2's Order Summary Report revealed the following orders: a. On 12/14/17, Wandergaurd (sic) in place, check to ensure in place Q (every) shift, two times a day for elopement risk. b. On 12/14/17, Q Sunday ensure Wander Guard functioning, change PRN, one time a day every Sun (Sunday) for elopement risk. (Note: As mentioned previously, the manufacturer's instructions for the facility's wanderguard's indicate that the devices should be checked for proper functioning daily. No order for a wanderguard could be found prior to 12/14/17 in resident 2's medical record.) A review of resident 2's TAR and MAR from (MONTH) (YEAR) - (MONTH) (YEAR) revealed that there was no documentation for staff to ensure that the wanderguard was functioning. On 3/26/18 at approximately 10:00 AM, the DON was interviewed. The DON confirmed that the order to ensure the functioning of the wanderguard was not entered into the TAR and was not completed. The DON stated that the facility staff should have been following the manufacturer directions for testing the wanderguard. The DON stated that the reason a wanderguard was not put in place before 12/14/17 may have been due to a breakdown in communication. 2. A review of resident 2's Nursing Progress Notes revealed the following entry from 6/15/17 at 3:47 PM, Resident got a hold of some barrier cream and began to eat it and spit it out. Cleansed residents mouth with water, and gave resident some pudding and medpass, and resident finished it all quickly. No complaints of stomach ache, no adverse effect noted. As mentioned previously, the warning label on the barrier cream revealed, Keep out of reach of children. If swallowed, get medical help or contact a poison control center right away. On 3/26/18 at 8:55 AM, RN 1 was interviewed. RN 1 stated barrier cream should be locked in the treatment cart or locked in the supply room. RN 1 stated that barrier cream might have been left in a resident's room if that resident was alert and oriented. On 3/26/18 at approximately 10:00 AM, the DON was interviewed. The DON stated that facility staff were expected to secure and lock up barrier cream. 3. Resident 6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/19/18 at 10:05 AM, resident 6 was observed to be sitting on the edge of her bed while cleaning out a disposable razor with a pair of sharp-tipped scissor. On 3/19/18, the medical record for resident 6 was reviewed. In a Progress Note on 3/8/18, the Hospice MD stated that the resident was having episodes of confusion. It should be noted that resident 6's roommate, resident 43, was assessed as having a BIMS score of 3 on a quarterly MDS assessment from 2/22/18. A BIMS score of 3 indicates that the resident was severely cognitively impaired. On 3/19/18 at 1:18 PM, resident 6 was interviewed. Resident 6 stated that the scissor tweezers had been a gift and that she could not remember where she got the razor. On 3/19/18 at approximately 1:30 PM, an interview was conducted with CNA 4. CNA 4 stated that razors were stored in the locked supply room. CNA 4 stated that none of the residents on the first floor could have a razor. CNA 4 stated that resident 6 was confused and that her level of confusion would depend on the day. CNA 4 stated that resident 6 did not have a razor and that all razors were disposed of in the sharps container on the nursing cart. CNA 4 stated that resident 6 should not have scissor tweezers because of her confusion. On 3/19/18 at 1:37 PM, CNA 3 was interviewed. CNA 3 stated that disposable razors were locked in the supply room, and disposed of in the sharps container after use. CNA 3 stated that if a resident was independent, they were required to obtain a razor from the staff and return it to staff for disposal. CNA 3 stated that he had never seen resident 6 with a razor and that he was not aware of her ever using one. On 3/19/18 at 1:42 PM, RN 1 was interviewed. RN 1 stated that the only resident who was allowed to have a razor was resident 6. RN 1 stated that resident 6 knows to bring them to us so that the staff could dispose of the razor in the sharps container. RN 1 stated that the razors were locked in the supply room. RN 1 stated that she had been on shift for four straight days and was unaware that resident 6 had a razor. RN 1 stated that sometimes resident 6 kept disposable razors in a lock box under her bed and wore the key around her neck. RN 1 stated that the razor was not supposed to left open in her room. RN 1 further stated that resident 43, resident 6's roommate, wandered. RN 1 stated that she would be concerned about an unsecured razor because of resident 43's confusing. RN 1 stated that resident 6 has been a little more confused lately. On 3/19/18 at approximately 3:17 PM, resident 43 was observed to ambulate in her wheelchair from the nurse's station on the first floor to the southwest door on the first floor.
Based on interview, observation and record review the facility did not ensure that pain management was provided to 1 of 28 sample residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, a resident experienced high levels of pain after a surgical procedure without notification to the primary care physician. The deficient practice identified was cited at a harm level. Resident identifier: 153. Findings include: Resident 153 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/19/18 at 2:21 PM, an interview was conducted with resident 153. Resident 153 stated she was admitted to the facility after she sustained a fall with a [MEDICAL CONDITION]. Resident 153 stated that she had surgery to repair her [MEDICAL CONDITION]. Resident 153 stated she had been in constant pain since her admission to the facility. Resident 153 rated her pain at an 8.5 on a scale of zero which is no pain, to 10 which is the worst pain imaginable. Resident 153 stated that she wondered if she could ask the doctor for just a little more pain medication because her current pain medications were not working. On 3/20/18 at 9:53 AM, a follow up interview was conducted with resident 153. Resident 153 stated her pain was rated at an 8.5. Resident 153 stated she had an order for [REDACTED]. Resident 153 was observed crying and stated she could not understand why they did not give her more pain medication. Resident 153 was observed to be moving restlessly in bed and staring at the clock on the wall in her room. Resident 153 stated at 10:00 AM, she could receive more pain medication. Resident 153 stated she asked nursing to call the doctor for more pain medication. On 3/22/18, resident 153's medical record was reviewed. On 3/15/18, resident 153's physician wrote orders to administer the following pain medications: 1. On 3/15/18, [MEDICATION NAME] HCL ([MEDICATION NAME]) Tablet 5 MG (milligrams). Give 5 mg by mouth every 4 hours as needed for pain. (MONTH) have 1-2 tablets . 2. On 3/15/18, Tylenol Tablet 325 MG ([MEDICATION NAME]) Give 325 mg by mouth every 6 hours as need for pain may have 1-2 Tabs (tablets) every 6 hours as needed for pain . An ADMISSION CARE PLAN was developed on 3/15/18. The care plan addressed Pain with a goal that Resident will be as comfortable as possible. The interventions developed to achieve the goal included, Monitor pain; Non-drug interventions: (area left blank); Administer pain medication as ordered; and Establish causative factors and ways to alleviate them. The facility licensed nursing staff completed at Admission Assessment for resident 153 on 3/15/18. The facility staff documented that resident 153 had severe pain that aches (and) throbs that affected her sleep, mood, socialization and physical activity. At the time the assessment was completed, resident 153 stated that her pain score was 3, on a scale of 1-10 with 1 being no pain and 10 being excruciating pain. The licensed nursing staff documented that resident 153's acceptable level of pain was a 4. On 3/16/18 at 11:18 PM, a licensed nurse (LN) documented in a N[NAME] (night) ADMISSION 72HOUR ASSESSMENT, that resident 153 had severe pain in the left hip with a pain rating of 8. The LN further documented that resident 153 was Medicated for pain, effective. Resident in bed with eyes closed at this time. On 3/17/18 at 6:39 AM, a LN documented in a Daily skilled Assessment, that resident 153 had moderate pain in the left hip with a pain rating of 8. The LN further documented that resident 153's Pain pill to be given upon request. On 3/18/18 at 1:24 PM, a LN documented in a Daily skilled Assessment, that resident 153 had moderate pain in the left hip with a pain rating of 8. The LN further documented that resident 153's, pain meds effective for pain, able to request pain medications when needed. On 3/19/18 at 4:48 PM, a LN documented in a Daily skilled Assessment, that resident 153 had moderate pain in the left hip with a pain rating of 8. The LN further documented, PRN (as needed) medications per MAR (Medication Administration Record). On 3/20/18 at 10:36 AM, a LN documented in a Daily skilled Assessment, that resident 153 had moderate pain in the left hip with a pain rating of 8. The LN further documented, PRN medications, states not very effective. left message for MD (Medical Doctor) to re-evaluate her pain control. On 3/21/18 at 2:30 PM, a LN documented in a Daily skilled Assessment, that resident 153 had moderate pain in the left hip with pain rating of 8. The LN prn oxy ([MEDICATION NAME]) effective. WCTM (will continue to monitor) effectiveness. Review of the electronic Progress Notes revealed the following entries: 1. 3/15/18 at 5:02 PM, .Pain Level/Pain Medication Administered: 3/10. 2. 3/16/18 at 7:16 PM: .Res. (Resident) is calm and cooperative with some cares. She has refused some cares do (sic) to pain.Managed with prn [MEDICATION NAME]. 3. 3/16/18 at 8:15 PM, [MEDICATION NAME] HCL Tablet 5 MG was given and noted, Administration was: Ineffective. 4. 3/16/18 at 11:39 PM: .pain.PRN pain medication effective. 5. 3/17/18 at 2:12 AM, [MEDICATION NAME] HCL Tablet 5 MG was given and noted, Administration was: Ineffective. 6. 3/17/18 at 7:18 AM: .Res noted to have swollen left foot and states her pain is 8/10.Nurse notified and medication will be given when available. 7. 3/18/18 at 5:02 AM, [MEDICATION NAME] HCL Tablet 5 MG, 2 tablets were given and noted, Follow-up Pain Scale was: 8. 8. 3/18/18 at 1:59 PM: .Has c/o (complained of) pain in LLE (left lower extremity) but is stating that her pain is generalized. Pain medications seem to be effective. 9. 3/19/18 at 8:27 AM, [MEDICATION NAME] HCL Tablet 5 MG, 2 tablets were given and noted, 2 requested for pain 9/10. 10. 3/19/18 at 1:15 PM, [MEDICATION NAME] HCL Tablet 5 MG, 2 tablets were given and noted, 2 requested pain 10/10. 11. 3/19/18 at 11:49 PM, [MEDICATION NAME] HCL Tablet 5 MG, 2 tablets were given and noted, Administration was: Ineffective . resident stated that pain is still a 8 . Follow-up pain scale: 8. 12. 3/20/18 at 9:59 AM, [MEDICATION NAME] HCL Tablet 5 MG, 2 tablets were given and noted, 'Administration was: Ineffective . Follow-up pain scale was: 9. Resident 153's (MONTH) (YEAR) MAR revealed the following entries: 1. Document Pain Level Q (every) shift on a 1-10 scale. two times a day (there was no time documented for when the pain scores were obtained) . The following pain scores were documented: a. 3/15/18: 8 b. 3/16/18: 6 and 6. c. 3/17/18: 3 and 9. d. 3/18/18: 8 and 8. e. 3/19/18: 10 and 6. 2. [MEDICATION NAME] HCL Tablet 5 MG (milligrams). Give 5 mg by mouth every 4 hours as needed for pain may have 1-2 tablets . [MEDICATION NAME] two tablets was documented to be administered the following days: a. On 3/15/18 at 8:16 PM for a pain score of 6. b. On 3/16/18 at 1:19 AM for a pain score of 5; at 5:26 AM for a pain score of 6; at 11:46 AM for a pain score of 6; at 6:37 PM for a pain score of 5; and at 10:40 PM for a pain score of 6. c. On 3/17/18 at 2:59 AM for a pain score of 6; at 9:43 AM for a pain score of 7; and at 5:29 PM for a pain score of 8. d. On 3/18/18 at 12:54 AM for a pain score of 9; at 9:08 AM for a pain score of 8; at 4:14 PM for a pain score of 10; and at 11:39 PM for a pain score of 7. e. On 3/19/18 at 4:08 AM for a pain score of 9; at 8:27 AM for a pain score of 9; at 1:15 PM for a pain score of 10; at 6:43 PM for a pain score of 6; and at 11:43 PM for a pain score of 7. f. On 3/20/18 at 3:55 AM for a pain score at 9 and at 9:59 AM for a pain score at a 10. 3. Tylenol Tablet 325 MG ([MEDICATION NAME]) Give 325 mg by mouth every 6 hours as need for pain may have 1-2 Tabs (tablets). Resident 153's administration of the pain medication and pain scores were recorded on her MAR on the following dates and times: a. On 3/17/18 at 8:00 AM for a pain score of 8 and at 12:08 PM for a pain score of 8. b. On 3/19/18 at 8:50 PM for a pain score of 5. c. On 3/20/18 at 9:36 AM for a pain score of 7. On 3/20/18 at 9:58 AM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated resident 153 had pain medication around 5:00 AM on 3/20/18. LPN 2 stated resident 153 was administered pain medication every 4 to 6 hours as needed. (Note: The order for resident 153's [MEDICATION NAME] was for every 4 hours as needed not every 4 to 6 hours as needed). LPN 2 stated resident 153 had been complaining of pain. LPN 2 stated, Maybe the doctor should be called to adjust her pain medication. LPN 2 stated that she did not know if the doctor had been contacted regarding resident 153's pain. LPN 2 stated she was not aware that resident 153 had requested her physician be contacted. (Note: The facility did not provide any documentation that the physician was called regarding resident 153's pain.) On 3/20/18 at 2:39 PM, a follow up interview was conducted with resident 153. Resident 153 stated that she was experiencing pain and did not know why the nurse had not contacted the physician. On 3/21/18 at 8:54 AM, a follow up interview was conducted with resident 153. Resident 153 stated yesterday was the worse pain she had after surgery. Resident 153 stated, No one talked to me about my pain. Resident 153 stated she asked for an ice pack and help with a pillow, then the nurse attempted to reposition her. Resident 153 stated on the afternoon of 3/20/18 the therapist brought the house doctor in and he increased her pain medication. Resident 153 stated that her pain had decreased. Resident 153 stated she has had to wait more than 4 hours to get her pain medication. Resident 153 stated, If they (nurses) are busy you have to wait. Resident 153 stated prior to her admission she was taking [MEDICATION NAME] 10 mg 4 times a day for pain in her back, ankles and toes. Resident 153 stated, I don't know what they were giving me here but it was not enough. On 3/21/18 at 9:24 AM, and interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident 153 had complained of pain and asked for pain medication. CNA 1 stated, (resident 153) is the only one I have seen cry when she was in pain. CNA 1 stated that resident 153 said to her I wonder when my doctor is going to come and see me? CNA 1 stated for a resident with pain she would give them an ice pack, heat pack or reposition them. CNA 1 stated she did not know of any specific interventions to decrease resident 153's pain. CNA 1 stated, I will try anything to make them comfortable. CNA 1 stated that she assisted resident 153 with placing a pillow under her hip. CNA 1 stated she was told verbally in general terms about care plans for residents and that she had not seen a written care plan. CNA 1 stated, It's hard with residents I'm less familiar with. CNA 1 stated that with newly admitted residents she talked to them about what works for the resident. On 3/21/18 at 9:33 AM, and interview was conducted with Registered Nurse (RN) 2. RN 2 stated if a residents pain was high and pain medication was not effective, she would try ice, heat, and other interventions. RN 2 stated if interventions were not effective she would contact the physician, even if a resident had a history seeking medications. RN 2 stated a resident may need increased pain medication after a [MEDICAL CONDITION] and surgery. RN 2 stated after pain medication administration, she assessed residents pain medication effectiveness 30 to 60 minutes later. RN 2 stated she was aware that resident 153's pain was uncontrolled. RN 2 stated on 3/20/18, resident 153's physician increased her pain medication. RN 2 stated care plan interventions made for residents for pain usually included ice, heat, and repositioning. RN 2 stated most resident's have specific interventions. RN 2 stated she did not know if there was a care plan with interventions for resident 153's pain control. On 3/21/18 at 10:07 AM, the facility Medical Director (MD), who was resident 153's physician, was interviewed. The MD stated the facility called him when a resident's pain was uncontrolled. The MD stated that he had not been contacted prior to 3/20/18 regarding resident 153's uncontrolled pain. The MD stated that he would have expected the facility to contact him the first day that resident 153's pain was uncontrolled. The MD stated that he increased resident 153's pain medication from 5 mg 1-2 tablets every 4 hours to 15 mg every 4 hours. On 3/21/18 at 10:10 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 153 was assessed regarding her acceptable level of pain upon admission. The DON stated she did not know resident 153's acceptable level of pain without looking in the medical record. The DON stated the facility did not have a written policy or procedure regarding pain. The DON stated nurses assessed the resident's pain with each pain medication administration. The DON stated if the resident's pain scores were consistently at a high level and the pain medication was, not holding or the pain medication was ineffective on one occasion, then the nurse would, maybe try again in 4 hours. The DON stated that the physician was not notified if there was only one time the pain medication was ineffective. The DON stated if pain medications were consistently ineffective she would expect the nursing staff to notify the physician. The DON stated resident 153, likes to stay in bed a lot and move herself for comfort. The DON stated non-pharmacological interventions for resident 153 were to offer for her to go to activities and that the therapists were doing stretching and other interventions. The DON stated if the physician was called for resident 153's pain it would have been documented in the progress notes. (Note: There was no documentation that resident 153's physician was notified of resident 153's complaints of pain prior to 3/20/18.) On 3/26/18 at 1:44 PM, a follow up interview was conducted with the DON. The DON stated the floor nurses were unable to visualize resident 153's pain score history documented on the MAR. The DON stated if the nurses could visualize resident 153's pain score history she expected that they would have called the physician. The DON stated a different nurse assessed and scored resident 153's pain on each shift. The DON confirmed resident 153's admission acceptable level of pain assessment score of 4. The DON confirmed that based on the resident 153's MAR, she waited more than 4 hours for pain medication. The DON confirmed when resident 153 rated her pain at a 10 out of 10 on 3/20/18 at 9:59 AM, an order for [REDACTED]. On 3/20/18, a new order was received to administer [MEDICATION NAME] HCL 15 mg every 4 hours as needed for pain.
Inspection of June 27, 2013
1 findingBased on observation, interview and record review, it was determined the facility did not ensure that resident's having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for 4 of 41 sample residents. Specifically, (1) one resident developed an unstageable deep tissue injury and (2) four residents did not have their nutritional status evaluated or re-evaluated after the development of pressure sores or worsening of pressure sores. Resident identifiers: 2, 11, 24, and 126. Findings include: 1. Resident 11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/24/13 at 12:46 PM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated that resident 11 did not have any pressure ulcers at the time of admission to the facility but developed a deep tissue injury on his heel. Resident 11's medical record was reviewed on 6/25/13. On 1/5/13, an admission Minimum Data Set (MDS) Assessment was completed by the facility staff. The facility staff documented that resident 11 required extensive assistance of two people for bed mobility and transfers. Resident 11 was assessed as having one stage I pressure ulcer (intake skin with non-blanchable redness or a localized area usually over a bony prominence), one stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer over a bony prominence), and one surgical wound. The facility staff documented that resident 11 had a pressure relieving device to his chair and bed, but was not on a turning and repositioning schedule and did not have any nutrition or hydration interventions in place to manage the skin problems. A Care Area Assessment (CAA) triggered for pressure sores. The facility staff documented that the care area would be addressed in a care plan. On 1/12/13, a fourteen day MDS assessment was completed. The facility staff documented that resident 11 continued to need extensive assistance of two people for bed mobility and transfers. The facility staff documented that resident 11 had one stage I pressure and one stage II pressure ulcer. The facility staff further documented that resident 11 had a pressure relieving device to his chair and bed, was on a turning and repositioning schedule and had nutrition and hydration interventions in place to manage the skin problems. On 1/26/13, a 30-Day MDS assessment was completed. The facility staff documented that resident 11 continued to need extensive assistance of two people for bed mobility and transfers. The facility staff documented that resident 11 had one stage I pressure and one unstageable pressure ulcer that measured 4.0 cm (centimeters) X (by) 4.0 cm with necrotic tissue (black, brown, or tan tissue that adhered firmly to the wound bed or ulcer edges). The facility staff further documented that resident 11 had a pressure relieving device to his chair and bed, but was not on a turning and repositioning schedule and did not have any nutrition or hydration interventions in place to manage the skin problems. (Note: The unstageable pressure ulcer was not present on admission to the facility.) On 3/2/13, a 60-Day MDS assessment was completed. The facility staff documented that resident 11 continued to need extensive assistance of two people for bed mobility and transfers. The facility staff documented that resident 11 had one stage I pressure ulcer. The facility staff further documented that resident 11 had a pressure relieving device to his chair and bed, was on a turning and repositioning schedule and had nutrition and hydration interventions in place to manage the skin problems. On 3/30/13, a quarterly MDS assessment was completed. The facility staff documented that resident 11 continued to need extensive assistance of two people for bed mobility and transfers and had 5% (percent) weight loss from the previous month. The facility staff assessed resident 11 as having one unstageable pressure ulcer that measured 2.5 cm X 3.5 cm X 0.0 cm. The facility staff further documented that resident 11 had a pressure relieving device to his chair and bed, was receiving nutrition and hydration interventions but was not on a turning and repositioning schedule. (Note: Resident 11's weight at the time of admission was 224 pounds (lbs). The documented weight on the quarterly assessment was 196 lbs, a weight loss of 28 lbs.) On 6/14/13, a quarterly MDS assessment was completed. The facility staff documented that resident 11 continued to need extensive assistance of two people for bed mobility and transfers. The facility staff assessed resident 11 as having one unstageable pressure ulcer but did not document measurements of the pressure ulcer. The facility staff further documented that resident 11 had a pressure relieving device to his chair and bed, was on a turning and repositioning schedule and had nutrition and hydration interventions in place to manage the skin problems. A review of the care plans that were developed for resident 11 revealed the following: a. "At risk for nutritional problem or potential nutritional problem Meal intake provides less than estimated needs; Nutrition needs increased r/t (related to) need for healing" was developed on 1/2/13. The goals that were developed included (1) "The resident will maintain adequate nutritional status as evidenced by maintaining weight within 5% of baseline" and (2) "The resident will consume at least 75% of meals/day through next review." The interventions that were developed to achieve those goals included: (1) "Monitor/document/report to MD (medical doctor) PRN (as needed) s/sx (signs or symptoms) of [MEDICAL CONDITION], emaciation (cachexia), muscle wasting, significant weight loss (3 lbs in 1 week, (greater than) 5% in 1 month, (greater than) 7.5% in 3 months, (or greater than) 10% in 6 months; (2) Provide and serve diet as ordered. Offer & (and) provide alternate foods PRN; (3) Provide and serve supplements as ordered; and (4) RD (Registered Dietitian) to make diet change recommendations PRN." The facility staff did not document updating the care plan since 1/2/13. b. "Potential for skin breakdown r/t incontinence, diabetes, needs assist from staff with mobility" that was developed on 1/16/13. The goal that was developed for resident 11 was "no untreated skin breakdown thru (through) next review." The interventions that were developed to achieve that goal included: "(1) complete Braden scale assessment; (2) dietary consult per protocol; (3) encourage independent turning and repositioning; (4) labs as ordered; (5) Notify MD and Family of any new skin conditions; (6) nurse to assess and provide interventions; (7) Perform weekly skin checks; (8) pressure reducing bed; (9) pressure reducing device to w/c (wheelchair); (10) preventative cares as follows: turn and reposition as neededapply (sic) lotion as neededthorough (sic) peri care after each episode of incontinencecreams (sic) as needed; (11) Skin checks on saturdays (sic); and (12) thera boots BLE (bilateral lower extremities) at all times." The facility staff did not document updating the care plan since 1/16/13. c. "Impaired skin integrity potential for complications coccyx ie resolved and right heel 2/12 (2/12/13) right heal resolved 2/13 (2/13/13) right hellux (sic) [MEDICAL CONDITION] resolved 4/19 (4/19/13) red war right great toe resolved 5/13 (5/13/13) open scar to buttocks resolved 5/17 (5/17/13) right heel DTI (deep tissue injury)." The goal that was developed was "resident skin integrity will show ssx (signs or symptoms) of improvement by evidenced bydecreased (sic) size depthdecreased (sic) rednessincrease (sic) of health tissue through next review." The interventions that were developed to achieve the goal included: "(1) dietary consult as needed; (2) labs as ordered; (3) monitor for ssx of infectiona (sic): rednessb (sic): swellingc (sic): warmthd (sic): drainage/ordere (sic): increased painf (sic): increase in temp; (4) notify MD and family of wound and wound changes; (5) nursing will perform treatments as ordered and with any treatment changes CLEAN WOUND TO RIGHT HEEL WITH NS (normal saline) OR WOUND CLEANER AND THEN APPLY SANTYL, GAUZE, KERLIX AND COBAN. CHANGE TWICE A WEEK AND PRN SOILAGE (this intervention was implemented on 6/25/13); (6) obtain culture of wound as ordered; (7) obtain wound consult as needed; (8) podietry (sic) eval (evaluation) as needed; (9) pressure reducing bed; (10) pressure reducing device to w/c; and (11) total [MEDICATION NAME] and protein levels prn." The physician's orders [REDACTED]. Resident 11's primary care physician ordered the following: a. 1/13/13: "clarification: Theraboots to BLE while in bed." b. 1/14/13: "clarification: blister from admit to RLE (right lower extremity, shin, next to incision. Monitor blister to R (right) heel daily (see theraboots). [MEDICATION NAME] to coccyx, non-blanchable, unstageable wound BID (twice a day) & PRN. Clarification theraboots to BLE (at) all x's (times)." c. 1/21/13: "(1) Daily cleanser with deral (sic) wound cleaner, dry, apply [MEDICATION NAME] solution until resolved (R) heel." d. 1/25/13: "DC (discontinue) [MEDICATION NAME] to R heel.. Apply [MEDICATION NAME] oint (ointment) to R heel dry flaking area QHS (every evening) until resolved." e. 2/12/13: "Blister (DTI) to R heel resolved. Cont (continue) [MEDICATION NAME] oint for dry skin." f. 3/12/13: "Wound to coccyx healed, scar remaining. DC [MEDICATION NAME]. Apply barrier creams BID et (and) PRN to coccyx for prevention." g. 3/18/13: "Posterior heel draining vesicular lesion - daily apply [MEDICATION NAME] dressing until resolved. Off load..." h. 3/25/13: "(Check) CMS (circulation, movement and sensation) to R foot Q shift. Resident to have wound consult with (wound clinic) for wound to R heel." i. 5/17/13: "clarification (1) area to R heel is DTI. Continue current tx (treatment. DX (Diagnosis: [REDACTED]. j. 6/10/13: "(1) Pt. (patient) returned to (wound clinic) for a non-healing ulcer on the R heel. D/C discontinue unna boot." On 12/30/12, a facility licensed nurse completed an "Admission Skin Condition Assessment." The licensed nurse documented that resident 11 had a "sore R great toe" that measured 0.5 cm X 1 cm that was "red" with "mult. (multiple) incisions LLE (left lower extremity)" that were black, purple, and red. Additionally, the licensed nurse documented that resident 11 had a blister to the left lower extremity that measured 2 cm X 2.5 cm. The licensed nurse did not document that resident 11 had any pressure sores. The "Nutritional Assessment(s)" completed by the Registered Dietitian (RD) were reviewed. The RD documented: a. 12/31/12: Admission weight: 221, BMI (Body Mass Index) 30, regular diabetic diet with 25% of intake. The RD calculated that resident 11 required 0.9-1.1 gm (grams) per kilogram of protein per day. The RD documented "Resident admitted after hospital treatment r/t leg fracture. Dx also includes diabetes that is controlled woth (sic) insulin and diet. However, blood glucose was poorly controlled at home AEB (as evidenced by) HgbA1c (hemoglobin A1C) of 13.7. Other labs checked at hospital were minimally outside normal ranges. Skin intact but he is at moderate risk for breakdown. Weight of 221# (pounds) is above desirable range. he states no recent weight change. No problems chewing or swallowing. Meal intake since admission has averaged only about 25% which does not meet his needs. He says that his appetite is starting to get a little better, but is willing to have house supplement to help meet his protein needs and aid healing. Will evaluate weight and po intake prn." (Note: According to the American Dietetic Association: Nutrition Care of the Older Adult, Second Edition, page 120, a resident with wound healing should have protein needs calculated between 1.20-1.60 grams of protein per kilogram. Additionally, there was no documentation available for review which indicated that resident 11 received the "house supplement" as the RD recommended.) b. 2/6/13: "Dietary Note: Resident's weight was down 5# in the last week, probably r/t decrease in meal intake for a few days due to being ill. Over past month weight has gradually decreased by 12#/5% to 208#. This weight is still above desirable weight range. Intake of meals has improved back to 75%. Areas on coccyx and right heel continue to be treated but have improved per nursing. House supplement and MVI (multivitamin) continue to be given to aid skin integrity. No further changes at this time." c. 2/18/13: "Dietary Note: Resident's weight was down to 204# last week, a 2% decrease in one week, but is back up to 209# this week (up 2%). After a significant decrease on 17#/7.6% in 6 weeks, weight may not be stabilizing. Weight is still well above desirable range. Area on coccyx has continued to improve. Area on heel resolved. Meal intake has been 75% or more and he continues to receive house supplement TID and multivit (multivitamin) daily to aid healing and weight maintenance." d. 3/28/13: "Dietary Note: Resident's weight has decreased by about 10#/5% over the last 2 weeks to 197#. This is still at upper end of desirable range. Skin breakdown on coccyx resolved but area on right heel now being treated. He has continued to consume 50-75% of meals on Diabetic diet. Multivit, Vit (vitamin)D, Iron all given routinely as well as diabetic house supplement to help meet his energy and protein needs and aid healing. [MEDICATION NAME] slowly (sic) low at 3.1 on 3/10/13. Addition of Vit C 500 mg bid and Prostat/Promod 30 ml daily may also aid skin integrity." e. 4/12/13: "Dietary Note: Resident's weight has continued to decrease and is down to 190# this week. This is still in upper end of desirable range with BMI of 25.8. However, weight is down 15#/8% X 1 month; down 25#/10% X 3 months. Meal intake has averaged only about 50% recently. He says that he does not have much appetite and does not know what to do about it. He has been treated for [REDACTED]. Recommend increaseing (sic) this to 8 oz with each meal to help meet his needs. He does not think this increase will affect his appetite. DTI (deep tissue injury) to heel continues to be treated by wound clinic. MVI, Vit C given to aid healing as well as Prostat daily and supplement with meals." f. 5/23/13: "Dietary Note: Resident's weight has now remained stable at 187-190# for about 6 weeks. Weight is currently at 190# and in adesirable (sic) range. DTI to R heal (sic) continues to be treated. Last check of [MEDICATION NAME] on 4/7/13 was 3.4, slightly low but improved. To aid healing and weight maintenance he receives MVI, Vit C Prostat daily and Diabetic house supplement TID with meals. He has continued to have variable meal intake but averages about 50-75% of meals. Meal intake plus supplement appears adequate to meet his needs at this time." g. 6/12/13: Nutritional Assessment: "Weight down 31# (pounds)/14% over last 6 month. Weight has been 190+/-5# for most of the last 3 months and at upper end of desirable range. Weight 197# last week & down to 190# this week r/t decreased meal intake/infection." The RD further documented "Resident's weight has been stable around 190# for last 3 months and is in desirable range. weight has decreased by over 10% over last 6 months due to illness and variable meal intake at times. Weight down 7#/3.5% over 1 week due to decrease in meal intake. He is currently being treated for [REDACTED]. Meal intake has been less eating in his room (50% avg (average)). He has continued to take diabetic house supplement tid (three times a day) with meals, receives MVI, Vit C, Prostat to aid healing. [MEDICATION NAME] is still low but slightly improved at 3.2 on last check (6/9/13). Will continue on weekly wt (weight) with no changes at this time. Will eval wt and po intake prn." h. 6/26/13 (Note: This note was made after state surveyor was investigating the pressure ulcer and an interview was conducted with the RD): "Dietary Note: Resident weight is at 189# this week and staying fairly stable. Meal intake has improved with at least 75% intake of meals during past week. He has also continued to take 100% of diabetic house supplement 8 oz TID. Area on heel continues to be treated but condition worse. MVI daily, Vit C bid (two times per day) and Prostate daily have continued. Current intake of meals and supplement provide about 95 gm of Protein day. At 1.3 gm/kg, est needs are at least 112gm/day. Recommend increase in Prostat to 30 ml TID and addition of Zinc Sulfate 220 mg daily X 14 days to promote healing." On 6/25/13 at 1:15 PM, an interview was conducted with the facility RD. The RD stated the facility provided a list of residents with pressure sores for the RD to evaluate. The RD stated resident 11 had a DTI but not a pressure sore. A follow up interview was conducted at 4:18 PM with the RD. The RD stated usually she used 1.2g/kg of protein for wound healing. The RD further stated she may have estimated resident 11's protein low and was not sure why she calculated resident 11's protein needs so low. The RD stated the diabetic diet resident 11 was receiving provided 80 grams of protein per day. The RD further stated after resident 11 developed the pressure sore a high protein drink was ordered. The RD stated no interventions were initiated for increasing protein with food. The RD stated resident 11 had a poor appetite after admission. The RD stated "I waited to make sure (resident 11's) appetite did not increase prior to adding supplements." On 6/25/13 at 10:45 AM, Licensed Practical Nurse (LPN) 1, who also functioned as the facility wound nurse was observed while changing the dressing to resident 11's heel. LPN 1 was assisted by LPN 2. The old dressing was covered with a serosanguinous drainage that required a normal saline soak before the old dressing could be removed from the wound bed. The wound bed was observed to be covered with yellow slough and measured 4 cm X 5 cm X 0.3 cm. LPN 1 applied a thin layer of santyl (a chemical wound debridement) to the wound bed and covered the area with gauze bandage. On 6/25/13 at 9:40 AM, an interview was conducted with RN 2 . RN 2 stated resident 11 had a cushion in his wheelchair. RN 2 stated resident 11 was repositioned every 2 hours when in bed. RN 2 further stated resident 11 had a boot on his right food because of a DTI on his heel. On 6/25/13 at 9:43 AM, an interview was conducted with CNA 7. CNA 7 stated she assisted resident 11 into his wheelchair this morning and resident 11 did not have a cushion in his chair. CNA 7 stated she repositioned resident 11 in bed every 2 hours. On 6/25/13 at 9:38 AM, an interview was conducted with resident 11. Resident 11 stated there was a boot on his foot at all times because he could not have any pressure on it. Resident 11 stated he developed the pressure sore from rubbing his heel on the bed. Resident 11 stated he did not have cushion in his chair and he did not have his heels elevated while in bed before the pressure sore developed. On 6/25/13 at 12:44 PM, an interview was conducted with the Wound Clinic RN. The RN stated resident 11 was evaluated for his right heel at the wound clinic on 3/26/13. The RN stated resident 11's right heel was noted to be healed on 5/9/13. The RN further stated on 6/14/13 resident 11 was reevaluated at the wound clinic because his right heel opened again and was a stage 2 pressure sore. The RN further stated resident 11's skin was very fragile and the doctor instructed for the facility to perform "off loading" to prevent breakdown. The RN stated the pressure sore needed weekly debridement and the heel must be floated and to keep off of pressure and avoid being wet. The RN stated the reason for the breakdown was because the heel was not floated and that the pressure sore was avoidable both times. The RN further stated if the facility had provided the precautions instructed by the doctor the pressure sore would have been prevented. On 6/25/13 at 12:32 AM, an interview was conducted with resident 11's family member. The family member stated facility staff informed her about resident 11's pressure sore in March 2013. The family member stated prior to the development of the pressure sore resident 11 did not have anything to elevate his heels off the bed. The family member further stated the facility staff informed her the pressure sore was caused from resident 11 rubbing his heel on the bed. The family member further stated resident 11 did not have any pressure sores prior to admission. 2. Resident 126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/26/13 at 9:30 AM, Licensed Practical Nurse (LPN) 1 was observed while performing a dressing change to resident 126's stage III pressure ulcer on the left Achilles area. The old dressing that was removed had an area of serousanginous drainage. The wound bed was cleansed with normal saline. The wound bed was observed to have yellow slough with two areas that appeared to be necrotic. LPN 1 measured the wound to be 3.0 cm X 3.0 cm X 0.1 cm. LPN 1 stated that the necrotic areas to the wound bed were new. Resident 126's socks and shoes were placed on his feet, after the dressing change was completed. On 6/26/13 at 12:30 PM, resident 126 was observed to be sitting in a tilt-in-space wheelchair. Resident 126 continued to have his shoe in place without off-loading devices to relieve the pressure on the left heel. On 6/26/13 at 4:30 PM, resident 126 was observed to be sitting in a tilt-in-space wheelchair with his shoes in place. Resident 126 stated that he had not been laid down and that his shoes had not been removed since he got out of bed before 9:30 AM. Resident 126 did not have an off-loading device in place to relieve the pressure on the left heel. (Note: Resident 126 had pressure placed on the stage III pressure ulcer for 7 1/2 hours.) Resident 126's medical record was reviewed on 6/26/13. On 5/8/13, the facility staff completed an admission MDS Assessment for resident 126. The facility staff assessed resident 126 as being alert and oriented. The facility staff documented that resident 126 needed extensive assistance of one person for eating and extensive assistance of two people for bed mobility (how the resident moved to and from lying position, turned side to side, and positioned his body while in bed...) The facility staff documented that resident 126 had a stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle was not exposed. Slough may be present but did not obscure the depth of tissue loss. May include undermining and tunneling.) The stage III pressure ulcer was documented as measuring 1.0 cm X 1.0 cm X 0.0 cm with necrotic tissue. A CAA triggered for pressure sores. The facility staff documented that the care area would be addressed in a care plan. On 5/15/13, the facility staff completed a fourteen day MDS assessment. Resident 126 was assessed as being alert and oriented. The facility staff documented that resident 126 needed extensive assistance of one person for eating and extensive assistance of two people for bed mobility. The facility staff documented that resident 126 had a stage III pressure ulcer. The stage III pressure ulcer was documented as measuring 1.8 cm X 1.5 cm X 1.0 cm with necrotic tissue (eschar that was black, brown, or tan tissue that adhered firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin.) (Note: The stage III pressure ulcer increased in size from the measurements obtained on 5/8/13.) On 5/29/13, the facility staff completed a 30 day MDS Assessment. Resident 126 was assessed as being alert and oriented. The facility staff documented that resident 126 needed extensive assistance of one person for eating and extensive assistance of two people for bed mobility. The facility staff documented that resident 126 had a stage III pressure ulcer. The stage III pressure ulcer was documented as measuring 1.5 cm X 1.5 cm X 1.0 cm with slough. (Note: The stage III pressure ulcer increased in size from the measurements obtained on 5/8/13 and was 0.3 cm smaller in length than the measurements obtained on 5/15/13.) The care plans that were developed for resident 126 were reviewed. The facility staff developed: a. "Impaired skin integrity potential for complications pressure ulcer..." on 5/6/13. The goal that was developed was "resident skin integrity will show ssx (signs and symptoms) of improvement as evidenced bydecreased (sic) size depthdecreased (sic) rednessincrease(sic) of health tissue through next review." The interventions that were developed to achieve the goal included: (1) "dietary consult as needed; (2) labs as ordered; (3) monitor for ssx of infectiona (sic): rednessb (sic): swellingc (sic): warmthd (sic): drainage/ordere (sic): increased painf (sic): increase in temp (temperature); (4) nursing will preform (sic) treatments as ordered and with any treatment changes ie apply [MEDICATION NAME] to left distal Achilles change every 5-7 days and prn monitor q (every) shift; (5) nursing will preform (sic) treatments as ordered and with any treatment changes ie Apply foam drsg (dressing) to Right distal achillies for prevention and change Q (every) 3-5 days and PRN (as needed). Monitor Q shift; (6) obtain culture of wound as ordered; (7) obtain wound consult as needed; (8) podietry (sic) eval (evaluation) as needed; (9) pressure reducing device to w/c (wheelchair); and (10) total [MEDICATION NAME] and protein levels prn." b. "At risk for nutritional problem or potential nutritional problem r/t (related to) Meal intake provides less than estimated needs." The goal that was developed was "The resident will maintain adequate nutritional status as evidenced by maintain weight within 5% of baseline through next review." The interventions that were developed to achieve that goal included: (1) "RD (Registered Dietitian) to evaluate and make diet change recommendations PRN." The "ADMISSION NOTE" completed by the primary care physician on 5/2/13 was reviewed. The primary care physician did not document that resident 126 had any abnormalities of the skin and did not document that resident 126 had any pressure sores. The physician's orders [REDACTED]. The following orders were obtained: a. 5/1/13 (admission orders [REDACTED] i. Theraboots to bilateral feet when in bed. ii. Regular mechanical soft diet b. 5/3/13: "Clarifications from admit: ...(2) Stage III DQ (decubitus ulcer) to L (left) distal achilles. Apply [MEDICATION NAME]. Change q 5-7 days et (and() PRN. Monitor Q shift." c. 5/8/13: "House Supplement 120 ml (milliters) BID (twice a day). Multivit (multivitamin)/ (with) mineral daily. Clarify diet order to reg (regular) diet reg texture." d. 6/7/13: "...Cleanse wound to L achilles (distal) & (and) apply santyl oint (ointment). Cover (with) foam drsg (dressing) & change daily..." e. 6/14/13: "(1) D/C (discontinue) santyl to L distal achillies (sic). (2) Cleanse wound to L distal achillies (sic) et apply [MEDICATION NAME], cover (with) foam drsg et (change) daily. Monitor q shift." Review of the "ADMISSION SKIN CONDITION ASSESSMENT", completed by a facility licensed nurse on 5/1/13, revealed that resident 126 was assessed as having an area on the left achilles area that measured 1 cm X 1 cm that was red in color. The licensed nurse documented that there was no drainage or odor present. On 5/4/13, the consultant Registered Dietitian (RD) completed a nutritional assessment for resident 126. The RD documented that resident 126 was only consuming 25% of his meals and calculated that resident 126 required 1.0-1.1 gm (grams)/kg (kilogram) of protein per day. The RD further documented "...current weight of 167# (pounds) is in a desirable range but has decrease a few pounds since admit. He also stated that his normal weight was closer to 180#. Uncertain how long ago his weight was at 180#. Has small open ares (sic) being treated on buttocks and left achilles. He is at significant risk for skin breakdown. [MEDICATION NAME] low at 2.3, possibly r/t (related to) recent stress factors as well as decreased PO (oral) intake. He states that he has no appetite due to having a hard time having bowel movements... PO intake has averaged only 25% so far which is significantly less than estimated needs. He states that he can tolerate a regular texture diet although chewing some foods will make his bad teeth hurt at times. He does not want ground meat. Recommend giving house supplement 120 ml BID and adding a multivit daily to aid healing. Resident stated that he did not want to have a "protein drink" all the time so will try 2X (twice)( per day. Will eval (evaluate) weight and po intake prn." (Note: The laboratory results obtained for resident 126 revealed that on 4/19/13 (preadmission laboratories) resident 126's total protein was low at 6.2 g/dL (grams per deciliter.) A normal laboratory value for a protein level was documented 6.4-8.2 g/dl. Resident 126's [MEDICATION NAME] was low at 2.3 g/dl with a normal range documented as 3.4-5.0. ) The "Weekly Wound Record(s)" for resident 126 were reviewed. LPN 1, who also functioned as the "wound nurse", documented the following: a. 5/3/13: Stage III pressure ulcer to the "L distal achilles." LPN 1 documented that the wound measured 1.0 cm X 1.0 cm with yellow slough to 60% and eschar to 40% of the wound bed. b. 5/10/13: Stage III pressure ulcer to the "L distal achilles." LPN 1 documented that the wound measured 1.8 cm X 1.5 cm X 0.1 cm with granulation tissue to 70% and 30% slough to the wound bed. (Note: The pressure ulcer increased in size from the original measurement of 1.0 cm X 1.0 cm.) c. 5/17/13: Stage III pressure ulcer to the "L distal achilles." LPN 1 documented that the wound measured 1.7 cm X 1.5 cm X 0.1 cm with 30% granulation tissue and 40% yellow slough to the wound bed. d. 5/24/13: Stage III pressure ulcer to the "L distal achilles." LPN 1 documented that the wound measured 1.5 cm X 1.5 cm X 0.1 cm with 40% granulation and 30% yellow slough to the wound bed. e. 5/31/13: Stage III pressure ulcer to the "L distal achilles." LPN 1 documented that the wound measured 1.5 cm X 1.5 cm X 0.2 cm with 25% granulation tissue and 50% yellow slough. LPN 1 documented that the surround tissue was "peeling (and) macerated." (Note: The pressure ulcer increased in depth.) f. 6/7/13: Stage III pressure ulcer to the "L distal achilles." LPN 1 documented that the wound measured 1.8 cm X 1.8 cm X 0.2 cm with 50% granulation tissue and 50% yellow slough to the wound bed. LPN 1 documented "Resident with no improvement noted to wound this week and [MEDICATION NAME] drsg (dressing) noted to be sticking significantly to skin. Douderm (sic) DCd (discontinued) and new tx (treatment) ordered. Will monitor for effectiveness." g. 6/14/13: Stage III pressure ulcer to the "L distal achilles." LPN 1 documented that the wound measured 3.0 cm X 3.0 cm X 0.2 cm with 5% granulation tissue, 60% yellow slough, and 5% eschar to the wound bed. LPN 1 documented "Resident continues with wound to L achilles with maceration noted to surrounding area with hardness noted. Will change treatment to [MEDICATION NAME] with foam drsg daily and continue to monitor." (Note: There was a significant increase in the size of the stage III pressure ulcer.) h. 6/21/13: Stage III pressure ulcer to the "L distal achilles." LPN 1 documented that the wound measured 2XXX
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