Based on observations, interviews, record reviews, and a policy review, the facility failed to ensure care and services to prevent accidents for 3 of 9 sampled residents reviewed for nutrition and falls, as evidenced by the failure to provide supervision while eating for Resident #37; failure to implement preventative measures to prevent a fall related injury for Resident #14; and failure to complete a post fall investigation to determine the cause of the fall for Resident #20.On 06/24/25 it was determined the facility failed to ensure adequate supervision for Resident #37, a resident with diagnoses of Cerebral Infarction (Stroke) and Dysphagia (difficulty swallowing), to prevent the likelihood of choking, aspiration (the accidental ingestion of food particles or fluids into the lungs), and/or death. Resident #37, who was ordered to have a mechanically altered diet, was not supervised during meals as per her current care plan and was subsequently provided with a whole hot dog that she consumed. The resident had a history of being served potato chips, Goldfish crackers by facility staff members. The likelihood of Resident #37 choking on the hot dog with the potential of aspiration or death was determined and the Administrator was informed of the Immediate Jeopardy on 06/27/25 at 10:50 AM. The Immediate Jeopardy was identified on 06/24/25 and was removed on 06/27/25. The scope and severity were decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 06/27/25 and verified by interview, observation and record review on 06/27/25. Although, the facility submitted an acceptable removal plan, the potential for more than minimal harm remains without the implementation of a plan of correction and monitoring of the corrective actions.Cross Reference - F805. The findings included:A Review of the policy titled, Meal Supervision and Assistance revised on 11/29/22 documented that the resident will be prepared for a well-balanced meal in a calm environment, with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event. This included identifying hazards and risks. The listed guidelines for compliance included checking the meal tray before serving it to the resident to make sure that it was the correct diet ordered and that the food texture was appropriate for the resident's ability to chew and swallow. Photographic Evidence Obtained.A record review revealed that Resident #37 was admitted to the facility on [DATE]. Her diagnoses included Cerebral Infarction (Stroke) due to Embolism of the Left Carotid Artery (lack of blood flow to the brain caused by a blood clot), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction Affecting the Right Dominant Side, Aphasia (impaired ability to speak) Following Cerebral Infarction, Dysphagia (swallowing difficulty) Following Cerebral Infarction, and Muscle Weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE] documented this resident's Brief Interview of Mental Status (BIMS) score equaled 5, which indicated that Resident #37 had severe cognitive impairment.A record review of Resident #37's care plan, last revised on 02/13/25, revealed that Resident #37 was at risk for malnutrition due to her medical history which included Dysphagia, Aphasia, Anxiety, and Cerebrovascular Accident (stroke). Since 12/02/22, the interventions listed in the care plan included providing the diet as ordered, and monitoring for signs and symptoms of aspiration such as coughing, choking, pocketing of foods, spitting out food, wet vocal quality, and wet lungs. If symptoms of aspiration or choking were found, the physician and the Speech Language Pathologist were to be notified. An intervention since 12/02/22 specified to set-up the trays, supervise, cue, and assist the resident as needed with meals. It specified to allow adequate time to consume food/fluids provided. Record review of the medical record Listing of Tasks for Eating showed no checkmarks under the column that denoted the provision of supervision from 06/13/25 through 06/26/25. The eating task in the electronic medical record was used by Certified Nursing Assistants (CNAs) to document how much a resident ate or drank, and how much assistance was provided by the CNA.Record review revealed the physician ordered diet for Resident #37, dated 06/01/25, documented a Regular Diet, with mechanical soft texture foods, and thin consistency fluids. The diet listed in the Meal Tracker (meal ticket software program) was Regular - Mechanical Altered/Ground. The diets in the electronic medical record documented (mechanical soft), and the meal ticket software program documented (ground). Both were mechanically altered diets that were used for residents with swallowing difficulties. Photographic evidence of the meal ticket was obtained.During an observation of Resident #37's dinner meal, on 06/24/25 at 5:26 PM, Resident #37 refused her meal. The meal ticket on her tray specified that she was on a Regular-Mechanical Altered/Ground diet. Staff A, Certified Nursing Assistant (CNA), offered the resident several food options including grilled cheese, a peanut butter and jelly sandwich, and an egg salad sandwich. Resident #37 communicated that she didn't want any of those alternatives. Staff A mentioned she would look at the menu to see what other alternatives were available. Staff A saw that a hot dog was listed on the menu as an available option, and asked Resident #37 if she wanted a hot dog. Resident #37 said, yes. During an interview on 06/24/25 at 5:38 PM, while in the hallway in front of the dining room, Staff A, CNA, stated she had given Resident #37 a hot dog and she ate it. Upon receiving this information, the surveyor returned to the resident's room, Resident #37 held a quarter of the hot dog bun while still sitting on her bed. The hot dog was not visible and it appeared the resident had consumed the hotdog.During an interview on 06/24/25 at 5:42 PM with Staff A, when asked if the hot dog was whole or cut-up into small pieces, the CNA stated she served Resident #37 a whole hot dog that was not cut-up. When asked if the kitchen staff knew it was for Resident #37, Staff A said that she told the kitchen it was for Resident #37. Staff A confirmed that Resident #37 ate 100% of the hot dog.During an interview on 06/24/25 at 5:52 PM, the Certified Dietary Manager (CDM) stated that she didn't know who the hot dog was for. She reported, Resident #37 wouldn't be given a whole (intact) hot dog because of her diet; it would be mechanically ground. The CDM stated that the kitchen staff would have been able to grind it for her. The surveyor asked to see the food processor that was used for grinding up foods, and the CDM showed the surveyor a clean food processor. The surveyor asked the CDM if the kitchen staff prepared any ground hot dogs on 06/24/25, and the CDM said that they did not. She explained that no one on a ground diet ordered a hot dog that day.During an observation of the dinner meal on 06/26/25 at 5:50 PM, Resident #37 was in bed and a tray of food was on her tray table. The food on the tray included, ground beef, mashed potatoes, and vegetables were on the main dinner plate. There appeared to be warm ground chicken salad was on a separate small plate covered with plastic wrap. The resident moved the plate onto her lap and peeled back the plastic wrap. She used her fingers to pick up and taste the chicken salad. She shook her head from left to right and waved her hands back and forth. She said no ., no ., and she placed the plate back on the meal tray. She did not eat any more chicken salad. There was no staff from the facility present in Resident #37's room when she tasted the chicken salad. The surveyor continued to observe Resident #37 in her room. No staff members provided supervision for Resident #37 during the dinner meal from 5:50 PM through 6:05 PM. 2) Review of the record revealed Resident #14 was admitted to the facility on [DATE] and was sent out to the emergency room (ER) on 02/26/25 and 03/01/25, with a return to the facility those same days. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 1, on a 0 to 15 scale, indicating severe cognitive impairment. This MDS documented Resident #14 had a fall with injury since the prior assessment of 12/24/24.Review of the current care plan initiated on 01/21/22 documented Resident #14 was at risk for falls and fall related injury related to cognitive loss, stroke, non-ambulatory status, impaired mobility, weakness, medication use, fall history, osteopenia (small bones), and bilateral knee contractures. An intervention included providing a mat on the floor to the left side of the bed as of 11/07/23. A second intervention initiated on 12/04/23 documented the use of bilateral wedges to sides of bed for safety and fall risk prevention.Review of the current physician orders documented the need for a floor mat to the left side of the bed for safety since 11/07/23. A current order dated 06/23/25 documented the use of bed bolsters to bilateral sides of bed.Review of a change in condition form dated 02/26/25 documented Resident #14 had a fall with no apparent injury and was sent out to the hospital.Review of progress notes documented, in part, the following:a) On 02/26/25 at 4:25 PM, Resident #14 suffered an unwitnessed fall at about 3:45 PM, and was sent to the ER.b) On 02/26/25 at 10:22 PM the nursing staff received information from the ER (Emergency Room) that the resident was being returned back to the facility. A CT (Computed Tomography) of the brain and cervical spine (upper part) indicated no fractures or injuries.c) On 03/01/25 at 10:18 AM and 10:52 AM the resident's brother insisted Resident #14 return to the ER due to increased back pain and to get additional studies. The resident was sent back to the ER.d) On 03/01/25 at 8:06 PM the resident returned to the facility with diagnoses to include a closed wedge compression fracture of T10 (thoracic or mid back) vertebra and a closed compression fracture of L3 lumbar (lower back) vertebra. The resident was medicated with Dilaudid (an opioid/narcotic pain medication), Toradol (an anti-inflammatory medication), and Zofran (a medication for nausea) at 1:53 PM. He returned to the facility with orders for Percocet (an opioid/narcotic pain medication) as needed.Review of the radiology studies from the ER visit on 03/01/25 documented both compression fractures as acute/subacute, indicating they could not tell if the fracture was recent or anytime within the past few months.Review of the facility provided fall investigation documented there were interventions/strategies in place from the care plan but lacked documentation of whether the fall mat and wedges/bolsters were in place. The Assigned CNA Statement Form and Registered Nurse (RN) Statement Form both lacked documentation as to whether the fall mat and wedges/bolsters were in place. Review of the Fall Root Cause Analysis documented, in part, there were no floor mats in place.During an interview on 06/27/25 at 8:44 AM, when asked about the investigation related to the care plan interventions at the time of the fall, the Administrator, who was also the Risk Manager, did not comment, while the Director of Nursing (DON) explained the resident would play with the bed remote and had raised the bed up and rolled out of bed. The DON further stated the fall mat was in place. When asked to locate evidence of this on the fall investigation and was also notified the root cause analysis documented a lack of the fall mat, the DON stated, I'm sure I saw it but agreed to the conflicted information in the investigation.During an interview on 06/27/25 at 11:23 AM, when asked about the radiological report documentation of acute/subacute fracture, the Medical Director stated that more than likely, because of the minimal 10% height loss, the fractures were chronic. When asked about the resident's increased yelling/pain with movement, the Medical Director reviewed the full radiological report and stated the bulging disk may have been affected with the fall and caused the pain.3) Review of the record revealed Resident #20 was admitted to the facility on [DATE]. Review of the current MDS assessment dated [DATE] documented the resident had a BIMS score of 15, indicating the resident was cognitively intact.Review of a change in condition form dated 11/02/24 documented Resident #20 slipped out of the shower chair with no open injuries.During an interview on 06/23/25 at 4:08 PM, when asked about his fall in the bathroom, Resident #20 stated he was being assisted with a shower in his bathroom, was seated in the rolling shower chair, and further stated, Apparently the wheels were not locked as it went out from under me. The resident denied any fracture, but stated it happened about three months ago, that he had fallen on his bottom and had twisted his shoulder, and it took him a couple of months to recover.On 06/25/25 at 11:21 AM, the DON was asked to locate and provide evidence of the fall investigation for Resident #20 from 11/02/24. At 12:47 PM the DON provided a folder labeled with the name of Resident #20, stated, I wasn't here when it (the fall for Resident #20 in November 2024) happened and I couldn't find any investigation, so I printed out the information that I could find in PCC (Point Click Care, the facility's electronic medical record (EMR)) and filled out the Fall Investigation Form. I wanted you to have something. There aren't any statements or anything else.Review of the folder revealed the Fall Investigation Form with only page one filled out with information the DON had obtained from the EMR. The possibility of an equipment issue was not addressed in any of the documents. The Fall Investigation Form documented the fall was unwitnessed whereas the nursing post fall evaluation documented the fall as being witnessed.During a phone interview on 06/27/25 at 11:36 AM, when asked if she recalled the fall in the shower for Resident #20, Staff M, CNA, stated she did as she was present during the fall. When asked what happened, the CNA stated she really wasn't sure, but I always lock the wheels (of the shower chair). The CNA further explained the resident fell as he was trying to pull himself up with the grab bar when the chair slipped back.During an interview on 06/27/25 at 8:40 AM, the DON confirmed she had not found an investigation for the fall of Resident #20 on 11/02/24 but had found a statement. At 9:59 AM the DON returned with a statement and Fall Hand Off form. Review of the statement revealed Staff M, CNA, documented the resident was trying to stand up to dry off and the shower chair slid back, and he fell on his bottom. The Fall Hand Off form lacked any information regarding the actual fall but was an instruction sheet for the nursing staff. The DON confirmed there was no root cause analysis or evidence the event was investigated. The DON also agreed to the lack of any information related to the shower chair. The facility's Immediate Jeopardy removal plan dated 06/27/25 included the following, which was also verified:On 06/24/25 Resident #37 was immediately assessed. A speech referral was submitted to assess diet appropriateness. A chest x-ray was ordered to rule out aspiration. Respiratory assessments were initiated every shift for 72 hours for signs and symptoms of aspiration. The resident's diet order, care plan, and Kardex were reviewed and updated as indicated for accuracy. The physician and responsible party were notified. On 06/25/25 a speech evaluation was ordered for Resident #37.On 06/26/25 a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) bedside study was ordered.On 06/24/25 the CNA and dietary employee involved were removed from the floor and received one-on-one education by the Staff Development Coordinator and Dietary Manager on verifying diet slips with current orders, appropriate food textures for mechanical soft diets, how to address concerns regarding tray accuracy, possible consequences of serving inappropriate diets, and ensuring proper supervision of residents who require it during meals.On 06/25/25 the facility reviewed residents with mechanically altered diets to ensure current orders matched tray ticket diets. There were 18 current residents who were on mechanically altered diets at the time of the survey.On 06/24/25 through 06/26/25 current staff were educated on supervision of residents related to accidents and incidents specifically to proper supervision of residents who require it during meals, including alternate food options and snacks as requested. Newly hired staff will receive education on supervision of residents during meal consumption in their orientation. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.On 06/27/25 current staff were educated on how to respond to a choking resident. Education was done via the facility on-line portal, in person, and via telephone.On 06/27/25 the information in the facility's removal plan was verified. Observations of the lunch and dinner meals on 06/27/25 demonstrated a process to ensure physician ordered diets were being delivered to residents. A new diet communication manual was placed in the main dining room and on each tray cart. On 06/27/25 six staff, including Staff B, the CNA who provided Resident #37 with potato chips and permitted the resident to choose Gold Fish crackers were interviewed. Each staff member was able to verbalize the education provided during the week. They verbalized what needs to be done before providing an alternate food item or snack to a resident, the new process for meal tray delivery, and how residents are identified who need supervision. On 06/24/25 Resident #37 was immediately assessed by her assigned nurse. A speech referral was submitted to assess diet appropriateness. A chest x-ray was ordered to rule out aspiration and was refused by the resident. Respiratory assessments were initiated and documented every shift for 72 hours for signs and symptoms of aspiration. The resident's diet order, care plan, and Kardex were reviewed and updated as indicated for accuracy. The physician and responsible party were notified. On 06/24/25 Staff L, dietary cook and Staff A, CNA, were provided the one-on-one education.On 06/24/25 a total of 109 current staff, including all disciplines, received the education related to supervision.On 06/25/25 the speech evaluation was completed for Resident #37.On 06/25/25 an audit was completed confirming the meal textures in Meal Tracker (the dietary software used to print meal tickets) matched the physician's order for all current residents.On 06/26/25 a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) bedside study was conducted. The recommendations from this study were to advance the resident diet to a mechanically soft chopped diet.On 06/27/25 it was verified that all 27 licensed nurses had CPR (cardiopulmonary resuscitation)/Heimlich maneuver (procedure recommended for a choking resident) certifications in good standing.As of 06/27/25, 100% of staff received education on responding to a choking resident via their on-line portal. In addition, 30% of current staff were educated in person and 23% via telephone on how to respond to a choking resident. Staff who received this education via telephone will receive the in-person education upon their next working shift at the facility.An Ad Hoc/Quality Assurance Performance Improvement (QAPI) meeting was held on 06/25/25 with the Medical Director, the Administrator, the Director of Nursing, the Staff Development Coordinator, and the Dietary Manager. Supervision during meal consumption was discussed. A plan for continued monitoring and sustained compliance was reviewed. An additional Ad Hoc/QAPI meeting was held on 06/26/25 to evaluate the effectiveness of the education.The facility's Immediate Jeopardy was removed on 06/27/25 at 6:50 PM.
Every finding on record at Garden View Health and Rehabilitation Center
Vero Beach, Florida · CCN 106075
26 findings across 6 inspections, in the inspector's own words, 8 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 July 9, 2025
13 findingsBased on observations, interviews, record reviews, policy review, and review of professional standards of practice, the facility failed to prepare foods in a form to meet the individual needs for 4 of 5 sampled residents, Resident #37, Resident #10, Resident #15, and Resident #21, reviewed for nutritional concerns. This had the potential to affect 18 current residents who were on mechanically altered diets at the time of the survey.On 06/24/25 it was determined the facility failed to follow a physician ordered diet, that was mechanically altered, for Resident #37, a resident with diagnoses of dysphagia (difficulty swallowing), to prevent the likelihood of choking, aspiration (the accidental sucking in of food particles or fluids into the lungs), and or death. Resident #37, who was ordered to have a mechanically altered diet, was provided with a whole hot dog that she consumed.The likelihood of Resident #37 choking on the hot dog with the potential of aspiration or death was determined. The Administrator was informed of the Immediate Jeopardy on 06/27/25 at 10:22 AM.The Immediate Jeopardy was identified on 06/24/25, and was removed on 06/27/25. The scope and severity were decreased to a D, no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy for F689 and F805. The scope and severity were lowered as a result of the facility's corrective actions implemented as of 06/27/25 and verified by interview, observation and record review on 06/27/25. Although, the facility implemented corrective actions to remove the immediacy of the deficient practice, the potential for harm remains without the implementation of a plan of correction and monitoring of the corrective actions.Cross Reference - F689.The findings included:A review of the facility's Policy titled, Nutritional Management last revised 04/27/22, documented examples of interventions for nutrition that were to be individualized to address the specific needs of each resident. One example that was listed was the mechanically altered-consistency diet that may be prescribed for a resident diagnosed with dysphagia or with chewing difficulties.The National Dysphagia Diet Task Force (2002) created the National Dysphagia Diet: Standardization for Optimal Care. It described the Level 2: Dysphagia Mechanically Altered (Dysphagia Ground) diet as foods that are moist, soft-textured, and easily formed into a bolus. Meats are ground or are minced no larger than one-quarter-inch pieces. They are still moist, with some cohesion. Hot dogs, peanut butter, potato chips, dry, coarse cakes and cookies, and bread that has not been pureed, gelled, or slurried to a moist texture, were listed as foods to avoid on the Dysphagia Ground diet.The Level 1: Dysphagia Pureed diet was described as pureed, homogenous, and cohesive foods. Foods should have a pudding-like texture.A review of information on the Mechanical Soft Diet (used by the University of Wisconsin-[NAME] integrated health system) and provided as a reference by the Corporate Certified Dietary Manager documented the Mechanical Soft diet was designed for people who had trouble chewing and swallowing. It included chopped, ground, and pureed foods, as well as foods that broke apart without a knife, (like fish). It specified that sausage, [NAME] (hot dogs), peanut butter, and chips were foods to avoid on the mechanical soft diet. 1) Record review revealed Resident #37 was admitted to the facility on [DATE]. Her diagnoses included Cerebral Infarction due to Embolism of the Left Carotid Artery (lack of blood flow to the brain caused by a blood clot), Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness on one side of the body) Following Cerebral Infarction Affecting the Right Dominant Side, Aphasia (impaired ability to speak) Following Cerebral Infarction, Dysphagia (swallowing difficulty) Following Cerebral Infarction, and Muscle Weakness. Per the Minimum Data Set (MDS) assessment dated [DATE], this resident's BIMS score equaled 5, which indicated that Resident #37 had severe cognitive impairment. At the time of admission, Resident #37 received no foods or liquids by mouth. She was dependent on tube feeding for total nutrition. She started eating by mouth and was served meals from the kitchen as of 02/01/22.A record review of Resident #37's care plan, last revised on 02/13/25, revealed that Resident #37 was at risk for malnutrition because of her medical history which included Dysphagia, Aphasia, Anxiety, and a Cerebrovascular Accident (stroke). Since 12/02/22, the interventions listed in the care plan included providing the diet as ordered, and monitoring for signs and symptoms of aspiration such as coughing, choking, pocketing of foods, spitting out food, wet vocal quality, and wet lungs. If symptoms of aspiration or choking were found, the physician and the Speech Language Pathologist were to be notified.Record review revealed the physician ordered diet for Resident #37, dated 06/01/25, was for a regular diet, with mechanical soft texture foods, and thin consistency fluids. The diet listed in the Meal Tracker (meal ticket software program) was Regular - Mechanical Altered/Ground. The diets in the electronic medical record (mechanical soft), and the meal ticket software program (ground), were both mechanically altered diets that were used for residents with swallowing difficulties. The two diets were not identical. Photographic evidence of the meal ticket was obtained.During an observation of Resident #37's dinner meal, on 06/24/25 at 5:26 PM, Resident #37 refused her meal. The meal ticket on her tray specified that she was on a Regular-Mechanical Altered/Ground diet. Staff A, Certified Nursing Assistant (CNA), offered the resident several food options including grilled cheese, a peanut butter and jelly sandwich, and an egg salad sandwich. Resident #37 communicated that she didn't want any of those alternatives. Staff A mentioned she would look at the menu to see what other alternatives were available. Staff A saw that a hot dog was listed on the menu as an available option, and asked Resident #37 if she wanted a hot dog. Resident #37 said yes. During an interview on 06/24/25 at 5:38 PM, while in the hallway in front of the dining room, Staff A, CNA, stated she had given Resident #37 a hot dog and she ate it. Upon immediate return to the resident's room, Resident #37 held a quarter of the hot dog bun while still seated in her bed. The hot dog was not visible.During an interview on 06/24/25 at 5:42 PM, when asked if the hot dog she provided was whole or cut-up into small pieces, Staff A stated she served Resident #37 a whole hot dog that was not cut-up. When asked if the kitchen staff knew it was for Resident #37, Staff A said that she told the kitchen it was for Resident #37. Staff A confirmed that Resident #37 ate 100% of the hot dog. During an interview on 06/24/25 at 5:52 PM, the Certified Dietary Manager (CDM) stated that she didn't know who the hot dog was for. She said Resident #37 wouldn't be given a whole (intact) hot dog because of her diet; it would be mechanically ground. The CDM stated that the kitchen staff would have been able to grind it for her. The surveyor asked to see the food processor that was used for grinding up foods, and the CDM showed the surveyor a clean food processor. The surveyor asked the CDM if the kitchen staff prepared any ground hot dogs on 06/24/25, and the CDM said that they did not. She explained that no one on a ground diet ordered a hot dog that day. The menu for the dinner meal on 06/24/25 was reviewed. It included a Ground Hot Dog (no bun) as an alternate entrée for residents on the mechanical altered/ground diet.During an observation on 06/24/25 at 4:45 PM, Resident #37 pointed to the picture of the place setting (plate with fork, spoon, and knife), with the word Hungry above the picture on her communication board. Photographic Evidence Obtained. During an interview with a Staff B, CNA, on 06/24/25 at 4:45 PM, when asked what she thought Resident #37 meant when she pointed to that picture, Staff B said that either she was hungry, or she didn't like her food. Staff B said Resident #37 wanted to know when dinner was ready. She said she offered Resident #37 a peanut butter and jelly sandwich that she didn't want it. When asked if snacks were available, Staff B identified a snack basket that was kept at the nurse's station. It contained graham crackers, Goldfish crackers, and soft/pliable chocolate cookies. Staff B said that she normally took the snack basket to Resident #37 and let her choose a snack from the basket. She also said that normally she gave Resident #37 potato chips. When asked how frequently she gave the resident potato chips, Staff B said that in the past 3 weeks she provided Resident #37 with potato chips two times. The CNA brought the basket of snacks to the resident. The Resident picked a bag of Goldfish crackers from the basket. The surveyor asked Staff B why Resident #37 was on a soft foods diet, and Staff B responded, I don't know, her meal ticket says regular. Then she said that Resident #37 had no problem swallowing foods and that she ate Goldfish crackers with ease. She also reported that in the past Resident #37 was also served hamburgers and fries.An observation on 06/25/25 at 8:49 AM revealed that Resident #37's meal tray had been removed from her room and placed into the meal cart. Staff C, CNA was asked to identify Resident #37's meal tray. The CNA located the tray and the resident's breakfast meal ticket. The tray was placed back onto the resident's tray table. Resident #37's tray was observed to have, a large plate with a crumpled up light-yellow biscuit that appeared to be dry. The plate and the muffin were garnished with parsley flakes. There was no sausage gravy as listed on the menu; there was no moisture providing sauce or syrup on it. During an interview on 06/25/25 at 9:52 AM, the CDM explained that sandwiches were not allowed on Resident #37's diet.An interview was conducted with the Speech Language Pathologist (SLP, expert on swallowing disorders) on 06/25/25 at 5:34 PM. When asked if the diets in the electronic medical record and the diets on the meal tickets were supposed to be identical, the SLP answered, yes. She said they should be the same. When the SLP was told that Resident #37's diet on the meal ticket documented she was on a Regular - Mechanical Altered/Ground diet, the SLP confirmed that was the diet she wanted for Resident #37. The physician's diet order in the electronic medical record was documented as Regular diet, Mechanical Soft texture, Thin consistency.During the continued interview on 06/25/25 at 5:34 PM with the SLP about the possible consequences of non-compliance with the diet texture, the SLP said that the big concerns were aspiration and choking. She explained that both Aspiration Pneumonia and choking could be fatal. When asked about Resident #37's request for a hot dog, the SLP said that it should have been ground. The SLP said that on her diet she can have soft sandwiches. When the SLP was asked about the potato chip and Goldfish crackers items, she said that hard and crunchy foods can be problematic. She said that potato chips and Goldfish crackers can be difficult to swallow because they are dry.During an interview with the SLP on 06/26/25 at 2:21 PM, when asked what the difference was between a mechanical soft and a mechanically altered ground diet, the SLP said that it depends on the specific facility and their dietary policy. She added that in her experience the mechanical soft diet also warranted ground meats. The SLP stated that having the word Regular in the diet can be confusing and easy to misinterpret. She explained that the term Regular diet meant that he was not on a therapeutic diet like a Renal diet, or a diet for hypertension or diabetes.During the continued interview with the SLP on 06/26/25 at 2:21 PM, the SLP revealed a Speech Therapy treatment encounter note dated 03/01/2022 that listed the resident's response to treatment. She stated Resident #37 was on Speech Therapy from 01/04/22 through 03/02/22. The treatment encounter note documented the SLP's recommendation was for Current Foods/Solids to be Minced + Moist Foods MM5. This terminology was documented under a note that clarified the diet as per The International Dysphagia Diet Standardization Initiative 2016. The SLP said that Resident #37 had been on a mechanical soft diet for a long time. She equated the Mechanical Soft Ground diet with the Minced and Moist diet.2) Record review revealed Resident #10 was admitted to the facility on [DATE]. Her diagnoses included Barrett's esophagus without dysplasia (changes to the lining of the esophagus without precancerous changes to the cells), Encounter for Attention to Gastrostomy (feeding tube), Moderate Protein Calorie Malnutrition, Muscle Wasting and Atrophy, and Muscle Weakness. Her diet orders since 06/10/25 included provision of 4 cartons (237 milliliters each) of Osmolite 1.5 Cal (calorie) tube feeding daily, and a regular diet, with puree texture foods, and thin consistency fluids.A record review revealed Resident #10's Brief Interview for Mental Status (BIMS) score, per the Minimum Data Set (MDS) admissions assessment dated [DATE], was 15. This indicated that she was cognitively intact. The assessment also documented that she had swallowing problems within the 7-day lookback period prior to this assessment. The care area for nutrition noted that the doctor's order for the mechanically altered diet was related to swallowing problems.A record review of Resident #10's care plan dated 06/12/25 focused on the resident's risk for malnutrition. One of the interventions listed by the Registered Dietitian was to provide the diet as ordered.During an observation on 06/23/25 at 11:55 AM, Resident #10 was provided and ate her soup, while sitting at a table in the dining room. The soup had whole grains of white rice, and whole intact yellow kernels of corn in a light-yellow broth. This was the same soup that was served to residents who were on regular diets with no dietary restrictions. There were no meal tickets on the tables for any of the residents seated in the dining room at that time. During an observation of breakfast served to the residents in the Dining Room, on 06/25/25 at 8:29 AM, it was noted that the resident received portions of pureed sausage with gravy and a pureed biscuit on a plate. It was noted that there was a garnish on the plate that appeared to be chopped parsley. 3) A record review revealed that Resident #15 was admitted to the facility on [DATE]. His medical history included Moderate Protein-Calorie Malnutrition, Gastro-Esophageal Reflux Disease with Esophagitis (Inflammation of the Esophagus), Acute Respiratory Failure with Hypoxia (a lack or lowered amount of oxygen), and Metabolic Encephalopathy (metabolic derangements that affect brain function). Per the Minimum Data Set assessment dated [DATE], this resident's BIMS score equaled 3, which indicated he had severe cognitive impairment. The care plan initiated by the Registered Dietitian on 05/08/25 focused on Resident #15's risk for altered nutrition. A listed intervention was to provide the diet as ordered.A record review of Resident #15's diet order revealed that since 05/22/25, he was on a regular diet, with puree texture foods, and thin consistency fluids. The term Regular diet meant that he was not on a therapeutic diet like a Renal diet, or a diet for hypertension or diabetes.During an observation of lunch on 06/23/25, Resident #15 was served pureed breaded shrimp, pureed cabbage, pureed carrots, and mashed potatoes. The pureed shrimp and the pureed carrots were lumpy. There were distinct pieces of breaded shrimp and carrots visible. The scoops of food were not homogenous, pudding like textures. Photographic Evidence Obtained.During an observation in the kitchen on 06/25/25 at approximately 11:55 PM, the pureed baked ham with glazed honey was lumpy. An interview was conducted on 06/25/25 at 12:00 PM with Staff D, a cook. When asked how she knew how long to puree the foods, she answered that foods were pureed until they were smooth, and until they had no chunks and no separate particles at all. Concern for the lumpy appearance of the pureed foods was voiced to the CDM, and a trial plate of the lunch meal was requested. The CDM lifted a spoonful of the pureed baked ham with glazed honey, and it had small lumps of meat surrounded by a thinner substance. Two different textures were observed. Photographic Evidence Obtained. The CDM tasted the pureed ham and said it could have been smoother. A taste of the pureed ham revealed it contained small separate particles of ham.During an interview with the Staff D, cook, on 06/25/25 at 12:15 PM, she said that this morning the pureed ham was really smooth, and most likely when it was warmed up it got lumpy. 4). Resident #21 was admitted to the facility on [DATE]. According to the resident's most recent full assessment, an Annual MDS, with a reference date of 06/15/25, Resident #21 had a BIMS score of 12, indicating the resident was cognitively intact. Resident #21's diagnoses at the time of the assessment included: Anemia, Malnutrition, COPD, Dysphagia. Resident #21's diet orders included: Regular diet, Pureed texture, Nectar consistency - 06/13/25During an observation of breakfast served to the residents in the Dining Room, on 06/24/25 at 8:24 AM, Resident #21 was served pureed French toast and pureed sausage. It was noted that there was a garnish sprinkled about the plate and on the foods that appeared to be chopped parsley. The facility's Immediate Jeopardy removal plan dated 06/27/25 included the following, which was also verified:On 06/24/25 Resident #37 was immediately assessed. A speech referral was submitted to assess diet appropriateness. A chest x-ray was ordered to rule out aspiration. Respiratory assessments were initiated every shift for 72 hours for signs and symptoms of aspiration. The resident's diet order, care plan, and Kardex were reviewed and updated as indicated for accuracy. The physician and responsible party were notified. On 06/25/25 the speech evaluation was ordered for Resident #37.On 06/26/25 a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) bedside study was ordered.On 06/24/25 the CNA and dietary employee involved were removed from the floor and received one-on-one education by the Staff Development Coordinator and Dietary Manager on verifying diet slips with current orders, appropriate food textures for mechanical soft diets, how to address concerns regarding tray accuracy, possible consequences of serving inappropriate diets, and ensuring proper supervision of residents who require it during meals.On 06/25/25 the facility reviewed residents with mechanically altered diets to ensure current orders matched tray ticket diets. There were 18 current residents who were on mechanically altered diets at the time of the survey.On 06/24/25 through 06/26/25 current nursing and dietary staff were educated on verifying diet orders with current physician orders and consequences of serving inappropriate diets, to include regular meals, alternate options and snacks. Newly hired staff will receive education on these matters. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.On 06/27/25 the information in the facility's removal plan was verified. Observations of the lunch and dinner meals on 06/27/25 demonstrated a process to ensure physician ordered diets were being delivered to residents. A new diet communication manual was placed in the main dining room and on each tray cart. On 06/27/25 six staff, including Staff B, the CNA, who provided Resident #37 with potato chips and permitted the resident to choose Goldfish crackers, were interviewed. Each staff member was able to verbalize the training provided during the week. They verbalized what needed to be done before providing an alternate food item or snack to a resident, and the new process for meal tray delivery.On 06/24/25 Resident #37 was immediately assessed by her assigned nurse. A speech referral was submitted to assess diet appropriateness. A chest x-ray was ordered to rule out aspiration and was refused by the resident. Respiratory assessments were initiated and documented every shift for 72 hours for signs and symptoms of aspiration. The resident's diet order, care plan, and Kardex were reviewed and updated as indicated for accuracy. The physician and responsible party were notified. On 06/24/25 Staff L, dietary cook and Staff A, CNA, were provided the one-on-one education.On 06/25/25 the speech evaluation was completed for Resident #37.On 06/25/25 an audit was completed confirming the meal textures in Meal Tracker (the dietary software used to print meal tickets) matched the physician's order for all current residents.By 06/26/25 a total of 79 nursing and dietary staff, to encompass 100%, received the above-mentioned education.On 06/26/25 a FEES (Fiberoptic Endoscopic Evaluation of Swallowing) bedside study was conducted. The recommendations from this study were to advance the resident diet to a mechanically soft chopped diet.An Ad Hoc/Quality Assurance Performance Improvement (QAPI) meeting was held on 06/25/25 with the Medical Director, the Administrator, the Director of Nursing, the Staff Development Coordinator, and the Dietary Manager. Supervision during meal consumption was discussed. A plan for continued monitoring and sustained compliance was reviewed. An additional Ad Hoc/QAPI meeting was held on 06/26/25 to evaluate the effectiveness of the education.The facility's Immediate Jeopardy was removed on 06/27/25 at 6:50 PM.
Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses. This had the potential to affect 63 out of 66 residents who consume foods PO (by mouth).The findings included:During the initial tour of the Main Kitchen on 06/23/25 at 9:15 AM, accompanied by the CDM (Certified Dietary Manager) and the RD (Registered Dietician), the following was observed:1. The gaskets on the door of the reach in cooler had dark brown/black streaks and spots on the rubber pleats. The bottom of the gasket attached to the door was torn. Pieces of the rubberized material that were still attached to the door hung downward. The CDM agreed with this finding. Photographic Evidence Obtained.2. A bag of pasta was observed on the floor behind the lowest shelf in the dry food storage area. A large dark brown/black colored insect was dead and lying on floor in the same area. Another large dark brown/black colored insect was dead and lying on the floor under the area where the cookies were stored. There was a yellow packet of a condiment (mayonnaise or mustard) on the floor next to it. The CDM agreed with these findings and proceeded to sweep the floor. Photographic Evidence Obtained.3. The muffin pans were ladened with brown residue. The CDM agreed with this finding. Photographic Evidence Obtained.4. The storage rack for clean serving scoops and baking sheets had yellow/brown, and brown/black residue on the individual shelves. The baking sheets had dark black and yellow/brown residue on them. The CDM agreed with this finding. Photographic Evidence Obtained.5. The wash cycle temperature of the low-temp dishwasher reached 100' F. It did not reach the required temperature of 120' F. The CDM agreed with this finding. TheCDM immediately told the Maintenance Director. During an interview with the Maintenance Director at approximately 10:00 AM, he said that he raised the temperature on the hot water heater to fix the problem.6. The Vulcan fryer contained residue from food. It was not clean. When asked if it was used during breakfast, the CDM said no. When asked how often it was used, she said once per week. When asked how often it was cleaned, the CDM said that it would be cleaned that day after it was used for frying food. Photographic Evidence Obtained.
Based on observation, and interview, the facility failed to ensure the proper storage of linens in 3 of 3 linen carts.The findings included:On 06/25/2025, it was revealed the facility had four residents under transmission-based precautions due to various health concerns, including positive COVID-19 status, Methicillin-resistant Staphylococcus aureus (MRSA), which is a type of staph bacteria resistant to many commonly used antibiotics, Extended-spectrum beta-lactamase (ESBL) production, which refers to enzymes that make certain bacteria resistant to many beta-lactam antibiotics, and Shingles.On 06/25/2025 at 11:09 AM, an observation revealed that the linen cart in the [NAME] Wing was torn and opened, exposing the linens inside. Additionally, a glove was found on the floor next to the linen cart. At 11:28 AM, the surveyor noted that the linen cart in the East Wing was not fully uncovered, exposing the linens to potential contamination. Similarly, at 11:33 AM, it was observed that the linen cart in the North Unit was also not fully covered, making the linens vulnerable to contaminants. Later, at 4:41 PM, the surveyor conducted another tour of the areas of concern, accompanied by the Infection Preventionist (IP). The IP acknowledged that the linen carts were torn and uncovered, which posed a risk of exposing the linens to contaminants.
Based on record review and interview, the facility failed to provide care and services in a manner to maintain residents' dignity for 2 of 20 sampled residents, reviewed for dignity (Resident #118 and #218).The findings included:1. Record review revealed Resident #118 was admitted to the facility on [DATE]. An assessment completed on 06/19/25 documented a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact.During an interview on 06/23/25 at 1:58 PM, when asked if staff treat her with respect and dignity, Resident #118 stated, When I use the call light to be changed or if I need something, at times it takes over 30 minutes to have it answered, and then sometimes they say I'll have to wait, as they are busy. They are on their own pace, and they'll get to you when they get to you. Some of the staff have a chip on their shoulders. When asked how it makes her feel, Resident #118 stated, Not good. Some of them complain a lot. Most seem stressed out.During an interview on 06/27/25 at 3:04 PM, when told what was said by Resident #118, the Director of Nursing (DON) agreed the resident was not being treated with dignity. 2. Record review revealed Resident #218 was admitted to the facility on [DATE] with diagnoses that included Right Artificial Hip Joint, Left Artificial Hip Joint, Muscle Weakness, Muscle Atrophy, Fracture of Part of Neck of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Anxiety Disorder, and Major Depressive Disorder. According to an assessment of cognition performed on 06/19/25, Resident #218 had a Brief Interview for Mental Status (BIMS) score of 15. This indicated that he was cognitively intact.A review of Resident #218's care plan dated 06/17/25, documented the resident had the potential for pain related to the surgical procedure, a Total Hip Arthroplasty (THA, damaged hip joint was replaced), which was performed in the hospital prior to admission. Interventions included encouraging the resident to inform staff if experiencing pain. Another care plan dated 06/17/25, focused on Resident #218's ability for activities of daily living (ADLs). It documented that Resident #218 had an ADL self-care performance deficit related to the Right THA, weakness, impaired balance and mobility, and fall risk. The resident had a fall history that resulted in a fracture. An intervention was to keep frequently used items within reach.During an interview on 06/24/25 at 9:18 AM, Resident #218, shared two descriptions of events that occurred when he felt disrespected. First, he explained that when CNA's (Certified Nursing Assistants) entered his room, they failed to offer the resident assistance with tasks. He said that while a CNA leaned against the wall near the vanity area across from his bed, she watched him as he leaned over the edge of the bed and reached to pick something up from the floor that he dropped. The CNA didn't offer to help him. Another time Resident #218 felt disrespected was when he felt manhandled during the provision of care to receive ADL care. He explained that he told the CNA's that he could roll over slowly if he was given the time. He added that if he wasn't fast enough the CNA's grabbed onto his right hip area where he had the surgery and that hurt. When asked if he told the CNA's that he was in pain, Resident #218 said that he told them, and they still kept pushing. He said that the CNA's facial expressions didn't change. It was as if they weren't listening. Resident #218 said that this occurred two times.During an interview with the DON on 06/27/25 at 2:53 PM, the DON said that she knew Resident #218 wanted to be discharged . The DON said she was not aware about Resident #218's complaints about not being treated with dignity. When asked how CNAs were made aware that a resident recently had surgery, the DON explained that one function of the Resident's primary nurse was to tell the CNAs about special instructions for the resident. The DON also said that the CNAs should be handling the residents gently if they had surgery or not. The DON added that it was one thing to teach nurses and to provide them with education, but she couldn't give them compassion. She said that nursing 101 was to go into the room, to introduce yourself, and to be polite and to offer your services.
Based on observations, record reviews, and interviews, the facility failed to maintain the call bell within the reach of 2 of 20 sampled residents, reviewed for accommodation of needs (Resident #2 and Resident #40).The findings included:1.Record review revealed Resident #2 was admitted to the facility on [DATE]. Her diagnoses included Non-Alzheimer's Dementia, Anxiety disorder, Depression, Muscle weakness, and Overactive Bladder. This resident's Brief Interview for Mental Status (BIMS) score, per the Minimum Data Set (MDS) assessment dated [DATE] was 08, indicating she was cognitively impaired. The assessment indicated Resident #2 was dependent on assistance for most activities of daily living (ADL), which included toileting, hygiene, bed mobility, and transfers. Review of Resident #2's care plan for ADL self-care performance deficit, dated 08/13/20, was related to impaired balance and mobility, weakness, limited range of movement, cognitive loss, and history of Polio Disease. The care plan listed an intervention, initiated 08/13/20, to encourage the resident to use the bell to call for assistance.Record review of Resident #2's care plan for falls, dated 05/08/24 listed an intervention to maintain the resident's call light within reach, and to respond promptly to all requests for assistance. The interventions included that Resident #2 needed a safe environment with a reachable call light.During an interview with Resident #2 on 06/23/25 at 4:39 PM, when asked if she knew where her call bell was, she was unable to find it. Observation revealed it was located on the upper area of the bed, approximately ten inches above her right shoulder. The cord that the call bell was attached to was neatly wrapped into circles. The circular coiled cord and the call bell were located on the bed, approximately ten inches above the resident's right shoulder. It was not within reach of Resident #2. When the resident was asked if she knew what the call bell was used for, she answered yes, it's to call someone if I need help. Resident #2 said thank you and added that she really needed to have the call bell within reach, and that she has needed help the past couple of days. Resident #2 placed the call bell on the blanket in her lap and said she would leave it right there.During an observation on 06/25/25 at approximately 7:05 PM, Staff M entered Resident #2's room. Staff M looked around and then exited the room. Further observation on 06/25/25 at 7:11 PM revealed Resident #2's call bell was located on the floor. (Photographic Evidence Obtained).During an interview with Staff M on 06/25/25 at approximately 7:20 PM, Staff M was asked what she did when she entered Resident #2's room at 7:05 PM. Staff M said that she wanted to make sure the resident was comfortable, had water, and that the garbage can was clean. When asked if she thought it was important for the call bell to be within reach of the resident, she said it was important for the call bell to be close to the resident in case she needed to go to the bathroom, or if she needed care, or for anything at all. Staff M then saw that the call bell was on the floor, she picked it up and placed it in the resident's lap.2. Record review revealed Resident #40 was admitted to the facility on [DATE]. Her diagnoses included Renal Insufficiency, Diabetes Mellitus, Hemiplegia following Cerebral Infarction (paralysis on one side of the body following stroke), Muscle Weakness, and Insomnia. Per the Minimum Data Set (MDS) quarterly assessment dated [DATE], Resident #40's Brief Interview for Mental Status (BIMS) score equaled 8, which indicated she was cognitively impaired. The assessment documented that she required substantial, maximal assistance for transfers, and that she was always incontinent.Record review of Resident #40's care plan for falls, last revised on 02/12/25, included an intervention to ensure the call light was within reach. The staff was to encourage the resident to use the call light when she needed assistance with standing, transferring and ambulating. Another intervention documented the need for Resident #40 to have a working and reachable call light.During an interview on 06/23/25 at 5:50 PM, Resident #40 requested assistance with adjusting the bedding for her comfort. When asked if she could press her call bell for assistance, she said she didn't know where her call bell was. The call bell was observed dangling between the mattress and the floor. Resident #40 was handed the call bell, and she pressed the button. (Photographic Evidence Obtained)During an interview with Resident #40, while she was in bed on 06/25/25 at 11:37 AM, when asked if she knew where her call bell was, she said no. She added that it would be a good idea if she knew where it was. The call bell was located on the floor behind the bed, and close to the wall (Photographic Evidence Obtained).
Based on observations, interviews and record reviews, the facility failed to promptly address grievances voiced for 2 of 20 sampled residents (Resident #10 and Resident #7). The findings included: An interview was conducted on 06/23/25 at 12:47 PM, with Resident #7, who was admitted to the facility on [DATE], and with a Brief Interview for Mental Status (BIMS) of 15, according to a Quarterly Minimum Data Set (MDS) with a reference date of 05/17/25, indicating that the resident was cognitively intact. When asked of any concerns voiced by the Resident Council, Resident #7 replied, I made recommendations during the meetings when I wasn't president, I suggested that they do something with the patio and the grass, and they still haven't done anything about that. Resident #7 stated that the concern was voiced about 5 months ago, they wrote it down and that was it. I go out on the patio once in a blue moon. They just need a few more plants and some more mulch, like they do the rest of the grounds. During the Resident Council meeting on 06/24/25 at 4:15 PM, with active members of the Resident Council, when asked about the outside patio, Resident #7 reiterated concerns regarding the patio. After reiterating the concern, Resident #10, with a BIMS score of 15, according to an Admission/Medicare 5-day MDS, with a reference date of 06/13/25, agreed with the statements echoed by Resident #7. During a follow up interview, on 06/26/25 at 3:30 PM, Resident #7 repeated that the Resident Council mentioned that the back patio needs some mulch and some plants or something, when I look out my room window, the landscaping is really nice (referring to the front of the facility facing the street), when we use the patio, it is just not as appealing and is mostly rocks and dirt. Resident #7 further stated that the concern was mentioned during Resident Council in April. (There was no documentation of the concern being voiced during the Resident Council meeting from the 04/30/25 in the meeting minutes). During an interview on 06/26/25 at approximately 3:45 PM, Resident #10, who was admitted to the facility on admitted [DATE], stated, The plants are too old, and they don't take care of the outside like they used to. They don't do anything with the fallen debris on the walkways and sometimes I am afraid to fall when I get up when I am out there. Resident #10 stated that she uses the patio, Three times a week when I am in therapy. During an observation on 06/25/25, at approximately 4:00 PM, while it was raining, the roof over the screened patio was noted to have several leaks. During an interview, on 06/26/25 at 4:07 PM, with the Activities Director, when asked about the concerns regarding the patio and courtyard area that was voiced during the Resident Council meeting, the Activities Director replied, they have not mentioned it since the March 2025 meeting, because it would have been documented in the minutes and a follow up sheet would have been provided to Administration and the Administrator would have to follow through with it. We have landscaping company come in at least weekly. During a tour of the actual patio and the area around the patio, the Activities Director acknowledged that the patio was not maintained as the rest of the grounds, as described by the Resident Council. During an interview, on 06/27/25 at 8:02 AM, with Staff M, Occupational Therapist (OTA), when asked about residents voicing concerns with the patio and courtyard area, the OTA stated that residents had stated that the patio and courtyard needs some work and could use some color. During a tour of the outside patio and courtyard area, on 06/27/25 at 1:09 PM, entering from the therapy gym, it was noted that there were areas of dirt and rocks with minimal vegetation and litter, including milk cartons, used masks in the corner of the patio by the dumpster area. Trees and shrubbery were growing out of the overhanging awning of the screened in patio. There was also a planter that was more than half full of garbage that was not being used as a planter. During a tour of the outside patio and courtyard area, on 06/27/25 at 1:18 PM, accompanied by the Maintenance Director, the Maintenance Director acknowledged the container that was more than half full of garbage and stated that it was not supposed to be used for trash and that it was a planter for small trees or shrubbery.
Based on interviews and record reviews, the facility failed to respond to requests for resident's records in a timely manner for 1 of 2 sampled residents reviewed for records requests (Resident #69). The findings included: Resident #69 was admitted to the facility on [DATE] and discharged [DATE]. According to the resident's most recent full assessment, an Admission/Medicare 5-Day Minimum Data Set, with a reference date of 01/30/25, Resident #69 had a Brief Interview for Mental Status (BIMS) score of 03, indicating a severe cognitive impairment. Resident #69's diagnoses at the time of the assessment included: Non-Alzheimer's Dementia, Anxiety Disorder and Depression. During an interview, on 06/24/25 at 12:31 PM, with Resident 69's family member, it was reported that there had been no response from the facility to the family's request for Resident #69's medical records. The family member stated, My [.] tried to contact them several times to talk to the Business Office Manager (BOM), to get a copy of the contract. We don't believe that none of the [family members] have a copy of the admission contract and there has been no effort by the facility to provide one. At the time that he was transferred to the facility from the hospital, he was delirious and should not have signed on his own behalf. We would like to get a copy of the contract for the resident's stay. This would tell us whether there is any language about their responsibility for a resident's belongings. None of the [family members] nor the resident recall signing a contract, none have a copy, and Garden View refuses to provide it to us. We'd really like to get a copy of that contract if it exists. Review of the resident's record revealed that one of Resident #69's [family member] were designated as Power of Attorney and two of Resident #69's [family members] were designated as Health Care Surrogates. During an interview, on 06/27/25 at 12:05 PM, with Medical Records Clerk, when asked about requests for a resident's medical records, the Medical Records Clerk replied, I have them fill out a medical records release form and then I scan it into my computer and then depending on what it is for, I send it to Corporate for approval. At the conclusion of the interview, the Medical Records provided documentation of [a family member] signing admission paperwork for initial admission on [DATE] and another of the resident's daughter signing admissions documentation for readmission [DATE]. There was no documentation of any requests for copies of resident's health records and/or admission packet. During an interview, on 06/27/25 at 2:58 PM, with the BOM, when asked about Resident #69's [family member's] request for the resident's medical records, the BOM replied, I emailed it to the Social Services Director (SSD), the Assistant Director of Nursing (ADON), Staff H, LPN/Unit Manager, the Director of Nursing (DON), and the Administrator). Anytime that I receive a request for records, I send it to the Medical Records Clerk, this was a contract. I don't know what happened to the request after that. I met the [family members] when they came in. The resident's [family member] was here and one of the sisters brought me his insurance cards (one designated as Health Care Surrogate and POA), she handled most of the decision making and financials. They tag teamed very well. During an interview, on 06/27/25 at 4:14 PM, with the Administrator, the DON and the ADON, the Administrator stated that there were no requests by Resident #69's family for records. The Administrator stated, if they are not POA or HCS, we can't send them anything. During a follow up interview, on 06/27/25 at 5:02 PM, The BOM stated that she realized she forwarded the request to the wrong staff. The Surveyor reviewed the chain of emails with the BOM. The chain was as follows: 06/02/25 at 9:46 AM, the BOM received a request from Resident #69's POA/HCS requesting a copy of a contract for Resident #69. On 06/13/25 at 2:33 PM, The BOM received a follow up request from Resident #69's POA/HCS. On 06/16/25 at 8:15 AM, The BOM received a follow up request from Resident #69's POA/HCS. The BOM stated, I realized today (06/27/25) that I forwarded the request to the wrong people. when asked about responding to Resident #69's emails, the BOM did not provide a rationale for not responding to the emails.
Based on record review and interview, the facility failed to ensure behavior monitoring for 1 of 4 sampled residents, Resident #119, reviewed for unnecessary psychotropic medications. The findings included: Review of the record revealed Resident #119 was admitted to the facility on [DATE]. Review of the current physician orders included the administration of Seroquel and Oxcarbazepine, both twice daily for mood. The medication Seroquel had a classification of an antipsychotic drug. Psychiatric progress notes dated 06/16/25 and 06/23/25 documented, in part, monitoring for agitation, aggression, combativeness, refusal of care, refusal of medications, along with numerous symptoms of Depression. Review of the record lacked any type of behavior monitoring by staff for Resident #119. During an interview on 06/25/25 at 7:43 PM, when asked the process for staff to monitor and document resident behaviors, the Director of Nursing (DON) stated the nurses should document any behaviors on the behavior monitoring forms in the electronic medical record. During a side-by-side review of the record, the DON confirmed the lack of behavior monitoring.
Based on record reviews, interviews, and a review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI), the facility failed to accurately complete Minimum Data Set (MDS) assessments for 3 of 5 sampled residents, reviewed for nutrition (Resident #15, Resident #23 and Resident #37).The findings included:The CMS RAI was reviewed, which provides guidelines for assessing the needs of residents in long-term care facilities. It helps staff gather information about residents' needs in order to create individualized care plans. The RAI manual specifies that weight entries should be based on the most recent weight within the past 30 days of the Assessment Reference Date (ARD) date of the assessment. If the resident's last recorded weight was taken more than 30 days prior to the ARD date of the assessment, then the facility should weigh the resident again. If a resident cannot be weighed, the directions specify to use the standard no information code (-), and to document the rationale on the resident's medical record. The ARD date specifies the endpoint of observations to be entered into the assessment.1. Record review revealed Resident #15 was admitted to the facility on [DATE]. His diagnoses included Depressive Disorder, Malnutrition, Dementia, Gastro-Esophageal Reflux Disease with Esophagitis (stomach acid flows back into the esophagus causing inflammation to the esophageal lining), and Metabolic Encephalopathy (metabolic derangements that affect brain function). The MDS assessment with an ARD date of 05/08/25 documented that his weight was 153 pounds. According to the electronic medical record, the weight of 153 pounds was taken on 05/01/25. The most recent weight within the 30 days of the ARD date that should have been entered was 149 pounds, as documented as Resident #15's recorded weight on 05/08/25 of 149 pounds.During an interview on 06/27/25 at 7:32 PM, Staff F, the MDS Coordinator, agreed with the findings. She confirmed that the weight of 153 pounds was taken on 05/01/25, and the weight of 149 pounds reflected the correct weight that should have been entered.2. Record review revealed Resident #23 was admitted to the facility on [DATE]. His diagnoses included Cerebral Infarction, Hemiplegia and Hemiparesis affecting Left Dominant Hand Contracture, Dementia, and Depressive Disorder. The MDS assessment with an ARD date of 12/17/24 documented Resident #23's weight was 157 pounds. According to the electronic medical record (EMR), Resident #23's weight on 11/7/24 was 157 pounds. The weight that was entered reflected this resident's weight 41 days prior to the ARD date. There were no weights documented in the EMR between the dates 11/07/24 and 03/11/25. The documentation that should have been entered was (-), the standard code for no information.During an interview on 06/27/25 at 5:04 PM with Staff F, MDS Coordinator, the weight entry for Resident #23 on the assessment dated [DATE] was confirmed. Staff F confirmed the finding that the entered weight was not taken within the past 30 days.3. Record review revealed Resident #37 was admitted to the facility on [DATE]. The Minimum Data Set assessment with an ARD date 12/11/25 documented Resident #37's weight was 169 lbs. According to the EMR, the weight of 169 lbs. was taken on 02/13/25. This weight was not obtained within 30 days prior to the ARD date.During an interview on 06/27/25 at 6:20 PM with Staff F, MDS coordinator, the weight entry was confirmed. Staff F confirmed that this weight did not represent a weight taken within the past 30 days.
Based on policy review, observation, interview, and record review, the nursing staff failed to follow physician orders for wound care for 1 of 2 sampled residents, observed with pressure ulcers (Resident #119). The findings included: Review of the policy titled, Wound Treatment Management revised on 11/23/22 documented, in part, Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. Review of the record revealed Resident #119 was admitted to the facility on [DATE] with diagnoses to include osteomyelitis (infection of the bone) and stage 4 pressure ulcer (a deep wound with full-thickness tissue loss with exposed bone, tendon, or muscle). The wound care physician progress note dated 06/19/25 documented Resident #119 had two stage 4 pressure ulcers, one to the right buttock and one to the left hip. Review of the wound care progress note dated 06/19/25 documented, in part, to cleanse both wounds with wound cleanser, add a fluffed gauze moistened with Dakin's solution (a diluted bleach solution), and cover with a bordered gauze. Two physician orders dated 06/19/25 documented to cleanse both pressure ulcers with normal saline or wound cleanser, pat dry, apply wet to dry gauze with Dakin's solution 1/4 strength, and secure with bordered gauze, daily. A wound care observation for Resident #119 was made on 06/23/25 at 2:44 PM with Staff J, Licensed Practical Nurse (LPN). During the care, large pressure ulcers were noted to the right buttock and left hip. The LPN provided wound care to the right buttock first by cleansing the wound bed with Dakin's-soaked gauze. The LPN cleansed the left hip wound with the Dakin's-soaked gauze as well. During an interview on 06/25/25 at 6:59 PM, the Assistant Director of Nursing (ADON) was made aware of the wound care observation of Resident #119 by Staff J, LPN, and she agreed the wound care order had not been followed.
Based on observations, record reviews, and interviews, the facility failed to provide a resident with restorative therapy per physician's orders for 1 of 2 sampled residents reviewed for Range of Motion (ROM), (Resident #24).The findings included:Record review revealed Resident #24 was admitted to the facility on [DATE]. His medical history included Polyosteoarthritis, Contracture of Muscle Left Lower Leg, Contracture of Muscle Right Lower Leg, Foot Drop Right Foot, Presence of Right Artificial Hip Joint, Short Achilles Tendon (Acquired) Left Ankle, Obesity, Chronic Pain Syndrome, Peripheral Vascular Disease, and Muscle Weakness. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that Resident #24 had a Brief Interview for Mental Status of 15, which indicated that he was cognitively intact. A review of the treatments provided in the MDS assessment dated [DATE] revealed that Resident #24 did not receive any restorative therapy during the 7-day lookback period prior to 04/24/25.Record review of Resident #24's care plan last revised on 12/11/23, documented that he required a restorative nursing program for active range of motion. The goal was to maintain the current level of function, and the interventions included to complete the restorative nursing program as written. A physician's order dated 06/10/24 was for the restorative nursing program for active and passive range of motion of the bilateral lower extremities, recumbent bike, and bilateral lower extremities splint application during daytime as tolerated three to five times per week.During an interview on 06/23/25 at 1:56 PM, Resident #24 said that the therapeutic exercises for his feet wasn't provided consistently. He stated that the restorative nursing program didn't follow the orders given by his doctor. Resident #24 said he should have been provided with the TENS (transcutaneous electrical nerve stimulation) massager daily as his doctor recommended. Resident #24 said that sometimes he received range of motion (ROM) therapy once in ten days, and sometimes he received it four days in a row; and sometimes they missed a week.During an observation on 06/23/25 at 3:58 PM, the box with the TENS massager inside of it was observed on the windowsill in Resident #24's room. Photographic Evidence Obtained. Resident #24 explained that the therapy department ordered the machine after his doctor ordered therapy with the TENS massager. Photographic evidence Obtained.During an interview on 06/25/25 at 9:10 AM, Resident #24 said that no one had used the TENS this week. He stated that the only way to get it done was if he moaned and groaned. He added that he got tired of yelling after a while. Resident #24 complained that half of the time, when the facility didn't have enough help, the restorative person (a certified nursing assistant), was reassigned to the duties of the floor Certified Nursing Assistants (CNAs).During the continued interview on 06/25/25 at 9:10 AM, when asked how not receiving consistent restorative therapy as ordered had affected him, he explained that his feet started to stiffen up when the TENS massager wasn't used. When asked if his feet were stiff at that moment, Resident #24 stated that his feet felt stiff.During an interview with Staff E, a physical therapist, on 06/25/25 at 9:21 AM, he explained that after Resident #24 was discontinued from physical therapy, he trained a few of the nursing staff on how to apply and use the TENS massager correctly.A record review of a treatment encounter signed by Staff E, on 11/15/24, documented that Staff E provided training on the electronic stimulator to the restorative staff. The treatment encounter was titled Therapy Referral to Restorative Nursing Program Form.During an interview on 06/26/25 01:48 PM, the Director of Rehab (DOR) revealed that Resident #24 was on Physical Therapy Services from 08/14/24 through 11/15/24. When asked what the process was for therapy services to be transferred from the therapy department to the restorative program, he said that a set of papers describing the indications for the therapy and the specific directions for the exercises was given to the DON (Director of Nursing) . When asked if there was a specific order in PCC (Point Click Care) that addressed the use of the TENS, or E-Stim, the DOR answered, one got missed.Record review of the Restorative Nursing Services Daily Documentation (RNSDD) Forms for the month of June was conducted. The indication for the restorative services was for Resident #24's increased risk of progression of contractures to right lower extremity. The listed goals on the RNSDD were to maintain the current range of motion, and to protect the resident's skin integrity. Documentation revealed during the second week, from June 8, 2025 through June 14, 2025 , restorative nursing for 15 minutes was provided one time. The restorative program should have been provided three to five times per week according to the doctor's order. During the fourth week, from June 22, 2025 through June 26, 2025, there was no restorative nursing program provided. Photographic Evidence Obtained.During an interview on 06/27/25 at 12:07 PM, the DON was asked to review the (RNSDD) Forms for Resident #24. When asked if she could provide any documentation about the provision of restorative therapy for Resident #24 during the week of June 22, 2025 through June 26, 2025, the DON said she couldn't show any documentation about it because there was no documentation of this activity.
Based on observation, interview, record review, and professional standards, the facility failed to ensure appropriate care and services to prevent an Urinary Tract Infection (UTI) for 2 of 2 sampled residents reviewed with indwelling urinary catheters, as evidenced by the failure to change the urinary drainage device collection bags using appropriate infection control techniques for Resident #36, and failure to ensure proper anchoring for the tubing of the indwelling urinary catheters for Residents #36 and #120.The findings included:Review of the Agency for Healthcare Research and Quality (AHRQ) document titled Catheter Care and Maintenance AHRQ Safety Program for Long-Term Care dated March 2017 documented, in part, Gloves play a key role in preventing hand contamination - but do NOT replace hand hygiene. Perform hand hygiene and wear gloves immediately before accessing the drainage system, emptying the drainage bag . Drainage Bag Care: . stabilize the catheter tubing and drainage bag. Leg Bags: Leg bag care and changing should be done per your facility's policy.On 06/25/25 at 11:21 AM the Director of Nursing (DON) was asked to locate and provide their policy on indwelling urinary catheter care and maintenance. The policy provided lacked any information related to changing the urinary drainage device collection bags. When asked to provide documentation for that procedure the Administrator stated they did not have that specific policy or procedure.1) Review of the record revealed Resident #36 was admitted to the facility on [DATE] with an indwelling urinary catheter and UTI. Review of the current care plan initiated on 05/27/25 documented the resident was at risk for further infections related to his urinary catheter. Interventions initiated on 06/16/25 included to change out the leg bag to straight drainage bag at bedtime or when lying in a flat/supine (facing upward) position and to utilize regular hand hygiene before and after handling of the catheter.Review of the current physician orders included to Ensure securement device in place as of 06/16/25.During an observation on 06/25/25 at 6:09 PM, Resident #36 was sitting up in his wheelchair. A leg bag was noted to the resident's leg with an anchor noted at his thigh. The catheter tubing had been placed through the anchoring device but was not secured at the Y junction of the tubing, allowing the tubing to move freely and pull tightly from the insertion point. Staff K, Certified Nursing Assistant (CNA) stated she was going to get him dressed for bed and change out the leg bag to the straight drainage bag.During the continued observation, Resident #36 was assisted to the toilet. After Resident #36 used the toilet, expelling gas, the CNA cleaned the resident's buttock with a washcloth while wearing gloves. The CNA changed her gloves without hand hygiene and cleaned the resident's back side again. Resident #36 stood up and the leg bag was noted unstrapped from the resident's leg, dangling loosely with the tubing noted to be tight from the insertion site. Staff K assisted Resident #36 into bed and proceeded to change out the leg bag to the straight drainage bag, which had a larger urine collection bag. The CNA failed to change her gloves and provide hand hygiene prior to working with the indwelling catheter. The CNA changed the leg bag to the larger drainage back without cleaning the ends of the tubing. The CNA covered the resident and stated she was done and failed to properly secure the indwelling catheter tubing into the anchor.After the observation, when asked the purpose of the anchor, Staff K, CNA, described how the straps of the leg bag held it in place. When shown the anchor on the resident's thigh and asked the purpose of that, the CNA stated, I'm not sure, but if I had to guess I would say it's to keep it from yanking up or out. When asked if the tube was secured in the anchor the CNA was able to move the tubing in the anchor as it was not secured.During an observation and interview on 06/25/25 at 6:39 PM, the Assistant DON (ADON)/Infection Preventionist (IP) was asked to observe the indwelling catheter anchoring device for Resident #36. The ADON noted the loose tubing and immediately secured the tubing into the anchor at the tubing Y junction. The ADON explained and demonstrated how to properly secure the urinary catheter tubing at the Y junction, to the CNA, who was still in the resident's room.During an interview on 06/27/25 at approximately 9:00 AM, when asked the process for changing the indwelling catheter leg bag to the large collection bag, the DON stated she would expect the CNA to clean the ends of the catheter tube with alcohol prior to hooking up the new bag. When told the CNA also failed to ensure glove change with hand hygiene after assisting Resident #36 clean himself after toilet use and prior to disconnecting the leg bag and applying the large bag, the DON had no response.2) Review of the record revealed Resident #120 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, on a 0 to 15 scale, indicating the resident was cognitively intact. This MDS documented the resident had an indwelling urinary catheter.A physician's order dated 06/12/25 documented the use of the indwelling urinary device with instructions to ensure securement device was in place. A progress note dated 06/21/25 documented Resident #120 complained of urine retention, the urinary catheter was flushed, the collection bag was changed, and a urine sample was obtained for a urinalysis to rule out a UTI.Review of the current care plan dated 06/26/25 documented Resident #120 developed a UTI with the initiation of an antibiotic.An observation on 06/25/25 at 9:35 AM revealed Resident #120 in bed with the indwelling urinary large collection bag to bedside drainage. When asked if his catheter tubing was anchored, the resident was not sure but pulled his blanket to the side. Resident #120 was wearing shorts, and an anchor was noted to his thigh, but the tubing was not secured properly with the tubing Y junction in the anchor. Photographic evidence obtained.An additional observation on 06/25/25 at 5:35 PM revealed the tubing to the urinary catheter remained not secured.During an observation and interview on 06/25/25 at 6:44 PM, the ADON/IP confirmed the incorrect placement of the urinary catheter tubing for Resident #120.
Inspection of February 21, 2025
1 findingBased on policy review, interview, and record review, the facility failed to ensure timely provision of medications for 2 of 3 sampled residents, as evidenced by the failure to provide insulin and an antibiotic timely upon Resident #1's admission to the facility, and failure to provide insulin timely upon Resident #2's admission to the facility. The findings included: 1) Review of the record revealed Resident #1 was admitted to the facility from the hospital on 01/28/25 at 6:00 PM, with diagnoses to include Type 1 Diabetes. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating he was cognitively intact. This MDS also documented the resident received both insulin and an antibiotic during the look-back period of 01/28/25 through 02/01/25. Review of the hospital discharge paperwork documented Resident #1 was to receive insulin, one short-acting and one long-acting, but the paperwork lacked any specific dose or frequency. Further review of the discharge paperwork revealed documentation the resident was to receive Zosyn (an antibiotic), intravenously, every 8 hours. During an interview on 02/21/25 at 11:21 AM, Resident #1 stated it took a long time to get his insulin, upon admission to the facility. The resident stated he thought it was because he was admitted to the facility late in the evening, and they had to get the insulin from an outside pharmacy. Review of the January 2025 Medication Administration Record (MAR) for Resident #1 revealed the following: a) Lantus insulin (long-acting) was ordered to start on 01/29/25 at 6 AM, but was discontinued and not provided. b) A sliding scale insulin regimen with Novolog (short-acting) was ordered to start on 01/29/25 at 7:30 AM with blood sugar checks ordered before each meal and at bedtime but was discontinued and not provided. This order was then initiated on 01/29/25 at 4:30 PM, missing three opportunities for coverage on 01/28/25 at bedtime, 01/29/25 before breakfast, and on 01/29/25 before lunch. This order was initiated nearly 24 hours after admission to the facility. The resident's blood sugar was high at 335 at that time, with a desired blood sugar of less than 200. c) Glargine insulin (long-acting) was not started or provided until 01/29/25 at 4:30 PM, nearly 24 hours after admission to the facility. The resident's blood sugar was high at 335 at that time, with a desired blood sugar of less than 200. d) The antibiotic Zosyn was ordered to start on 01/29/25 at 6:00 AM. The Zosyn was not administered at this time, as evidenced by a blank area on the MAR, but started on 01/29/25 at 2 PM, nearly 24 hours after admission to the facility. Review of the progress notes lacked any reason for the lack of medication administration. During a side-by-side record review on 02/21/25, the Assistant Director of Nursing (ADON) confirmed the lack of insulin dosing from the hospital record. The ADON stated the nurse would have had to call the physician to get clarification. The ADON stated that sometimes the issue was with which insulin the insurance would cover, and the pharmacy would then contact the facility for an order to substitute. Upon further review of the orders, the ADON noted the pharmacy had entered an order for the Novolog FlexPen to be administered as per the sliding scale on 01/28/25 at 11:35 PM, and the order was not confirmed by the nursing staff until 01/29/25 at 12:10 PM, fourteen hours later. When asked about the delivery of the FlexPens, the ADON explained the admission or night nurse should have called the physician to get an order to use their stock insulin until the pharmacy delivered the FlexPen. Upon further review of the January 2025 MAR, the ADON agreed Resident #1 did not receive any insulin until 01/29/25 at 4:30 PM, nearly 24 hours after the resident was admitted . During this continued interview, the ADON agreed with the lack of antibiotic administration on 01/29/25 at 6:00 AM. The ADON provided evidence that the Zosyn was available in the facility's stock medications at the time of the survey, although she was unsure if it was available on 01/29/25. During the exit conference on 02/21/25 at approximately 4:45 PM, the Director of Nursing (DON) stated she had reached out to the nurse who should have provided the antibiotic on 01/29/25 at 6 AM, and the nurse would not confirm if she had provided the medication or not. 2) Review of the record revealed Resident #2 was admitted to the facility on [DATE] at approximately 9:00 PM, with diagnoses to include Diabetes. Review of the February 2025 MAR for Resident #2 revealed the following: a) Insulin Asparte (short-acting) was ordered to start on 02/25/25 at 8 AM and not provided. b) Novolog (short-acting) FlexPen was ordered by the pharmacy (as an insurance approved substitute) on 02/14/25 at 11:35 PM. The order was confirmed by nursing staff on 02/15/25 at 12:14 PM, with the first dose administered at that time, 15 hours after admission. c) Insulin Glargine (long-acting) was ordered to start on 02/15/25 at 9 AM and not provided. The pharmacy placed an order for an insurance approved substitute on 02/14/25 at 11:35 PM. The nursing staff confirmed the order on 02/15/25 at 12:16 PM, with the first dose administered at 6 PM, 21 hours after admission. During an interview on 02/21/25 at approximately 4:30 PM, the ADON confirmed the medication delay.
Inspection of December 10, 2024
1 findingBased on interview, policy review and record review, the facility failed to assess a resident's skin under a knee immobilizer to prevent a pressure injury for 1 of 5 sampled residents (Resident #1). The findings included: The facility policy Titled Skin Assessment and revised on 10/01/22 documented in part: 1. A full body or head to toe skin assessment will be conducted by a Registered Nurse upon admission/readmission and weekly thereafter. The assessment may also be performed after a change in condition or after a newly identified pressure injury. The facility policy titled, Pressure Injury Prevention and Management, revised on 10/03/24, documented in part: The facility is committed to the prevention of avoidable pressure injuries. Avoidable means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident clinical condition and risk factors, define and implement interventions that are consistent with resident needs, resident goals and professional standards of practice. Record review revealed on 10/19/24, Resident #1 was transferred from a hospital to the facility. She had diagnosis to include unspecified Fracture of Lower end of Left Femur with encounter for closed fracture with routine healing, Pleural Effusion, Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease, Muscle Weakness, Difficulty in Walking, Muscle Wasting and Atrophy, Malnutrition, Hypothyroidism, Non-rheumatic Aortic Valve, Periprosthetic Fracture around internal prosthetic left knee joint, Hyperlipidemia, and pain in right hip. Resident #1's admission MDS (Minimum Data Set) assessment dated [DATE] documented the resident had a BIMS (Brief Interview for Mental Status) score of 5, indicating severe cognitive impairment. Further record review revealed Resident #1 arrived at the facility with a left knee immobilizer to secure her knee movements following a fracture of the lower end of her left femur. On 11/18/24 a pressure injury was found under Resident #1 left knee immobilizer after drainage was discovered from the site. Review of the record for Resident #1 indicates the last weekly skin check before the discovery of the left calf pressure injury was dated 11/04/24 and did not contain any documentation of skin injury on the resident's left calf. The next documented skin assessment was done on 11/18/24. The skin assessment was not documented as completed for 14 days. In reviewing the chart, the DON (Director of Nursing) agreed there was no documentation of a skin assessment for 2 weeks. An interview was conducted on 12/10/24 at 10:21 AM with Staff A, the Director of Rehabilitation. He was asked what the protocol was for removing an immobilizer for skin care and observation. He stated the rehabilitation department never tells nursing services they cannot remove an immobilizer for skin care or skin assessment. He stated it is standard to remove it for care unless there are orders to not remove it. On 12/10/24 at 11:05 AM Staff B, a CNA (Certified Nursing Assistant) was interviewed. She stated she has taken care of Resident #1 many times. She stated she was told by the Physical Therapy (PT) personnel not to remove Resident #1's immobilizer from her leg. She stated she wasn't sure who told her not to remove it. She didn't remove it for care. On 12/10/24 at 11:10 AM Staff C, a CNA was interviewed. She was asked about immobilizers. She stated they always look at the orders to see if the immobilizer is allowed to be removed for showers and peri care. She will follow the orders. On 12/10/24 at 11:12 AM Staff D, a CNA, was interviewed. She was asked about Resident #1's immobilizer; she stated she heard they were not supposed to take it off. She stated she was the one who discovered the drainage on Resident #1 linen, which led to the immobilizer being removed and the discovery of the pressure injury. On 12/10/24 at 11:14 AM, an interview was conducted with Staff E, a RN (Registered Nurse). She was asked about immobilizers and how she performed a skin check when a resident had an immobilizer. She stated she would remove it. She was asked about Resident #1 and her immobilizer. She stated she had removed it when she took care of Resident #1 to check her skin under the immobilizer. Further interview revealed Staff E could not recall the last time she took care of Resident #1. On 12/10/24 at 2:10 PM, Resident #1's Physician was interviewed. He was asked about Resident #1, and he stated the pressure injury under her immobilizer was preventable. He was asked about orders for checking skin integrity. He stated, I wrote protocols for the facility to follow. He stated nursing knows to check skin and circulation under an immobilizer. He stated he now has started writing orders to check skin integrity and circulation for patients with any type of immobilizer.
Inspection of March 21, 2024
5 findingsBased on record review, interview, and policy review, the facility failed to ensure reconciliation of controlled medications for 4 of 4 sampled residents reviewed (Resident #22, #68, #37 and #6). The findings included: Review of the policy Controlled Substance Administration & Accountability revised 10/2023 documented, 1. General Protocols: . i. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source for documenting any patient-specific narcotic dispensed form the pharmacy. Review of the current Medication Monitoring/Control Records and the corresponding March 2024 Medication Administration Records (MARs) revealed the following discrepancies: 1). Resident #22, a 5 milligram (mg) tablet of oxycodone was signed out of the medication cart, as per the control record, on 03/12/24 at 12:30 PM, but not signed out on the corresponding MAR. 2). Resident #68, a 5 mg tablet of oxycodone was signed out as per the control record on 03/18/24 at 10:33 PM, but not signed out on the corresponding MAR. During this review on 03/21/24 at 12:22 PM, Staff D, Licensed Practical Nurse (LPN) agreed with the findings and confirmed the nurses were to sign out a controlled medication on both the control record and the MAR. Additional observations of the medication carts and controlled records revealed the following discrepancies: 3). Resident #37, one 50 mg tablet of Tramadol was signed out as per the control record on both 03/17/24 at 4:43 AM and on 03/19/24 at 4:36 AM, but not signed out on the corresponding MAR for either date. 4). Resident #6, one 50 mg tablet of Tramadol was signed out as per the control record on 03/14/24 at 3:13 AM, but not signed out on the corresponding MAR. During this review on 03/21/24 at 12:29 PM, Staff F, Registered Nurse (RN) agreed with the findings.
Based on interview and record review, the facility failed to ensure showers were provided per resident preference and as scheduled for 1 of 3 sampled residents reviewed for choices (Resident #13). The findings included: During an interview on 03/18/24 at 10:07 AM, Resident #13 explained that staff keep her clean and dry as far as her incontinence, but they don't give her a full bed bath daily as she would like. The resident also stated she would like a shower. When asked how many showers she would like each week, the resident stated two. Resident #13 confirmed she does not get two showers weekly. Review of the record revealed Resident #13 was admitted to the facility on [DATE]. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating intact cognition. This MDS also documented the resident needed substantial assistance from staff for bathing. Review of the Significant Change MDS dated [DATE] documented it was very important for the resident to choose between a bath and a shower. Review of the current care plan initiated on 11/25/20, and revised on 03/18/24, documented the resident was at risk for decreased ability to perform ADLs (activities of daily living) in bathing, related to activity intolerance, and related to comorbidities that included quadriplegia, contractures, and traumatic brain injury. This care plan documented Resident #13 preferred showers and was dependent upon staff for showers and baths. Review of the shower schedule revealed Resident #13 was scheduled for a shower on Mondays and Thursdays during the 3 PM to 11 PM shift. Review of the tasks section of the electronic medical record for 02/19/24 through 03/19/24 documented the provision of 3 showers in 30 days, instead of the scheduled 9 showers for that same time period. The most recent shower was documented on Monday 03/18/24 by Staff A, Certified Nursing Assistant (CNA). A bed bath was also documented by the same CNA for the same day. During an interview on 03/21/24 at 9:22 AM, when asked if she provided a shower to Resident #13 on Monday, Staff A stated she had not given her a shower, but did a full bed bath instead. When shown that both a shower and bed bath were documented by her for Monday, the CNA stated it was a mistake. During a supplemental interview on 03/21/24 at 9:27 AM, when asked if she received a shower yesterday or any day this week, Resident #13 stated No. When asked if she still wanted a shower, the resident stated she did. When told she would have to get up out of bed, as the surveyor had only seen the resident up out of bed on one day that week, Resident #13 stated, I know!
Based on record review and interview, the facility failed to ensure of an accurate Minimum Data Set (MDS) assessment related to medications for 1 of 5 sampled residents reviewed for unnecessary medications, (Resident #62). The findings included: Review of Resident #62's electronic records revealed the resident was admitted to the facility on [DATE] with diagnoses to include Sequelae of Cerebral Infarction, Depression, Left Femur Fracture, Anxiety Disorder, Atrial Fibrillation, Muscle Weakness, and Acute Respiratory Failure. Review of the Minimum Data Set (MDS) Medicare 5-day assessment dated [DATE] documented the resident has a BIMS (Brief Interview for Mental Status) score of 12, indicating the resident's cognition is moderately intact. Review of the MDS section N, (Medications) documented the resident had 4 days of insulin injection and high-risk drugs antidepressant and anticoagulant. Review of Resident #62's diagnoses and physician orders revealed the resident did not have a diagnosis of Diabetes and did not have or had a physician's order for insulin while a resident in the facility. Further record review revealed a physician's order for Enoxaparin Sodium Injection Solution Prefilled Syringe 40 MG/0.4ML, inject 40 mg subcutaneously in the afternoon for DVT (Deep Vein Thrombosis) prevention; Start date 02/27/24 through 03/11/24 and 03/11/24-04/01/24 Enoxaparin Sodium is an anticoagulant medication (blood thinner). During an interview on 03/20/24 at 2:05 PM with Resident #62 and her daughter, she was asked about being on Insulin. She stated that she is not a Diabetic and has never been on Insulin. Her daughter confirmed this. She stated she is taking a medication that the staff injects in her stomach, which is a blood thinner. During an interview on 03/20/24 at 2:34 PM with the MDS Director, she was asked to review Resident #62's MDS record. She reviewed Section N (Medications) and was asked if the resident was a diabetic and taking Insulin, and stated, she is not a diabetic and coded it looking at the Enoxaparin as a diabetic medication. She stated, I know it is not a diabetes medication and acknowledged it was an error on her part.
Based on interview and record review, the facility failed to assess for a voiced change in condition for 1 of 23 sampled residents (Resident #118), and the nursing staff held blood pressure medications without ordered parameters and failed to notify the physician of the low blood pressure readings for 1 of 5 sampled residents (Resident #21). The findings included: During an interview on 03/20/24 at 1:11 PM, Resident #118 was asked if she still had her indwelling urinary catheter. Resident #118 stated she did not as it was taken out a few days ago, but volunteered she had a difficult time with a night nurse before the catheter was placed. Resident #118 explained she had a history of urinary tract infections, had had issues with voiding (urinating), and could tell when she was having difficulties. The resident stated the night before the catheter was placed, at about 3 AM, she was having horrible abdominal pain and she thought she needed a catheter because of the pressure she was feeling. Resident #118 stated the night nurse told her, Do you expect me to call the physician at this time of night. The resident explained she had told the nurse she hadn't urinated and had asked for a catheter. Resident #118 stated the night nurse told her she could not place a catheter because she was having spasms and she would continue to spasm. Resident #118 explained she then asked for some pain medication hoping for relief, but it did not help. During this description, Resident #118 demonstrated how she was having abdominal pain, grimacing, and rolling back and forth holding her abdomen. Resident #118 explained Staff D, Licensed Practical Nurse (LPN) and her day nurse, arrived and was her angel. Resident #118 stated she explained to the day nurse that she had been in horrible pain since 3 AM, and the day nurse told her that was unacceptable. The resident explained that Staff D returned, placed a catheter, and she immediately drained over 700 milliliters of urine, followed by 200 more. Resident #118 stated when that urine drained out, I felt such relief, I felt like I was just floating. During an interview on 03/20/24 at 1:14 PM, Staff D, day LPN, confirmed she had placed the urinary catheter for Resident #118 one morning, and had obtained a large amount of urine upon placement. During a supplemental interview on 03/20/24 at 3:02 PM, Resident #118 stated, Maybe that night nurse was having a bad night or something, but it wasn't like I had a headache and asking her to call the doctor for that. It could have been solved so quickly if she would have just called the physician and got an ok to cath me. I've had this before. Review of the record revealed Resident #118 was admitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #118 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale. This MDS documented the resident had an indwelling urinary catheter. The physician orders revealed the indwelling urinary catheter was placed on 03/07/24. During a phone interview on 03/20/24 at 4:26 PM, when asked about Resident #118 and the night prior to the placement of the indwelling urinary catheter, Staff B, night LPN, explained she was told the resident wanted to see the nurse. Staff B stated the resident was in pain and pointed to her abdomen. Staff B stated she assessed the resident's abdomen and it was soft. Staff B stated Resident #118 asked about a catheter, but when she asked if she was voiding or needed to go to the bathroom, the resident stated she was voiding and had just been to the bathroom. Staff B stated she gave Resident #118 pain medication, the resident went back to sleep, and she did not complain of pain through the rest of the night. Staff B stated she obtained her blood sugar level about 5 AM and still didn't voice any further complaints. Staff B stated Resident #118 had often complained of pain and took pain medication. Review of the March 2024 Medication Administration Record (MAR) documented Resident #118 had taken pain medication three times prior to the 3 AM pain medication for her abdominal pain. This MAR and associated progress notes revealed the following: On 03/02/24 at 1:33 AM the resident took Tylenol for complaint of bone pain in her legs rated at a 6, on a 0 to 10 scale. Follow-up rating at 2:29 AM was a 2. On 03/05/24 at 8:05 AM the resident took Oxycodone for documented chronic pain. The follow-up documented the intervention was ineffective, although the pain rating for the shift was documented as 0. On 03/06/24 at 10:03 AM the resident took Oxycodone for complaint of left hip pain rated at a 7, with a follow-up rating of 0. Staff B, the night LPN, documented she provided Oxycodone on 03/07/24 at 3:19 AM for severe pain in back rated at an 8. A follow-up note at 4:44 AM documented the resident then rated her pain at a 3. The progress notes lacked any documented assessment for the abdominal pain as voiced by Resident #118. 2) Review of the record revealed Resident #21 was admitted to the facility on [DATE]. Review of the current care plan initiated on 11/10/23 and revised on 02/16/24 documented Resident #21 had altered cardiovascular status related to hypertension. This care plan documented for staff to administer medication as per order, and to monitor for effectiveness and possible side effects. This care plan also documented for staff to monitor vital signs and to notify the physician of significant abnormalities. Review of the current orders revealed Resident #21 was taking Exforge (a medication to lower blood pressure) once daily. Review of the March 2024 Medication Administration Record (MAR) revealed the Exforge was not provided on 03/07/24 with a blood pressure of 117/57, on 03/12/24 with a blood pressure of 96/66, and on 03/13/24 with a blood pressure of 129/57. All three days the direct care nurse was Staff C, LPN. The documented reason for not administering the medication was that the blood pressure was outside of parameters for administration. Further review of the orders lacked any parameters for holding the medication. During an interview on 03/21/24 at 10:47 AM, when asked about the holding of the Exforge blood pressure medication for Resident #21 on the above three dates, Staff C stated she held it because the blood pressure was low. When asked if she asked or notified the physician, the LPN stated she did not.
Based on observation, interview, record review, and policy review, the facility failed to ensure proper catheter care and services for 2 of 5 sampled residents with indwelling urinary catheters (Residents #32 and #4), and failed to ensure proper peri-care (personal care provided after an incontinent episode of urination) for 1 of 1 sampled resident observed (Resident #16). The findings included: 1) Review of the policy Catheter Care revised 01/06/23 documented after having cleaned the peri-area, 12. With a new moistened cloth, starting at the urinary meatus moving out, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter. Review of the record revealed Resident #32 was admitted to the facility on [DATE]. Review of the orders revealed an indwelling urinary catheter was placed on 02/20/24. Review of the current care plan initiated on 02/21/24, and revised on 03/11/24 documented, Resident #32 had an indwelling urinary catheter. Care plan interventions included catheter care with soap and water each shift and as needed. During an observation on 03/20/24 at 11:00 AM, Staff E, Certified Nursing Assistant (CNA) provided appropriate peri-care to the resident's front and back sides, but failed to wipe the urinary catheter tubing in any way. The CNA then placed an adult pull-up (adult incontinence brief) on Resident #32. Upon completion of care, when asked about cleaning the catheter tubing, the CNA stated, I thought I did. When asked if she had worked this week with Resident #32, the CNA stated she had. When asked if the resident had had any type of anchor or thigh strap to secure the catheter tubing that week, the CNA stated she had not. When asked if they use them at the facility, the CNA stated they do. When asked why the anchor or thigh strap would be used with the urinary catheter tubing, the CNA stated, So it won't come out. The CNA was unaware the anchor or thigh strap helped secure the urinary catheter tubing, to assist with the prevention of infection. 2) Review of the record revealed Resident #4 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired with a Brief Interview for Mental Status (BIMS) score of 0, on a 0 to 15 scale. This MDS also indicated the resident was dependent upon staff for all activities of daily living (ADLs) and had an indwelling urinary catheter. Review of the current care plan initiated on 02/24/22 and revised on 06/29/22 documented the resident required the indwelling catheter due to urinary retention. One of the interventions was to maintain the catheter off of the floor. Observations on 02/19/24 at 8:23 AM and on 03/21/24 at 8:59 AM revealed the indwelling urinary catheter bag lying directly on the floor. On 03/21/24 the catheter bag was not hooked or secured to the bed frame in any way (Photographic Evidence Obtained). During the observation on 03/21/24, the Unit Manager was passing by the room. The Unit Manager agreed the catheter bag should not be on the floor and noted it was not hooked to the bed frame. The Unit Manager properly secured the catheter bag to the bed frame and off of the floor. 39167 3) Record review revealed that Resident #16 was admitted to the facility on [DATE] with a diagnosis to include: Urinary Tract Infection (UTI). Review of the admission Minimum Data Set (MDS) assessment, reference date 01/12/24, documented a Brief Interview for Mental Status (BIMS) score of 08, indicating Resident #16 was moderately cognitively impaired. Laboratory test dated 03/10/24 for urinalysis, culture, and sensitivity (UA/ C&S) were reviewed. It indicated to straight catheterize the resident for a urine sample for symptom of urinary frequency, relating to strong smelling urine. It was revealed the lab was completed 03/10/24. The lab result was reported to the facility on [DATE]. The result was >100,000 CFU/ML [greater than 100,000 colony forming units per milliliter] Klebsiella pneumoniae, ESBL [Extended Spectrum Beta-Lactamase]. ESBL is an enzyme found in some strains of bacteria. ESBL bacteria can be spread from person to person on contaminated hands of both patients and healthcare workers. The risk of transmission is increased if the person has diarrhea or has a urinary catheter in place as these bacteria are often carried harmlessly in the bowel. Review of physician orders dated 03/13/24 revealed an order for Ciprofloxacin HCl [antibiotic] oral tablet, give 500 mg by mouth two times a day for UTI for 7 Days. Review of a care plan dated 03/14/24, documented, Resident #16 had a Urinary Tract Infection related to ESBL. Review of interdisciplinary progress note dated 03/14/24 recorded (Resident #16) 'was being skilled for right pelvic fracture, she was positive for ESBL as of 03/13/24, she was on an antibiotic by mouth until 03/21/24 with contact precautions.' On 03/21/24 at 9:23 AM, the surveyor met Staff G, Certified Nursing Assistant (CNA), in the hallway in front of the resident's room, to observe peri-care. The surveyor and Staff G donned gowns and gloves and entered the room. Once inside the room, Staff G and the surveyor introduced themselves to Resident #16. The resident was observed sitting in the wheelchair. Staff G removed Resident #16's shoes and assisted her to get into the bed. Staff G obtained the bed remote control and placed the bed in a high position. Staff G opened the resident's drawers, removed a basin, and went to the bathroom to collect water into the basin and left it in the bathroom. Staff G obtained a plastic bag which had towels and washcloths in it. She removed a large towel from the plastic bag, removed Resident #16's pants and adult brief and covered her private area with the large towel. At 9:27 AM, Staff G went to the bathroom and obtained the basin of water, placed the basin on the bedside table, put soap in the basin, and then placed a small washcloth in the water. At 9:29 AM, without changing her gloves, she began the peri care. She washed the peri area using one wash cloth at a time. After she completed the care, she removed her gloves, collected new gloves from her pocket and put them on without preforming hand hygiene in between glove changes. Staff G looked for cream in the drawers and applied the cream to Resident #16's groin and bottom area. After the peri care was completed, an interview was held with Staff G, who was asked why she didn't change her gloves before she began the peri care. She then acknowledged that she did not change her gloves. On 03/21/24 at approximately 9:50 AM, an interview was conducted with the Director of Nursing (DON) and the Regional Nurse Consultant. They were made aware of the concern, as the surveyor explained the whole procedure, and the matter of which the peri care was rendered. They acknowledged the findings.
Inspection of July 6, 2022
1 findingBased on record review and interview, it was determined, the facility staff failed to provide timely and necessary care and services to respond to a medical emergency. The failure affected 1 of 3 sampled residents (Resident #2), who experienced a choking episode and was subsequently intubated by emergency personnel and admitted to the hospital for Acute Respiratory Failure and [CONDITION(S)], (lack of oxygen). The findings included: Clinical record review conducted on [DATE] revealed Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Minimum Data Set, admission assessment with reference date of [DATE] documents the resident was assessed as severely impaired for skills of daily decision making; required extensive assistance to total dependence with activity of daily living; had difficulty swallowing and was holding foods in his mouth; had mouth and facial pain when chewing; and was on a mechanically altered diet. Care plan initiated for Resident #2 on [DATE] included the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurses Notes dated [DATE] documents as follows I went into the resident's room to administer residents medication that he takes crushed in pudding . As I was monitoring that the patient successfully swallowed his medication before I offered him water I observed his lips had a blue discoloration. I went to my cart and grabbed my pulse ox (oximeter). Resident was alert when I placed it on his finger. I could not get a reading, but the resident was still alert and had a pulse. I called for the unit manager and lowered the bed in case we would have to do CPR (cardiopulmonary resuscitation). The female visitor shoved me out of the way and began sticking her finger down his throat saying he was choking, she then pulled him on his left side. I asked her not to do that. The patient was still awake. The aides grabbed the crash cart and I grabbed a suction tube. The female visitor snatched the suction tube from my hand and yelled that she was a critical care nurse and we did not know what we were doing . I observed that the patient was not in distress and was alert and breathing so I ran down to assist with the 911 call that was in progress. When the paramedics left facility, the resident was awake and had no signs of distress. The resident was pale in color and had no oxygen on. The head of the stretcher was up, and the paramedics were not doing CPR. Interview with Staff A, the Licensed Practical Nurse, who wrote the nurses notes documented above, was conducted on [DATE] at 11:15 AM. Staff A revealed her recollection of the events, Resident #2 had a change in condition and a code blue was called, emergency personnel were called and the resident was transferred to the hospital and has not returned. The nurse recalled on Sunday, [DATE], she was giving Resident #2 his afternoon medications, the pill was crushed and mixed with pudding. The resident likes to open his mouth and talk and sing and needs cueing to help him swallow. Then she noticed his lips were blue, she put the head of the bed down she went to get the pulse oximeter and could not get a reading. Then the resident's sister jumped out of her chair and said something like he has seizures and turned him over and started to insert her finger in his mouth. She left the room to get suction, the crash cart was already on the way. The nurse stated they had already called 911 and a code blue was called. She made the second call to 911. The nurse went back with the suction and the resident's sister told her that was not oxygen, she could not assess the resident, the sister would not get out of her way. Staff A verbalized she was not going to get hurt, this woman (the resident's family member) was bigger than her. Then recalls the resident's brother was coming in and saying that someone was going to die here, it was not true. The paramedics took the patient in a sitting position, he was not wearing oxygen, and they were not doing CPR. The nurse was asked if she thought the patient was in distress, and said no, he did not need CPR, he was awake and breathing and when she did the pulse oximeter, he had a pulse. The resident has [CONDITION(S)] he likes to talk and sing when eating and sometimes he has to clear his throat. The nurse also stated she did not know why his lips were turning blue and did not think he was choking. The resident left the facility breathing and awake. Staff A verified the staff did not provide the resident with oxygen or suction during the event. Phone interview with Staff B, a Licensed Practical Nurse, conducted on [DATE] at 1:49 PM revealed her recollection of the events. Staff B heard the code blue and responded. The resident's family member was outraged yelling at the nurse, she is not doing anything right to help me, stating the resident was not breathing he may be aspirating, the resident was talking and breathing, the resident's family member was telling them they were not using the equipment right. The staff was asked if she was sure the resident was breathing and had a pulse, and she then clarified the resident's family member had the resident turned to the side so she could not see him and confirmed the resident's family member was asking for oxygen or suction, she could not recall which one, and added at some point she handed the family member the wrong tubing. Again Staff B cannot recall if it was oxygen tubing or suction tubing, she was just giving her what someone else handed to her and stated the resident's family member snatched the tubing and said that is not what she asked for and then slapped her hand with the tubing, she left the room and stayed by the door. She could not see what happened after that. Staff B stated the resident was awake and breathing without oxygen when the paramedics left the facility. Interview with Staff E, a Certified Nursing Assistant, on [DATE] at 9:06 AM, revealed her recollection of the events, that afternoon. The nurse was at the resident's door and was giving him the medications; they were standing by the door and noticed the resident color was gray and his lips were a little blue; the nurse went to check the pulse, she said call 911, she thinks she told Staff B to call 911 and the receptionist ended up calling 911. Then Staff E recalled grabbing the crash cart just in case they needed it and she ran in the room. Soon after Staff E left the room to attend to another resident. The aide recalled the resident's family member was asking for suction and other things, maybe CPR and then later on, she was asking to call 911, but they had already called and the paramedics were on site in less than 10 minutes. The aide was asked if she saw the resident's family member do a finger swipe to get anything out of the resident's mouth and she stated she did but the resident was turned to the side so she could not see what she took out of his mouth. The aide recalled the nurse gave the medications with pudding as she always did for him and denied seeing the resident's family member doing chest compressions. Phone interview with Staff C, Registered Nurse and Supervisor, conducted on [DATE] at 9:49 AM, revealed the nurse reported something was wrong with the resident, she asked to call a code, someone did over the intercom, then she went in the room, the resident's family member was yelling, telling them they don't know what they were doing, she wanted oxygen, suction and a doctor. Staff C confirmed the resident did not receive oxygen or suction during the event. Staff C stated she stayed in the room until the paramedics arrived, because everyone else left because of the family member's behavior and that the paramedics told her the resident was fine, his oxygen saturation was fine and she even recalls hearing the resident singing on the way out of the facility. Review of the 911 call records dated [DATE] indicates the facility called 911 at 1:25 PM and that the resident's family called 911 at 1:26 PM. Despite the nurse statement indicating 911 was called immediately after she was unable to get oxygenation readings and that her call was the second call to 911. In fact her call was the first call for emergency assistance. Review of the 911 call made by Staff A indicates no urgency, the staff told the operator the resident was choking but was responsive and breathing. The nurse also stated she was no longer in the room when making the call. Review of the 911 call made by the resident's family on [DATE] at 1:26 PM revealed the family member was yelling they needed help, the resident was dying, he cannot breath'. During this call the nursing supervisor got on the phone, and stated the resident was choking on a pill and that he was conscious and breathing at the time. Review of the Paramedic Report dated [DATE] revealed the call was received at 1:26 PM and they arrived at the scene at 1:36 PM. The reason for the call was foreign body in respiratory tract, shortness of breath and choking on food. First contact with the patient was at 1:38 PM, the patient was found unresponsive, cold, cyanotic and pale. The patient was placed on non-rebreather mask, with high flow oxygen at rate of 15 liters. The oxygen saturation was 70 percent upon arrival (normal range above 95 percent). The resident was subsequently intubated while in route. The interviews conducted with the staff involved revealed multiple inconsistencies regarding the clinical presentation of the resident, the urgency of the event, the provision of oxygen and suction and timely initiation of the emergency response system. The resident was unconscious and had a low oxygen saturation upon the paramedics arrival, he required the use of a non rebreather mask with high flow oxygen and subsequent intubation. Hospital record dated [DATE] noted the emergency room triage notes, blood pressure ,d+[DATE], intubated by paramedics on the field, heart rate 67 and oxygen saturation 100 percent. The medical screening exam noted the patient was unresponsive, patient is intubated, Paramedic reports family member reported after patient took pills he began to choke and fell back into his bed. Paramedics notes document family member noted patient became unresponsive and started performing CPR. On their arrival patient's oxygen saturation was in the 70's on room air. They immediately placed him on non rebreather mask. Then improved to the 80's. Patient was intubated. Patient admitted to intensive care unit with acute respiratory failure and [CONDITION(S)], septic shock, aspiration pneumonitis and urinary tract infection. Based on the review, the facility staff was not able to recognize the gravity of the resident's condition; the nursing staff failed to ensure the residents airways was not compromised before leaving the room to get a pulse oximeter; the nursing staff did not provide first aid including oxygenation and suction when needed; and the nursing staff provided inconsistent statements regarding the resident's condition. The paramedic reports contradict the resident was awake and breathing on room air upon transfer. The paramedics report indicates upon their arrival, the resident was unresponsive and cyanotic and the oxygen level in the blood was at 70 percent, indicating severe [CONDITION(S)]. The normal range is greater than 95 percent.
Inspection of August 22, 2020
5 findingsBased on observations, staff and physician interviews, record review, and policy review the facility failed to identify neglect and failed to notify the attending physician of the complete and accurate events for 1 of 1 known elopements, resulting from inadequate supervision of Resident #1 on 08/09/20. Resident #1, a cognitively impaired vulnerable adult, was outside of the building in direct sunlight in his wheelchair on 08/09/20, having rolled partially off the sidewalk. The resident was found by Staff A, a Certified Nursing Assistant (CNA), in a slumped position, with decreased level of consciousness, an elevated temperature of 102 or 103 degrees Fahrenheit, and subsequently sustained second-[MEDICAL CONDITION] his upper and lower extremities, and to the back of his head. The attending physician was not informed of the condition of Resident #1 on 08/09/20 or with the development of the blisters from the second-degree burns, and was later told the resident was found on the back patio and got a little sun. The findings included: During an observation on 08/19/20 at 10:51 AM, Resident #1 was lying in bed covered by a sheet. The resident's feet were uncovered, and multiple scabbed open wounds were noted on the top of the feet. A large yellowish scabbing wound, approximately 10 to 12 centimeters (cm) long by 4 to 6 cm wide was noted to the resident's left foot. While attempting to speak with the resident, who did not verbalize anything at that time, the Director of Nursing (DON) and a representative from another State agency entered the room. The DON immediately covered up the resident's feet. The other State agency representative was unable to get any answer from the resident. Upon removal of the covers, the scabbing wound to the resident's left foot was described as a scrape of some sort by the DON. Further observation revealed large scabbing wounds to the resident's bilateral thighs just above knees, approximately 6 to 8 cm round. The DON was asked about the wounds to the resident's thighs and confirmed the two areas were from the sunburn. The DON stated he also had an area to the back of the head. Observation of the back of the head revealed a scabbed wound approximately 5 to 7 cm round. When asked how long Resident #1 was out in the sun, the DON stated, about 10 minutes. Interviews with staff who observed Resident #1 on Sunday 08/09/20 revealed the following timeline: 10:45 AM: As per an interview on 08/19/20 at 12:02 PM with Staff G, a Certified Occupational Therapy Assistant (COTA), Resident #1 was observed in the therapy room on 08/09/20 at about 10:45 AM, and was returned to the direct care nurse on the North unit. 11:30 AM: As per an interview on 08/21/20 at 2:32 PM, Staff C, the direct care CNA for Resident #1, the CNA last saw Resident #1 in his room on 08/09/20 at about 11:30 AM. Staff C stated the next time she saw Resident #1 was around 2 or 2:30 PM, when he was being pushed into the building through the East Unit fire exit door and taken into the conference room, referred to the bird room on the East Unit. Staff C explained Resident #1 was placed in front of the A/C (air conditioner) because he was so hot, she went to get ice, and they poured ice and water on him. Staff C stated she heard his temperature was like 104 when the resident got into the conference room. Staff C stated that she believes Resident #1 was missing an hour or two. Staff C stated when she returned to work on Tuesday 08/11/20, Resident #1 had little bubbly looking things on his legs and that she reported it to her nurse that day, Staff F, a Licensed Practical Nurse (LPN). 11:30 AM - 11:50 AM: As per a phone interview on 08/20/20 at 7:58 AM, Staff E, the direct care RN and Nurse Manager for 08/09/20, was asked to explain the events that led to the sunburn for Resident #1. The RN stated Resident #1 was found outside on the patio, and he was a tad warm like 99 degrees, I think. The RN stated she completed a quick assessment and gave him additional fluids. The RN stated Resident #1 was ok and alert. The RN stated she notified everyone who needed to be notified and the doctor. When asked who found Resident #1, the RN stated she was the one who found him on the screened in patio. When asked what led her to the patio, the RN stated she had provided a tube feeding about 11:30 AM or 11:40 AM, and shortly after that she didn't see him in his room, so she went and looked for him. When asked his condition when she found him, the RN stated, He looked a little flushed, but was still his normal self. When asked who exactly she notified, the RN stated (name of attending physician), the resident's son, and the DON. The RN stated the DON told her to do a thorough assessment, call the doctor and to notify his family. 2:30 PM: As per a phone interview on 08/20/20 at 9:43 AM, Staff D, a CNA, observed Resident #1 around lunch time on 08/09/20 in his room, and next observed him after 2:30 PM as a nurse and Staff A, a CNA, were bringing Resident #1 into the building through the East Unit fire door exit. Staff D stated they were saying his temperature was 103 degrees. Staff D explained they had Resident #1 in front of the A/C in the bird room, putting ice on him and he was slumped over. Staff D stated she asked if he was going out (referring to the hospital), and they said no and that they had pumped him full of water. The CNA stated his skin was very red. Staff D explained when she returned to work on Thursday 08/13/20 she saw open blisters all over him. 2:30 PM - 2:50 PM: As per an interview on 08/19/20 at 1:08 PM, Staff A, a CNA, explained that on 08/09/20 she was doing her last rounds at about 2:50 PM, and was assisting Resident #4 in room [ROOM NUMBER]W, when she looked out the window and saw someone out on the sidewalk, facing away from her. When she finished with Resident #4, the resident was still outside in the same location. Staff A stated she went outside and realized it was Resident #1. His wheelchair was partially off the sidewalk and she stated she could not get him out of the grass, so she ran back in and called for a nurse, who helped her get his wheelchair out of the grass. Staff A stated when she found him, He was a hot mess. He had snot running out of his nose, he was boiling hot, and he wasn't with it. It took us until 3:15 PM to get him cooled down and back talking. Staff A explained they put ice packs and cold rags all over him, and his temperature was 102 degrees when they found him. He was sunburned and she took a bottle of lotion and just started putting it all over him, anywhere there was not clothing, as he was hot and burned. Staff A was asked to show the surveyor where she found Resident #1 on that Sunday 08/09/20. Staff A took the surveyor through the main dining room, through the gym, through the screened in patio, through the outside back patio, down the sidewalk to an area past the East unit fire exit door just past where the sidewalk splits off to the left. (Photographic evidence obtained). During a subsequent phone interview on 08/19/20 at 6:44 PM, Staff A, the CNA, identified the nurse who assisted her to get Resident #1 out of the grass, as Staff B, a Licensed Practical Nurse (LPN). 2:30 PM - 2:50 PM: As per a phone interview on 08/20/20 at 10:02 AM, Staff B, a LPN, explained she was working on the East and West units on Sunday 08/09/20, and saw Resident #1 up in his wheelchair that morning (unsure of time), as he wheeled himself up to her and they spoke briefly. Staff B explained a CNA got her and took her to the screened in patio. The LPN stated his nurse said everything was OK and that she had it under control, so the LPN went back to her unit. When asked if she assisted a CNA to get Resident #1 out of the grass and back onto the sidewalk, the LPN stated she did not. During a subsequent phone interview on 08/20/20 at 10:43 AM, the LPN stated, I'm sorry, my brain was foggy. This is what happened. The LPN explained she was on the East unit on 08/09/20 at 2:30 PM, recalling that it was close to shift change, and Staff A was putting Resident #4 back to bed. The LPN recalled the CNA called out her name and that someone was outside. The LPN stated she hoped it wasn't Resident #1 as she had seen him up earlier in the day, which was unusual for him. The LPN stated they went out so she could help the CNA as Resident #1 was stuck in the grass. The LPN stated as she was pushing him in through the East Unit fire exit door, Staff E, his direct care RN, was right there and took the resident. When asked if she took any of the resident's vital signs, the LPN stated she took his blood pressure, but denied taking his temperature. When asked if she remembered what his temperature was, the LPN stated that she did not remember, but it was up there. Additional staff interviews conducted revealed the following: During an interview on 08/19/20 at 11:28 AM, Staff F, a LPN, explained she returned to work on Tuesday 08/11/20. The LPN stated she was told Resident #1 was outside and got sunburned and was extremely alarmed looking at the wounds. She stated she contacted the attending physician and received order for [MEDICATION NAME] (from the Medical Director as per review of the order). The LPN explained Resident #1 had sunburns to his left foot, bilateral thighs, left forearm, and the back of his head. The LPN explained they were closed raised blisters upon her assessment on 08/11/20, exactly like sun poisoning. (Note that review of the record lacked any nurse's note dated 08/11/20). When asked about pain, Staff F stated when the wounds were open and care was being provided, she could tell it was uncomfortable as Resident #1 would grimace a little, so Tylenol was provided. The LPN stated he did not scream out, but that he isn't cognitively with it enough to describe or verbalize pain. During an interview on 08/19/20 at 12:29 PM, Staff H, a LPN, stated on Monday 08/10/20 Resident #1's skin was reddened and later became fluid filled blisters that opened up (unsure of the time frame). The LPN confirmed Resident #1 was cognitively impaired and able to wheel himself around the facility. The LPN stated she had seen the resident up and down the halls, as far as the receptionist, but had never seen him trying to get out of a door. Staff H explained the resident needs frequent rounding and re-direction when trying to go past the nurse's station, which can be done with tube feeding or calls to his son. (Note that review of the record lacked any nurse's note dated 08/10/20). On 08/19/20 at 3:19 PM, the DON was asked what happened with Resident #1 on 08/09/20. The DON stated on Sunday afternoon (08/09/20) she was notified that Resident #1 was outside on the back patio for no more than 10 minutes. The DON explained she asked the direct care nurse how he was doing and she stated he was fine. The DON told the nurse to do his vital signs, call the family and physician, and to continue to monitor him. On 08/19/20 at 3:31 PM the DON was asked to show the surveyor where Resident #1 was found on that Sunday 08/09/20. The DON identified a location on the back open patio area, just behind the screened in patio. (Photographic evidence obtained.) During a phone interview on 08/20/20 at 8:20 AM, the attending physician for Resident #1 stated he was notified a couple days ago that Resident #1 was out and got a little sun. The attending physician volunteered that he received a phone call from the resident's son, who was upset stating he (Resident #1) got out the front door, and said the facility was neglectful. The attending physician stated he went to the facility on Tuesday 08/18/20 and talked to the staff who told him he was out on the back patio, not out the front door. When asked if he was notified on Sunday 08/09/20 of Resident #1 being outside and sunburned, the attending physician stated no as there is nothing wrong with being out on the patio. When asked if he had seen Resident #1 and the wounds on his feet and legs, the physician stated that he has had those sores at least 6 weeks or more as he has trouble with circulation. The physician stated he tries to get out of bed and gets himself in awkward positions, and that he doesn't know if those wounds will ever heal, but he is being treated by the wound care physician. During a phone interview on 08/20/20 at 10:33 AM, the Medical Director was asked when he was informed of Resident #1 being found outside with subsequent sunburns. The Medical Director explained Resident #1 was not one of his patients, but he was asked to take a look at him for new blisters on 08/11/20. The Medical Director stated he was told the resident had been outside in the sun and a day later developed the blisters. Upon examination, the Medical Director found clear demarcated evidence of sun exposure of both upper and lower extremities, and can say it was evident of a thermal injury from being in sun. The Medical Director stated he can't tell a time frame of exposure, but can collaborate that this could be blistering from the sun. The Medical Director stated he then gave the order for the [MEDICATION NAME]. The Medical Director confirmed sunburn blisters to both thighs, one arm, and the back of his head. The Medical Director did not assess the resident's feet. During a subsequent phone call on 08/20/20 at 11:16 AM the Medical Director stated he would classify the sunburns as second-degree (a burn severe enough to cause blistering of the skin) burns. During a phone interview on 08/21/20 at 8:17 AM, the Wound Care physician explained he usually sees patients at the facility on Mondays, and makes rounds with the ADON. The physician confirmed he sometimes does virtual visits due to the current pandemic. When asked about Resident #1 and his sunburns, the Wound Care physician explained he was at the facility this past Monday 08/17/20, and it was reported to him by the ADON that somehow Resident #1 had gotten outside for I guess an extended time . at noon an hour is long enough . and [MEDICAL CONDITION] top of knees and scalp. The Wound Care physician stated he was not told of the sunburn on Monday 08/10/20 and confirmed that was a virtual visit. When told staff had reported Resident #1 was on the screened in patio or the back porch from anywhere from 10 minutes to up to an unknown amount of time, the Wound Care physician stated, It would definitely take longer than 10 minutes. The Wound Care physician classified the wounds as second-degree sunburns, with the most significant being on the thighs. The physician reviewed his note and stated he did not include the scalp and foot, but stated, I do remember them there. On 08/21/20 at 1:50 PM the Maintenance Assistant was asked if there had been any changes to the physical building since 08/09/20. The Maintenance Assistant stated the only change since Resident #1 was found outside, was the coded back patio exit door was previously locked by a timer at night, but now it is locked 24/7. The Maintenance Assistant was shown the area the DON identified as the location Resident #1 was found on the open back patio, along with the location Staff A found Resident #1 just off the sidewalk and in the grass. The Maintenance Assistant measured between the two locations and it was a difference of about 113 feet. During an interview on 08/21/20 at 3:13 PM, the ADON stated she does not routinely work weekends. The ADON stated she heard about Resident #1 during the Monday morning (08/10/20) stand up meeting and that he was located outside on the back patio. The ADON confirmed she made rounds with the Wound Care physician. The ADON stated on 08/10/20 they did virtual rounds and that Resident #1 was red on that day, but had no blisters. The ADON stated on Tuesday 08/11/20 the Medical Director was in the building and was made aware of the blisters, and ordered the [MEDICATION NAME]. Review of the record revealed Resident #1 was admitted to the facility on [DATE] having sustained a right knee and leg fracture, was diabetic, was fed by a feeding tube, was at risk for falls and skin breakdown, and had dementia with a Brief Interview for Mental Status (BIMS) score of 11 on a 0 to 15 scale as per the Admission Minimum Data Set (MDS) assessment dated [DATE], indicating some cognitive deficits. Resident #1 was transferred to the hospital related to critical laboratory values on 07/16/20, and returned to the facility to reside on the East Observation unit on 07/23/20. Record review revealed Resident #1 was re-admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #1 was transferred to the North unit and into room [ROOM NUMBER], the second to last room on that hall, on 08/06/20. The three fire exit doors located at the end of all three units were locked and alarmed. For Resident #1 to get from his room to the location he was found by Staff A, the resident would have had to go up the North unit hallway, past the nurse's station, through the hallway past the lobby area, into and through the main dining room (that was not being utilized because of the pandemic), through the gym, through double doors onto a screened in patio, out onto a back patio, down a sidewalk approximately another 113 feet past the location identified by the DON, to the opposite side of the East unit from the back patio. A physician's order dated 08/11/20 documented the administration of Silver [MEDICATION NAME] ([MEDICATION NAME]) cream to blisters on top of the resident's head and bilateral upper and lower extremities, twice daily for sunburn, written by Staff F, and signed by the Medical Director. A single nurse's note dated 08/09/20 at 1746 by Staff E documented, Resident observed upright alert in w/c (wheelchair) on Facility back patio, last observed 10 minutes prior on North hall. T-99.3 . Resident administered additional fluids via [DEVICE] and reassessed. Temp 98.3. (Name of attending physician) and family notified of resident on facility's back patio. Will cont to monitor. This note lacked any documented evidence it was a late entry and lacked any documented time of the event or interventions. Review of the current Baseline Care Plan dated 07/23/20 documented Resident #1 was at risk for falls related to poor safety awareness. This care plan documented N/A for elopement. Review of the Wound Care physician's Wound Evaluation and Management Summary note dated 08/17/20 documented Site #9 as a burn wound of the right thigh measuring 8 cm long by 7 cm wide and 0.1 cm deep. This note also documented Site #10 as a burn wound of the left thigh measuring 9 cm long by 5 cm wide by 0.1 cm deep. Review of the policy Abuse, Neglect and Exploitation (not dated) documented the definition of neglect as the failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Key components of this policy included the identification of neglect.
Based on observations, staff and physician interviews, record review, and policy review, the facility failed to immediately report, or within 24 hours of the event, the neglect of 1 of 1 known elopements, resulting from inadequate supervision of Resident #1 on 08/09/20, to the State Survey Agency. Resident #1, a cognitively impaired vulnerable adult, was outside of the building in direct sunlight in his wheelchair on 08/09/20, having rolled partially off the sidewalk. The resident was found by Staff A, a Certified Nursing Assistant (CNA), in a slumped position, with decreased level of consciousness, an elevated temperature of 102 or 103 degrees Fahrenheit, and subsequently sustained second-[MEDICAL CONDITION] his upper and lower extremities, and to the back of his head. Contradictory interviews with Staff E, the direct care Registered Nurse (RN) for Resident #1 and Nurse Manager for the day on 08/09/20, along with the Director of Nursing (DON), alleged Resident #1 was found on the back patio, having been seen 10 minutes previously. The findings included: During an observation on 08/19/20 at 10:51 AM, Resident #1 was lying in bed covered by a sheet. The resident's feet were uncovered, and multiple scabbed open wounds were noted on the top of the feet. A large yellowish scabbing wound, approximately 10 to 12 centimeters (cm) long by 4 to 6 cm wide was noted to the resident's left foot. While attempting to speak with the resident, who did not verbalize anything at that time, the Director of Nursing (DON) and a representative from another State agency entered the room. The scabbing wound to the resident's left foot was described as a scrape of some sort by the DON. Further observation revealed large scabbing wounds to the resident's bilateral thighs just above knees, approximately 6 to 8 cm round. The DON was asked about the wounds to the resident's thighs and confirmed the two areas were from the sunburn. The DON stated he also had an area to the back of the head. Observation of the back of the head revealed a scabbed wound approximately 5 to 7 cm round. When asked how long Resident #1 was out in the sun, the DON stated, about 10 minutes. Interviews with staff who observed Resident #1 on Sunday 08/09/20 revealed the following timeline: 10:45 AM: As per an interview on 08/19/20 at 12:02 PM with Staff G, a Certified Occupational Therapy Assistant (COTA), Resident #1 was observed in the therapy room on 08/09/20 at about 10:45 AM, and was returned to the direct care nurse on the North unit. 11:30 AM: As per an interview on 08/21/20 at 2:32 PM, Staff C, the direct care CNA for Resident #1, the CNA last saw Resident #1 in his room on 08/09/20 at about 11:30 AM. Staff C stated the next time she saw Resident #1 was around 2 or 2:30 PM, when he was being pushed into the building through the East Unit fire exit door and taken into the conference room, referred to the bird room on the East Unit. Staff C explained Resident #1 was placed in front of the A/C (air conditioner) because he was so hot, she went to get ice, and they poured ice and water on him. Staff C stated she heard his temperature was like 104 when the resident got into the conference room. During this interview, Staff C volunteered, The DON told me to say I saw him 10 minutes prior to the event. Staff C stated the DON wanted her to say he was only missing 10 minutes, but explained she could not say that. Staff C stated that she believes Resident #1 was missing an hour or two. Staff C stated when she returned to work on Tuesday 08/11/20, Resident #1 had little bubbly looking things on his legs and that she reported it to her nurse that day, Staff F, a Licensed Practical Nurse (LPN). 11:30 AM - 11:50 AM: As per a phone interview on 08/20/20 at 7:58 AM, Staff E, the direct care RN and Nurse Manager for 08/09/20, was asked to explain the events that led to the sunburn for Resident #1. The RN stated Resident #1 was found outside on the patio, and he was a tad warm like 99 degrees, I think. The RN stated she completed a quick assessment and gave him additional fluids. The RN stated Resident #1 was ok and alert. The RN stated she notified everyone who needed to be notified and the doctor. When asked who found Resident #1, the RN stated she was the one who found him on the screened in patio. When asked what led her to the patio, the RN stated she had provided a tube feeding about 11:30 AM or 11:40 AM, and shortly after that she didn't see him in his room, so she went and looked for him. When asked his condition when she found him, the RN stated, He looked a little flushed, but was still his normal self. When asked who exactly she notified, the RN stated (name of attending physician), the resident's son, and the DON. The RN stated the DON told her to do a thorough assessment, call the doctor and to notify his family. 2:30 PM: As per a phone interview on 08/20/20 at 9:43 AM, Staff D, a CNA, observed Resident #1 around lunch time on 08/09/20 in his room, and next observed him after 2:30 PM as a nurse and Staff A were bringing Resident #1 into the building through the East Unit fire door exit. Staff D stated they were saying his temperature was 103 degrees. Staff D explained they had Resident #1 in front of the A/C in the bird room, putting ice on him and he was slumped over. Staff D stated she asked if he was going out (referring to the hospital), and they said no and that they had pumped him full of water. The CNA stated his skin was very red. Staff D explained when she returned to work on Thursday 08/13/20 she saw open blisters all over him. When asked if management or anybody ask her about that day or what happened, Staff D stated they had not. Staff D further stated, The people (referring to staff) who told management the same as her (referring to the condition of Resident #1 when found outside), were told that what they are saying is not true and that he (Resident #1) was found on the patio. 2:30 PM - 2:50 PM: As per an interview on 08/19/20 at 1:08 PM, Staff A, a CNA, explained that on 08/09/20 she was doing her last rounds at about 2:50 PM, and was assisting Resident #4 in room [ROOM NUMBER]W, when she looked out the window and saw someone out on the sidewalk, facing away from her. When she finished with Resident #4, the resident was still outside in the same location. Staff A stated she went outside and realized it was Resident #1. His wheelchair was partially off the sidewalk and she stated she could not get him out of the grass, so she ran back in a called for a nurse, who helped her get his wheelchair out of the grass. Staff A stated when she found him, He was a hot mess. He had snot running out of his nose, he was boiling hot, and he wasn't with it. It took us until 3:15 PM to get him cooled down and back talking. Staff A explained they put ice packs and cold rags all over him, and his temperature was 102 degrees when they found him. He was sunburned and she took a bottle of lotion and just started putting it all over him, anywhere there was not clothing, as he was hot and burned. Staff A was asked to show the surveyor where she found Resident #1 on that Sunday 08/09/20. Staff A took the surveyor through the main dining room, through the gym, through the screened in patio, through the outside back patio, down the sidewalk to an area past the East unit fire exit door just past where the sidewalk splits off to the left. (Photographic evidence obtained). During a subsequent phone interview on 08/19/20 at 6:44 PM, Staff A identified the nurse who assisted her to get Resident #1 out of the grass, as Staff B, a LPN. 2:30 PM - 2:50 PM: As per a phone interview on 08/20/20 at 10:02 AM, Staff B, a LPN, explained she was working on the East and West units on Sunday 08/09/20, and saw Resident #1 up in his wheelchair that morning (unsure of time), as he wheeled himself up to her and they spoke briefly. Staff B explained a CNA got her and took her to the screened in patio. The LPN stated his nurse said everything was OK and that she had it under control, so the LPN went back to her unit. When asked if she assisted a CNA to get Resident #1 out of the grass and back onto the sidewalk, the LPN stated she did not. When asked if management or anyone asked her about the event, Staff B stated they did not. Staff B stated, I thought it was done and over with until I heard State was in the building last night. During a subsequent phone interview on 08/20/20 at 10:43 AM, the LPN stated, I'm sorry, my brain was foggy. This is what happened. The LPN explained she was on the East unit on 08/09/20 at 2:30 PM, recalling that it was close to shift change, and Staff A was putting Resident #4 back to bed. The LPN recalled the CNA called out her name and that someone was outside. The LPN stated she hoped it wasn't Resident #1 as she had seen him up earlier in the day, which was unusual for him. The LPN stated they went out so she could help the CNA as Resident #1 was stuck in the grass. The LPN stated as she was pushing him in through the East Unit fire exit door, Staff E, his direct care RN, was right there and took the resident. When asked if she took any of the resident's vital signs, the LPN stated she took his blood pressure, but denied taking his temperature. When asked if she remembered what his temperature was, the LPN stated that she did not remember, but it was up there. Additional staff interviews conducted revealed the following: During an interview on 08/19/20 at 11:28 AM, Staff F, a LPN, explained she returned to work on Tuesday 08/11/20. The LPN stated she was told Resident #1 was outside and got sunburned and was extremely alarmed looking at the wounds. She stated she contacted the attending physician and received order for [MEDICATION NAME] (from the Medical Director as per review of the order). The LPN explained Resident #1 had sunburns to his left foot, bilateral thighs, left forearm, and the back of his head. The LPN explained they were closed raised blisters upon her assessment on 08/11/20, exactly like sun poisoning. (Note that review of the record lacked any nurse's note dated 08/11/20). During an interview on 08/19/20 at 1:31 PM, the DON was asked if the provided list of incidents from 08/01/20 to present included any potential adverse or adverse event, and if it was complete. The DON confirmed the provided list was complete. The list lacked any event for 08/09/20 or any event related to an elopement or sunburn for Resident #1. When asked if they did any kind of report related to Resident #1 and the events on Sunday 08/09/20, the DON stated they did not because the blisters were not present at the time, but developed later. During a subsequent interview on 08/19/20 at 2:45 PM, the DON was asked what type events would she report to the State, and she answered abuse, neglect, and elopements. The DON stated she did not do any immediate or 5 day report for Resident #1. When asked about an adverse report, the DON stated they were looking at it. During a phone interview on 08/20/20 at 8:20 AM, the attending physician for Resident #1 stated he was notified a couple days ago that Resident #1 was out and got a little sun. The attending physician volunteered that he received a phone call from the resident's son, who was upset stating he (Resident #1) got out the front door, and said the facility was neglectful. The attending physician stated he went to the facility on Tuesday 08/18/20 and talked to the staff who told him he was out on the back patio, not out the front door. When asked if he was notified on Sunday 08/09/20 of Resident #1 being outside and sunburned, the attending physician stated no as there is nothing wrong with being out on the patio. When asked if he had seen Resident #1 and the wounds on his feet and legs, the physician stated Resident #1 has had those sores at least 6 weeks or more as he has trouble with circulation. The physician stated he tries to get out of bed and gets himself in awkward positions, and that he doesn't know if those wounds will ever heal, but he is being treated by the wound care physician. During a phone interview on 08/20/20 at 10:33 AM, the Medical Director was asked when he was informed of Resident #1 being found outside with subsequent sunburns. The Medical Director explained Resident #1 was not one of his patients, but he was asked to take a look at him for new blisters on 08/11/20. The Medical Director stated he was told the resident had been outside in the sun and a day later developed the blisters. Upon examination, the Medical Director found clear demarcated evidence of sun exposure of both upper and lower extremities, and can say it was evident of a thermal injury from being in sun. The Medical Director stated he can't tell a time frame of exposure, but can collaborate that this could be blistering from the sun. The Medical Director stated he then gave the order for the [MEDICATION NAME]. The Medical Director confirmed sunburn blisters to both thighs, one arm, and the back of his head. The Medical Director did not assess the resident's feet. When asked if the facility management had talked to him about the event related to an investigation, the Medical Director stated they had and they took measures to lock that back door. During a subsequent phone call on 08/20/20 at 11:16 AM the Medical Director stated he would classify the sunburns as second-degree (a burn severe enough to cause blistering of the skin) burns. During a phone interview on 08/21/20 at 8:17 AM, the Wound Care physician explained he usually sees patients at the facility on Mondays, and makes rounds with the ADON. The physician confirmed he sometimes does virtual visits due to the current pandemic. When asked about Resident #1 and his sunburns, the Wound Care physician explained he was at the facility this past Monday 08/17/20, and it was reported to him by the ADON that somehow Resident #1 had gotten outside for I guess an extended time . at noon an hour is long enough . and [MEDICAL CONDITION] top of knees and scalp. The Wound Care physician stated he was not told of the sunburn on Monday 08/10/20 and confirmed that was a virtual visit. When told staff had reported Resident #1 was on the screened in patio or the back porch from anywhere from 10 minutes to up to an unknown amount of time, the Wound Care physician stated, It would definitely take longer than 10 minutes. The Wound Care physician classified the wounds as second-degree sunburns, with the most significant being on the thighs. The physician reviewed his note and stated he did not include the scalp and foot, but stated, I do remember them there. During an interview on 08/21/20 at 1:27 PM, the Interim Administrator was asked her account of the events of 08/09/20 related to Resident #1 or what was reported to her, and if she would consider the event an elopement. The Interim Administrator stated that as per the investigation by the DON, she was told Resident #1 was seen by the CNA (referring to Staff C) 10 minutes prior to finding him out on the outside patio. The Interim Administrator stated that would not be an elopement as he was found on the back patio. When asked what was done after Resident #1 was found on the outside patio, the Interim Administrator stated the priority was to ensure the resident was safe and he was placed on 1 on 1 supervision. She explained they also assessed all residents for wandering. The Interim Administrator stated on Monday (08/10/20) the door to the back patio was coded to be locked 24/7. The Interim Administrator confirmed she was made aware of the incident on Sunday 08/09/20. The DON, who was also the Risk Manager, was present during this interview, and was asked what was done when the blisters formed and they identified it was due to sun exposure. The DON stated they had the Medical Director assess the resident and received the order for the [MEDICATION NAME]. When asked if at that or any other point did she continue to do a further investigation, the DON stated she did verbal interviews with several staff related to the 'rumors' that were going around the building, but none were valid. When asked how she determined the rumors' were not valid, the DON stated none of the staff she spoke with actually saw anything or were part of the event. The Interim Administrator and DON were asked to locate and provide evidence of the intervention of one on one supervision of Resident #1, and as of the exit conference on 08/22/20 at 4:46 PM, the documentation had not been provided. Review of the daily schedules revealed Sunday 08/09/20 on the night shift (11 PM to 7 AM) was the only documented provision of one on one care. Review of the policy Abuse, Neglect and Exploitation (not dated) documented the definition of neglect as the failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. VII. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: . b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
Based on observations, staff and physician interviews, record review, and policy review, the facility failed to thoroughly investigate the neglect of 1 of 1 known elopements, resulting from inadequate supervision of Resident #1 on 08/09/20. Resident #1, a cognitively impaired vulnerable adult, was outside of the building in direct sunlight in his wheelchair on 08/09/20, having rolled partially off the sidewalk. The resident was found by Staff A, a Certified Nursing Assistant (CNA), in a slumped position, with decreased level of consciousness, an elevated temperature of 102 or 103 degrees Fahrenheit, and subsequently sustained second-[MEDICAL CONDITION] his upper and lower extremities, and to the back of his head. Contradictory interviews with Staff E, the direct care Registered Nurse (RN) for Resident #1 and Nurse Manager for the day on 08/09/20, along with the Director of Nursing (DON), alleged Resident #1 was found on the back patio, having been seen 10 minutes previously. The findings included: During an observation on 08/19/20 at 10:51 AM, Resident #1 was lying in bed covered by a sheet. The resident's feet were uncovered, and multiple scabbed open wounds were noted on the top of the feet. A large yellowish scabbing wound, approximately 10 to 12 centimeters (cm) long by 4 to 6 cm wide was noted to the resident's left foot. While attempting to speak with the resident, who did not verbalize anything at that time, the Director of Nursing (DON) and a representative from another State agency entered the room. The DON immediately covered up the resident's feet. The other State agency representative was unable to get any answer from the resident. Upon removal of the covers, the scabbing wound to the resident's left foot was described as a scrape of some sort by the DON. Further observation revealed large scabbing wounds to the resident's bilateral thighs just above knees, approximately 6 to 8 cm round. The DON was asked about the wounds to the resident's thighs and confirmed the two areas were from the sunburn. The DON stated he also had an area to the back of the head. Observation of the back of the head revealed a scabbed wound approximately 5 to 7 cm round. When asked how long Resident #1 was out in the sun, the DON stated, about 10 minutes. Interviews with staff who observed Resident #1 on Sunday 08/09/20 revealed the following timeline: 10:45 AM: As per an interview on 08/19/20 at 12:02 PM with Staff G, a Certified Occupational Therapy Assistant (COTA), Resident #1 was observed in the therapy room on 08/09/20 at about 10:45 AM, and was returned to the direct care nurse on the North unit. 11:30 AM: As per an interview on 08/21/20 at 2:32 PM with Staff C, the direct care CNA for Resident #1, the CNA last saw Resident #1 in his room on 08/09/20 at about 11:30 AM. Staff C stated the next time she saw Resident #1 was around 2 or 2:30 PM, when he was being pushed into the building through the East Unit fire exit door and taken into the conference room, referred to the bird room on the East Unit. Staff C explained Resident #1 was placed in front of the A/C (air conditioner) because he was so hot, she went to get ice, and they poured ice and water on him. Staff C stated she heard his temperature was like 104 when the resident got into the conference room. During this interview, Staff C volunteered, The DON told me to say I saw him 10 minutes prior to the event. Staff C stated the DON wanted her to say he was only missing 10 minutes, but explained she could not say that. Staff C stated that she believes Resident #1 was missing an hour or two. Staff C stated when she returned to work on Tuesday 08/11/20, Resident #1 had little bubbly looking things on his legs and that she reported it to her nurse that day, Staff F, a Licensed Practical Nurse (LPN). 11:30 AM - 11:50 AM: As per a phone interview on 08/20/20 at 7:58 AM, Staff E, the direct care RN and Nurse Manager for 08/09/20, was asked to explain the events that led to the sunburn for Resident #1. The RN stated Resident #1 was found outside on the patio around noon, and he was a tad warm like 99 degrees, I think. The RN stated she completed a quick assessment and gave him additional fluids. The RN stated Resident #1 was ok and alert. The RN stated she notified everyone who needed to be notified and the doctor. When asked who found Resident #1, the RN stated she was the one who found him on the screened in patio. When asked what led her to the patio, the RN stated she had provided a tube feeding about 11:30 AM or 11:40 AM, and shortly after that she didn't see him in his room, so she went and looked for him. When asked his condition when she found him, the RN stated, He looked a little flushed, but was still his normal self. When asked who exactly she notified, the RN stated (name of attending physician), the resident's son, and the DON. The RN stated the DON told her to do a thorough assessment, call the doctor and to notify his family. 2:30 PM: As per a phone interview on 08/20/20 at 9:43 AM, Staff D, a CNA, observed Resident #1 around lunch time on 08/09/20 in his room, and next observed him after 2:30 PM as a nurse and Staff A, a CNA, were bringing Resident #1 into the building through the East Unit fire door exit. Staff D stated they were saying his temperature was 103 degrees. Staff D explained they had Resident #1 in front of the A/C in the bird room, putting ice on him and he was slumped over. Staff D stated she asked if he was going out (referring to the hospital), and they said no and that they had pumped him full of water. The CNA stated his skin was very red. Staff D explained when she returned to work on Thursday 08/13/20 she saw open blisters all over him. When asked if management or anybody ask her about that day or what happened, Staff D stated they had not. Staff D further stated, The people (referring to other staff) who told management the same as her (referring to the poor condition of Resident #1 when found outside), were told that what they are saying is not true and that he (Resident #1) was found on the patio. 2:30 PM - 2:50 PM: As per an interview on 08/19/20 at 1:08 PM, Staff A, a CNA, explained that on 08/09/20 she was doing her last rounds at about 2:50 PM, and was assisting Resident #4 in room [ROOM NUMBER]W, when she looked out the window and saw someone out on the sidewalk, facing away from her. When she finished with Resident #4, the resident was still outside in the same location. Staff A stated she went outside and realized it was Resident #1. His wheelchair was partially off the sidewalk and she stated she could not get him out of the grass, so she ran back in a called for a nurse, who helped her get his wheelchair out of the grass. Staff A stated when she found him, He was a hot mess. He had snot running out of his nose, he was boiling hot, and he wasn't with it. It took us until 3:15 PM to get him cooled down and back talking. Staff A explained they put ice packs and cold rags all over him, and his temperature was 102 degrees when they found him. He was sunburned and she took a bottle of lotion and just started putting it all over him, anywhere there was not clothing, as he was hot and burned. Staff A was asked to show the surveyor where she found Resident #1 on that Sunday 08/09/20. Staff A took the surveyor through the main dining room, through the gym, through the screened in patio, through the outside back patio, down the sidewalk to an area past the East unit fire exit door just past where the sidewalk splits off to the left. (Photographic evidence obtained). During a subsequent phone interview on 08/19/20 at 6:44 PM, Staff A identified the nurse who assisted her to get Resident #1 out of the grass, as Staff B, a LPN. 2:30 PM - 2:50 PM: As per a phone interview on 08/20/20 at 10:02 AM, Staff B, a Licensed Practical Nurse (LPN) explained she was working on the East and West units on Sunday 08/09/20, and saw Resident #1 up in his wheelchair that morning (unsure of time), as he wheeled himself up to her and they spoke briefly. Staff B explained a CNA got her and took her to the screened in patio. The LPN stated his nurse said everything was OK and that she had it under control, so the LPN went back to her unit. When asked if she assisted a CNA to get Resident #1 out of the grass and back onto the sidewalk, the LPN stated she did not. When asked if management or anyone asked her about the event, Staff B stated they did not. Staff B stated, I thought it was done and over with until I heard State was in the building last night. During a subsequent phone interview on 08/20/20 at 10:43 AM, the LPN stated, I'm sorry, my brain was foggy. This is what happened. The LPN explained she was on the East unit on 08/09/20 at 2:30 PM, recalling that it was close to shift change, and Staff A, a CNA, was putting Resident #4 back to bed. The LPN recalled the CNA called out her name and that someone was outside. The LPN stated she hoped it wasn't Resident #1 as she had seen him up earlier in the day, which was unusual for him. The LPN stated they went out so she could help the CNA as Resident #1 was stuck in the grass. The LPN stated as she was pushing him in through the East Unit fire exit door, Staff E, his direct care RN, was right there and took the resident. When asked if she took any of the resident's vital signs, the LPN stated she took his blood pressure, but denied taking his temperature. When asked if she remembered what his temperature was, the LPN stated that she did not remember, but it was up there. Additional staff interviews conducted revealed development of blisters from the sun exposure of Resident #1: During an interview on 08/19/20 at 11:28 AM, Staff F, a LPN, explained she returned to work on Tuesday 08/11/20. The LPN stated she was told Resident #1 was outside and got sunburned and was extremely alarmed looking at the wounds. She stated she contacted the attending physician and received order for [MEDICATION NAME] (from the Medical Director as per review of the order). The LPN explained Resident #1 had sunburns to his left foot, bilateral thighs, left forearm, and the back of his head. The LPN explained they were closed raised blisters upon her assessment on 08/11/20, exactly like sun poisoning. (Note that review of the record lacked any nurse's note dated 08/11/20). During an interview on 08/19/20 at 12:29 PM, Staff H, a LPN, stated on Monday 08/10/20 Resident #1's skin was reddened and later became fluid filled blisters that opened up (unsure of the time frame). The LPN confirmed Resident #1 was cognitively impaired and able to wheel himself around the facility. The LPN stated she had seen the resident up and down the halls, as far as the receptionist, but had never seen him trying to get out of a door. Staff H explained the resident needs frequent rounding and re-direction when trying to go past the nurse's station, which can be done with tube feeding or calls to his son. (Note that review of the record lacked any nurse's note dated 08/10/20). During an interview on 08/19/20 at 1:31 PM, the DON was asked if the provided list of incidents from 08/01/20 to present included any potential adverse or adverse event, and if it was complete. The DON confirmed the provided list was complete. The list lacked any event for 08/09/20 or any event related to an elopement or sunburn for Resident #1. When asked if they did any kind of report related to Resident #1 and the events on Sunday 08/09/20, the DON stated they did not because the blisters were not present at the time, but developed later. During a subsequent interview on 08/19/20 at 2:45 PM, the DON confirmed she had started an investigation. The DON was asked to provide evidence of an investigation for Resident #1 related to being found out in the sun on 08/09/20 with subsequent second-degree sunburns. Upon return with the investigation, and during the continued interview on 08/19/20 at 3:19 PM, the DON was asked what happened with Resident #1 on 08/09/20. The DON stated on Sunday afternoon (08/09/20) she was notified that Resident #1 was outside on the back patio for no more than 10 minutes. The DON explained she asked the direct care nurse (Staff E) how he was doing and she stated he was fine. The DON told the nurse to do his vital signs, call the family and physician, and to continue to monitor him. On 08/19/20 at 3:31 PM the DON was asked to show the surveyor where Resident #1 was found on that Sunday 08/09/20. The DON identified a location on the back open patio area, just behind the screened in patio. (Photographic evidence obtained.) When asked what had been completed as far as the investigation for Resident #1, the DON stated she reviewed to determine if he was exit seeking and put him on frequent monitoring, and received statements from the assigned nurse and CNA. When asked if she did any type of report or investigation, the DON stated she did not because Resident #1 was found on the back patio and he was fine. When asked if she spoke with other staff and or got any other written statements from any other staff, the DON stated she obtained verbal statements that confirmed what the assigned nurse (Staff E) and CNA (Staff C) told her. Review of the investigation provided by the DON revealed a progress note from the attending physician dated 08/18/20, the statements from the direct care nurse (which was a copy of the nurse's note from the record), a statement from the direct care CNA, a new Wandering Assessment for Resident #1 dated 08/09/20, a skin assessment for Resident #1 dated 08/09/20 that documented new redness to the back of the head, the back of the left elbow, a small amount of redness to bilateral thighs, and a blister to the top of the left foot (along with wounds previous to the date), and a census with checkmarks next to each resident signed by an RN and dated 08/09/20 (which was described by the DON as their heads in the bed resident check), and an new care plan dated 08/11/20 for Resident #1 being at risk for elopement. Review of the nurse's note dated 08/09/20 at 1746 by Staff E, that was provided as part of the investigation, documented, Resident observed upright alert in w/c (wheelchair) on Facility back patio, last observed 10 minutes prior on North hall. T-99.3 . Resident administered additional fluids via [DEVICE] and reassessed. Temp 98.3. (Name of attending physician) and family notified of resident on facility's back patio. T.O (telephone order) received for [MEDICATION NAME] . for night restlessness. Will cont to monitor. This note lacked any documented evidence it was a late entry and lacked any documented time of the event or interventions. During a phone interview on 08/20/20 at 8:20 AM, the attending physician for Resident #1 stated he was notified a couple days ago that Resident #1 was out and got a little sun. The attending physician volunteered that he received a phone call from the resident's son, who was upset stating he (Resident #1) got out the front door, and said the facility was neglectful. The attending physician stated he went to the facility on Tuesday 08/18/20 and talked to the staff who told him he was out on the back patio, not out the front door. When asked if he was notified on Sunday 08/09/20 of Resident #1 being outside and sunburned, the attending physician stated no as there is nothing wrong with being out on the patio. When asked if he had seen Resident #1 and the wounds on his feet and legs, the physician stated Resident #1 has had those sores at least 6 weeks or more as he has trouble with circulation. The physician stated he tries to get out of bed and gets himself in awkward positions, and that he doesn't know if those wounds will ever heal, but he is being treated by the wound care physician. During a phone interview on 08/20/20 at 10:33 AM, the Medical Director was asked when he was informed of Resident #1 being found outside with subsequent sunburns. The Medical Director explained Resident #1 was not one of his patients, but he was asked to take a look at him for new blisters on 08/11/20. The Medical Director stated he was told the resident had been outside in the sun and a day later developed the blisters. Upon examination, the Medical Director found clear demarcated evidence of sun exposure of both upper and lower extremities, and can say it was evident of a thermal injury from being in sun. The Medical Director stated he can't tell a time frame of exposure, but can collaborate that this could be blistering from the sun. The Medical Director stated he then gave the order for the [MEDICATION NAME]. The Medical Director confirmed sunburn blisters to both thighs, one arm, and the back of his head. The Medical Director did not assess the resident's feet. When asked if the facility management had talked to him about the event related to an investigation, the Medical Director stated they had and they took measures to lock that back door. During a subsequent phone call on 08/20/20 at 11:16 AM the Medical Director stated he would classify the sunburns as second-degree (a burn severe enough to cause blistering of the skin) burns. During a phone interview on 08/21/20 at 8:17 AM, the Wound Care physician explained he usually sees patients at the facility on Mondays, and makes rounds with the ADON. The physician confirmed he sometimes does virtual visits due to the current pandemic. When asked about Resident #1 and his sunburns, the Wound Care physician explained he was at the facility this past Monday 08/17/20, and it was reported to him by the ADON that somehow Resident #1 had gotten outside for I guess an extended time . at noon an hour is long enough . and [MEDICAL CONDITION] top of knees and scalp. The Wound Care physician stated he was not told of the sunburn on Monday 08/10/20 and confirmed that was a virtual visit. When told staff had reported Resident #1 was on the screened in patio or the back porch from anywhere from 10 minutes to up to an unknown amount of time, the Wound Care physician stated, It would definitely take longer than 10 minutes. The Wound Care physician classified the wounds as second-degree sunburns, with the most significant being on the thighs. The physician reviewed his note and stated he did not include the scalp and foot, but stated, I do remember them there. During an interview on 08/21/20 at 1:27 PM, the Interim Administrator was asked her account of the events of 08/09/20 related to Resident #1 or what was reported to her, and if she would consider the event an elopement. The Interim Administrator stated that as per the investigation by the DON, she was told Resident #1 was seen by the CNA (referring to Staff C) 10 minutes prior to finding him out on the outside patio. The Interim Administrator stated that would not be an elopement as he was found on the back patio. When asked what was done after Resident #1 was found on the outside patio, the Interim Administrator stated the priority was to ensure the resident was safe and he was placed on 1 on 1 supervision. She explained they also assessed all residents for wandering. The Interim Administrator stated on Monday (08/10/20) the door to the back patio was coded to be locked 24/7. The Interim Administrator confirmed she was made aware of the incident on Sunday 08/09/20. The DON, who was also the Risk Manager, was present during this interview, and was asked what was done when the blisters formed and they identified it was due to sun exposure. The DON stated they had the Medical Director assess the resident and received the order for the [MEDICATION NAME]. When asked if at that or any other point did she continue or do a further investigation, the DON stated she did verbal interviews with several staff related to the 'rumors' that were going around the building, but none were valid. When asked how she determined the rumors' were not valid, the DON stated none of the staff she spoke with actually saw anything or were part of the event. The Interim Administrator and DON were asked to locate and provide evidence of the intervention of one on one supervision of Resident #1, and as of the exit conference on 08/22/20 at 4:46 PM, the documentation had not been provided. Review of the daily schedules revealed Sunday 08/09/20 on the night shift (11 PM to 7 AM) was the only documented provision of one on one care. On 08/21/20 at 1:50 PM the Maintenance Assistant was shown the area the DON identified as the location Resident #1 was found on the open back patio, along with the location Staff A found Resident #1 just off the sidewalk and in the grass. The Maintenance Assistant measured between the two locations and it was a difference of about 113 feet. During an interview on 08/21/20 at 3:13 PM, the ADON stated she does not routinely work weekends. When asked if she had any part in the follow up investigation for Resident #1, the ADON stated the investigation was done by the DON and the Interim Administrator. Review of the policy Abuse, Neglect and Exploitation (not dated) documented the definition of neglect as the failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. V. Investigation of Alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include: . 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5 Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation.
Based on observations, staff and physician interviews, record review, and policy review the facility failed to supervise 1 of 4 sampled residents, resulting in elopement for approximately two hours, and subsequent second-degree sunburns to Resident #1. Resident #1 was last observed in his room by Staff D, a Certified Nursing Assistant (CNA), on 08/09/20 around noon. Between 2:30 PM and 2:50 PM on 08/09/20, Staff A, a CNA, was assisting Resident #4 who resides in room [ROOM NUMBER] on the East Unit, when she looked out the window and saw Resident #1 outside. Resident #1, a cognitively impaired vulnerable adult, was outside of the building in direct sunlight in his wheelchair on 08/09/20, having rolled partially off the sidewalk. The resident was found by Staff A, CNA, in a slumped position, with decreased level of consciousness, an elevated temperature of 102 or 103 degrees Fahrenheit, and subsequently sustained second [MEDICAL CONDITION] his upper and lower extremities, and to the back of his head. Contradictory interviews with Staff E, the direct care Registered Nurse (RN) for Resident #1 and Nurse Manager for the day on 08/09/20, along with the Director of Nursing (DON), alleged Resident #1 was found on the back patio, having been seen 10 minutes previously. Interview with Staff C, the direct care CNA for Resident #1 on 08/09/20 during the 7 AM to 3 PM shift, revealed she last observed Resident #1 on 08/09/20 around 11:30 AM. The facility also failed to ensure Elopement Risk assessments upon admission as per their policy and procedure, for 4 (Residents #1, #2, #3, and #4) of 4 sampled residents, and failed to accurately identify 1 (Resident #4) of 3 residents at risk for elopement in their current Elopement Book located at the receptionist desk. The findings included: 1) During an observation on 08/19/20 at 10:51 AM, Resident #1 was lying in bed covered by a sheet. The resident's feet were uncovered, and multiple scabbed open wounds were noted on the top of the feet. A large yellowish scabbing wound, approximately 10 to 12 centimeters (cm) long by 4 to 6 cm wide was noted to the resident's left foot. While attempting to speak with the resident, who did not verbalize anything at that time, the Director of Nursing (DON) and a representative from another State agency entered the room. The DON immediately covered up the resident's feet. The other State agency representative was unable to get any answer from the resident. Upon removal of the covers, the scabbing wound to the resident's left foot was described as a scrape of some sort by the DON. Further observation revealed large scabbing wounds to the resident's bilateral thighs just above knees, approximately 6 to 8 cm round. The DON was asked about the wounds to the resident's thighs and confirmed the two areas were from the sunburn. The DON stated he also had an area to the back of the head. Observation of the back of the head revealed a scabbed wound approximately 5 to 7 cm round. When asked how long Resident #1 was out in the sun, the DON stated, about 10 minutes. Interviews with staff who observed Resident #1 on Sunday 08/09/20 revealed the following timeline: 10:45 AM: As per an interview on 08/19/20 at 12:02 PM, Staff G, a Certified Occupational Therapy Assistant (COTA) explained she finished seeing her residents on 08/09/20 at about 10:45 AM, and returned to the gym (therapy room), and found Resident #1 with Resident #5, with no staff present. Staff G wheeled Resident #1 back to the North Unit, with Resident #5 following independently, and informed Staff E, the direct care nurse for Resident #1 and the designated Nurse Manager for the day, that the two residents were in the gym with no staff present, and that the therapy staff were leaving for the day. Staff G explained that neither resident could be left alone, as Resident #1 was cognitively impaired, especially related to safety issues, and Resident #5 could have possibly let Resident #1 out because Resident #5 thinks he is security. The Staff G explained that most mornings upon her arrival, Resident #5 is in the main dining room, located next to the gym, drinking his coffee and greets her with a comment like, You are the first one here today as she turns on the lights. Staff G stated Resident #1 was alert and oriented to self and place, but not accurate and not reliable as far as safety. 11:30 AM: As per an interview on 08/21/20 at 2:32 PM, Staff C, the direct care CNA for Resident #1, explained that Resident #1 was in his room on 08/09/20 at about 11:30 AM, when she asked Staff D, another CNA working on the North Unit to cover her rooms as she needed to go outside for a phone call. The direct care CNA stated when she got back about 11:45 AM or noon, she was told by Staff D that Resident #1 was still in his room, but did not go to the resident's room at that time. Staff C, the direct care CNA, explained that shortly after that, Staff E, the direct care RN, asked her to check on Resident #1, and he was not in his room. Staff C stated she started looking in every room on the North Unit, could not find Resident #1, so she reported that to her supervisor, Staff E, who went outside and found him. When asked if she knew where they found Resident #1, Staff C was unsure. When asked at what time Resident #1 was found, Staff C stated, He was gone for a while. I just can't remember the time they found him outside. Then Staff C stated she thought they found Resident #1 around 2 or 2:30 PM. When asked when and where she saw Resident #1 around 2 or 2:30 PM, Staff C, the direct care CNA explained she saw him being pushed into the building through the East Unit fire exit door and taken into the conference room, referred to the bird room on the East Unit. Staff C explained her supervisor (Staff E) put Resident #1 in front of the A/C (air conditioner) because he was so hot, she went to get ice, and they poured ice and water on him. When asked who was involved, Staff C stated (Name of Staff E, the direct care RN) did everything. Staff C stated she heard his temperature was like 104 when the resident got into the conference room, and she was then asked to leave. When asked if staff were looking for him from shortly after noon until 2 or 2:30 PM as she described, Staff C stated she really was unsure of the times. Staff C volunteered to the surveyor that she was told by the DON to say she saw him 10 minutes before he was found. Staff C explained that she wrote a statement that meant the last time she saw the resident was about 10 minutes before she noticed he was missing, but then again stated, The DON wanted me to say he was only missing for 10 minutes. Staff C stated that she thinks he was missing an hour or two. Staff C stated she worked a double shift that day, and confirmed Resident #1 was on her assignment from 7 AM the morning of 08/09/20 until 11 PM that night. Staff C stated Resident #1 was definitely red from the sun that evening, slept a lot, but would wake up when the nurse did his tube feeding or to talk with his son. Staff C denied any signs or symptoms of pain. Staff C stated when she returned to work on Tuesday 08/11/20, Resident #1 had little bubbly looking things on his legs and that she reported it to her nurse that day, Staff F, a LPN. 11:30 AM - 11:50 AM: As per a phone interview on 08/20/20 at 7:58 AM, Staff E, the direct care RN and Nurse Manager for 08/09/20, was asked to explain the events that led to the sunburn for Resident #1. The RN stated Resident #1 was found outside on the patio, and he was a tad warm like 99 degrees, I think. The RN stated she completed a quick assessment and gave him additional fluids. The RN stated Resident #1 was ok and alert. The RN stated she notified everyone who needed to be notified and the doctor. When asked who found Resident #1, the RN stated she was the one who found him on the screened in patio. When asked what led her to the patio, the RN stated she had provided a tube feeding about 11:30 AM or 11:40 AM, and shortly after that she didn't see him in his room, so she went and looked for him. When asked his condition when she found him, the RN stated, He looked a little flushed, but was still his normal self. When asked who exactly she notified, the RN stated (name of attending physician), the resident's son, and the DON. The RN stated the DON told her to do a thorough assessment, call the doctor and to notify his family. The RN stated 08/09/20 was the first day she saw Resident #1 self-propelling around and active. When asked where she saw him self-propelling, the RN stated, pretty much in the north hall. 2:30 PM: As per a phone interview on 08/20/20 at 9:43 AM, Staff D, a CNA, explained she saw Resident #1 around lunch time on 08/09/20, and he had been continuously propelling himself up and down the hall that day. Staff D explained that on 08/09/20 at about 2:30 PM she was starting to take the vital signs for her residents, as she was working a double that day, and Staff C told her she was unable to find Resident #1. Staff D stated they both went to the nurse's station, and then went in different directions to search for Resident #1. Staff D explained she went to the main dining room and peeked through the windows, then went into the rehab room/gym, then into the screened in patio and saw a nurse (unsure which one) and Staff A, a CNA, bringing Resident #1 into the building through the East Unit fire door exit. Staff D stated they were saying his temperature was 103 degrees. Staff D explained they had Resident #1 in front of the A/C in the bird room, putting ice on him and he was slumped over. Staff D stated she asked if he was going out (referring to the hospital), and they said no and that they had pumped him full of water. The CNA stated his skin was very red. Staff D explained when she returned to work on Thursday 08/13/20 she saw open blisters all over him and he didn't seem himself. During a subsequent interview on 08/21/20 at 5:02 PM, when asked if she covered Staff C, the direct care CNA, on 08/09/20 while she took a phone call, Staff D stated she covered Staff C while she went for lunch. Staff D stated the CNA returned from lunch about noon and that was the last time she saw Resident #1, until the search at 2:30 PM. Staff D stated the evening of 08/09/20 Resident #1 was very lethargic and just wanted to lie down, but was able to talk to his son on the phone. Staff D stated Resident #1's skin was really red on 08/09/20, but no blisters on that date. Staff D stated she returned to work on Thursday (08/13/20) and Resident #1 had open blisters. Staff D stated she saw Resident #1 in the hallway that day, but he was not as active just sitting in his wheelchair, but not wandering around. 2:30 PM - 2:50 PM: As per an interview on 08/19/20 at 1:08 PM, Staff A, a CNA, explained that on 08/09/20 she was doing her last rounds at about 2:50 PM, and was assisting Resident #4, who resided on the East Unit in room [ROOM NUMBER]W, a room located on the opposite side of the hall from the back patio. Staff A stated while assisting Resident #4 to bed, she looked out the window and saw someone out on the sidewalk, facing away from her. While assisting Resident #4, she kept glancing outside, expecting someone to come get the person. When she finished with Resident #4, the resident was still outside in the same location. Staff A stated she went outside and realized it was Resident #1. His wheelchair was partially off the sidewalk and she stated she could not get him out of the grass, so she ran back in and called for a nurse, who helped her get his wheelchair out of the grass. Staff A stated when she found him, He was a hot mess. He had snot running out of his nose, he was boiling hot, and he wasn't with it. It took us until 3:15 PM to get him cooled down and back talking. Staff A explained they put ice packs and cold rags all over him, and his temperature was 102 degrees when they found him. He was sunburned and she took a bottle of lotion and just started putting it all over him, anywhere there was not clothing, as he was hot and burned. Staff A stated she left at 3:18 PM, as she remembered looking at the time and realized she needed to go. Staff A was asked to show the surveyor where she found Resident #1 on that Sunday 08/09/20. Staff A took the surveyor through the main dining room, through the gym, through the screened in patio, through the outside back patio, down the sidewalk to an area past the East unit fire exit door just past where the sidewalk splits off to the left. (Photographic evidence obtained). During a subsequent phone interview on 08/19/20 at 6:44 PM, Staff A identified the nurse who assisted her to get Resident #1 out of the grass, as Staff B, a Licensed Practical Nurse (LPN). As per www.timeanddate.com the weather for Vero Beach, the city where the facility is located, on 08/09/20 from noon to 6 PM was 88 to 90 degrees Fahrenheit, with passing clouds. 2:30 PM - 2:50 PM: As per a phone interview on 08/20/20 at 10:02 AM, Staff B, a Licensed Practical Nurse (LPN) explained she was working on the East and West units on Sunday 08/09/20, and saw Resident #1 up in his wheelchair that morning (unsure of time), as he wheeled himself up to her and they spoke briefly. Staff B explained a CNA got her and took her to the screened in patio. Staff B stated his nurse said everything was OK and that she had it under control, so the LPN went back to her unit. When asked if she assisted a CNA to get Resident #1 out of the grass and back onto the sidewalk, Staff B stated she did not. During a subsequent phone interview on 08/20/20 at 10:43 AM, Staff B stated, I'm sorry, my brain was foggy. This is what happened. Staff B explained she was on the East unit on 08/09/20 at 2:30 PM, recalling that it was close to shift change, and Staff A, a CNA was putting Resident #4 back to bed. Staff B recalled the CNA called out her name and that someone was outside. Staff B stated she hoped it wasn't Resident #1 as she had seen him up earlier in the day, which was unusual for him. Staff B stated they went out so she could help the CNA as Resident #1 was stuck in the grass. Staff B, the LPN stated as she was pushing him in through the East Unit fire exit door, Staff E, his direct care RN, was right there and took the resident. When asked if she took any of the resident's vital signs, Staff B stated she took his blood pressure, but denied taking his temperature. When asked if she remembered what his temperature was, Staff B stated that she did not remember, but it was up there. Additional staff interviews conducted revealed the following: During an interview on 08/19/20 at 11:28 AM, Staff F, a LPN, confirmed she usually works the North unit were Resident #1 resided, and works every other weekend. The LPN stated she was off the weekend of 08/09/20, but returned to work on Tuesday 08/11/20. The LPN stated she was told Resident #1 was outside and got sunburned, but was not informed of the time of the event. The LPN stated she was wondering how he was outside by himself, as he can self-propel but needs help getting into the wheelchair. The LPN stated she was extremely alarmed looking at the wounds. She stated she contacted the attending physician and received order for [MEDICATION NAME] (from the Medical Director as per review of the order). Staff F, the LPN explained Resident #1 had sunburns to his left foot, bilateral thighs, left forearm, and the back of his head. The LPN explained they were closed raised blisters upon her assessment on 08/11/20, exactly like sun poisoning. The LPN stated Resident #1 needs to be monitored at least every 30 minutes to ensure safety. The LPN stated if Resident #1 is up in his wheelchair, she does not let him go off the unit, and she would ask the CNAs to also help watch him. The LPN stated Resident #1 does talk but does not make sense. When asked about pain, Staff F stated when the wounds were open and care was being provided, she could tell it was uncomfortable as Resident #1 would grimace a little, so Tylenol was provided. The LPN stated he did not scream out, but that he isn't cognitively with it enough to describe or verbalize pain. During an interview on 08/19/20 at 12:29 AM, Staff H, a LPN, stated on Monday 08/10/20 Resident #1's skin was reddened and later became fluid filled blisters that opened up (unsure of the time frame). Staff H confirmed Resident #1 was cognitively impaired and able to wheel himself around the facility. Staff H stated she had seen the resident up and down the halls, as far as the receptionist, but had never seen him trying to get out of a door. Staff H explained the resident needs frequent rounding and re-direction when trying to go past the nurse's station, which can be done with tube feeding or calls to his son. On 08/19/20 at 3:19 PM, the DON was asked what happened with Resident #1 on 08/09/20. The DON stated on Sunday afternoon (08/09/20) she was notified that Resident #1 was outside on the back patio for no more than 10 minutes. The DON explained she asked the direct care nurse how he was doing and she stated he was fine. The DON told the nurse to do his vital signs, call the family and physician, and to continue to monitor him. The DON stated she was told the resident was on the phone with the family and she (Staff E, the direct care RN) spoke with family at that time. The DON stated this was an isolated incident for him as he was previously on the observation (closed) unit after a recent hospitalization , and he had stayed in his room. The DON stated when the resident was transferred to the North unit (on 08/06/20) he became more active. When asked what has been done as far as an investigation related to finding him alone on the back patio with subsequent sunburns, the DON stated she reviewed if he was exit seeking, put him on frequent monitoring, and obtained a written statement from the assigned nurse and CNA. On 08/19/20 at 3:31 PM the DON was asked to show the surveyor where Resident #1 was found on that Sunday 08/09/20. The DON identified a location on the back open patio area, just behind the screened in patio. (Photographic evidence obtained.) During a phone interview on 08/20/20 at 8:20 AM, the attending physician for Resident #1 stated he was notified a couple days ago that Resident #1 was out and got a little sun. The attending physician volunteered that he received a phone call from the resident's son, who was upset stating he (Resident #1) got out the front door, and said the facility was neglectful. The attending physician stated he went to the facility on Tuesday 08/18/20 and talked to the staff who told him he was out on the back patio, not out the front door. When asked if he was notified on Sunday 08/09/20 of Resident #1 being outside and sunburned, the attending physician stated no as there is nothing wrong with being out on the patio. When asked if he had seen Resident #1 and the wounds on his feet and legs, the physician stated that he has had those sores at least 6 weeks or more as he has trouble with circulation. The physician stated he tries to get out of bed and gets himself in awkward positions, and that he doesn't know if those wounds will ever heal, but he is being treated by the wound care physician. During a phone interview on 08/20/20 at 10:33 AM, the Medical Director was asked when he was informed of Resident #1 being found outside with subsequent sunburns. The Medical Director explained Resident #1 was not one of his patients, but he was asked to take a look at him for new blisters on 08/11/20. The Medical Director stated he was told the resident had been outside in the sun and a day later developed the blisters. Upon examination, the Medical Director found clear demarcated evidence of sun exposure of both upper and lower extremities, and can say it was evident of a thermal injury from being in sun. The Medical Director stated he can't tell a time frame of exposure, but can collaborate that this could be blistering from the sun. The Medical Director stated he then gave the order for the [MEDICATION NAME]. The Medical Director stated Resident #1 was up in his wheelchair in the main dining room when he saw him on 08/11/20. The Medical Director confirmed sunburn blisters to both thighs, one arm, and the back of his head. The Medical Director did not assess the resident's feet. During a subsequent phone call on 08/20/20 at 11:16 AM the Medical Director stated he would classify the sunburns as second degree (a burn severe enough to cause blistering of the skin) burns. During a phone interview on 08/21/20 at 8:17 AM, the Wound Care physician explained he usually sees patients at the facility on Mondays, and makes rounds with the ADON. The physician confirmed he sometimes does virtual visits due to the current pandemic. When asked about Resident #1 and his sunburns, the Wound Care physician explained he was at the facility this past Monday 08/17/20, and it was reported to him by the ADON that somehow Resident #1 had gotten outside for I guess an extended time . at noon an hour is long enough . and [MEDICAL CONDITION] top of knees and scalp. The Wound Care Physician stated he recommended [MEDICATION NAME] cream and they had already placed that order. When asked about the timeframe for blisters to develop, the Wound Care physician stated it would depend upon the timeframe he was out there. The Wound Care physician stated he was not told of the sunburn on Monday 08/10/20 and confirmed that was a virtual visit. When told staff had reported Resident #1 was on the screened in patio or the back porch from anywhere from 10 minutes to up to an unknown amount of time, the Wound Care physician stated, It would definitely take longer than 10 minutes. The Wound Care physician classified the wounds as second-degree sunburns, with the most significant being on the thighs. The physician reviewed his note and stated he did not include the scalp and foot, but stated, I do remember them there. On 08/21/20 at 1:50 PM the Maintenance Assistant was shown the area the DON identified as the location Resident #1 was found on the open back patio, along with the location Staff A found Resident #1 just off the sidewalk and in the grass. The Maintenance Assistant measured between the two locations and it was a difference of about 113 feet. During an interview on 08/21/20 at 3:13 PM, the ADON stated she does not routinely work weekends. The ADON confirmed she made rounds with the Wound Care physician. The ADON stated on 08/10/20 they did virtual rounds and that Resident #1 was red on that day, but had no blisters. The ADON stated on Tuesday 08/11/20 the Medical Director was in the building and was made aware of the blisters, and ordered the [MEDICATION NAME]. The ADON stated when Resident #1 was on the East unit he would sit in his wheelchair just outside of the bird room. She explained the resident transferred to the North unit to room [ROOM NUMBER] on 08/06/20. Review of the record revealed Resident #1 was admitted to the facility on [DATE] having sustained a right knee and leg fracture, was diabetic, was fed by a feeding tube, was at risk for falls and skin breakdown, and had dementia with a Brief Interview for Mental Status (BIMS) score of 11 on a 0 to 15 scale as per the Admission Minimum Data Set (MDS) assessment dated [DATE], indicating some cognitive deficits. Resident #1 was transferred to the hospital related to critical laboratory values on 07/16/20, and returned to the facility to reside on the East Observation unit on 07/23/20. Record review revealed Resident #1 was re-admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #1 was transferred to the North unit and into room [ROOM NUMBER], the second to last room on that hall, on 08/06/20. The three fire exit doors located at the end of all three units were locked and alarmed. For Resident #1 to get from his room to the location he was found by Staff A, the resident would have had to go up the North unit hallway, past the nurse's station, through the hallway past the lobby area, into and through the main dining room (that was not being utilized because of the pandemic), through the gym, through double doors onto a screened in patio, out onto a back patio, down a sidewalk approximately another 113 feet past the location identified by the DON, to the opposite side of the East unit from the back patio. A physician's orders [REDACTED]. A single nurse's note dated 08/09/20 at 1746 by Staff E documented, Resident observed upright alert in w/c (wheelchair) on Facility back patio, last observed 10 minutes prior on North hall. T-99.3 . Resident administered additional fluids via [DEVICE] and reassessed. Temp 98.3. (Name of attending physician) and family notified of resident on facility's back patio. Will cont to monitor. This note lacked any documented evidence it was a late entry and lacked any documented time of the event or interventions. Review of the current Baseline Care Plan dated 07/23/20 documented Resident #1 was at risk for falls related to poor safety awareness. This care plan documented N/A for elopement. Review of the Wound Care physician's Wound Evaluation and Management Summary note dated 08/17/20 documented Site #9 as a burn wound of the right thigh measuring 8 cm long by 7 cm wide and 0.1 cm deep. This note also documented Site #10 as a burn wound of the left thigh measuring 9 cm long by 5 cm wide by 0.1 cm deep. Review of the policy Elopements and Wandering Residents (not dated) documented, 2. 'Elopement' occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. 8. Procedure Post-Elopement a. A nurse will perform a physical assessment, document, and report findings to physician. 2) Review of the policy Elopements and Wandering Residents (not dated) documented, 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering. a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. An interview on 08/19/20 at 3:08 PM with Staff I, a receptionist, revealed the facility has an Elopement book maintained at the receptionist desk that identified any resident at risk for elopement. Review of the Elopement Book revealed three current residents, Resident #1, #2, and #3. On 08/21/20 at approximately 4:00 PM, the Minimum Data Set (MDS) Coordinator was asked to provide any care plan related to elopement or wandering behaviors Residents #2 and #3. On 08/21/20 at 4:40 PM, the DON and MDS Coordinator informed the surveyor that the two roommates, Resident #3 and Resident #4 were mixed up, and that Resident #3 who was in the Elopement Book was not at risk, but her roommate Resident #4 was an elopement risk but was not in the Elopement Book. During an interview on 08/22/20 at 11:30 AM, the Assistant Director of Nursing (ADON) was asked the facility's policy or practice related to wandering behaviors and an elopement risk assessment. The ADON explained the elopement risk assessment was to be completed upon admission and if there is an event, utilizing the Gates Wandering Assessment. Review of the Gates Wandering Assessment documented, Instructions: Complete on admission/readmission, at 72 hours, and one month later, with change of condition and annually on all residents. For residents at risk or high risk to wander, update quarterly. Record review revealed Resident #3 was admitted to the facility on [DATE]. Further review lacked any elopement risk assessment. On 08/22/20 at 11:30 AM, the ADON was asked to locate and provide the admission elopement risk assessment for Resident #3, and was unable to locate one. Record review revealed Resident #4 was admitted to the facility on [DATE]. Further review lacked any elopement risk assessment. During an interview on 08/22/20 at 11:39 AM, the ADON was asked to locate and provide the admission elopement risk assessment for Resident #4. Review of the Baseline Care plan dated 08/04/20 for Resident #4 revealed the problem that Resident #4 was at risk for elopement as evidenced by wandering. Interventions included to complete the elopement risk assess, ensure staff are aware, and to apply a Wandergaurd device. During this interview the ADON was asked if the facility uses the Wandergaurd alarm system. The ADON explained they have not used Wandergaurds in more than a year because it was only set up to alarm if the resident went out the front door. On 08/22/20 at 11:46 AM, the ADON stated she was unable to locate the admission elopement risk assessment for Resident #4. Record review revealed Resident #1 was re-admitted to the facility on [DATE]. On 08/22/20 at 11:46 AM, the ADON was asked to locate and provide the admission elopement risk assessment for the 07/23/20 admission. On 08/22/20 at 12:05 PM, the ADON provided an Admission Data Collection Tool dated 07/23/20 with a question related to wandering answered as no, but was unable to locate the elopement risk assessment. The ADON confirmed the elopement risk assessment should have been completed. Record review revealed Resident #2 was admitted on [DATE]. On 08/22/20 at 12:05 PM the ADON was unable to locate and provide the admission elopement risk assessment for Resident #2.
Based on observation, staff and physician interviews, record review, policy review, and review of job descriptions, Administration failed to implement their neglect policy and procedure related to appropriate notification of the attending physician, reporting, and investigation of the known elopement of 1 of 1 residents, resulting from inadequate supervision of Resident #1 on 08/09/20. Administrative failure to ensure staff implementation of resident supervision/monitoring resulted in Resident #1, a cognitively impaired vulnerable adult, being outside of the building in direct sunlight in his wheelchair on 08/09/20, having rolled partially off the sidewalk. The resident was found by Staff A, a Certified Nursing Assistant (CNA), in a slumped position, with decreased level of consciousness, an elevated temperature of 102 or 103 degrees Fahrenheit, and subsequently sustained second-[MEDICAL CONDITION] his upper and lower extremities, and to the back of his head. Administration failed to ensure staff provide adequate treatment when Resident #1 was found with a significant change in condition and failed to ensure accurate documentation to ensure needed care and services were provided timely. The attending physician was not informed of the condition of Resident #1 on 08/09/20 or with the development of the blisters from the second-degree burns, and was later told the resident was found on the back patio and got a little sun. The Director of Nursing (DON), who was also the Risk Manager, along with the Interim Administrator, failed to complete a thorough investigation that would have revealed the actual elopement, and failed to report the elopement to the State Agency. The findings included: During an observation on 08/19/20 at 10:51 AM, Resident #1 was lying in bed covered by a sheet. The resident's feet were uncovered, and multiple scabbed open wounds were noted on the top of the feet. A large yellowish scabbing wound, approximately 10 to 12 centimeters (cm) long by 4 to 6 cm wide was noted to the resident's left foot. While attempting to speak with the resident, who did not verbalize anything at that time, the Director of Nursing (DON) and a representative from another State agency entered the room. The DON immediately covered up the resident's feet. The other State agency representative was unable to get any answer from the resident. Upon removal of the covers, the scabbing wound to the resident's left foot was described as a scrape of some sort by the DON. Further observation revealed large scabbing wounds to the resident's bilateral thighs just above knees, approximately 6 to 8 cm round. The DON was asked about the wounds to the resident's thighs and confirmed the two areas were from the sunburn. The DON stated he also had an area to the back of the head. Observation of the back of the head revealed a scabbed wound approximately 5 to 7 cm round. When asked how long Resident #1 was out in the sun, the DON stated, about 10 minutes. During an interview on 08/19/20 at 1:31 PM, the DON was asked if the provided list of incidents from 08/01/20 to present included any potential adverse or actual adverse events, and if the list was complete. The DON confirmed the provided list was complete. The list lacked any event for 08/09/20 or any event related to an elopement or sunburn for Resident #1. When asked if they did any kind of report related to Resident #1 and the events on Sunday 08/09/20, the DON stated they did not because the blisters were not present at the time, but developed later. During a subsequent interview on 08/19/20 at 2:45 PM, when asked what types of events she would report, the DON confirmed she would report abuse, neglect, and elopements. The DON again stated Resident #1 was found on the back patio within 10 minutes, so there was no need to report anything at that time. When asked about an investigation and a possible adverse event, the DON confirmed she had started an investigation and they were looking into it (referring to an adverse event. The DON was asked to provide evidence of an investigation for Resident #1 related to being found out in the sun on 08/09/20 with subsequent second-degree sunburns. Upon return with the investigation, and during the continued interview on 08/19/20 at 3:19 PM, the DON was again asked what happened with Resident #1 on 08/09/20. The DON stated on Sunday afternoon (08/09/20) she was notified that Resident #1 was outside on the back patio for no more than 10 minutes. The DON explained she asked the direct care nurse (Staff E) how he was doing and she stated he was fine. The DON told the nurse to do his vital signs, call the family and physician, and to continue to monitor him. On 08/19/20 at 3:31 PM the DON was asked to show the surveyor where Resident #1 was found on that Sunday 08/09/20. The DON identified a location on the back open patio area, just behind the screened in patio. (Photographic evidence obtained.) When asked what had been completed as far as the investigation for Resident #1, the DON stated she reviewed to determine if he was exit seeking and put him on frequent monitoring, and received statements from the assigned nurse and CNA. When asked if she did any type of report, the DON stated she did not because Resident #1 was found on the back patio and he was fine. When asked if she spoke with other staff and or got any other written statements from any other staff, the DON stated she obtained verbal statements that confirmed what the assigned nurse (Staff E) and CNA (Staff C) told her. Review of the investigation provided by the DON revealed a progress note from the attending physician dated 08/18/20, the statements from the direct care nurse (which was a copy of the nurse's note from the record), a statement from the direct care CNA, a new Wandering Assessment for Resident #1 dated 08/09/20, a skin assessment for Resident #1 dated 08/09/20 that documented new redness to the back of the head, the back of the left elbow, a small amount of redness to bilateral thighs, and a blister to the top of the left foot (along with wounds previous to the date), and a census with checkmarks next to each resident signed by an RN and dated 08/09/20 (which was described by the DON as their heads in the bed resident check), and an new care plan dated 08/11/20 for Resident #1 being at risk for elopement. During an interview on 08/21/20 at 1:27 PM, the Interim Administrator was asked her account of the events of 08/09/20 related to Resident #1 or what was reported to her, and if she would consider the event an elopement. The Interim Administrator stated that as per the investigation by the DON, she was told Resident #1 was seen by the CNA (referring to Staff C) 10 minutes prior to finding him out on the outside patio. The Interim Administrator stated that would not be an elopement as he was found on the back patio. When asked what was done after Resident #1 was found on the outside patio, the Interim Administrator stated the priority was to ensure the resident was safe and he was placed on 1 on 1 supervision. She explained they also assessed all residents for wandering. The Interim Administrator stated on Monday (08/10/20) the door to the back patio was coded to be locked 24/7. The Interim Administrator confirmed she was made aware of the incident on Sunday 08/09/20. The DON, who was also the Risk Manager, was present during this interview, and was asked what was done when the blisters formed and they identified it was due to sun exposure. The DON stated they had the Medical Director assess the resident and received the order for the [MEDICATION NAME]. When asked if at that or any other point did she continue or do a further investigation, the DON stated she did verbal interviews with several staff related to the 'rumors' that were going around the building, but none were valid. When asked how she determined the rumors were not valid, the DON stated none of the staff she spoke with actually saw anything or were part of the event. The Interim Administrator and DON were asked to locate and provide evidence of the intervention of one on one supervision of Resident #1, and as of the exit conference on 08/22/20 at 4:46 PM, the documentation had not been provided. Review of the daily schedules revealed Sunday 08/09/20 on the night shift (11 PM to 7 AM) was the only documented provision of one on one care. During an interview on 08/21/20 at 3:13 PM, the ADON stated she does not routinely work weekends. The ADON stated she heard about Resident #1 during the Monday morning (08/10/20) stand up meeting and that he was located outside on the back patio. The ADON confirmed she made rounds with the Wound Care physician. The ADON stated on 08/10/20 they did virtual rounds and that Resident #1 was red on that day, but had no blisters at that time. The ADON stated on Tuesday 08/11/20 the Medical Director was in the building and was made aware of the new blisters, and ordered the [MEDICATION NAME]. When asked if she had any part in the follow up investigation for Resident #1, the ADON stated the investigation was done by the DON and the Interim Administrator. The Interim Administrator and DON failed to investigate past the interviews of the two direct care givers (Staff C, the direct care CNA and Staff E, the direct care nurse) to determine and reveal the actual lack of supervision and subsequent elopement of Resident #1 on 08/09/20. The Administrator and DON also failed to continue the investigation with the development of second-[MEDICAL CONDITION] the resident's extremities and back of head, as identified by the Medical Director on Tuesday 08/11/20. Staff interviews conducted by the surveyor revealed the following: Interviews with Staff A, a Certified Nursing Assistant (CNA), on 08/19/20 at 1:08 PM and Staff B, a Licensed Practical Nurse (LPN), on 08/20/20 at 10:02 AM and 10:43 AM, both revealed Resident #1 was found outside of the facility, in the back, on the opposite side of the East unit that was described by both the DON and direct care nurse. Both staff A and B described Resident #1 in a slumped position, with decreased level of consciousness, and an elevated temperature of 102 or 103 degrees Fahrenheit. Both staff also explained Resident #1 was taken inside of the building, placed in front of an air conditioner, cooled by placing ice and cool clothes on the resident, and that additional fluids were provided. Interviews with Staff F, a LPN on 08/19/20 at 11:28 AM, Staff H, a LPN on 08/19/20 at 12:29 PM, Staff D, a CNA on 08/20/20 at 9:43 AM, all described the subsequent development of blisters to Resident #1. An interview with the attending physician on 08/20/20 at 8:20 AM, revealed he was not notified of the elopement of Resident #1 or the subsequent blistering. The attending physician stated he was told a couple days ago that Resident #1 was out and got a little sun. The attending physician stated he was informed on 08/18/20 Resident #1 was found on the back porch. Interviews with the Medical Director on 08/20/20 at 10:33 AM and 11:16 AM, and the Wound Care physician on 08/21/20 at 8:17 AM, both confirmed the subsequent second-degree sunburns on Resident #1's bilateral thighs, left foot, and back of his head. The Medical Director was asked if the facility had discussed with him the elopement of Resident #1 on 08/09/20 in a Risk Management point of view and or the completion of an investigation. The Medication Director stated they had and they took measures to lock that back door 24/7. Interview and observation with the Maintenance Assistant on 08/21/20 at 1:50 PM confirmed the difference between the location where Resident #1 was found as described by the direct care nurse (Staff E) and DON, compared to the location described by both Staff A, the CNA, who found Resident #1 and Staff B, the LPN who assisted the CNA to get him out of the grass, was about 113 feet further from the back open patio. Review of the record revealed Resident #1 was admitted to the facility on [DATE] having sustained a right knee and leg fracture, was diabetic, was fed by a feeding tube, was at risk for falls and skin breakdown, and had dementia with a Brief Interview for Mental Status (BIMS) score of 11 on a 0 to 15 scale as per the Admission Minimum Data Set (MDS) assessment dated [DATE], indicating some cognitive deficits. Resident #1 was transferred to the hospital related to critical laboratory values on 07/16/20, and returned to the facility to reside on the East Observation unit on 07/23/20. Record review revealed Resident #1 was re-admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #1 was transferred to the North unit and into room [ROOM NUMBER], the second to last room on that hall, on 08/06/20. The three fire exit doors located at the end of all three units were locked and alarmed. For Resident #1 to get from his room to the location he was found by Staff A, the resident would have had to go up the North unit hallway, past the nurse's station, through the hallway past the lobby area, into and through the main dining room (that was not being utilized because of the pandemic), through the gym, through double doors onto a screened in patio, out onto a back patio, down a sidewalk approximately another 113 feet past the location identified by the DON, to the opposite side of the East unit from the back patio. A physician's orders [REDACTED]. A single nurse's note dated 08/09/20 at 1746 by Staff E documented, Resident observed upright alert in w/c (wheelchair) on Facility back patio, last observed 10 minutes prior on North hall. T-99.3 . Resident administered additional fluids via [DEVICE] and reassessed. Temp 98.3. (Name of attending physician) and family notified of resident on facility's back patio. Will cont to monitor. This note lacked any documented evidence it was a late entry and lacked any documented time of the event or interventions. Review of the current Baseline Care Plan dated 07/23/20 documented Resident #1 was at risk for falls related to poor safety awareness. This care plan documented N/A for elopement. Review of the Wound Care physician's Wound Evaluation and Management Summary note dated 08/17/20 documented Site #9 as a burn wound of the right thigh measuring 8 cm long by 7 cm wide and 0.1 cm deep. This note also documented Site #10 as a burn wound of the left thigh measuring 9 cm long by 5 cm wide by 0.1 cm deep. Review of the policy Abuse, Neglect and Exploitation (not dated) documented the definition of neglect as the failure of the facility, it's employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Key components of this policy included the identification of neglect, the necessity of a thorough investigation, and the obligation to report neglect to the State Agency. Review of the Administrator Job Description dated April 2020 documented, Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential Duties and Responsibilities included: Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Oversee regular rounds to monitor delivery of nursing care, . morale of the staff, and ensure resident needs are being addressed. Responsible for the QA (Quality Assurance) program. Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services. Review of the Director of Nursing (DON) Job Description dated April 2020 documented, Summary: To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs. Essential Duties and Responsibilities included: Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as it's programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations. Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required. Ensure that all nursing service personnel follow established departmental policies and procedures, including appropriate dress codes. Assure proper handling and emergency care of residents, personnel, and visitors while on the job or in the building. Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines. Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Review of the Charge Nurse (LPN or RN) Job Description dated April 2020 documented, Summary: Provide direct nursing care to the residents and supervise the day-to-day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern our facility, and as may also be required by the Director of Nursing to maintain the highest degree of quality care at all times. Essential Duties and Responsibilities included: Direct the day-to-day functions of the nursing assistants in accordance with rules, regulations, and guidelines that govern the long-term care industry. Complete accident/incident reports, as necessary. Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care. Review of the Certified Nursing Assistant (CNA) Job Description dated April 2020 documented, Summary: Perform direct resident care duties under the supervision of licensed nursing personnel. Assist with promoting a [MEDICATION NAME] physical and psychosocial environment for the residents. Essential Duties and Responsibilities included: Observe residents carefully and report changes in condition to Charge Nurse. Be alert for proper ventilation, temperature, light and noise control.
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