Based on observation, interview, and record review, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, for 1 out of 40 sampled residents, the facility did not implement pressure ulcer interventions to prevent infection and new ulcers from developing. This will be cited at a harm level. Resident identifier: 3. Findings included:Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included pressure ulcer of sacral region stage 4, pressure ulcer of right buttock stage 4, pressure ulcer of left buttock stage 4, and pressure ulcer of left heel.Resident 3's Minimum Data Set (MDS) completed on 3/26/26 showed a Brief Interview of Mental Status (BIMS) score of 99. A score of 99 indicated the resident was unable to complete the assessment. Resident 3's MDS section GG mobility indicated that resident 3 was dependent on staff for rolling, transferring from bed to chair, personal hygiene, putting on and taking off footwear, upper body dressing, and toileting hygiene. The following observations were made of resident 3:a. On 6/22/26 at 12:55 PM, there were multiple dry brownish-red discolorations on the sheets near resident 3's feet. Resident 3 was positioned on her back with the head of the bed slightly elevated. Resident 3's heels were on top of the mattress. Resident 3 had bandages dated with 6/21 to both of her heels that were peeling off the skin and sticking to the sheet of the bed. b. On 6/23/26 at 7:49 AM, there were multiple dry brownish-red discolorations on the sheets near resident 3's feet and the sheets appeared to be the same as the day before. Resident 3 was positioned on her back with the head of the bed slightly elevated. Resident 3 had bandages dated with 6/21 to both heels and the left heel bandage was stuck to the top of the sheet. Resident 3's heels were resting on top of the mattress. There were no off-loading boots or pillows observed. c. On 6/23/26 at 11:26 AM, resident 3 was on her back with the head of her bed positioned at approximately 30-degree angle. Resident 3's feet were up on top of a pillow with the heels resting directly on the pillow. d. On 6/24/26 at 7:19 AM, resident 3 was positioned on her back with the head of the bed slightly elevated. Resident 3's sheets had multiple dry brownish-red discolorations near the feet. Resident 3 had both heels on top of a pillow. Resident 3's right heel had two bandages attached to the heel and stuck to the pillow.It should be noted that resident 3 was not observed wearing compression socks or heel booties on 6/22/26 through 6/24/26.A review of resident 3's physician orders revealed:a. On 5/20/26, Ensure Heel booties to bilateral heels while in bed every day and night shift for heel booties.b. On 5/20/26, R [right] heel pressure sore: Cover site with border foam dressing QAM [every morning] and PRN [as needed]. Check dressing placement q [every] shift. every day and night shift for R heel PU [pressure ulcer].c. On 6/4/26, Compression stockings to BLE [bilateral lower extremities]. On in the AM [morning], off at HS [night]. every day and night shift.d. On 6/6/26, RIGHT HEEL UNSTAGEABLE PRESSURE ULCER (DRY STABLE ESCHAR): Cleanse, pat dry, Apply skin prep to periwound, apply Betadine to wound bed, cover with calcium alginate, then apply bordered gauze cover dressing. Special Instructions: Maintain offloading boots in place bilaterally. Unable to float due to inability to keep patients BLE on pillow every day shift.e. On 6/15/26, OOB [out of bed] to chair as much as possible every day and night shift.A review of resident 3's progress notes revealed:a. On 3/16/26 at 2:03 PM, an admission evaluation note documented, .SKIN CHECK: Impairments noted: Sacrum - pressure site to buttocks approximately 6x2 cm [centimeter] in dimensions, odorous, with skin noted to be dark in color, scant to no drainage, Groin - multiple small open areas to buttock, scant to no drainage noted, . b. On 3/20/26 at 1:00 AM, an encounter note documented, .Wound care is concerned with her wound on her bottom and wants to get an MRI [magnetic resonance imaging] to r/o [rule out] osteomyelitis. We are going to try and get this done as soon as possible.c. On 4/1/26 at 11:37 PM, a skin check note documented, Skin: Resident has an external device. External device(s) description: wound vac [vacuum] . Skin issue education: Signs and symptoms of infection. Skin issue education: Dressing change(s). Skin issue education: Care of skin issue(s). Skin issue education: Turn every 2 hours. Skin issue education: Change clothing/ briefs. Skin issue education: Treatment of skin issue. Additional skin issue education documentation: Education on the need for wound vac and keeping itworking [sic] properly. Skin issue notification: Wound nurse. Additional skin issue notification documentation: wound has been an on going [sic] problem.d. On 4/2/26 at 1:00 AM, an encounter note documented, .Wound care is concerned with the wound on her bottom and wants to get an MRI to r/o osteomyelitis. She does have a wound vac in place. We are going to try and get this done as soon as possible.e. On 4/3/26 at 3:54 PM, a skin note documented, Skin Issue: #001: : New skin Issue. Location: Buttocks - generalized. Issue type: Pressure ulcer/ injury. Progress: Deteriorating: .f. On 4/5/26 at 4:42 PM, an order note documented, obtain anaerobic and aerobic swab from sacral wound: r/o infection to sacral wound site/wound bed.g. On 4/6/26 at 2:07 PM, a progress note documented, New orders from [name redacted] to start Doxycycline 100 mg [milligram] po [by mouth] bid [twice daily] for wound.h. On 4/9/26 at 11:12 AM, an infection note documented, Wound Culture results received and show streptococcus constellatus, streptococcus anginosa and pseudomonas aeruginosa. NP [nurse practitioner] reviewed results and changed antibiotic to levofloxacin 750mg x 14 days. Doxycycline discontinued. Contact precautions are in place. MRI scheduled to r/o osteomyelitis on 4/15 [26].i. On 4/11/26 at 10:05 AM, an alert charting note documented, Alert note : Wound to sacrum dsg [dressing] changed as ordered, dressing was saturated with foul odor, wound is deep with slough to parts of wound bed, resident crying in pain during dsg change despite being medicated prior, continues on Levaquin PO for infection to wound, no ASE [adverse side effects] noted or reported at this time.j. On 4/17/26 at 11:59 AM, a skin note documented, .Skin Issues Note: Education:- Frequent brief checks/changes are to essential to ensure affected area remains clean and dry- Ensure area is completely dryprior [sic] to application of wound care product.- Recommend frequent offloading and repositioning to alleviate pressure from affected area.- Monitor for s/s [signs and symptoms] of infection (i.e. warmth, erythema, purulent drainage, increased pain, etc).k. On 4/21/26 at 10:33 AM, a progress note documented, MD [medical doctor] ordered for patient to be sent to [name redacted] ER [emergency room] since patient has refused last 2 attempts for MRI.Pt [patient] continues to refuse to eat an adequate amount for healing wounds and confusion and aggitation [sic] have increased in the last few days. Pt is on the last 2 days of pseudomonas treatment for sacrum wound.l. On 5/21/26 at 1:00 AM, an encounter note documented, [resident 3] was seen for readmission H&P [history and physical] today. She was sent to the hospital for possible osteomylitis [sic] in her sacrum. It is now down to the bone and no treatment other than dressings were sent with her. She also developed a pressure ulcer to her left heel while there.m. On 5/27/26 at 1:12 PM, an electronic Medication administration record (eMar) note documented, 1. SACRAL PRESSURE ULCER - STAGE IV [4] WITH BONE EXPOSURE: Cleanse, pat dry, apply wound vac to area per instructions. every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] Wound vac has been ordered per [name redacted] ADON [Assistant Director of Nursing]. Awaiting shipment. Instructed to provide wound care per other TAR [Treatment Administration Record] until arrived.n. On 5/27/26 at 3:44 PM, an infection note documented, NP gave orders for Levofloxacin 750mg Qd [every day] x 14 days for sacral wound infection and elevated WBC [white blood cells].o. On 5/29/26 at 3:04 AM, an eMar note documented, Wound vac to sacrum: Ensure it is in place and functioning properly each shift, set to 125 mmHg [millimeters of mercury]. Empty chamber if needed. every day and night shift Wound vac is not in place.p. On 5/30/26 at 10:54 AM, an eMar note documented, Wound vac to sacrum: .No wound vac in place, order for wet to dry.q. On 5/30/26 at 8:44 PM, an infection note documented, .Np reviewed wound cx [culture] results and added bactrim treatment along with levofloxacin treatment for sacral wound infection.r. On 5/31/26 at 1:06 AM, an eMar note documented, Wound vac to sacrum: .Wound vac not installed.s. On 5/31/26 at 3:02 PM, an eMar note documented, R heel pressure sore: Cover site with border foam dressing QAM and PRN. Check dressing placement q shift. every day and night shift for R heel PU.t. On 6/1/26 at 1:00 AM, an encounter note documented, .[resident 3] is a [AGE] year-old female with a history of CIDP [chronic inflammatory demyelinating polyneuropathy], GERD [gastroesophageal reflux], dementia/altered mental status, stage IV decubitus ulcer, DVT [deep vein thrombosis] history, hypothyroidism, depression, and chronic pain who has returned to this facility following a recent hospitalization for worsening decubitus ulcer and altered mental status. She continues to have a feeding tube in place. Wound culture results have returned positive for MRSA [methicillin resistant Staphylococcus aureus] and Enterobacter. She is currently on antibiotic therapy including daptomycin, vancomycin, valacyclovir, and Bactrim for wound coverage.u. On 6/1/26 at 12:05 PM, an eMar note documented, Wound vac to sacrum: . No wound vac, dressing changed per orderIt should be noted that the wound vac was ordered on 5/27/26 and was still not available for use as of 6/1/26. This resulted in at least a 5 day delay in treatment. A review of resident 4's wound care visit notes on 6/18/26, documented, .The wound vacuum-assisted closure (wound VAC) was examined and fecal contamination was noted to the wound bed; the wound was soaked with Dakin's solution prior to wound VAC reapplication. Significant time was spent educating facility staff on adequate wound VAC placement with bridging to the left hip and use of colostomy paste dam between the anus and wound bed to decrease risk of fecal contamination. The right heel unstageable pressure ulceration presents with stable, dry, intact eschar with no improvement noted. A new deep tissue injury (DTI) to the left heel was identified for the first time at today's visit.On 6/24/26 at 9:01 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 3 had a wound vac and was seen by an outside wound company. RN 1 stated that resident 3 had a wound near her coccyx and necrotic tissue to a wound on her right heel. RN 1 stated that resident 3 should be wearing off-loading boots. RN 1 stated that resident 3 should be up and out of bed daily. On 6/24/26 at 9:14 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 3 had wound changes done daily. CNA 1 stated that resident 3's bed linens were changed on shower days, but resident 3 screamed a lot so she did not change the sheets. CNA 1 stated that resident 3 got a new heel wound because resident 3 was not wearing unna boots. CNA 1 stated that resident 3 was unable to reposition herself and required facility staff assistance.On 6/24/26 at 10:55 AM, an interview was conducted with Assistant Director of Nursing (ADON) 2. ADON 2 stated that resident 3 should be wearing her booties and compression socks and the nurse was putting them on now. On 6/25/26 at 7:31 AM, a follow-up interview was conducted with RN 1. RN 1 stated that she had not been trained on how to use a wound vac in the facility. RN 1 stated that she thought there were videos to watch, but she had not watched them. RN 1 stated that if she had a problem with a wound vac, she would try and find a nurse that knew how to use one. On 6/25/26 at 9:26 AM, an interview was conducted with ADON 1. ADON 1 stated that the Director of Nursing usually handled the residents with wounds, but since she was out on leave it was handed to him last week. ADON 1 stated that the facility used wound vacs and facility staff were trained on how to use them. ADON 1 stated that facility staff had a mandatory nurse meeting last week where they were trained on how to properly use a wound vac. ADON 1 stated that he would try and locate the sign in sheet that nursing staff were required to sign for the wound vac training. It should be noted that wound vac training sign in sheet was not provided by the facility.On 6/25/26 at 10:16 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she was not sure that there was proof that wound vac training had occurred last week.
Every finding on record at Monument Healthcare Stonecreek
Bountiful, Utah · CCN 465156
24 findings across 6 inspections, in the inspector's own words, 5 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 June 25, 2026
18 findingsBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the refrigerator and freezer were undated and opened to air. Additionally, food items in resident refrigerators were undated and/or expired.Findings included:1. On 6/22/26 at 7:41 AM, the initial tour of the kitchen was conducted. The following were observed:a. In the freezer was an opened bag of chicken breasts that were undated.b. In the freezer was a bag of raisin swirl bread that was opened and undated.c. In the refrigerator was an expired small carton of milk with the use by date of 5/9/26.2. On 6/22/26 at 10:25 AM, the resident refrigerators were observed. The following were observed:a. In the 100 hall resident refrigerator there was an expired yogurt container with a use by date of 6/14/26.b. In the 100 hall resident refrigerator there were four expired yogurt containers with a use by date of 5/22/26.c. In the 300/400 hall resident refrigerator there was an expired yogurt container with a use by date of 6/14/26.d. In the 200 hall resident freezer there were open chimichangas with no use by date.3. On 6/24/26 at 11:45 AM, a follow-up tour was conducted of the kitchen. The following were observed:a. In the freezer was a box with a bag that was open to air that contained garlic toast that did not have an opened date.b. In the freezer was an opened box with a bag of meat patties that were open to air and undated.c. In the freezer was an opened box with a bag of [NAME] fillets that were open to air and undated. 4. On 6/24/26 at 12:06 PM, lunch tray line was observed. During the tray line there were multiple observations of kitchen staff touching multiple surfaces without changing gloves. At 12:18 PM, an observation was made of the cook touching a hamburger bun with gloved hands. The cook then picked up gluten free bread with the same gloved hands to serve a gluten free resident. On 6/22/26 at 7:58 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that all foods in the refrigerator and freezer should be dated with an opened date. On 6/22/26 at 10:31 AM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that the nursing staff were in charge of monitoring resident refrigerators and that all items should be dated. RN 5 stated that items in the refrigerators were good for 4 days or the expiration date.On 6/25/26 at 10:04 AM, a follow-up interview was conducted with the DM. The DM stated that kitchen staff were supposed to use utensils for everything and to not touch the food. The DM stated that kitchen staff should not cross-contaminate foods. On 6/25/26 at 11:26 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated that kitchen staff should be wearing gloves or washing hands often when they were in contact with food. The RD stated that kitchen staff should put a date when items were received or opened. The RD stated that items should not be open to air and should be wrapped or sealed. The RD stated that facility nursing staff were responsible for maintaining resident refrigerators.
Based on interview and record review, the facility did not file in the resident's clinical record the laboratory reports that were dated and contained the name and address of the testing laboratory. Specifically, for 3 out of 40 sampled residents, laboratory results were not located in the medical record. Resident identifiers: 4, 46, and 99.Findings included:1. Resident 4 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease.Resident 4's physician's orders revealed the following:a. On 5/15/26, Admit labs: CBC [complete blood count], CMP [comprehensive metabolic panel], prealbumin, Hga1c [hemoglobin A1C], TSH [thyroid stimulating hormone] one time only for 1 Day.b. On 5/18/26, repeat CBC one time only for 1 day.c. On 5/19/26, Repeat CBC one time only for 1 dayIt should be noted that no laboratory results could be located in the medical record.2. Resident 99 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included unspecified kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia.Resident 99's physician's order revealed the following: a. On 5/12/26,, Admit labs: CBC, CMP, Prealbumin, HgA1c, Lipid panel one time only for 1 Day.b. On 5/14/26, Lab draw: CBC & [and] BMP [Basic metabolic panel] one time only for 1 day.c. On 6/15/26, CBC, CMP one time a day for 1 day.It should be noted that no laboratory results could be located in the medical record.On 6/24/26 at 10:51 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that they had to get the lab results from the hospital and they were not in the resident's medical record. 3. Resident 46 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome.Resident 46's physician's order revealed the following: a. On 1/2/26, a Liver Function Panel (LFP), urine potassium, and urine sodium.b. On 1/9/26, a BMP.c. On 1/7/26, a LFP.d. On 3/2/26, a CBC, BMP, International Ratio/Prothrombin Time (INR/PT), and prealbumin.e. On 3/5/26, a Urinalysis with a Culture and Sensitivity. f. On 4/6/26, a LFP, urine potassium, and urine sodium.g On 4/15/26, a CBC, BMP, INR/PT, prealbumin.h. On 5/21/26, a LFP, urine potassium, and urine sodium.i. On 5/25/26, a LFP, urine potassium, and urine sodium.j. On 5/26/26, urine potassium and urine sodium.The laboratory results for all listed laboratory orders were not located in resident 46's medical record. On 6/23/26 at 4:19 PM, an interview was conducted with the RNC. The RNC stated that all laboratory reports were printed from the laboratory portal today and were not contained within resident 46's medical record.
Based on observation, interview, and record review, the facility did not ensure each resident who entered the facility with an indwelling catheter or subsequently received one was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization was necessary. Specifically, for 3 out of 40 sampled residents, the facility did not discontinue residents' Foley catheters when there were no indications for use. Additionally, facility staff were not trained on the use of a PureWick for a resident and the PureWick tubing was observed draped over the head of the bed and not able to down drain. Resident identifiers: 3, 46, and 98.Findings included:1. Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included encephalopathy, altered mental status, type 2 diabetes, and dysphagia oropharyngeal phase.On 6/22/26 at 8:50 AM, an observation was made of resident 3. Resident 3 had a urinary catheter hanging on the right side of the bed.A review of resident 3's physician orders revealed:a. An order with a start date of 5/20/26, documented, CATHETER: Change catheter securement device q [every] week and PRN [as needed] as needed for CATHETER: Change catheter securement device q week and PRN.b. An order with a start date of 5/20/26, documented, Change Drainage bag monthly and PRN as needed for Infection, leakage, obstructions.c. An order with a start date of 5/20/26, documented, CATHETER: Change urinary catheter PRN as needed for Obstruction, Leaking, or infection.d. An order with a start date of 5/25/26, documented, CATHETER: Change catheter securement device q week and PRN one time a day every Mon [Monday] for catheter care.A review of resident 3's progress notes revealed:a. On 5/20/26 at 5:41 PM, an admission evaluation nursing note documented, . NURSING EVALUATION: EBP [Enhanced Barrier Precautions] qualifiers; Urinary Catheter Feeding Tube. BOWEL INCONTINENCE; No. NA [not applicable] due to catheter. Catheter present: Yes. Type if applicable: Foley Catheter. b. On 5/25/26 at 5:02 PM, an alert note documented, pt [patient] had labs and urine sample sent to central lab for assessment this date. Urine sample collected and sent for processing.c. On 5/26/26 at 1:00 AM, a physician encounter note documented, . her recent UA [urinalysis] came back positive. I am going to restart her on Levaquin and await culture results.d. On 5/28/26 at 4:58 PM, an infection note documented, Urine culture grew 50,000 enterococcus faecalis. Pt is currently taking levofloxacin for wound infection. wound culture is still pending. Levofloxacin is on sensitivity list for urine cx [culture]. Pt is also being treated prophylactic for UTI [urinary tract infection] since pt didn't meetmcgeer's [sic] criteria for UTI.On 6/24/26 at 9:01 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 that she was unaware of a urinary catheter for resident 3.On 6/24/26 at 9:08 AM, a follow-up interview was conducted with RN 1. RN 1 stated that resident 3 did have a urinary catheter and she was unsure of the reason resident 3 had one. On 6/24/26 at 9:14 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 3 had to have her brief changed every 2 hours. CNA 1 stated that resident 3 came back from the hospital with a urinary catheter and she did not know why resident 3 needed one because she had frequent brief changes. On 6/24/26 at 9:30 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she thought resident 3 had a urinary catheter in place because she had a sacral wound, but would look for documentation as to the reason why. It should be noted that the facility did not provide any additional information or documentation for the indication of the use of a urinary catheter.2. Resident 98 was admitted to the facility on [DATE] with diagnoses which included malignant neoplasm of endometrium, secondary malignant neoplasm of bone, and pathological fracture.On 6/22/26 at 9:57 AM, an interview was conducted with resident 98. Resident 98 stated that she did not know why she had a urinary catheter.A review of resident 98's physician orders revealed:a. An order with a start date of 6/18/26, documented, CATHETER: Change catheter securement device q week and PRN as needed for CATHETER: Change catheter securement device q week and PRN.b. An order with a start date of 6/18/26, documented, CATHETER: Change urinary catheter 14FR [french] /10ml [milliliter] PRN as needed for Obstruction, Leaking, or infection.A review of resident 98's progress notes revealed:a. On 6/17/26 at 12:47 AM, an admission evaluation nursing note documented, .NURSING EVALUATION: EBP qualifiers; Urinary Catheter. LOC Urinary Catheter. BOWEL INCONTINENCE; No. BLADDER INCONTINENCE; No. No. Catheter present: No. Type if applicable: b. On 6/21/26 at 8:39 AM, a daily skilled evaluation note documented, .Nursing Evaluation: Complete. CATHETER use. Type: Foley catheter in place. urinary catheter 14 fr 10 mL with dignity bag and drain intact, securement device in place DME [durable medical equipment] used by pt includes: c [cervical] collar and bedside commode pt requires assist from surface to surface with nurse assisting and perineal cares completion prior to morning medication pass this date. Pt requires guidance and mininmal [sic] support. Encouragement for completion of task. Education provided for safe transfer techniques. Pt requires perineal cares as provided by staff at this time post bowel movement.On 6/24/26 at 1:34 PM, an interview was conducted with CNA 1. CNA 1 stated that resident 98 was a stand by assist but could get up by herself. CNA 1 stated that resident 98 used a bedside commode in her room. CNA 1 stated that resident 98 came to the facility with a urinary catheter and she was unsure why resident 98 needed one because she was able to get up and use the bedside commode, use a call light to call for assistance, and could transfer herself.On 6/24/26 at 2:11 PM, an interview was conducted with RN 4. RN 4 stated that resident 98 was admitted to the facility after experiencing a ground level fall at home and fracturing her cervical vertebrae. RN 4 stated that resident 98 was continent and did not know if she had a urinary catheter.On 6/24/26 at 2:16 PM, an interview was conducted with the RNC. The RNC stated that resident 98 had an admitting diagnosis of pathological fracture. The RNC stated that she thought that resident 98 might have the urinary catheter because of malignant neoplasm of the endometrium but she would find out why resident 98 had a urinary catheter. On 6/25/26 at 10:13 AM, a follow-up interview was conducted with the RNC. The RNC stated that she called resident 98's daughter to see why she had the urinary catheter as there was no diagnosis for the use of the urinary catheter. The RNC stated the facility Nurse Practitioner wanted to follow-up with resident 98 before they took out the catheter. 3. Resident 46 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome.On 6/22/26 at 10:08 AM, an interview was conducted with resident 46. Resident 46 stated she had a PureWick device in place that she purchased for use. A urine collection canister was observed on the bedside table and contained 950 milliliters of urine. The PureWick tubing was observed running up the inclined mattress over the top of the head of the bed. The urine tubing was not positioned downward or aided by gravity and was observed to have a back and forth flow with the suction. On 6/13/24, resident 46 had a physician order for Pure wick catheter to be in place at all times while in bed. Change purewick catheter q 12 hours or if soiled every day and night shift for purewick. On 6/13/24, resident 46 had a physician order for Ensure privacy cover is over purewick urine canister every day and night shift for purewick. On 6/13/24, resident 46 had a physician order for Ensure purewick urine canister is emptied q shift every day and night shift for purewick. On 4/23/24, resident 46 had a Care Plan initiated for PureWick catheter in place related to urinary incontinence. Interventions identified were that resident 46 would be free of any untreated discomfort related to the PureWick catheter; patient was able to maintain suction to catheter as desired; and PureWick catheter in place while in bed. On 6/23/26 at 3:02 PM, an interview was conducted with CNA 7. CNA 7 stated that resident 46 was fully dependent on staff for toileting assistance and was bed bound. CNA 7 stated that resident 7 had a PureWick device in place. CNA 7 stated that they emptied the urine canister, they changed the PureWick device every 2 hours, and the change of the device was patient guided. CNA 7 stated that resident 46 told staff when to change the device and how to place it. CNA 7 stated that resident 46 would let staff know if the PureWick was positioned correctly or if it was too high or too low. CNA 7 stated that resident 46 had different PureWick sizes that were used at different times of the day. CNA 7 stated that the placement of the PureWick was based on how comfortable the resident was. CNA 7 stated that the PureWick tubing was placed over the top of the mattress and depended on resident 46's liking. On 6/23/26 at 3:35 PM, an interview was conducted with RN 3. RN 3 stated that the CNAs have been trained on how to replace the PureWick device and the nurses were trained this month on how to use the device. RN 3 stated that the device should be positioned in between the labia with the white weaved part positioned against the urethral opening and then the suction was turned on. RN 3 stated that there was not a suction setting for use. RN 3 stated that the tubing should be over the leg and positioned like a down drain. RN 3 stated that she was not sure if there was a potential for a back flow if the tubing was not positioned off the side of the bed. RN 3 stated that resident 46 had a history of urinary tract infections and the last infection was a couple of months ago. RN 3 stated that she had been working at the facility for 2 years and resident 46 had always had the device. On 6/24/26 at 3:46 PM, an interview was conducted with the RNC. The RNC stated that they identified an issue with the PureWick staff education, implemented training on 6/1/26, and required staff complete the training by 6/30/26. The RNC stated that the staff training included a video demonstration on how to place the device. The RNC stated that the video training included placement of the device with the pubic bone, how to remove the device safely to prevent injury, replacing the device every 8-12 hours, how to empty the urinary canister, and to empty the canister before 1800 milliliters of urine were collected. The RNC stated that the video was provided by the PureWick manufacturer and did not contain information on prevention of potential complications. On 6/25/26 at 10:18 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated that if resident 46 did not like a CNA she would refuse care from that CNA. The CNA Coordinator stated that resident 46 did not want CNA 2, CNA 3, CNA 4, CNA 5, and any male CNAs providing incontinence care to her. The CNA Coordinator stated that if resident 46 believed that the CNA did not know how to assist her she would wait until the next shift for incontinence care. The CNA Coordinator stated that all incontinence care refusals from resident 46 were related to staff not knowing how to place the brief and staff not knowing how to use a PureWick device. The CNA Coordinator stated that prior to the beginning of this month there was no CNA training on how to use the PureWick device. The CNA Coordinator stated that staff positioned the PureWick device with the white mesh over the urethral opening. The CNA Coordinator stated that the tubing exited the top of the device and was positioned under the resident's left arm. The CNA Coordinator stated that they positioned the tubing the way the resident preferred it and the device was changed when resident 46 informed them to change it.
Based on observation, interview, and record review, the facility did not ensure that the resident right to self-administer medications was clinically appropriate and safe. Specifically for 4 out of 40 sampled residents, residents were observed to have medications in their rooms and were not evaluated to determine if they were safe to self-administer medications. Resident identifiers: 8, 22, 35, and 78.Findings included:1. Resident 8 was admitted to the facility on [DATE] with diagnoses which included fracture of left femur, difficulty in walking, and muscle weakness.On 6/22/26 at 9:21 AM, a concurrent observation and interview were conducted with resident 8. On resident 8's bedside table there was a bottle of turmeric tablets and one white tablet. Resident 8 stated that the facility gave him a bunch of pills and he was unsure what the white tablet was. Resident 8 stated that he better take the white pill. A self administration evaluation or an order to self administer medications was not located.On 6/24/26 at 7:32 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that residents could not self-administer medications without an order and an evaluation. RN 1 stated that resident 8 was unable to self-administer medications. On 6/24/26 at 10:44 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that he was unable to locate an assessment or an order for resident 8 to self-administer medications and it was not careplanned. 2. Resident 35 was admitted to the facility on [DATE] with diagnoses which included, type 2 diabetes mellitus without complications.On 6/22/26 at 12:49 PM, an observation was conducted of resident 35's room. Prescription medication was observed in resident 35's room. A self administration evaluation was not located.A physician's order dated 11/13/25, documented Triamcinolone Acetonide External Cream 0.1 % (Triamcinolone Acetonide (Topical)) Apply to arms topically three times a day related to PSORIASIS, UNSPECIFIED . unsupervised self-administration.On 6/25/26 at 12:58 PM, an interview was conducted with ADON 1. ADON 1 stated he was unable to locate a self administration evaluation in resident 35's medical record. 3. Resident 78 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, type 2 diabetes mellitus with diabetic neuropathy, personal history of urinary tract infections, polyosteoarthritis,and asthma.On 6/22/26 at 10:17 AM, an observation was made of resident 78 while she was seated in bed with her bedside table within reach. The following medications were observed on resident 78's bedside table: two tablets on top of a napkin, six tablets in a medication cup, and an inhaler. An interview was conducted with resident 78, who stated that she needed to swallow her medications slowly, otherwise her stomach would become upset. Resident 78 was unable to state what medications were at her bedside. A self administration evaluation or a current order to self administer medications was not located.A physician's order dated 5/12/25, documented Resident prefers to administer own medications independently. Nurse will prepare and monitor at bedside for safety. every shift. The order was discontinued on 10/23/25. On 5/9/26, a Brief Interview for Mental Status (BIMS) was conducted and resident 78 received a BIMS score of 12, which indicated moderate cognitive impairment. On 6/20/26 at 7:56 AM, a progress note documented that resident 78 had several medicine cups with her name written on them one which had a pill in it. Pt [patient] educated that medications can not be left at bedside. Nurse could not identify what pill was. Pt educated as to medication safety. She states that she takes one pillat [sic] a time and requires nurse to leave medications at bedside. On 6/25/26 at 12:31 PM, an interview was conducted with RN 2, who stated that a resident could not self-administer medications without an order and an evaluation. RN 2 stated that she received education about the requirements for residents to self-administer medications that morning. RN 2 stated that resident 78 did not have an order for self administration, and that before the education she received that morning medications were left at resident 78's bedside because it was the resident's preference. RN 2 stated that she needed to wait until all of resident 78's medications were administered before leaving the room.On 6/25/26 at 1:35 PM, an interview was conducted with ADON 1. ADON 1 stated that if a resident wished to administer their own medications, and the resident had a BIMS score of 13 or higher, facility staff would conduct a self administration evaluation to determine if the resident could safely self administer medications, discuss the results with the provider to receive an order, and create an individualized care plan. ADON 1 stated that an evaluation, order, and care plan needed to be in the resident's medical record in order for a resident to self administer medications. ADON 1 stated that he was unaware of anyone in the facility who had orders for self administration. ADON 1 stated that resident 78 did not have an evaluation or orders for self administration.4. Resident 22 was admitted to the facility on [DATE] with diagnosis which included alcoholic cirrhosis, bipolar disorder, anxiety disorder, and chronic obstructive pulmonary disease (COPD). On 6/23/26 at 8:48 AM, an interview was conducted with resident 22. Resident 22 stated that he kept his inhalers at the bedside for self administration. Resident 22 stated that he used the albuterol throughout the day and the red one [Symbicort] he used two times a day. Resident 22 stated that he administered the albuterol 2-3 times a hour and it helped him breathe. Resident 22 stated he currently did not have any shortness of breath. A metered dose inhaler of Albuterol and Symbicort was observed on resident 22's bedside table. On 3/3/26, resident 22's physician ordered Symbicort Inhalation Aerosol 80-4.5 micrograms (MCG)/actuation (ACT) (Budesonide-Formoterol Fumarate Dihydrate), 2 puffs inhale orally one time a day for COPD.On 5/25/26, resident 22's physician ordered Albuterol Sulfate Hydrofluoroalkane (HFA) Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate), 1 puff inhale orally every 6 hours as needed for asthmatic ** MD [Medical Doctor] order for resident to keep at bedside*** Not to exceed 4 doses in 24 hours, resident must report use to nurse***.On 5/25/26, resident 22 had a physician order to keep inhalers at the bedside. Resident to report to nurse when self administered to document. Report to MD if resident exceeds daily dose or improper administration.On 5/25/26, the Self Medication Evaluation documented that resident 22 was not alert and oriented to person, place, and time. The evaluation documented Resident at risk to self administer excess Albuterol rescue inhaler. The evaluation documented that the resident did not know the correct dose to be administered, and the resident was not a candidate for self administration of medication.On 6/15/26 at 1:00 AM, the provider note documented under assessment and plan, COPD / Obstructive lung disease - Patient continues on Symbicort. Albuterol use identified as excessive at 8 to 9 times per day; educated patient at length on appropriate use and risks of overuse. Will investigate additional controller medications to reduce reliance on albuterol. Will continue to monitor respiratory status closely. On 3/2/26, resident 22 had a care plan initiated for the potential for altered respiratory status related to COPD. An intervention identified on the care plan was to administer medications/puffers as ordered and to monitor for effectiveness and side effects. On 6/23/26 at 12:52 PM, an interview was conducted with RN 3. RN 3 stated that resident 22 was sometimes alert and oriented to person and place, but not time. RN 3 stated that resident 22 had short term memory deficits and was not safe to self administer his medications. RN 3 stated that they determined that resident 22 was self administering the Albuterol too much, and because of this they should store the Albuterol in the medication cart. RN 3 stated that they determined that resident 22 was over-administering Albuterol after she spoke with the provider about needing a premature Albuterol refill. RN 3 stated the provider was not comfortable with the medication being stored in resident 22's room.On 6/23/26 at 12:59 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that resident 22's Self Medication Evaluation on 5/25/26, documented that the resident was not capable of self administering medications. On 6/24/26 at 12:57 PM, an interview was conducted with Nurse Practitioner (NP) 1. NP 1 stated that they discussed the risk versus benefit of resident 22 keeping his inhalers at bedside. NP 1 stated that she was aware of the risk of resident 22 overusing the medication, but that the resident had wanted it available to use whenever he needed it without waiting for staff assistance. NP 1 stated that she was worried that resident 22 would use the medication too frequently. NP 1 stated she had provided resident 22 with education several times on the use of the medication and that she would continue to provide him with education at each visit. NP 1 stated that she educated resident 22 to use the Albuterol every 4 hours. NP 1 stated that resident 22 had cognitive deficits with short term memory loss and had difficulty retaining education. NP 1 stated that she was concerned that resident 22 had reported using the Albuterol inhaler 2-3 times an hour and that was not what he had told her. NP 1 stated that resident 22 had refused to give the medication back to them.
Based on interview and record review, the facility did not ensure that each resident who was given a psychotropic drug had adequate monitoring of that drug. Specifically, for 1 out of 40 sampled residents, a resident receiving an antidepressant did not receive a gradual dose reduction (GDR) in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. Resident identifier: 35.Findings included:Resident 35 was admitted to the facility on [DATE] with a diagnosis which included major depressive disorder. A physician's order dated 9/12/25, documented DULoxetine HCL [hydrochloride] Capsule Delayed Release Particles 30 MG [milligrams]. Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE . for 7 Days THEN Give 2 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE . The physician's order was discontinued on 9/24/25.A physician's order dated 9/24/25, documented DULoxetine HCl Capsule Delayed Release Particles 30 MG Give 2 tablet by mouth one time a day for Phantom leg pain. On 6/25/26 at 12:58 PM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that he remembered doing a GDR in April 2026, but he could not find the documentation. ADON 1 stated a GDR would depend on what the resident was using the medication for. ADON 1 stated if the medication was used for phantom leg pain or off label they would request that the Medical Director document a contraindication. ADON 1 stated if the medication was used for depression they would reduce the medication and if the resident failed the reduction they would request that the Medical Director document a contraindication.
Based on observation and interview, the facility did not keep confidential all information contained in the resident medical records and safeguard against unauthorized access. Specifically, observations were made of the licensed nurse leaving the computer unattended and open to resident medical records and leaving the report sheet with resident health information unattended and visible on the medication cart.Findings included: On 6/24/26 at 8:15 AM, an observation was made of Registered Nurse (RN) 8 during the morning medication administration. RN 8 was observed to leave her report sheet unattended and visible on the medication cart outside room [ROOM NUMBER]. A resident roster with health information was visible to passersby. At 8:34 AM, RN 8 walked away from the medication cart to obtain additional medication. RN 8's nurse report sheet and computer were left unattended, open and resident identifiable health information was visible to passersby. An immediate interview was conducted with RN 8 upon her return to the medication cart. RN 8 stated that she should lock the computer and turn over her nurse report sheet when she walked away from the medication cart. On 6/24/26 at 10:24 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that the staff should lock the computer screen or close the lid to ensure no resident identifiable information was visible and anything with personal information should be covered or secured.
Based on interview and record review, the facility did not file in the resident's medical record signed and dated reports of radiological services. Specifically, for 1 out of 40 sample residents, a resident's Electrocardiogram (EKG) report was not located in the medical record. Resident identifier: 99.Findings included:Resident 99 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included unspecified kidney failure, thrombocytopenia, and chronic myelomonocytic leukemia.On 6/1/26 at 4:49 PM, an order note documented, STAT [immediate] order for EKG due to HR [heart rate] ranging from 37 to 54, she also has been having N [nausea] .It should be noted that an EKG report was not located in resident 99's medical record.On 6/24/26 at 3:53 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated the EKG was not in the resident's medical record and the facility had to call and get the results.
Based on observation and interview, the facility did not ensure that all drugs and biologicals were stored in compartments under proper temperature controls. Specifically, observations were made of multiple medications stored in a refrigerator that had a registered temperature of 24 degrees Fahrenheit (F). Resident identifiers: 5, 41, 46, and 73. Findings included:On 6/24/26 at 9:27 AM, an observation was made of the medication refrigerator on 300/400 hallway with Registered Nurse (RN) 3. The internal temperature gauge read 24 degrees Fahrenheit (F). RN 3 stated that temperature was not in the safe zone as indicated on the thermometer which was between 34-40 degrees. RN 3 stated that at a temperature of 24 degrees F they risked having the medication freeze. RN 3 stated that she would adjust the temperature and check the thermometer again later. The following medications were observed inside the refrigerator on 6/24/26 at 9:27 AM.Resident 5's Insulin Lispro 100 unit /milliliter (ml) - 5 pens totalResident 5's Insulin Lispro 100 unit/ml - 3 vialsResident 73's Admelog solostar 100 unit/ ml - 4 pensResident 73's Insulin Lispro 100 unit/ml - 1 penResident 46's Trulicity 4.5 milligram (mg)/0.5 ml - 1 penResident 41's Lorazepam 2 mg/ml liquid - approx 2.5 ml remaining in bottle On 6/24/26 at 10:24 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated the medication refrigerator temperatures were labeled on the fridge and should be within 36-46 degrees Fahrenheit. ADON 1 stated that a refrigerator temperature that was 24 degrees could cause the medication to freeze. ADON 1 stated that they would move the medication to another fridge until they could verify the accurate temperature of the refrigerator. It should be noted that ADON 1 did not seek to verify the integrity of the medication that was stored within the refrigerator. Review of the facility policy for Medications: Medication Labeling and Storage documented that the facility stored all drugs and biologicals in locked compartments under proper temperature, humidity, and light controls. The policy did not address what the proper temperature would be for a refrigerator that stored medication. The policy was last revised on February 1, 2024.
Based on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 40 sampled residents, a resident taking a phosphate binder was not administered the medication with meals. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease.On 6/23/26 at 8:38 AM, an interview was conducted with resident 4. Resident 4 stated that she had been receiving her phosphate binder before and after meals and not with meals as she should be taking them. Resident 4 stated the medication needed to bind the phosphates in her food so her body did not absorb them. Resident 4 stated that she ate her meals in her room.A review of resident 4's physician orders revealed:a. On 5/14/26, Sucroferric Oxyhydroxide 500 MG [milligram] Tablet Give 2 tablet by mouth three times a day for Phosphorus Binder With meals (08 [8:00 AM], 12 [12:00 PM], 17 [5:00 PM])b. On 5/16/26, Renvela Oral Tablet (Sevelamer Carbonate) Give 400 mg by mouth before meals for phosphorus binderc. On 5/19/26, Renvela Oral Tablet (Sevelamer Carbonate) Give 400 mg by mouth three times a day for phosphorus binder before mealsA review of the facility's posted meal times for the 200 hall revealed that breakfast was served at 8:10 AM, lunch was served at 12:40 PM, and dinner was served at 5:55 PM.A review of resident 4's Medication Administration Record revealed the following:a. On 5/15/26, sucroferric was administered at 9:07 AM and 1:39 PM.b. On 5/16/26, sucroferric was administered at 8:36 AM and 1:15 PMc. On 5/17/26, Renvela was administered at 6:57 AM and 2:25 PM.d. On 5/18/26, Renvela was administered at 6:48 AM and 11:46 AM.e. On 5/19/26, Renvela was administered at 6:42 AM and 12:16 PM.f. On 5/20/26, Renvela was administered at 7:26 AM, 10:32 AM, and 4:21 PM,g. On 5/21/26, Renvela was administered at 7:18 AM, 10:55 AM, and 4:25 PM.h. On 5/22/26, Renvela was administered at 8:27 AM, 1:29 PM, and 5:16 PM.i. On 5/23/26, Renvela was administered at 9:07 AM, 12:05 PM, and 4:15 PM.j. On 5/24/26, Renvela was administered at 6:54 AM, 11:33 AM, and 4:42 PM.k. On 5/25/26, Renvela was administered at 6:32 AM, 10:07 AM, and 4:34 PM.l. On 5/26/26, Renvela was administered at 7:13 AM, 11:14 AM, and 4:16 PM.m. On 5/27/26, Renvela was administered at 8:02 AM, 10:47 AM, and 5:28 PM.n. On 5/28/26, Renvela was administered at 8:04 AM, 11:08 AM, and 4:37 PM.o. On 5/29/26, Renvela was administered at 8:40 AM, 10:34 AM, and 4:37 PM.p. On 5/30/26, Renvela was administered at 7:57 AM, 11:38 AM, and 4:59 PM. q. On 5/31/26, Renvela was administered at 7:31 AM, 11:25 AM, and 5:10 PM.r. On 6/1/26, Renvela was administered at 6:31 AM, 11:13 AM, and 7:02 PM.s. On 6/2/26, Renvela was administered at 6:58 AM, 10:54 AM, and 4:26 PM.t. On 6/3/26, Renvela was administered at 6:40 AM, 12:20 PM, and 4:34 PM.u. On 6/4/26, Renvela was administered at 7:22 AM, 10:59 AM, and 4:01 PM.v. On 6/5/26, Renvela was administered at 8:16 AM, 10:25 AM, and 5:14 PM. w. On 6/6/26, Renvela was administered at 7:55 AM, 11:08 AM, and 4:52 PM.x. On 6/7/26, Renvela was administered at 7:59 AM, 11:05 AM, and 4:04 PM.y. On 6/8/26, Renvela was administered at 7:11 AM, 12:21 PM, and 5:42 PM.z. On 6/9/26, Renvela was administered at 9:17 AM, 12:07 PM, and 4:06 PM.aa. On 6/10/26, Renvela was administered at 8:07 AM, 12:59 PM, and 4:33 PM.bb. On 6/11/26, Renvela was administered at 7:52 AM, 11:09 AM, and 4:49 PM.cc. On 6/12/26, Renvela was administered at 8:08 AM, 12:23 PM, and 5:20 PM.dd. On 6/13/26, Renvela was administered at 8:54 AM, 11:53 AM, and 4:09 PM.ee. On 6/14/26, Renvela was administered at 7:08 AM, 10:18 AM, and 4:09 PM.ff. On 6/15/26, Renvela was administered at 6:37 AM, 10:24 AM, and 4:59 PM.gg. On 6/16/16, Renvela was administered at 7:34 AM, 11:21 AM, and 4:13 PM.hh. On 6/17/26, Renvela was administered at 8:06 AM, 12:43 PM, and 4:01 PM.ii. On 6/18/26, Renvela was administered at 7:26 AM, 10:57 AM, and 4:27 PM.jj. On 6/19/26, Renvela was administered at 8:13 AM, 12:05 PM, and 4:01 PM.kk. On 6/20/26, Renvela was administered at 8:10 AM, 12:18 PM, and 4:02 PM.ll. On 6/21/26, Renvela was administered at 7:27 AM, 10:52 AM, and 4:29 PM.mm. On 6/22/26, Renvela was administered at 8:05 AM, 11:06 AM, and 4:00 PM.On 6/23/26 at 3:03 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that Renvela was for dialysis patients and it was a binder that was supposed to be given with meals. RN 5 stated that the medication needed food to bind with in order to work. RN 5 stated that with Renvela, she would wait until she saw the resident receive their meal tray before administering the medication. On 6/23/26 at 3:16 PM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that Renvela was a phosphate binder that needed to be taken with food. ADON 1 stated that Renvela binded with phosphate in food and helped to absorb it. ADON 1 stated that the order for resident 4 stated that Renvela was to be given three times a day before meals. ADON 1 stated that Renvela needed to be taken with meals in order to be effective. ADON 1 stated that he expected nursing staff to know that the phosphate binder needed to be given with food. ADON 1 stated that Renvela was time stamped to be administered at 6:00 AM, 10:00 AM, and 4:00 PM, and these times should be adjusted to when she received meals.
Based on observation, interview, and record review, the facility must ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 40 sampled residents, a resident receiving dialysis had incomplete communication notes. Resident identifier: 4.Findings included:Resident 4 was admitted to the facility on [DATE] with diagnoses which included dependence on renal dialysis, type 2 diabetes, and anemia in chronic kidney disease.A review of resident 4's physician orders revealed:a. An order with a start date of 5/18/26, documented, COMPLETE the Dialysis Post Assessment Form after resident returns from dialysis. Ensure resident returns from dialysis with the Pre-Dialysis Assessment and Communication Form. Review and follow up as indicated. Call Dialysis center if not returned with resident. every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday].b. An order with a start date of 6/19/26, documented, COMPLETE and PRINT the Pre-Dialysis Assessment and Communication Form and ensure it is sent to dialysis with the resident. in the morning every Mon, Wed, Fri for Assessment and vitals for dialysis COMPLETE and PRINT the Pre-Dialysis Assessment and Communication Form and ensure it is sent to dialysis with the resident.The facility's pre and post dialysis assessment evaluation was reviewed. The pre evaluation documented resident's vital signs, cognition, mood, skin condition, presence of edema, abnormal lung sounds, gastrointestinal status, cardiac condition, type of dialysis access, presence of a a bruit and thrill, access condition, pain level and location, and any additional comments. The post evaluation documented whether the resident had dialysis, the resident's vital signs, cognition, mood, skin condition, presence of edema, abnormal lung sounds, gastrointestinal status, cardiac condition, type of dialysis access, presence of a bruit and thrill, access condition, pain level and location, and any additional comments. A review of resident 4's pre and post dialysis assessment evaluations revealed:a. On 5/20/26, resident 4's post assessment evaluation was blank.b. On 5/29/26, resident 4's post assessment evaluation was blank.c. On 5/31/26, resident 4's post assessment evaluation was blank.d. On 6/3/26, resident 4's pre assessment did not have vital signs documented. e. On 6/12/26, resident 4's pre assessment did not document the type of dialysis access, an assessment on resident 4's lungs, gastrointestinal and cardiac systems, and pain level. The post assessment only documented that resident 4 had dialysis. The rest of the form was blank. f. On 6/22/26, resident 4's post assessment evaluation was blank.On 6/23/26 at 3:03 PM, an interview was conducted with Registered Nurse (RN) 5. RN 5 stated that for dialysis residents, nurses had to complete a pre and post evaluations. RN 5 stated there was an evaluation in the computer and nurses had to check for a thrill and bruit before and after dialysis and chart this. RN 5 stated that the evaluation included resident vital signs, dressing check, and a pain scale.On 6/23/26 at 3:16 PM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that there was one resident in the facility that was on dialysis. ADON 1 stated that he expected nursing staff to complete the pre and post evaluation for dialysis. ADON 1 stated that staff should be completing vital signs when resident 4 returns from dialysis. ADON 1 stated that the pre and post evaluation form should be filled out in its entirety.
Based on interview and record review, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the person-centered care plan and the residents' goals and preferences. Specifically, for 1 out of 40 sampled residents, a resident reported that his Tramadol dose was frequently administered late and it impacted his pain control. Resident identifier: 54. Findings included:Resident 54 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses which included asthma, pneumonia, type 2 diabetes mellitus, congestive heart failure, hypertension, chronic kidney disease, and low back pain. On 6/22/26 at 11:51 AM, an interview was conducted with resident 54. Resident 54 stated that he had pain in his lower back, bilateral knee pain, and coccyx related to a pressure ulcer. Resident 54 stated he took Tramadol and Tylenol for pain. Resident 54 stated that the dose of Tramadol was frequently administered late and it impacted his pain control. On 1/3/26, resident 54 had a physician order initiated for Tramadol Hydrochloride Oral Tablet 50 milligrams (mg), Give 2 tablet by mouth one time a day for pain AND Give 1 tablet by mouth one time a day for Pain AND Give 2 tablet by mouth one time a day for Pain. Resident 54's June 2026 Medication Administration Record (MAR) documented that 2 tablets of Tramadol were scheduled for administration at 8:00 AM, one tablet was scheduled for administration at 12:00 PM, and 2 tablets were scheduled for administration at 8:00 PM. Resident 54's June 2026 MAR documented that the Tramadol was administered greater than one hour after the scheduled administration time on 6/1/26 at 1:34 PM, on 6/3/26 at 3:01 PM, on 6/8/26 at 9:14 AM, on 6/11/26 at 2:02 PM, on 6/20/26 at 9:25 PM, and on 6/22/26 at 9:35 PM. On 6/25/26 at 11:41 AM, an interview was conducted with Registered Nurse (RN) 6. RN 6 stated that resident 54's Tramadol had scheduled administration times and staff could administer the medication one hour before and one hour after the scheduled time. On 6/25/26 at 1:01 PM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated staff should administer medications as ordered during the timeframe it was ordered. ADON 1 stated that if a medication was ordered at a specific time staff had one hour before and one hour after to administer the medication. ADON 1 stated that resident 54 slept a lot and it impacted his medication administration. ADON 1 stated that staff should document that it was administered late because resident 54 was sleeping and they should notify the provider if it was not given as ordered. ADON 1 stated that if it was documented it would be in a progress note or medication administration note. It should be noted that no documentation was located for the late administration of the Tramadol.
Based on interview and record review, for 2 out of 40 sampled residents, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident left the facility and called his daughter to report he was lost and a week later another resident, who needed to be supervised during a Leave of Absence, left the facility. Resident identifiers: 29 and 110.Findings included:1. Resident 110 was admitted to the facility on [DATE] and discharged on 3/27/26 and readmitted on [DATE] and discharged on 6/2/26 with diagnoses which included depression, alcohol dependence, and history of transient ischemic attack. The facility reported to the State Survey Agency (SSA) on 5/22/26 at 11:32 AM, that resident 110 took an uber to get a haircut and called his daughter because he did not know how to get back on 5/14/26 at 11:35 AM. The daughter called the facility and they went and picked him up. It should be noted the incident happened on 5/21/26, not 5/14/26 as reported. An elopement risk evaluation completed on 3/19/26, documented that resident 110 scored a 2. There was no information regarding what a score of 2 meant and if he was an elopement risk. It should be noted this was from his previous admission and he did not have a current elopement assessment. An admission Minimum Data Set assessment dated [DATE], revealed resident 110 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. An admission Nursing assessment dated [DATE], revealed resident 110 had altered mental status and was alert and oriented to person and place. There were no care plans regarding a possible wander risk or elopement. A nursing progress note dated 5/21/26 at 12:59 PM, revealed Resident left in an Uber to get a haircut and his nails done, notified his daughter when he was finished with the hair cut that he did not know how to get back. Resident [sic] daughter is concerned with his confusion as it is not baseline, notified NP [Nurse Practitioner], to obtain UA [urine analysis]. Resident is being retrieved from salon and back to the facility. Will place wander guard on resident to promote safety, daughter consent. A care plan focus area stating I utilize a wander guard devices to promote safety r/t [related to] potential or history of wandering/exit seeking was initiated on 5/26/26, along with the intervention wanderguard placed on 5/26/26. It should be noted the care plan was initiated 5 days after the incident. Resident 110 was found to have a urinary tract infection and was treated with antibiotics. The investigation the facility conducted into the incident was reviewed. There was a timeline that was created which revealed resident 110 left the building on 5/14/26 at 11:35 AM, unaccompanied in an Uber for a haircut. Shortly after resident 110 called his daughter stating he did not know how to get back. Resident 110's daughter called the facility and About 11:35 AM - 12:xx [sic] facility staff [name removed] went and picked him up. Resident was assessed upon return with no injuries. The facility determined the root cause was a: process gap - lack of a prominent, consistently utilized LOA [Leave of Absence] tracking mechanism at the main exit/front desk combined with momentary lapse in exit monitoring/verification for a resident with cognitive/mobility risk. The departure was not detected in real time because the sign-out step was not followed or verified. The Determination was This was an isolated event. There was no evidence of systemic neglect, willful failure to supervise, or violation of the resident's rights. Documented precautions were in place. The identified gap was procedural and had been immediately addressed through process improvement. No substantiated finding of neglect was warranted. Corrective Action Implemented was improvement dedicated LOA sign-out book/process at front desk/main exit, updated care plan and elopement-risk interventions, staff education on elopement protocols and new LOA process, reinforce special instructions and exit monitoring, and Quality Assurance and Performance Improvement initiated a review. 2. Resident 29 was admitted to the facility on [DATE] and discharged on 6/4/26 with diagnoses which included chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, convulsions, dementia, heart failure and cannabis use. The facility reported to the SSA on 5/31/26 at 6:50 PM, resident 29 required supervised LOA when leaving the facility. Left the building at approximately 6:50 PM. Staff identified that the resident was missing and contacted police for assistance in locating him. The resident returned to the facility on his own at approximately 7:10 PM. The resident stated that he was going to the gas station. Resident's care status requires supervision for any leave of absence; he was not authorized to leave the facility unaccompanied.Planned/initiated actions: Reassess resident on return and monitor respiratory status; review and update care plan and elopement-risk interventions; review supervision/staffing and exit-monitoring for the affected area; reinforce supervised-LOA status with staff; confirm smoking materials remain secured; provide staff education on monitoring and elopement protocols; notify physician. Investigation initiated.An elopement risk evaluation was completed on 3/15/26 at 7:48 PM. Resident 29 scored a 12 which indicated he was at risk for elopements. Resident 29 had a prior elopement or near-elopement and other behaviors that put him at risk for elopements marked on the evaluation. There was no care plan located in resident 29's medical record regarding his elopement risk. There were no nursing progress notes in resident 29's medical record about the incident on 5/31/26.The facility investigation was reviewed and revealed, The incident was classified as an isolated event with an identified process gap that has been promptly corrected. The timeline was on 5/31/26 at 6:50 PM, resident left the facility unaccompanied. Between 6:55 PM until 7:05 PM, staff identified resident 29 was missing. Local police were contacted for assistance in locating him. At 7:10 PM, resident 29 returned to the facility independently. Resident 29 stated he went to the gas station. There were no signs of distress or injury and the resident assessed. Notified police of resident return. The facility conducted a root cause analysis and determination which revealed there was a process gap - lack of a prominent, consistently utilized LOA tracking book/log at the main exit/front desk combined with a momentary lapse in exit monitoring/verification of supervision status for a high-risk resident. The resident's departure was not detected in real time because the sign-out step was not followed or verified. The determination was that This was an isolated event. There is no evidence of systemic neglect, willful failure to supervise, or violation of resident's rights. Documented precautions (supervised LOA designated and special instructions) were in place. The identified gap was procedural and has been immediately addressed through process improvement. No substantiated findings of neglect is warranted. The corrective action was Resident reassessment [plus] respiratory monitoring on return. The facility Implemented a dedicated LOA sign-out book at the front desk/main exit. The resident's care plan was updated, staff education on elopement and new LOA book process. It should be noted that resident 29's care plan was not updated. It should also be noted this was not an isolated event. Resident 29 eloped from the facility after he was evaluated as unsafe to leave the facility without supervision on 5/31/26, despite the root cause analysis performed and corrective action taken after Resident 110 had left the faciity on 5/21/26.On 6/25/26 at 10:35 AM, an interview was conducted with the Administrator (ADM). The ADM stated he must have put the wrong date on the initial reporting of resident 110's elopement. The ADM stated that previously there was an LOA binder for residents to sign out at each nurses station, but there was no check in or sign out at the front door. The ADM stated the process was updated to require the receptionist to check out residents for LOA after resident 110 left. The ADM stated if a resident scored a 14 or higher on the elopement evaluation then the resident was at risk. The ADM stated nurses completed the elopement evaluation and then the Interdisciplinary Team reviewed the assessment and created the care plan. The ADM stated there was no assessment available during resident 110's last admission. The ADM stated the assessment was being revamped and was unavailable for review.On 6/25/26 at 1:36 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated resident 110's elopement assessment in March 2026 was not useful. The RNC stated the facility wanted to update their elopement assessment because some residents triggered to be at risk when they should not have been. The RNC stated resident 29 did not have an elopement assessment and the facility would have gone off of his BIMS score. On 6/25/26 at 2:43 PM, a follow up interview was conducted with the ADM. The ADM stated resident 110 went out of the facility on 5/21/26, and they got consent from the daughter to put a wanderguard on him that day. The ADM stated the LOA sign out book was moved to the front desk and an elopement drill was completed on 5/26/26. The ADM stated resident 29 did not have a history of elopements until he left on 5/31/26, because he wanted cigarettes. The ADM stated he was a wander risk and needed to be supervised for LOA because of his BIMS score. The ADM stated they discussed putting a wanderguard on him but he stated he would cut it off. The ADM stated resident 29 was transferred to another facility for safety. The ADM stated all staff were provided training on elopements on 6/17/26, after he had finalized what the investigations and corrective actions. The ADM stated training was provided to the front desk staff to check out the elopement risk book prior to allowing a resident to leave. The ADM stated the front desk staff and the Social Service Director were educated prior to 6/17/26, but resident 29 was able to leave the facility unsupervised and did not have an elopement evaluation completed.
Based on interview and record review, the facility did not ensure that a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, for 1 out of 40 sampled residents, a resident did not receive bathing assistance per their schedule. Resident identifier 46. Findings included:Resident 46 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome.On 6/22/26 at 9:58 AM, an interview was conducted with resident 46. Resident 46 stated she had not had a bed bath in a week. Resident 46 stated that she required 2 staff to assist with bathing cares and the staff had reported not having enough time to complete the task. Resident 46 stated she was supposed to have bed baths 3 times a week and she had been provided one bed bath in the last 2 weeks. Resident 46 stated she has had to beg to get her hair washed. Resident 46 stated that the Certified Nursing Assistants (CNAs) tell her that they have to hurry through her bed bath, and they can only take 20 minutes to complete the task and her bed bath required a bit more time. Resident 46 stated that the CNAs would say that she refused the care and attempt to have her sign a refusal sheet. Resident 46 stated that they did not have enough staff to provide the care. Resident 46 stated that when she signed the refusal sheet she also documented on that sheet that the reason for the refusal was due to not enough staff available to provide the care. Resident 46 stated that sometimes they did not provide the refusal sheet because they did not want her documenting this as the reason. On 7/1/25, the Annual Minimum Data Set Assessment documented that resident 46 was dependent for shower/bathing assistance. On 10/9/25, resident 46 had an order initiated for Resident to be offered a bed bath on Tuesdays, Thursday, and Saturdays at around 4pm or 8pm per resident's request. If resident refuses, please document. The CNA task for bathing for the last 30 days documented that bed baths were provided on 6/13/26 at 2:00 PM. It should be noted that this was the only bed bath documented for resident 46 during the 30 day time period. The task documented that the bath was refused on 5/26/26, 5/28/26, 5/30/26, 6/2/26, 6/4/26, 6/6/26, 6/9/26, 6/11/26, 6/16/26, 6/18/26, and 6/20/26. The task documented the schedule was Tuesday, Thursday, and Saturday PM and as needed. No documentation of shower refusal sheets could be found in resident 46's medical record. Resident 46 had a care plan for ADL self-care performance deficit initiated on 4/3/24. Interventions identified on the care plan included Bathing/Showering: [Resident 46] needs substantial assist with bathing. She is able to wash her hands/face. She prefers bed baths. On 3/26/26, resident 46 had a grievance concern for bathing initiated. The form documented, -Accountability for After Hour Care-Need for bed Bath To Be By Someone /w [with] Experience.-Retrieving individuals Sometimes Are Inconvenienced and Says 'I Don't Have Time'. -Only Asking For 2 People One With Experience 1630 [4:30 PM] After Pain Med At 1600 [4:00 PM] Need Consistency-Also Exploring Chance For AM Instead For Flexibility.The investigation findings were Spoke with the resident and her husband regarding the plan that will be implemented, including the individual education to be provided to the staff involved. Both the resident and her husband verbalized understanding and agreed with the plan. On 6/24/26 at 7:57 AM, an interview was conducted with Registered Nurse (RN) 7. RN 7 stated that typically residents had a set shower day but they could have showers as needed. RN 7 stated that the process for shower refusals was that they would ask the resident a second time if they would like a shower and if they continued to refuse they would have the resident sign a shower sheet. RN 7 stated that for residents who refused a lot they had an order from the provider to ask 3 times or encourage the resident to have a shower. On 6/24/26 at 11:00 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that he was not sure if the signed shower refusal sheets were scanned into the resident medical record. On 6/24/26 at 11:01 AM, an interview was conducted with the Medical Records staff. The Medical Records staff stated that she did not scan shower refusal sheets into the resident's medical record, and the CNA Coordinator was responsible for the shower sheets. The Medical Records staff stated that she was the only person who scanned documents into the resident's medical record. On 6/24/26 at 11:09 AM, an interview was conducted with CNA 6. CNA 6 stated that resident 46 was dependent and a 2 person total assist for care. CNA 6 stated that resident 46 was scheduled for bathing in the afternoon shift, 3 times a week. CNA 6 stated that if a resident refused a shower she offered the resident 3 times a shower, then informed the nurse of the refusal. CNA 6 stated that the process was the CNA, nurse, and the resident signed the shower refusal sheet. On 6/24/26 at 3:23 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that the CNA Coordinator reported that they did away with the shower sheets a few months ago and the new process was to document the bathing in the tasks. The RNC stated that she was not sure if the process change had been implemented yet. The RNC stated that she preferred that they run a task report to determine who was refusing a lot so they could figure out why they were refusing.
Based on observation, interview, and record review, the facility did not ensure that the services provided met professional standards of quality. Specifically, for 1 out of 40 sampled residents, a resident's tube feeding was labeled with an incorrect formula, an incorrect administration rate, and was not labeled with the initials of the nurse who initiated the infusion. Furthermore, additional tube feedings were missing required labeling information. Resident identifier: 3.Findings included:Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included encephalopathy, altered mental status, type 2 diabetes, and dysphagia oropharyngeal phase.A review of resident 3's physician orders revealed:a. On 6/3/26, an order for Enteral Feed Order every 24 hours for enteral feed administer Jevity 1.5 at 60 ml [milliliters] continuously.b. On 6/9/26, an order for Enteral Feed Order every day and night shift Flush feeding tube with 100 cc [cubic centimeter] of water q [every] 4 hours and with 30 cc of water before and after medication administration.On 6/22/26 at 8:50 AM, an observation was made of resident 3. Resident 3 was receiving a tube feed via a nasogastric tube. The tube feed bag was labeled with resident 3's first name and last initial, Jevity 1.5, 60 mL/hr [milliliters an hour], and 6/21 2300 [11:00 PM]. The water bag next to the tube feed was unlabeled. On 6/23/26 at 7:49 AM, an observation was made of resident 3's tube feed that was infusing. The tube feed bag was labeled with the resident's first name and last initial, Jevity 1.5 @ [at] 60 mL/hr @ 2200 (10:00 PM). The water bag was unlabeled. On 6/24/26 at 7:19 AM, an observation was made of resident 3's tube feed that was infusing. The tube feed was labeled with the resident's first name and last initial, Jevity 1.2, 70 mL/hr, 6/23/26 2030 [8:30 PM]. The tube feed pump was administered at a rate of 60 mL/hr. The water bag was not labeled. It should be noted that a physician's order for Jevity 1.2 could not be located in resident 3's medical record. On 6/24/26 at 9:01 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 3 had a nasogastric tube that was used for tube feedings and medication administration. RN 1 stated that she was given in report that resident 3 had her tube feed order changed to Jevity 1.2 on 6/23/26, but she was unable to find the new order.On 6/24/26 at 9:08 AM, RN 1 was asked to observe the tube feed that was running. RN 1 stated that she did not know why there was a discrepancy of the tube feed that was written on the bag and what was ordered for the resident. RN 1 stated the night shift nurses changed out the tube feeds. RN 1 stated that the tube feed was incorrectly labeled because it did not contain the nurse's name that administered the tube feed and the water bag was not labeled. It should be noted that staff were unable to determine whether Jevity 1.2 or Jevity 1.5 was infusing. On 6/24/26 at 9:30 AM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that resident 3 was on a tube feed and received Jevity 1.5 at 60 mL/hr continuously and to flush with 100 mLs of water every 4 hours. The RNC stated that resident 3's tube feed order had not changed since 6/3/26. The RNC stated that she was unsure of a specific process for labeling tube feed bags. The RNC stated that water bags should be labeled to ensure they were changed out daily.On 6/25/26 at 11:26 AM, an interview was conducted with the Registered Dietitian (RD). The RD stated that she helped the facility with residents that required tube feeds and made the orders. The RD stated that she had not approved any recent changes to Resident 3's tube feed order, and stated that Jevity 1.2 was not the correct formula. The facility's tube feed policy was reviewed. T011-Gastrointestinal Conditions: Enteral Tube Feeding Via Continuous Pump.General Guidelines.3. Check the enteral nutrition label against the order before administration. Check the following information:a. Resident name, ID [identification] and room number;b. Type of formula;c. Date and time formula was prepared;d. Route of delivery;e. Access site;f. Method (pump, gravity, syringe); and g. Rate of administration (mL/hour) .The facility policy was in effect 2/1/24.Review of the Lippincott Nursing Procedures documented under Enteral Gastric, Duodenal, and Jejunal Tube Feeding for implementation to Make sure that the enteral formula container is labeled with the patient's identifiers; formula name (and strength if diluted); date and time of formula preparation; date and time the formula was hung; administration route, rate, and duration (if cycled or intermittent); initials of who prepared, hung and checked the enteral formula against the order; expiration date and time; dosing weight (if appropriate); and notation ENTERAL USE ONLY-NOT FOR IV USE.Wolters Kluwer. Lippincott Nursing Procedure. Ninth Edition. Philadelphia, PA. (2023), pp 296.
Based on interview and record review it was determined that the facility did not document in the resident's medical record the information that was provided to the receiving provider which must include a minimum of the practitioner responsible for the care of the resident; the resident representative contact information; advanced directive information; comprehensive care plan; a copy of the resident discharge summary; and all necessary information to ensure a safe and effective transition of care. Specifically, for 2 out of 40 sampled residents, the facility did not document in the resident's medical record the information conveyed to the receiving provider when the resident was transferred to the Emergency Room. Resident identifiers: 18 and 54.Findings included:1. Resident 54 was admitted to the facility on [DATE], and was readmitted on [DATE] with diagnoses which consisted of asthma, pneumonia, type 2 diabetes mellitus, congestive heart failure, hypertension, and chronic kidney disease. On 6/22/26 at 11:48 AM, an interview was conducted with resident 54. Resident 54 stated that he went to the emergency room (ER) for a bowel issue and they also identified pneumonia at that time. Resident 54's medical records were reviewed. On 6/13/26 a 11:18 AM, a discharge summary note documented, Type: Hospital Transfer Resident transferred to a Short-term General Hospital/Acute Care Hospital. Resident transported via Non-Emergent Transport. Responsible Party was notified prior to transfer. Physician was notified prior to transfer. Director of Nursing or Designee was notified prior to transfer. Details: resident's results showed colonic ileus, was advised by oncall provider to be sent out during previous shift but declined to go, wanted to go this AM [morning]. On 6/13/26 at 11:18 AM, resident 54's Discharge Transfer summary was completed. The summary documented the reason for transfer and that the current reconciled medication list was provided to the resident. On 6/25/26 at 8:28 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when they transferred a resident to the hospital they sent a copy of the facesheet, medication list, and documented the resident's change in condition. RN 1 stated that she documented this information in a progress note and evaluation form. RN 1 stated that she would document what information was sent to the receiving provider in the progress note. It should be noted that resident 54's progress notes did not contain the information that was sent to the receiving provider upon discharge/transfer. On 6/25/26 at 8:31 AM, an interview was conducted with RN 6. RN 6 stated that when she transferred a resident to the hospital she sent a copy of the orders and facesheet. RN 6 stated that this information was documented in the discharge paperwork. RN 6 stated she was not sure if the resident code status was contained on the facesheet. On 6/25/26 at 10:05 AM, an interview was conducted with Assistant Director of Nursing (ADON) 1. ADON 1 stated that the nurses send a copy of the resident facesheet, history and physical, labs, Physician Order for Life Sustaining Treatment (POLST), and medication list when a resident was transferred to the hospital, unless the Emergency Medical Technician (EMT) asked for other information. ADON 1 stated that the information sent to the receiving provider was not typically documented in a progress note and they never documented the actual forms that were sent to the receiving provider. 2. Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included fracture of unspecified part of neck of left femur. On 6/13/26 at 7:04 AM, a Discharge Summary documented Hospital Transfer Resident transferred to a Short-term General Hospital/Acute Care Hospital. Resident transported via Ambulance. Responsible Party was notified prior to transfer. Physician was notified prior to transfer. Director of Nursing or Designee was notified prior to transfer. Administrator was notified prior to transfer. The Discharge Transfer Leave of Absence Form dated 6/13/26, did not include all the required information that should have been sent to the receiving provider. The form did not include contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advance Directive information, and comprehensive care plan goals. On 6/25/26 at 12:56 PM, an interview was conducted with the Regional Nurse Consultant (RNC). The RNC stated that she could not find anything other than what was already located in resident 18's medical record. The RNC stated that she would update the evaluation form with their home office team to include a more comprehensive check boxes addressing the order for life-sustaining treatment (OLST) form and the other missing documents.
Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment. Specifically, for 2 out of 40 sampled residents, personal protective equipment (PPE) was not worn for high contact care for residents on Enhanced Barrier Precautions (EBP). Resident identifiers: 3 and 15.Findings included:1. Resident 3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included encephalopathy, altered mental status, type 2 diabetes, and dysphagia oropharyngeal phase.On 6/25/26 at 7:27 AM, an observation was made of Registered Nurse (RN) 1 administering medications to resident 3 through her Nasogastric tube and was not wearing a gown.On 6/25/26 at 8:22 AM, an interview was conducted with RN 1. RN 1 stated that EBP PPE included wearing gloves and a gown. RN 1 stated that EBP was used for any resident that had a urinary catheter, feeding tube, or wounds. RN 1 stated that a gown and gloves were to be worn when administering medications through a tube feed. RN 1 stated that she was not wearing a gown when she administered medications to resident 3 this morning. On 6/25/26 at 8:24 AM, an interview was conducted with the Infection Preventionist (IP). The IP stated that EBP would be required for any resident that had a urinary catheter, feeding tubes, and wounds. The IP stated that nursing staff should perform hand hygiene prior to donning gloves and a gown. The IP stated that administering medications through a feeding tube would require a gown and gloves to be worn. 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included nontraumatic intracranial hemorrhage, dysarthria, and encounter for gastrostomy tube. On 6/22/26 at 8:50 AM, an observation was made of resident 15's room. Resident 15 had a tube feed (TF) pole located inside the room. Gowns and gloves were located inside the room next to the door. An interview was conducted with resident 15. Resident 15 stated that the TF was for water only. Resident 15 replied yes when asked if he had a feeding tube in his stomach. Resident 15 had a physician order for EBP due to a feeding tube that was initiated on 3/16/26.On 6/22/26 at 12:34 PM, an observation was made of the Certified Nursing Assistant (CNA) Coordinator during lunch meal service. The CNA Coordinator provided dining assistance to resident 15. The CNA Coordinator donned gloves and assisted resident 15 in sitting up in his wheelchair. The CNA Coordinator reclined resident 15's wheelchair, positioned herself behind the head of the wheelchair, reached under resident 15's bilateral arms, and pulled the resident up in the chair. The CNA Coordinator's bilateral arms and torso came into direct contact with resident 15 and his wheelchair. The CNA Coordinator then adjusted the wheelchair to a high fowler's position. The CNA Coordinator then sat down on a stool and proceeded to assist resident 15 with his lunch meal. The CNA Coordinator did not have a gown donned while assisting resident 15.On 6/23/26 at 3:15 PM, an interview was conducted with the IP. The IP stated that EBP was initiated for residents with urinary catheters, intravenous access, wounds, or tube feeds. The IP stated that staff should be wearing a gown and gloves for any high contact care activities. The IP stated that staff should wear a gown and gloves when repositioning a resident if they are making direct contact with the resident or their immediate environment.
Based on interview and record review, the facility did not implement written policies and procedures on prohibiting and preventing abuse and investigating any such allegations. Specifically, for 1 out of 40 sampled residents, staff were aware of allegations of roughness during care but did not escalate the allegation up the chain of command to be investigated as a possible allegation of abuse. Resident identifier: 46. Findings included:Resident 46 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, alcoholic cirrhosis, hepatic failure, generalized anxiety disorder, major depressive disorder, and chronic pain syndrome.On 6/22/26 at 9:55 AM, an interview was conducted with resident 46. Resident 46 stated that a staff member previously provided rough care during a brief change and persisted despite resident 46's request to stop. Resident 46 stated that this staff member was no longer allowed to work with her. Resident 46 stated that she did not want to disclose the staff member's name. Resident 46 stated that the facility said they spoke with the staff member and instructed them on resident 46's care. Additionally, Resident 46 stated that certain staff were not allowed to work with her due to issues with their treatment and things that they had said to her. Resident 46 would not elaborate on the issues, but said the staff yelled at her and screamed inappropriate comments. Resident 46 stated that she felt like the Certified Nursing Assistants (CNAs) were immature and retaliated towards her by not providing care. Resident 46 stated that staff rushed with her bed bath and it felt like they were rough with cleaning her. Resident 46 stated that she stopped filling out the grievance forms because facility leadership were no longer providing her with the facility resolution to her concerns. Resident 46 began crying and stated that she struggled with getting her incontinence care and bed baths. On 6/25/26 at 10:18 AM, an interview was conducted with the CNA Coordinator with the Regional Nurse Consultant (RNC) present. The CNA Coordinator stated that if resident 46 did not like the CNA she would refuse care from that CNA. The CNA Coordinator stated that resident 46 did not want CNA 2, CNA 3, CNA 4, CNA 5, or any male CNAs providing incontinence care or bathing assistance to her. The CNA Coordinator stated that she was aware of reports from resident 46 that staff were rough with providing her care. The CNA Coordinator stated that resident 46 reported that the staff were rough when wiping during incontinence care and bathing. The CNA Coordinator stated if a resident had a concern related to staff being rough she provided that resident a grievance form and then she talked to the staff member about the concern. The RNC stated that she identified last week that the staff were not aware of abuse reporting and the difference between abuse and a grievance. The facility documentation on allegations of abuse were reviewed. No documentation could be found that resident 46's allegations of rough care were reported to the state agencies or thoroughly investigated. Review of the facility policy on Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating documented that any suspicion of resident abuse must be reported immediately to the administrator and to other officials according to state law, and all allegations were thoroughly investigated. The policy was last revised on February 1, 2024.
Inspection of January 5, 2026
2 findingsBased on interview and record review, it was determined for 1 out of 8 sampled residents, the facility did not ensure that all residents received the treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, a resident was not provided wound vac supplies in a timely manner. Resident identifier: 2.Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses which included, encounter for orthopedic aftercare, acquired absence of left great toe, and type 2 diabetes.A review of resident 2's medical record revealed the following:a. On 6/5/25 at 7:02 PM, a progress note documented, Resident back from wound clinic appointment from [local hospital]. Notes state to order wound vac, and send it with patient to next appointment and doctor wants patient to do hyperbaric oxygen therapy, team at [facility] needs to talk about a decision. Resident aware of orders. DON [Director of Nursing] [name redacted] and ADON [Assistant Director of Nursing] [name redacted] aware of requests and orders.b. On 6/13/25 at 11:37 AM, a progress note documented, [resident 2] returned from her appt [appointment] with [name redacted]. Nurse's not [sic] to physician: Wound Vac to be used Monday, Wednesday, Friday Dressing changed every two days. Physician note/orders: Please start wound vac ASAP [as soon as possible] L F [left foot]. We were unable to place due to lack of supplies.c. On 6/16/25 an order documented, Wound vac to left foot- ensure wound vac is in place and functioning. ** CHANGE MONDAY, WEDNESDAY, FRIDAY AND PRN [as needed]** as needed for wound healingOn 1/5/26 at 10:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the facility used wound vacs and they were supplied by a contracted company. LPN 1 stated that a wound vac required an order and was brought the same day it was ordered. LPN 1 stated that the wound vac was brought with all the supplies that a resident needed.On 1/5/26 at 1:23 PM, an interview was conducted with the DON. The DON stated that wound vacs arrived at the facility within two hours on the day they were ordered. The DON stated the facility used an outside company to supply the wound vac and supplies that were needed. The DON stated that she called the wound vac company with the order and gave the resident's name and insurance information and it would be delivered. The DON stated that it would not take more than a week for a wound vac and supplies to be delivered to a resident. The DON stated that she was unsure why it took so long for resident 2 to receive her wound vac supplies.
Based on interview and record review it was determined, for 2 out of 8 sampled residents, the facility did not provide routine and emergency drugs and biologicals to its residents. Specifically, residents were not provided multiple medications due to them being out of stock and unavailable from the pharmacy. Resident identifiers: 2 and 8.Findings included: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, encounter for orthopedic aftercare, acquired absence of left great toe, and type 2 diabetes.Resident 2's medical record was reviewed on 1/5/26.A review of resident 2's medication orders revealed:a. Glimepiride Oral Tablet 4 MG [milligram] Give 4 mg by mouth at bedtime for T2DM [Type 2 diabetes mellitus]. The start date of this medication was 5/15/25.b. Eucerin Advanced Repair External Cream (Emollient) Apply to [NAME] [bilateral] Lower extremites [sic] topically two times a day for Dry scaley [sic] skin. The start date of this medication was 5/26/25. c. Amitriptyline HCI [hydrochloride] Oral Tablet 25 MG. Give 25 mg by mouth at bedtime for antidepressant. The start date of this medication was 5/15/25.A review of resident 2's Medication Administration Record (MAR) revealed: a. Glimepiride was not administered on: 9/18/25, 9/19/25, 9/20/25, 9/21/25, 9/22/25, 9/23/25, 9/24/25, 9/25/25, 9/27/25, and 9/28/25.b. Eucerin Advanced Repair Cream was not administered on: 6/9/25, 6/10/25, 6/17/25, 6/23/25, 6/24/25, 6/25/25, 6/26/25, 6/27/25, 6/28/25, 6/29/25, 6/30/25, 8/24/25, 8/25/25, and 8/26/25. c. Amitriptyline was not administered on 6/15/25 and 6/16/25.A review of resident 2's progress notes revealed:a. On 6/9/25 at 10:02 AM, an eMAR (electronic Medication Administration Record) note documented, Eucerin Advanced Repair External Cream.Out of supply. Supply personal [sic] made aware.b. On 6/15/25 at 10:00 PM, an eMAR note documented, Amitriptyline HCl Oral Tablet 25 MG.No med [medication] .c. On 6/16/25 at 1:00 AM, an encounter note documented, . She wanted to verify that she was still receiving her amitriptyline dosing. I verified Mrs. Still [sic] active that she should be getting this on a nightly basis.d. On 6/16/25 at 10:00 PM, an eMAR note documented, Amitriptyline HCl Oral Tablet 25 MG.medication not available.e. On 6/17/25 at 9:10 AM, an eMAR note documented, Eucerin Advanced Repair External Cream.Out of supply, on order.f. On 9/18/25 at 9:17 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.Not able to give medication because we do not have it on hand.g. On 9/19/25 at 9:49 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.Med reordered.awaiting refill from the pharmacy.h. On 9/21/25 at 8:19 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.Unavailable on order.i. On 9/22/25 at 7:00 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.Reordered. Awaiting delivery.j. On 9/23/25 at 7:58 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.reordered. Awaiting delivery.k. On 9/24/25 at 9:19 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.Not able to give medication because we do not have it in stock.l. On 9/25/25 at 9:17 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.We do not have this medication on hand.m. On 9/27/25 at 7:57 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.Unavailable, unable to administer, resident notified.n. On 9/28/25 at 9:32 PM, an eMAR note documented, Glimepiride Oral Tablet 4 MG.On order-not given.On 1/5/26 at 10:18 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that when a medication needed to be refilled it was refilled in the Electronic Medical Record and this would alert the pharmacy that a resident was out of medication. LPN 1 stated that she would alert the medical provider that the resident was out of medication and see if the provider wanted an alternative medication or to place the medication on hold. LPN 1 stated that a resident should never go a week without a medication and that nurses should document that they have discussed medications with the provider. LPN 1 stated that there were several ways to communicate with the provider regarding medications. LPN 1 stated that the pharmacy delivered medications to the facility twice a day during the week and at least once a day on weekends. LPN 1 stated that she would contact the pharmacy if a medication was not brought on the same day it was ordered and document this in a progress note.On 1/5/26 at 10:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that once a resident had one week left of medication she would reorder the medication through the pharmacy. RN 1 stated that a resident should never run out of medications. RN 1 stated that she would contact the pharmacy and ask where the resident's medications were if they were not delivered. RN 1 stated that it was the nurses job to order medications for residents and to make sure they did not run out. On 1/5/26 at 1:23 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that medications should be reordered for residents when there were 5 days left of the medication. The DON stated that nurses order medications through the Electronic Medical Record. The DON stated that if a medication was not administered or was unavailable then this should be communicated to the medical provider for further direction. The DON stated that she expected staff to document this in a progress note and to alert nursing management. 2. Resident 8 was admitted to the facility on [DATE] with diagnoses which included orthopedic aftercare following an amputation, acute osteomyelitis of right ankle and foot, cellulitis of right lower limb, and type 2 diabetes mellitus.Resident 8's medical records were reviewed on 1/5/26.On 1/4/26 at 10:40 AM, an admission evaluation nursing progress note revealed the following. Resident 8 was admitted on [DATE] at 6:05 PM, from a Short-Term General hospital via stretcher for post-operative rehabilitation intravenous (IV) infusions. On 1/3/26, a physician's order for Piperacillin-Tazobactam Solution Reconstituted 3-0.375 grams (g) Use 3.375g intravenously every 6 hours for infection.The MAR revealed administer times for Piperacillin-Tazobactam Solution 3-0.375g were as follows: 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM.It should be noted that resident 8 did not receive his ordered Piperacillin-Tazobactam Solution on 1/3/26 at 6:00 PM, and 1/4/26 at 12:00 AM. On 1/3/26, a physician's order for Vancomycin Hydrochloride Solution Reconstituted 1g intravenously two times a day for infection.The MAR revealed administer times for Vancomycin HCl Solution were as follows: 8:00 AM and 8:00 PM. It should be noted that resident 8 did not receive his ordered Vancomycin on 1/3/26 at 8:00 PM until 1/4/26 at 1:59 AM.On 1/3/26 at 7:10 PM, a Medication Administration Note for the ordered Piperacillin-Tazobactam Solution revealed that resident 8 admitted after 6:00 PM and medications not delivered from the pharmacy.On 1/4/26 at 1:59 AM, a progress note stated the following. Resident is just now getting his 2000 [8:00 PM] dose of Vanco [vancomycin]. None of his scripts were faxed to pharmacy on his arrival and now the faxes aren't going thru [sic]. I am trying to get him pain meds and IV abx [antibiotic]. The Vanco was in the e-kit [emergency]. The Zosyn is not. Resident is veryupset [sic] and yelling at staff and nurse. On 1/4/26 at 2:06 AM, a Medication Administration Note for the ordered Piperacillin-Tazobactam Solution revealed that the medications were not delivered from the pharmacy.On 1/4/26 at 10:55 AM, a late entry progress note revealed that the pharmacy did not deliver the Piperacillin-Tazobactam Solution the night of admission. The medical doctor (MD) was notified and the order was placed on hold until the arrival of the medication.On 1/5/26 at 11:05 AM, a progress note for an incident report stated that a new admitting resident had orders for Piperacillin-Tazobactam Solution. The orders were faxed to the pharmacy and the medication was not located in the pharmacy bin. Resident 8 missed the first and second doses of the antibiotics. The MD was notified and new orders were given to hold the antibiotics until the pharmacy delivered the medication and adjusted the medication schedule as needed. The pharmacy was called and placed a STAT (immediately) order for the antibiotics. The medication orders were refaxed. The resident, MD, and management was notified.On 1/5/26 at 2:47 PM, an interview was conducted with Resident 8. Resident 8 stated that he had come into the facility at a later time and it was during shift change. Resident 8 stated that the facility knew he was coming so he did not know why they did not have the medication here for him. Resident 8 stated that he did not get his antibiotics for about 6 hours after they were due. Resident 8 stated that he was worried about not having his antibiotics since the hospital kept him three extra days due to his white blood cell count not low enough to transfer to a skilled nursing facility. Resident 8 stated that he did not want his infection to flare up again and cause more problems.On 1/5/26 at 1:30 PM, an interview was conducted with the DON. The DON stated that she was informed about resident 8's antibiotics not arriving at the facility as expected. The DON stated she just started looking into why the medications did not come from the pharmacy, since the prescriptions were faxed. The DON stated that the admitting nurse should fax the ordered medications to the pharmacy. The DON stated that she would need to follow up with the pharmacy about the undelivered antibiotics and ask them what happened on their end. The provider was notified about antibiotics not coming from the pharmacy, the MD reviewed the order and updated it to add one additional day on the back end.
Inspection of January 3, 2024
1 findingBased on interview and record review, it was determined for 1 of 5 sampled residents, that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the resident's preferences. Specifically, a resident with multiple co-morbidities who had a change in condition, was hospitalized after failure to identify the change in condition in a timely manner. The deficient practice for resident 1 was found to have occurred at a harm level. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included non-traumatic subdural hemorrhage, encephalopathy, epilepsy, end stage renal disease, hemiplegia and hemiparesis following cerebral infarct, history of falling, attention and concentration deficit following non-traumatic subarachnoid hemorrhage, Alzheimer's disease, dementia, and schizophrenia. Resident 1's medical record was reviewed on 1/3/24. Physician orders included: a. Olanzapine 5 mg tablet. b. Apixaban 2.5 mg tablet c. Aspirin 81 mg tablet d. Donepizil 10 mg tablet e. Divalproex 125 mg tablet f. Monitor for seizure activity every shift. Progress notes were reviewed and revealed the following: a. A provider progress note dated 9/28/23 revealed, Admission visit with [resident's name removed] .She has a fall mat next to her bed and her bed is in the lowest position .Review with staff. They report that she has significant dementia and requires significant assistance with standing and pivoting. Per their report she normally can answer questions and usually follows directions .Assessment and Plan .fall precautions . monitor for change in condition .Data .continues with confusion, recurrent falls despite intervention .(P)atient has a baseline level of dementia that will require additional monitoring for an accurate clinical picture. They are also at increased risk for falls, medication side effects and complications related to their baseline level of confusion .Patient is on anticoagulants. These pose a significant risk of increased bleeding. Pros and cons of these medications have been reviewed with patient and they have elected to proceed. Patient is aware of potential of significant bleeding from minor trauma, GI (gastrointestinal) bleeds and closed head injury with associated complications .rec. (recommend) that we stop anticoag given her falls .[Resodent's name removed] appears to have significant impairment. Per report some of this is baseline and some of this is new post her recent decline in illness . She is a huge fall risk and is on anticoagulants, thus increasing her risk. b. A provider progress note dated 9/29/23 revealed, .No reports of illness but she was found on her bottom on the floor, no injury. c. A provider progress note dated 10/2/23 revealed, Recheck with [Resident's name removed]. (S)he has had recurrent falls in house and no related injury. Interventions in place and still falls. Continues with significant confusion and generalized weakness. No new illness, pain. Review her labs, doing well with dialysis. Nurse without concerns. d. An advanced skilled evaluation dated 10/3/23 at 10:21 AM, revealed the following, Neurologic: Resident obeys commands. Resident has weakness (baseline). PERRLA (pupils are round and reactive to light and accommodation): Yes. Mental Status: Resident requires cues. Resident is confused. Oriented to person. Confused: Chronic. Requires cues: Chronic. Level of cognitive impairment: Mild impairment (some confusion). Resident is coherent. Speech is clear. Language barrier: No. Resident makes self understood. Resident understands others .Mood and behaviors: Mood is pleasant, no unwanted behaviors witnessed .Safety: Call light is within reach. Resident is not on seizure precautions .Safety note: High fall risk .Functional: Able to move all extremities. Upper extremity ROM (Range of motion): No impairment. Lower extremity ROM: No impairment. Gait is unsteady. Balance is poor. e. An IDT (interdisciplinary team) progress note dated 10/3/23 at 6:20 PM revealed, Reviewed in risk management meeting. 9/26/23 @2030: CNA (Certified Nursing Assistant) notified nurse that resident was on the floor. FN (Floor Nurse) went into room to assess resident, noted her on the floor sitting on her buttocks. Her brief had stool on it and stool on the floor. Resident alert and talking. Assisted resident to get cleaned up and toilet her, then assisted her back into bed in a safe position and fall mat placed to side of bed. No injuries noted. ROM at baseline. Emergency contact notified. MD (medical doctor) notified. Intervention: Will assist and encourage resident to toilet before bed. f. An IDT progress note dated 10/5/23 at 3:31 PM revealed, Reviewed in risk management meeting. 9/28/23 @0556: Resident was found sitting on floor at nurses station. Resident stated she was trying to go home but didn't know where to go so she sat at the nurse station until someone came to help her. Assessed resident and then redirected resident back to room. No injuries noted. ROM at baseline. VS (vital signs) taken. Assisted resident back to bed. Family notified. MD notified. Intervention: Will evaluated med regimen with provider to ensure resident is supported in sleep regimen. Will offer diversional activity around 0500 to help residents morning routine. Note: It should be noted that there were no nursing progress notes related to resident 1 falling on 9/26/23 or 9/28/23. g. A nursing progress note dated 10/7/23 at 10:41 AM revealed, Pt (patient) was found by CNA sitting on her floor next to her chair. Pt stated she had slid onto the floor, RN (registered nurse) assessed for pain and injury. Pt denied Pain and No evidence of injury noted. Pt was placed on Neuro Checks r/t (related to) unwitnessed fall. Pt education on use of call light and walker for assistance with ambulation. MD and On Call RN notified as well as family. h. An additional nursing progress note dated 10/7/23 at 11:00 AM revealed, No changes in LOC (level of consciousness). No visible injuries. PERRLA (Pupils Equal, Round, Reactive to Light Accommodation). ROM intact. No increase in pain. Pt placed on Neuro checks. Added to alert charting. MD, UM, and Family notified. INTERVENTION: Dycem pad on WC (wheelchair). i. An advanced skilled evaluation dated 10/15/23 revealed the following, .Neurologic: Resident obeys commands. Resident has weakness (baseline). Resident complains of numbness (baseline). PERRLA: Yes .Mental Status : Resident is alert & (and) oriented x3. Oriented to time. Oriented to person. Oriented to place .Level of cognitive impairment: Alert. Resident is coherent. Speech is clear. Language barrier: No. Resident usually makes self understood. Resident usually understands others . Level of cognitive impairment: Alert. Resident is coherent. Speech is clear. Language barrier: No. Resident usually makes self understood. Resident usually understands others. Mood and Behavior : Resident has a flat affect. Flat affect - No recent change in mood. Resident sleeps intermittently. Resident does not wander at night. Resident's psycho-spiritual needs are met. Resident is not currently experiencing unwanted behavior(s). j. A nursing progress note dated 10/16/23 at 5:44 AM revealed, Note Text : Change in condition noticed during AM shift. AM nurse reports that resident not verbally responding to commands from staff or family members. This behavior continued through the night. VS WNL (Within Normal Limits). COVID test negative. Resident now able to follow physical commands, able to squeeze nurses hands and nod in response to commands. Resident now in dialysis. k. A nursing progress note dated 10/16/23 at 1:53 PM revealed, ADON (Assistant Director of Nursing)called residents dialysis center. Resident continued to have stroke like symptoms when she arrived to dialysis- they sent her to [Hospital name removed] ED (Emergency Department) for further work up. Will attempt to call for an update. [NOTE: No additional documentation regarding resident 1 was found in progress notes until readmission on 10/24/23.] A pre-dialysis form dated 10/16/23 at 4:07 AM revealed that resident 1 was confused and disoriented. The document stated resident 1's baseline was alert and oriented x 2. Comments included, Resident has not been verbally responsive for the past 20 hours. VS WNL COVID negative. A history and physical dated 10/16/23 from the hospital where the resident was sent documented, [AGE] year-old female patient with history of end-stage renal disease, SLE (systemic Lupus erythematosis), relatively recent recurrent subdural hematoma, apparently was doing well until about 24 hours ago when she was noted to have decreased level of consciousness. I spoke with her mother who saw her 2 days ago when she appears to be in her usual state of health, but noticed last evening when she visited with her at her assisted living facility that she was not communicative, and although she was able to eat she was not able to verbalize, and only moaned and screamed when touched. The patient was taken to her dialysis center today according to her schedule but was noted to be altered and brought to the ER (emergency room ) for evaluation. In the ER she was found to have left-sided subdural hematoma and admitted for further evaluation and management. Patient herself is not able to answer questions or carry a conversation and only opens her eyes to verbal stimuli-which was reported in the ER note earlier this morning. Additionally, the note stated, Patient appears to be drooling occasionally at the mouth, without obvious facial asymmetry Her right upper extremity is flexed and with increased tone. On 1/3/23 at 10:49 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated if a resident was suspected to have a change in condition, she would do a full head to toe assessment, look at the resident's medications, any as-needed (PRN) medications, look at the last couple of progress notes for trends, and inform the Director of Nursing (DON), Physician (MD), and the resident's family. RN 2 stated she would follow orders or instructions for what to do next. If a resident needed to be sent out, there was an Situation, Background, Assessment, and Recommendation (SBAR) that would be completed, a change of condition form and a transfer form. RN 2 stated she would write a progress note. RN 2 stated there was a binder at the nurse's station with a check list of steps to take for a change in condition. RN 2 stated regarding falls, it would depend on if the fall was witnessed or not witnessed. RN 2 stated she would ask the resident about hitting their head or another body part, obtain vital signs, check the resident's range of motion and level of consciousness. RN 2 stated she would assess for any changes in behavior, look for blood, redness, or swelling, and then notify the MD, DON, and the resident's family. RN 2 stated she would write a progress note and fill out an indecent report, obtain x-rays if ordered, provide fluids, or other interventions as ordered and document them. On 1/3/23 at 10:58 AM, an interview was conducted with RN 3. RN 3 stated that based on the resident's baseline, if he felt there was a change, he would notify the Assistant Director of Nursing (ADON), and notify the MD. RN 3 stated he would document the changes in a progress note. If there was a change in the level of consciousness, RN 3 stated he would make sure the resident was safe, then contact the ADON. RN 3 stated if the ADON was not available, he would contact the next on-call (usually the provider or MD). RN 3 stated he could not think of any other physical paperwork he would need to do. RN 3 stated he would ask the Certified Nursing Assistant (CNAs) to monitor the resident more closely. RN 3 stated he would let someone else know depending on the severity of the situation. RN 3 stated if a resident had a fall, he would make sure the resident was safe, assess them, notify the doctor and the resident's emergency contact, and complete risk management paperwork. RN 3 stated if the fall was unwitnessed he would complete do neurological (neuro) checks. RN 3 stated he would follow the physician recommendations. On 1/3/23 at 11:10 AM, an interview was conducted with the ADON. The ADON stated he was in charge of the skilled nursing side of the facility. The ADON stated if there were skilled nursing issues, the staff would contact him first. The ADON stated the nurse would assess the resident and see what the change in condition was and notify the on-call provider. The ADON stated the nurse would then let the unit managers know, and depending on the severity, follow the protocols in place. The ADON stated protocols might mean sending to the resident to the emergency room (ER), contacting family, or completing forms that nurses fill out if the situation was not urgent. The ADON stated nurses could reach out to the provider through Tiger text. The ADON stated that at night, nursing staff were to bypass the tiger text and call the provider directly, and document that communication. The ADON stated that he and the DON were included in the communications so they could see the chatter about what happened. The ADON stated orders were reviewed every day and discussed in the leadership huddle to ensure follow-through. The ADON stated regarding resident 1, during the night shift she had stroke-like symptoms and the provider was notified. The ADON stated neuro checks were being done. The ADON stated an evaluation had been completed a short time prior and a stroke was ruled out. The ADON stated the provider was notified and resident 1 was going to be sent out and then the provider was informed that she was doing better. The ADON stated the provider told staff that if resident 1 was doing better, to send her to dialysis. The ADON stated while enroute to dialysis, resident 1 had another stroke-like event and the dialysis center sent her to the ED. The ADON stated he was not sure if the issue was metabolic in nature. The ADON stated the dialysis center called the facility to let them know what was happening. The ADON stated he would look to see if he had any additional documentation (neurochecks, communication between the provider and nursing staff, communication between the ADON or DON OR incident reports) about that event and provide the information to the surveyor. The ADON stated that resident 1 came back to the facility after hospitalization , and the 3rd party dialysis center would no longer provide dialysis due to the resident's condition. The ADON stated resident 1 was transferred to another facility where in-house dialysis could be provided. On 1/3/23 at 12:10 PM, an interview was conducted with the DON and the ADON when additional documentation was not received. The DON stated that the communication between the physician/provider and the nurse was only kept in the electronic medical record for 7 days, and then went to the trash. The DON stated that neuro checks were not completed since resident 1 did not hit her head during her unwitnessed falls. The DON stated that both she and the ADON were aware of the incident on 10/16/23 and that resident 1's cognition had improved to the point that she could go to dialysis. The DON stated that the dialysis center did call as they had concerns that the resident was not medically stable when she arrived for dialysis. Note: It should be noted that no additional documentation (neuro checks, physician, provider or administrative staff communication, or incident reports) was provided to the State survey agent. On 1/3/23 at 1:28 PM, an interview was conducted with RN 1. RN 1 stated resident 1 had a stroke prior to being admitted on [DATE] and was not herself and her baseline had changed from prior admissions. RN 1 stated it was hard to tell if she was having physical problems or having behaviors on 10/15/23. RN 1 stated resident 1 was going in and out of being verbal during his shift. RN 1 stated resident 1's mother came to the facility between 5:30 and 6 PM to help resident 1 with dinner, and her mother did not know what to think about resident 1's disposition. RN 1 stated resident 1's was acting strange during her dinner meal on 10/15/23. RN 1 stated resident 1 had become non-verbal, and that was different from her baseline. RN 1 stated later in the interview that he did not remember if resident 1 was verbal during his shift on 10/15/23. RN 1 stated, It was more like a behavior. RN 1 stated he did not know why resident 1 was not verbalizing with staff. RN 1 stated he was pretty sure there was a provider at the facility on the day prior to resident 1's dialysis visit, during his shift. RN 1 stated that he was fairly sure he mentioned resident 1's changes to the provider. RN 1 stated nobody was really concerned about resident 1 being unresponsive . RN 1 stated if what was going on with resident 1 had been something that was out of the ordinary, it would have been documented. RN 1 stated the oncoming nurse went to assess resident 1 after she arrived for her shift. RN 1 stated assessments were always ongoing, some residents got daily assessments and others just as needed. RN 1 stated whatever was going on was evolving. RN 1 stated he was surprised resident 1 had an incident at the dialysis center, and did not see her again until she came back on 10/24/23. RN 1 stated, again, that [physician's name removed] was at the facility on 10/15/23. RN 1 stated that on weekends there was a non-on-call person who could be contacted if there was a concern. RN 1 stated he was told to keep an eye on resident 1, and if something was different, to send her out. RN 1 stated if a resident had to be sent out for a fall, an injury of unknown origin, or change in condition, the nurses would document. On 1/3/23 at 2:59 PM, an interview was conducted with the Administrator (ADM) and the DON. The DON stated she expected staff to include her and the physician in communication about a resident. The DON stated if she was not on call, staff should contact the ADON, and the provider. On the weekend, the DON stated the process was the same. The DON stated the facility had an on-call contracted medical provider. The DON stated the MD did not typically come in on weekends. The DON stated the only standing orders at the facility were for bowel regimens, Tylenol or zofran, and there were standing orders for a change in condition. The DON stated all orders should come from the medical director. The DON stated the process for nurses reporting to the oncoming nurse was a direct handoff. The DON stated the nurse leaving would go through the report sheet on each patient, and it was a verbal handoff, then the nurses completed the narcotic counts. The DON stated behaviors could be a change in condition, but usually vital sign abnormalities would be seen. The DON stated a subdural hematoma presented a lot like a stroke. The DON stated a resident might sleep a lot more, vital signs would be a factor, there would be a drop in blood pressure, unequal hand grip, and pupils might not be reactive. On 1/3/23 at 3:15 PM, an interview was conducted with the transportation driver (TD) who took resident 1 to dialysis. The TD stated he had been transporting resident 1 to and from dialysis for quite some time. The TD stated the routine was that he would arrive at the facility at 4:30 AM, where resident 1 would be waiting at the front door for her ride. The TD stated resident 1 frequently complained about having to be up so early, and he would try to joke around with her to make the best of the situation. The TD stated he would load the resident onto the bus by 4:50 AM, and they would arrive at the dialysis center by about 5:00 AM and would have her in her chair by 5:15 AM. The TD stated on 10/13/23, when he picked up resident 1 for dialysis, she was able to talk to him. The TD stated on 10/16/23 when he picked up resident 1, she was leaning to one side and she was not able to respond to him. The TD stated resident 1 was drooling out of the left side of her mouth. The TD stated the staff member that was waiting at the door with resident 1 was someone he had spoken to before and recognized. The TD stated that he told the staff member that it looked like resident 1 was having a medical issue and asked if he should take her to the emergency room instead of dialysis. The TD stated on previous pick-ups, resident 1 would lift both arms up so he could put the red belt around her, but this particular day, the resident could not move her left arm. The TD asked the staff member what the facility stroke protocol was. The TD stated, I am not a doctor, but I transport people with all kinds of medical issues and I could tell there was something wrong. The TD stated the staff member stated that the resident had been like that for the past 12 hours. The TD stated the staff member stated that he should take the resident to dialysis. The TD stated the staff member at the facility did not appear to be concerned about the issue the resident was having. The TD stated when they arrived at dialysis, he took resident 1's paperwork to the front desk as he always did, and placed it on the counter. The TD told the staff member at the dialysis center that he was concerned about the state of the resident, but was told to bring her to dialysis and was going to leave her there. The TD asked the staff member to assess the resident. The TD stated the staff member began to assess the resident and was unable to get the resident to respond. The TD re-stated he was concerned that the resident was having a medical issue. On 1/3/23 at 3:28 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated she knew resident 1, but the night of 1/15/23 was one of the first times she had cared for the resident 1. LPN 2 stated the resident's baseline was that she was often confused. LPN 2 stated the resident was sometimes spacey but was able to verbally respond to her prior to this day. LPN 2 stated when she got the report from the previous nurse, she was told the resident had not been responsive during the day. LPN 2 stated the previous nurse told her that he had talked to the provider and was told just to monitor the resident. LPN 2 stated she was told to wait for her to go to dialysis. LPN 2 stated that she had worked at a dialysis center before and sometimes residents would become confused prior to having dialysis and she thought that might be what was going on. LPN 2 stated nurses did have report sheets that they kept throughout the shift, but the sheets were destroyed at the end of the shift. LPN 2 stated she did speak with the transport driver when he came to pick up resident 2, and the transport driver mentioned that he knew resident 1 did not like to get up early and might be tired. LPN 2 stated she was concerned for the resident, which was why she wrote the progress note, and noted on the dialysis pre-visit paperwork that the resident had been unresponsive. LPN 2 stated she did not know if resident 1's mother was at the facility during the dinner meal and did not speak with her. LPN 2 stated dialysis may have called the facility after the resident arrived there, but it was not while she was at the facility. LPN 2 stated she arrived at the facility at 6:00 PM and sometimes did not get a report until 7:00 PM because the previous nurse was still doing things. LPN 2 stated the resident was able to take her medications the night of 10/15/23 and on the morning of 10/16/23 without any problem. LPN 2 stated she was worried about the resident, but was told that resident 1 was ok so she did not take any additional action. LPN 2 stated she did not notice any drooling by resident 1. LPN 2 stated the resident was able to grip her hands strongly, and did not have any other noticeable symptoms of a problem. LPN 2 stated that resident 1 frequently was slumped over to one side in her wheelchair, and that was her baseline. 47432
Inspection of February 20, 2020
1 findingBased on interview and observation, it was determined the facility did not ensure that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, for 2 of 31 sampled residents, a resident to resident altercation occurred in which both residents sustained physical injuries. Additionally, one of the residents experienced increased anxiety from her baseline following the altercation. Resident identifiers: 52 and 169. Based on corrective measures taken by the facility, the non-compliance was determined to be past non-compliance. Corrective measures were implemented by 1/8/20. Corrective measures included: Treatment and evaluation of the residents involved in the altercation, identification and review of other residents at risk within the secured unit, documented staff education, audits of behavior monitoring performed by the Quality Assurance and Performance Improvement meeting members, and continued monthly dementia dialogue meetings to assess the efficacy of corrective measures. Findings include: 1. Resident 52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 52's medical record was completed on 2/20/20. An incident report, dated 12/17/19, documented the following information related to a resident to resident altercation: . At 0720 (7:20 AM) . (Resident 52) reported another resident wandered into her room. She stated she got up and yelled at him to get out and reported that he hit her in the face. She stated she hit him back and kicked him and he fell . She reported this to the nurse at the nurse's station after the incident. The resident's (sic) were kept separated . (Resident 52) was assessed for injury and bruising was noted on the left side of forehead, bleeding noted at gums . (Resident 52's family member) came to visit and decided to take (resident 52) to the ED (emergency department), leaving at approximately 1255 (12:55 PM). Stop sign was in place on her door at the time of the incident . The Emergency Documentation, dated 12/17/19, from the ED was reviewed and documented that staff found resident 52 being punched in the head by another resident of the dementia unit. The documentation further revealed that resident 52 had some bruising to the right side of her mouth and was very afraid that the man followed her and would find her at the ED. The documentation further revealed that resident 52 was punched several times in the head and once in the mouth hard enough to knock her dentures out . Resident 52 was diagnosed with [REDACTED]. An ELOPEMENT RISK care plan, dated 9/17/19 and revised 11/19/19, documented that resident 52 was at risk for elopement and wandering due to confusion and dementia. The care plan further documented that resident 52's higher level of cognition than most residents who also reside on the unit put her at risk for resident to resident altercations as others have potential to wander into her space. 2. Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of resident 169's medical record was completed on 2/20/20. Resident 169's medical record documented the following information related to a resident to resident altercation that occurred on 12/17/19: a. A Nursing SBAR (Situation, Background, Assessment, Recommendation) note, dated 12/17/19, documented the following information: . (Resident 169) is being aggressive towards others hit a woman in the face multiple times, the woman hit him back, his ear is bleeding and split requiring sutures that began on 12/17/2019 7:20 AM . being around others agitates him make the symptoms worse . Pressure and dressing on left ear laceration improve the symptoms. These symptoms have occurred before . He has been aggressive in the past never to this extent . Increased confusion . Resident seems unstable, may get worse . increased agitation . b. A Nursing Note, dated 12/17/19, documented the following information: . (Resident 169) was reported by another resident to have wandered into her room. She told him to get out and reported that he hit her in the face. She stated she hit him back and kicked him and he fell . She reported this to the nurse at the nurse's station after the incident. The resident's were kept separated . was assessed for injury, he has a laceration to his Left ear and redness to left his (sic) cheek. Stop sign was in place on the other residents door . new order to send to ED obtained . c. A Nursing Note, dated 12/17/19, documented the following information: . Risk Management Meeting Note: IDT (interdisciplinary team) met and reviewed incident between (resident 169) and another resident as previously noted . Intervention: Removed them from each other and placed (resident 169) on 1:1 (one-on-one monitoring) until EMS (emergency medical services) arrived . Sent to ED for evaluation . d. An incident report, dated 12/17/19, documented the following information: . (Resident 169) was reported by another resident to have wandered into her room. She told him to get out and reported that he hit her in the face and choked her. She stated she hit him back and kicked him and he fell . She reported this to the nurse at the nurse's station after the incident . he has a laceration to his Left ear and redness to left his (sic) cheek . new order to send to ED obtained . A History and Physical report, dated 12/17/19, from the hospital was reviewed and documented that resident 169 went into another resident's room and was involved in an altercation where he was pushed to the floor and sustained a L (left) ear laceration . repaired in ER (emergency room ) with topical skin adhesive . A Timeline Res (resident) to Res documented the following information related to altercations between resident 52 and resident 169: a. On 11/16/19; . 1820 (6:20 PM) (resident 169) went into (resident 52)'s bedroom. The female resident was standing in the bathroom and did not like this resident coming in and yelled at him to get out. (Resident 169) picked up a garbage can and tossed it in her direction. It hit the female resident on the R (right) shoulder. The resident was not hurt and this resident was redirected out of the room . Interventions: Stop sign placed to (resident 52)'s door . (resident 52's family member) is looking for placement for (resident 52) elsewhere . (Resident 52's family member) first filed a grievance, but upon following up, she decided she wanted (resident 52) to stay . b. On 12/17/19; . (Resident 169) wandered into (resident 52)'s room. Stop sign was in place. According to staff interview and resident interview the following was stated: She told him to get out. He hit her. He grabbed her neck. She hit him back. He fell . She stepped on his head . She went down to the nurse's station and told the nurse. (Resident 169) has a laceration to his ear and redness to his cheek. She has a bruise on left forehead. She was spitting out blood from being hit in the mouth, but no obvious injury was seen . Interventions: (Resident 169 was sent to ER for psych (psychological) evaluation and (resident 52) was sent to the ER . A Grievance Form, dated 11/18/19 and filed by resident 52's family member, was reviewed and documented the following information related to the resident to resident altercation between resident 52 and resident 169 on 11/16/19: I received a phone message . informing me that a resident of the 400 block threw a trash can at (resident 52) and it hit her on the shoulder . This incident was witnessed . (Resident 52) claims that it was (resident 169) . It was kinda (sic) cute when I was told there are 'shoppers' there, not so cute when it is her room (resident 169) shops at all the time . now (resident 169) is aggressive (sic) toward (resident 52). I feel we are both being neglectful of (resident 52)'s safety and well being . The investigation, submitted to the State Survey Agency on 12/20/19, related to the resident to resident altercation between resident 52 and resident 169 on 12/17/19 was reviewed. The investigation documented that resident 52 reported to the nurse that resident 169 hit her in the face and she kicked him causing him to fall to the ground. The investigation further documented that resident 169 was unable to provide a description of the incident, and resident 52's account of the incident changed several times. The investigation further documented that resident 52 had bruising above her left eye and resident 169 had an injury to his ear, and both residents were sent to the ER. Ultimately, the investigation documented that abuse was not substantiated due to the residents' cognition and perception of the incident altered by dementia. The facility's FREEDOM FROM ABUSE, NEGLECT, and EXPLOITATION policy, dated November 2017, was reviewed and documented the following information: PURPOSE: To keep residents free from abuse, neglect and corporal punishment of any kind by any person. POLICY: The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation or resident property, and exploitation. This includes freedom from verbal, mental, sexual or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. This protection extends to abuse by staff, consultants, contractors, volunteers, students and visitors . GUIDELINES: . 5. Resident to resident abuse: a. Cognitive impairment or mental disorder does not preclude a resident from being abusive . b. In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm . c. Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions (e.g. (for example) physical, sexual or verbal aggression; taking, touching or rummaging through another's property; wandering into another's rooms/space) . On 2/19/20 at 10:49 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated if she witnessed a situation involving abuse, she would notify the nurse and Administrator. CNA 1 further stated she was provided with training related to abuse at least 3-4 times per year. On 2/19/20 at 10:59 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident to resident altercations were reported to the Administrator and an incident report was completed. RN 2 further stated resident 52 was involved in altercations with other residents on two occasions, but it had been a while. On 2/19/20 at 11:24 AM, an interview was conducted with CNA 2. CNA 2 stated when a resident to resident altercation occurred, efforts were made to determine the cause of the altercation, identify the aggressor, and notify the nurse and Administrator. On 2/19/20 at 11:49 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 52 was involved in resident to resident altercations and on one occasion, she was hit in the head by another resident. LPN 1 further stated following that altercation, emergency services and police officers came to the facility to assess resident 52 and believed resident 52 sustained a small cut. On 2/19/20 at 12:56 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated resident 52 was involved in altercations with other residents, and two of the altercations involved resident 169. UM 1 further stated following the second altercation between resident 52 and resident 169, resident 52's family member took her to the hospital and she was prescribed anti-anxiety medication upon her return to the facility. UM 1 further stated an incident report was completed, and the Administrator and management were notified of the altercation. On 2/19/20 at 2:13 PM, an interview was conducted with the Administrator. The Administrator stated he heard ten different stories about what happened between resident 52 and resident 169 on 12/17/20, and resident 52 did not remember the altercation the following day. The Administrator further stated resident 52 experienced behavior changes from her baseline throughout the day following the altercation on 12/17/19, but did not exhibit a change from her baseline after that day. The Administrator further stated there were altercations in the past between resident 52 and resident 169, but the previous altercations did not escalate to the same level as the altercation on 12/17/19. The Administrator further stated it was unclear who the aggressor was in the altercation that occurred on 12/17/19, and both residents involved had cognitive impairments. The Administrator further stated resident 169's wandering was constantly evaluated and a stop sign was put on resident 52's door to prevent resident 169 from entering her room following the altercation on 11/16/19. On 2/20/20 at 7:35 AM, a follow up interview was conducted with UM 1. UM 1 stated resident 52 was prescribed anti-anxiety medication upon her return to the facility from the hospital on [DATE] because she was pretty worked up following the altercation with resident 169. (Note: Resident 52's physician's orders [REDACTED]. This order was discontinued on 12/18/19 and replaced with an order, started on 12/18/19, for [MEDICATION NAME] HCl Tablet Give 25 mg every 6 hours as needed for Anxiety related to ACUTE STRESS REACTION for 14 days. This medication was administered to resident 52 on one occasion following the altercation with resident 169 on 12/17/19. Additionally, a review of resident 52's physician's orders [REDACTED].) On 2/20/20 at 10:03 AM, an interview was conducted with the Administrator and Director of Nursing (DON). The Administrator stated resident 52's family member increased her anxiety related to the altercation with resident 169 on 12/17/20. The Administrator stated resident 52 would have been fine without hospital intervention, but her family member wanted to take her to the ER. The DON stated resident 52 barely had a bruise that she was aware of, and resident 52 was unable to remember the altercation the following day. The DON further stated resident 169 was sent to the hospital primarily for a psychological evaluation, and resident 169's laceration could have been treated at the facility. The DON further stated the stop signs posted on residents' doors to prevent resident 169 from entering were becoming less effective for resident 169 due to his worsening dementia, and resident 169 maybe became startled when resident 52 yelled at him. On 2/25/20 at 11:02 AM, a follow up interview was conducted with the Administrator. The Administrator stated staff intervened appropriately during the altercation between resident 52 and resident 169 on 12/17/19, interventions were effective for a month following the first altercation between resident 52 and resident 169 on 11/16/19, and there was not anything else staff could have done to prevent the incident on 12/17/19. The Administrator further stated corrective measures were implemented following the altercation, and the facility's compliance date was 1/8/20 in response to the identified concern.
Inspection of November 17, 2016
1 findingBased on interview and record review it was determined that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, after a resident fell , there was a delay in treatment during which the resident complained of intermittent pain for approximately17 hours before an x-ray was obtained that revealed the resident had a fracture that required surgical repair. Resident identifiers: 1. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 1's medical record was reviewed on 11/17/16. A form titled, Resident Incident Report dated 10/20/16 at 7:10 PM revealed, Resident was found by aid on the floor between bathroom door and recliner. Resident reported going into the bathroom to get some things to get ready for bed. She said that she fell and hit her head and left elbow. Later on she reported pain on her left inner thigh. There were no apparent signs of injury. 10/21/16 (resident 1) c/o (complained of) pain in left hip and leg, new order to do x-ray. The form revealed that resident 1's family was not contacted until 10/21/16 at 12:04 PM. Nurses notes revealed the following entries: 1. 10/19/16 at 7:27 AM, Pt. (patient) arrived at 1830 (6:30 PM) on 10/18/16 . transferred from (local hospital) for post fall dementia. Assessment performed, patient oriented to room and call light. Fairly significant memory loss and needed to be reminded multiple times about call light function and reason for stay.Patient instructed to call for assistance before ambulating, full weight bearing, one person assist. 2. 10/20/16 at 4:23 PM, Licensed Practical Nurse (LPN) 1 documented, .Patient was alert to self this AM. Only c/o pain when moving, did not specify location. 3. 10/21/16 at 12:42 AM, Registered Nurse (RN) 1 documented, Fall - (Resident 1) was found by aid lying on the ground between bathroom and recliner in resident's room. Resident reported that she walked into the bathroom with her walker to get some things to get ready for bed and fell coming back to recliner. She reported hitting her head and left elbow. There were no bumps or indications of injury upon examination. Later on, resident reported pain in inner left thigh. No exterior evidence of injury. Neuro (neurological) checks have been started, incident report completed, and physician/family will be notified of incident. (Note: Resident 1 was found on the floor on 10/20/16 at 7:10 PM.) 4. 10/21/16 at 9:27 AM, LPN 1 documented, .Patient was alert to self this AM. Only c/o pain when moving, hips. meds (medications) given, effective. No new issues noted this AM R/T (related to) FOF (fall on floor) incident on 10/20/16. 5. 10/21/16 at 12:48 PM, the Unit Manager (UM) documented, Notified daughter concerning fall last night, (resident 1) is c/o pain in left leg and hip. Contacted physician and new order for x-ray to left hip femur. Will continue to monitor. 6. 10/21/16 at 5:30 PM, the UM documented xray indicates acute non-displaced intertrochanteric femoral fracture TTMD (tiger texted physician). 7. 10/22/16 at 3:17 AM, LPN 1 documented, (resident 1) was transferred to (local) hospital at 1900 (7:00 PM) on 10/21/16 by physicians order. The PT (Physical Therapy) Daily Treatment Note dated 10/21/16 revealed, . the pt performed poorly due to her inability to stay focused and follow commands. The pt seemed to be having a considerable amount of L (left) thigh pain as well. (Note: There was no information that resident 1's pain had been reported the the nurse.) The OT (Occupational Therapy) Daily Treatment Note dated 10/21/16 revealed, Pt had fallen last night and told me that she had pain in her back and elbow. Nursing has scheduled x-rays.Daughters wanted to wait for therapy until xrays had been performed. A care plan dated 10/20/16 revealed, Fall r/t: _Dementia, decreased safety awareness 10/20/16 Was FOF in room. The goals developed were, Resident will have no falls through next review (and) Resident will have no episodes of entrapment through next review. The approaches developed for resident 1 to achieve the goals were, (1) give resident verbal reminders not to ambulate or transfer without assistance, (2) Rearrange environment to remove barriers for resident, (3) Assist with transfers and ambulation, as needed, (4) Assist resident to the restroom and with peri care/incontinent cares, as needed, (5) Ensure call light is in reach and answered promptly. Encourage resident to await assistance, (6) 10/20/16 Alarm to bed and W/C (wheelchair). Resident 1's October 2016 Medication Administration Record [REDACTED] 1. [MEDICATION NAME] 500 milligrams (mg) with a pain score of 5 was administered on 10/20/16 at 8:41 PM. (Note: The medication was administered after the fall.) 2. [MEDICATION NAME] 50 mg was administered: a. 10/20/16 at 10:09 AM with a pain score of 3 and a follow up pain score of 1. (Note: Medication was administered prior to fall). b. 10/21/16 at 1:26 AM with a pain score of 8. (Note: There was no follow up pain score.) c. 10/21/16 at 7:32 AM with a pain score of 3 with a follow up pain score of 0. d. 10/21/16 at 7:09 PM with a pain score of 8. (Note: There was no follow up pain score.) The x-ray results dated 10/21/16 at 3:55 PM revealed, Significant Findings Hip LT (left). Impression: 1. Acute nondisplaced intertrochanteric femoral fracture. Femur LT. Impression: 1. Acute non displaced intertrochanteric femoral fracture. (Note: The x-ray was not ordered until approximately17 hours after resident 1 had fallen. It should be noted that RN 1, LPN 1 and the physical therapy assistant documented that resident 1 was complaining of pain, however did not intervene timely to assist resident 1 in receiving the appropriate treatment. In addition, resident 1 received pain medication and pain scores were 3 and an 8.) The facility Policy and Procedures for Assessing Falls and Their Causes revealed, . Steps in the Procedure . After the Fall: . 4. Nursing staff will notify the resident's Attending Physician and family in an appropriate time frame. When a fall results in a significant injury or condition change, nurse staff will notify the practitioner immediately by phone. When a fall does not result in significant injury or a condition change, nursing staff will notify the practioner routinely . Reporting 1. Notify the following individuals when a resident falls: a. The resident's family; b. The Attending Physician (timing of notification may vary, depending on whether injury was involved); c. The Director of Nursing Services; and d. The Nursing Supervisor on duty. On 11/17/16 at 10:48 AM, an interview was conducted with resident 1's family. The family member stated that she visited resident 1 the morning of 10/21/16 and resident 1 told the family member that she (resident 1) had fallen. The family member stated that resident 1 had dementia and was complaining of pain in her hip. The family member stated that therapy staff performed Physical Therapy with resident 1 and had her try to walk on her hip. The family member stated that resident 1 complained that her hip hurt and the PT staff member had her walk about 4 steps on her left hip. The family member stated that she had to ask facility staff to obtain an x-ray for resident 1's hip. On 11/17/16 at 11:30 AM, an interview was conducted with RN 1. RN 1 stated that she was the nurse when resident 1 fell on [DATE] at approximately 7:00 PM. RN 1 stated that resident 1 was found on the floor. RN 1 stated that she assessed resident 1 and asked her how she was. RN 1 stated that resident 1 denied pain and walked on her hip a few steps. RN 1 stated that later in the evening resident 1 began complaining of pain and was pointing to her hip. RN 1 stated that pain medication [MEDICATION NAME] was administered about 1:00 AM. RN 1 stated that she did not contact the family during her shift, because it was too late in the evening. RN 1 stated that she Tiger Texted the physician around 6:00 AM when her shift ended but she received a response after her shift ended. RN 1 stated that the Tiger Text system goes to all the nurses and physician. RN 1 stated that the physician later responded to have an x-ray obtained. RN 1 stated she did not know what time the physician responded. RN 1 stated that the next night resident 1 was sent to the hospital. RN 1 stated after a resident fell the physician and family needed to be notified as soon as possible. RN 1 stated resident 1 did not appear to be injured so she did not contact the physician and family in a timely manner. RN 1 stated that the physician should have been notified immediately and she did not know why she did not contact the the physician after the fall. On 11/17/16 at 12:35 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was the day nurse on 10/21/16 after resident 1's fall on 10/20/16. LPN 1 stated that resident 1 had dementia and was unaware of how to use a call light. LPN 1 stated that resident 1 complained of pain on 10/21/16 when she was moved or when her bed was adjusted. LPN 1 stated that the night nurse did not ask her to contact the physician or family about the fall. On 11/17/16 at 1:17 PM, an interview was conducted with the Director of Nursing (DON) and Unit Manager (UM). The UM stated that the facility had a nursing meeting every morning. The UM stated that she reviewed the incident report and the physician and family had not been contacted. The UM stated that after her meeting in the morning she planned to called the family and physician regarding resident 1's fall. The UM stated that the family member came to her office about 12:00 PM to ask about resident 1's fall on 10/20/16. The UM stated that the family member told her that resident 1 was in pain The UM stated that she assessed resident 1 and could not feel any displacement of the hip. The UM stated that she offered to send resident 1 to the emergency room for an x-ray or have an x-ray done at the facility. The UM stated that the family decided to obtain an x-ray at the facility. The DON stated that the order for the x-ray was obtained at 12:47 PM and was not ordered by the physician stat. The DON stated that the x-ray was completed at 3:55 PM and reported to the facility at 5:30 PM. The UM and DON did not have additional information about resident 1 having pain scores of 8 and needing pain medication. The DON stated that RN 1 had received a verbal warning for not contacting the physician and family member in a timely manner. A form titled, Performance Documentation Form signed by the employee dated 11/8/16 revealed that RN 1 was written up for not contacting the physician after the fall. (Note: There was no information provided on the performance form or through the interviews that the facility appropriately assessed resident 1's pain; assessed the resident for a change in condition timely, despite multiple staff members being aware of the fall and/or pain; or intervene timely after RN 1's error had been identified, resulting in a delay in treatment.)
Inspection of May 29, 2012
1 findingBased on interview, observation, and record review it was determined, for 1 of 42 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well being of each resident. Specifically, a resident with a suprapubic catheter had been bypassing the catheter and urinating out of the urethra for 12 days before the Urologist was contacted. In addition,staff did not assess the resident for retention of urine nor notify the resident's Urologist of the catheter not functioning properly, thus giving the Urologist an opportunity to examine the resident and make recommendations based on his examination. Resident identfier: 52. Findings include: Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 5/23/12 resident 52's medical record was reviewed. On 5/23/12 at 11:15 AM, observations were made of resident 52. Upon entrance into resident 52's room with Licensed Practical Nurse (LPN) 2, resident 52 was observed to be grimacing, in what appeared to be pain. The surveyor asked LPN 2 about resident 52's urine output. LPN 2 stated that he had been told in report that the Certified Nursing Assistant (CNA) had changed resident 52's incontinence brief that morning around 5:00 AM. LPN 2 further stated that resident 52 had been bypassing the suprapubic catheter for several days. The surveyor then inquired about urine in the foley catheter bag. Observations revealed that the foley catheter bag contained no urine. LPN 2 stated that resident 52's foley catheter bag had contained no urine for several days and that the facility had been in contact with resident 52's Urologist to find out if the foley was needed. LPN 2 further stated that he would check with the CNA assigned to provide care to resident 52, to find out if resident 52 had urinated that morning. At 11:30 AM, CNA 8 was observed leaving resident 52's room as LPN 2 and the surveyor re-entered the room. CNA 8 stated to LPN 2, "Well, I did not do anything with him (resident 52) because he is dry." The surveyor then asked LPN 2 to inquire about resident 52 urinating that morning. LPN 2 stated, "Oh yeah, Hey did (resident 52) urinate this morning?" CNA 8 stated, "No, he has been dry." CNA 8 was observed to walk down the hall. LPN 2 was then observed to administer pain medication to resident 52 via the gastrostomy tube. LPN 2 was then observed to administer a 200 cc (cubic centimeter) [MEDICATION NAME] of water to resident 52 and then begin administering resident 52's scheduled feeding via the gastrostomy tube. Upon completion of hanging the scheduled feeding, LPN 2 stated, "Okay (resident 52), I will check on you in a little while." LPN 2 then stated that he wanted to provide oral care to resident 52 and was observed to leave resident 52's room. LPN 2 was observed to re-enter resident 52's room with a washcloth. LPN 2 was then observed to inspect resident 52's gastrostomy tube. The surveyor then asked LPN 2 if resident 52's bladder was distended. LPN 2 was observed to palpate resident 52's bladder. Resident 52 was observed to moan and began crying when LPN 2 began palpating resident 52's bladder. LPN 2 stated that resident 52's bladder was distended and that he would notify the Unit Manager (UM). (Note: Resident 52 was unable to communicate verbally with staff. Resident 52 communicated via blinking and was able to grimace and moan when in pain.) On 5/23/12 at 11:50 AM, LPN 2 was interviewed. LPN 2 stated that the CNAs had documented that resident 52 had no urine output in the foley catheter bag on 5/22/12. LPN 2 further stated that resident 52 must have been bypassing the catheter. LPN 2 then stated that he would contact the facility Medical Director and Urologist for orders. On 5/23/12 at 12:10 PM, CNA 8 was interviewed. CNA 8 stated that when she was delivering care to residents she would report certain things to the nurse. CNA 8 stated that she would report, "wacky vital signs, bruises, funky bowel movements and stinky urine." CNA 8 stated that she did not notice anything about resident 52 when she checked on him on 5/23/12 at 11:30 AM. CNA 8 stated that resident 52 was his normal self when she was in the room and she did not have anything to report to the nurse about resident 52. CNA 8 further stated that resident 52 had been leaking around his catheter and into an incontinence brief for some time. CNA 8 stated that the CNAs had no way to measure resident 52's urine output due to resident 52 urinating into an incontinence brief. Review of the medical record revealed that on 5/7/12 resident 52 was sent to a local hospital emergency room (ER) to have his suprapubic catheter changed due to the catheter not working properly on 5/6/12. Facility staff documented the following entry in the "Departmental Notes" on 5/6/12: "AM alert: Suprapubic foley not draining, attempt to flush with sterile NACL (sodium chloride) unsucessful (sic) - unable to clear blockage; ADON (Assistant Director of Nursing) notified; urinne (sic) is flowing freely through the urethra - res (resident) has has (sic) several wet briefs during this shift. will continue to monitor, call loght (sic) within reach." (Note: The above nurses note was the first documentation of the suprapubic catheter not draining properly or having a blockage. No other documentation could be found to show that resident 52 had been experiencing problems with the suprapubic catheter.) Review of the "Departmental Notes" revealed the following entries: 1. "5/11/12 7:00 PM: Nurses Note: Resident's pain managed with prn (as needed) meds (medications) to good effect. Some sedation noted. Flushed catheter per order, only 80cc (cubic centimeters) output prior to this AM in down drain. Pt. (patient) bypass and urinated briefs this AM. WCTM. (Will continue to monitor)." 2. "5/14/12 6:28 PM: Nurses Note: Suprapubic cath not patent, attempted to flush with 60 cc NS (normal saline) to poor effect. UM (Unit Manager) changed suprapubic cath (catheter) is (sic) afternoon. UM reports 300 cc output of cloudy urine noted. WCTM." 3. "5/16/12 11:59 PM: Nurses Note: Superpubic (sic) flushing met substantial resistance. No input allowed. NOC (night) nurse assisted with similar results. WCTM Output = 100cc." 4. "5/19/12 5:46 PM: Nurses Note: Attempted to flush suprapubic cath with 60ml (milliliters) NS. Unable to flush. Notified UM. Resident is bypassing suprapubic through penis. Encouraged CNA's (sic) (Certified Nursing Assistant) to check often for incontinency and change. Some 50-60cc urine from down drain this AM. CNA's (sic) report changed incont (incontinence) brief twice this AM. Resident is having output. UM notified. WCTM." 5. "5/20/12 6:58 PM: Nurses Note: Attempt to flush foley unsucessful (sic) D/T (due to) blockage. No urine collected in DD (down drain), but res (resident) has has (sic) 3+ (3 or more) wet briefs today. WCTM." 6. "5/21/12 6:04 PM: Nurses Note: Attempted to flush suprapubic foley this AM. Foley is blocked. Resident is by passing foley with 3 wet briefs this AM. UM notified. Encouraged CNA's (sic) to check for incont often. Resident with s/s (signs and symptoms) of pain this AM, PRN meds to good effect with some drowsiness noted. WCTM." 7. "5/23/12 12:02 PM: Nurses Note: Resident with s/s of pain this AM. Administered PRN medication. After flushing J-tube (gastrojejunostomy), resident still in discomfort, check ABD (abdomen) with area firm and tender to touch. No output from cath noted. Last by pass at 500 (5:00 AM) Attempted to flush. No success. DON (Director of Nursing) to change suprapubic. WCTM." (Note: The above nurses note was made after the surveyor's observations and inquiry about resident 52's bladder and urine output.) 8. "5/23/12 12:35 PM: Nurses Note: On 5/21/12, this nurse was told by floor nurse that resident's catheter would not flush. This nurse called the urologist that placed resident's suprapubic cath and told them that the cath was not patent but that the resident had been bypassing the catheter and had wet briefs. This nurse was told that the urologist would return the call. On 5/22/12, the cna's (sic) reported to this nurse that the resident had wet briefs during the day. On 5/23/12, the floor nurse reported to this nurse that there was no urine in the DD bag and no wet brief noted. This nurse called the urologist and told the nurse, (name of nurse), the situation. She advised to use a 20F (french) 10 cc catheter. Catheter was changed by acting DON. 250cc was drained from new catheter. Resident appeared to tolerate procedure well. Will continue to monitor." On 9/10/11, the facility Medical Director documented the following on an additional History and Physical located in the medical record: "... His (resident 52) communication is limited to blinking eyes. He can cry out at times when he is in pain." On 5/24/12, the Narcotic Administration Records (NAR) were reviewed for resident 52. Review of the NAR revealed that in April 2012, after the insertion of the suprapubic catheter and resident 52's readmission to the facility, facility staff administered ten doses of as needed pain medication to resident 52. Review of the May 2012 NAR revealed that from 5/8/12-5/23/12 facility staff had administered 13 doses of as needed pain medication to resident 52. On 5/23/12 at 4:00 PM, the Urologist's Secretary (US) was interviewed. The US stated that she was the secretary for resident 52's Urologist and that the first call she had received regarding resident 52 was on 5/23/12. The US stated that she triaged all calls and did not receive a call on 5/21/12 regarding resident 52. The US stated that if the facility was awaiting a return call on Monday, 5/21/12, regarding resident 52, they should not have waited 48 hours to call again. The US stated she had no documentation that the facility had called the Urologist's office on 5/21/12 regarding resident 52. On 5/24/12 at 9:15 AM, Urologist's Nurse (UN) was interviewed. The UN stated that if the resident was having pain and the facility was unable to irrigate or flush the catheter the facility should have notified the Urologist so resident 52 could have been seen. On 5/23/12 at 3:35 PM, resident 52's Public Guardian (PG) was interviewed. The PG stated that she had not been notified by the facility regarding resident 52's catheter. The PG stated that the last time she was notified of anything was on 5/6/12, via voicemail by the Unit Manager, that resident 52 was going to the hospital to have the feeding tube checked and the catheter replaced. The PG stated that the facility generally did not notify her about concerns with resident 52. The PG further stated that she had to ask questions in order to get the information that she needed. The PG stated that the facilty generally asked, " Oh, you didn't get notified?"
← Back to the Monument Healthcare Stonecreek record
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction