Every finding on record at The Forest At Duke Inc

Based on record review and staff interviews, the facility failed to transmit Minimum Data Set (MDS) discharge assessments for 2 of 2 residents reviewed for resident assessment (Resident #5 and Resident #6). The findings included: 1. Resident #5 was admitted on [DATE] with diagnoses including congestive heart failure and hypertension. An admission MDS assessment dated [DATE] indicated Resident #5 had received skilled therapy services. Facility documentation indicated Resident #5 had been discharged home on 8/5/24. Review of Resident #5's MDS records revealed the discharge assessment had not been transmitted. An interview was conducted with the MDS Nurse on 11/19/2024 at 1:45 PM who stated Resident #5 was admitted to the facility and had received skilled services. She explained she had completed the discharge assessment but was unsure how she missed transmitting it to the database. An interview with the Administrator and Director was conducted on 11/19/24 at 2:20 PM in conjunction with a record review. Both the Administrator and Director stated the discharge transmission should have been done at the time of discharge. 2. Resident #6 was admitted on [DATE] with diagnoses including atrial fibrillation and cerebral infarction. An admission MDS assessment dated [DATE] indicated Resident #6 had received skilled therapy services. Facility documentation indicated Resident #6 had been discharged home on 7/15/24. Review of Resident #6's MDS records revealed the discharge assessment had not been transmitted. An interview was conducted with the MDS nurse on 11/19/2024 at 1:45 PM. She stated Resident #6 was admitted to the facility and had received skilled services under a managed care program. She explained she had completed the discharge assessment but was unsure how she missed transmitting it to the database. An interview with the Administrator and Director was conducted on 11/19/24 at 2:20 PM in conjunction with a record review. Both the Administrator and Director stated the discharge transmission should have been done at the time of discharge.

Based on observation, staff interviews and facility policy and procedure review it was determined that the 2 of 2 staff facility (staff #1, #2) failed to don gowns when entering the room of resident with enhanced droplet contact precaution signs on their room doors. Findings included: Observation at 5:33 PM on 11/3/2020 revealed staff #1 entering room [ROOM NUMBER] wearing gloves and a mask. Staff #1 was then observed entering room [ROOM NUMBER] wearing gloves. Observation during this time revealed a sign posted on room [ROOM NUMBER] and 265 which stated, Enhanced Droplet Precautions: Perform Hand Hygiene, Surgical Mask when entering room, eye protection when entering room, gown when entering room, gloves when entering room, private room and keep door closed. Families and visitors do not enter the room, report to the nurses' station with questions. Staff #1 did not wear a gown when entering either resident room. Staff #2 was observed entering room [ROOM NUMBER] at 5:33 PM wearing gloves and a mask. She then entered room [ROOM NUMBER] wearing a fresh pair of gloves. Observation revealed that both room [ROOM NUMBER] and room [ROOM NUMBER] had a sign posed the resident room door which stated, Enhanced Droplet Precautions: Perform Hand Hygiene, Surgical Mask when entering room, eye protection when entering room, gown when entering room, gloves when entering room, private room and keep door closed. Families and visitors do not enter the room, report to the nurses' station with questions. Staff #2 did not wear a gown when entering either resident room. Interview with staff #1 at 6:02 PM on 11/3/2020 revealed that she did not believe she had to put on a gown because all the residents on that unit were in isolation. The nurse stated that she was told that if they are going to provide care, they have to don all PPE. As long as they were just doing meals, masks, face shields and gloves were fine. Review on 11/4/2020 of the facility COVID -19 response plan dated 3/13/2020 revealed protocols for identification and management of potential COVID-19 cases(healthcare); this policy stated that certified nursing assistants (CNAs) and floor nurses would strictly observe ordered droplet/contact precautions, alert charge nurse immediately with any questions regarding the use of PPE, if supplies require restocking, or other aspects of maintaining precautions.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect the active [DIAGNOSES REDACTED].#9) reviewed for unnecessary medications. The findings included: Resident # 9 was admitted to the facility 10/12/18 with [DIAGNOSES REDACTED]. A review of resident # 9's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] which was coded as an admission assessment was completed. The assessment had documentation of the resident being cognitively intact. Further review of the assessment revealed the resident received an antidepressant medication for 1 of 7 days of the look back period. The assessment was not coded as the resident having a [DIAGNOSES REDACTED]. A review of the Care Area Assessment (CAA) summary revealed the resident triggered for [MEDICAL CONDITION] Drug use and that it would be care planned. The CAA summary worksheet dated 10/19/18 under description of problem read in part: The resident has a new order for [MEDICATION NAME] with DX: Depression. He is just started on this medication and we will monitor the effect. Will update MD if any signs of side effects should present with med use. The will increase his risk for falls and he is aware of increased risk factors. A review of the physician's orders [REDACTED]. A review of the resident's (MONTH) (YEAR) Medication Administration Record [REDACTED]. An interview was conducted with the facility's MDS Coordinator on 11/14/18 at 12:42 PM. During the interview, the MDS Coordinator reviewed the admission MDS assessment and CAA summary worksheet for resident # 9. When the MDS Coordinator was asked if Section I should have been coded to reflect a [DIAGNOSES REDACTED]. She indicated that the absence of the [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on 11/14/18 at 1:38 PM she stated that the assessment should have been coded to reflect the [DIAGNOSES REDACTED].

Based on record review and staff interviews the facility failed to develop a baseline care plan within 48 hours of admission with measurable objectives and timetables to address the immediate needs of Continuous Positive Airway Pressure ([MEDICAL CONDITION]) for 1 of 2 residents (Resident # 111) reviewed. Findings included: Resident # 111 was admitted to the facility on [DATE]. The resident's cumulative [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment was in progress and had not been completed. A review of the physician orders [REDACTED]. A review of the baseline care plan dated 11/2/18 revealed no mention of [MEDICAL CONDITION] or its use. During an interview with the facility's nurse manager on 11/14/18 she stated that the admitting nurse completes the base line care plan. She also indicated that the baseline care plan was expected to include activities of daily living, assistive devices, toileting to include types of assistance needed as well as any skin conditions. She indicated that a care card (Nurse Aide's Information Sheet) is also completed on admission. She indicated that the care card is posted in the resident's room and staff do a huddle and the nurse manager and staff complete this care card together to discuss the resident's needs. The care card titled Nurse Aide's Information Sheet was in resident # 111's medication cabinet (to protect privacy) taped to the inside. Review of this revealed no mention of a [MEDICAL CONDITION] machine. During an interview with the MDS nurse on 11/14/18 at 1:05 PM she stated she was unaware the baseline care plan should include the use of a [MEDICAL CONDITION]. An interview was conducted with the Director of Nursing on 11/14/18 at 1:45 PM. During the interview she stated that she expected the [MEDICAL CONDITION] to be included on the base line care plan.

Based on observations, staff interviews and record review, the facility failed to clean the steam table and plate warmer. The findings included: 1 a. During an observation on 1/16/18 at 11:00 AM, 5 compartment steam table had food floating in standing water, brown matter around steam table lids and encrusted brown matter inside drip pan. During an interview on 1/16/18 at 11:05 AM, the Dietary Manager (DM) indicated the staff was expected to empty and clean and wipe down the steam table daily. The steam table should be deep cleaned weekly. The DM confirmed the steam table had not been cleaned. b. During a follow up on 1/20/18 at 2:41PM, the 5 compartment steam table had large amount of leftover food (chicken particles, eggs, soggy vegetables and bacon) from breakfast and lunch in standing water. During an interview on 1/20/18 at 2:45 PM, the DM stated the staff should have cleaned the steam table area, drained and removed any leftover food particles from the water. The expectation was for the dietary aide to clean the table after the lunch meal. 2 a. During an observation on 1/16/18 at 11:00 AM, the two drawer plate warmer had dried food, liquids spills and debris inside and outside where clean plates were stored. During an interview on 1/16/18 at 11:05 AM, the Dietary Manager (DM) indicated the staff was expected to empty and clean and wipe down plate warmer daily. The plate warmer should be deep weekly. The DM confirmed the plate warmer had not been cleaned. b. During a follow-up observation on 1/20/18 at 2:41 PM, the plate warmer had clean plate covers sitting inside the drawer with dried foods and liquids on the inside and outside. During an interview on 1/20/18 at 2:48 PM, the Dietary Aide Supervisor indicated that kitchen equipment was deep cleaned weekly and the dietary aides were expected to clean and wipe down the steam table and plate warmer prior to each meal. During an interview on 1/20/18 at 3:31PM, Health Service Director and Assistant Health Service Director, indicated the expectation was for staff to empty and clean the steam table /plate warmer prior to the completion of each shift.