Desert Blossom Health & Rehab Center

Based on observations, interviews, facility document reviews, and facility policy, the facility failed to ensure a comfortable and safe temperatures were maintained in one resident room (Resident #274). The deficient practice could place the resident's at risk for safety and illness.

Findings included:

Resident #274 was admitted on May 1, 2024 with diagnoses of osteomyelitis, urinary tract infection, chronic systolic heart failure.

The resident's Brief Interview for Mental Status (BIMS) dated May 1, 2024 revealed a score of 15 that indicated resident was cognitively intact.

During an initial screening on May 6, 2024 at 9:34 AM, Resident #68 stated that the room was hot, she had been in that same room for a month, and staff were aware of her concerns. Resident #68 added that the second week she got there that she almost passed out. She stated she was not used to hot temperatures since she was living in a different state. She further added that the staff brought her lots of ice and cool rags because she was very hot and she felt like she was going to pass out. Resident #274, who shared the same room with Resident #68, stated that the air conditioner did not work and the maintenance staff were aware that the air conditioning was not working.

An interview was conducted with Maintenance Director/Staff #115 on May 8, 2024 at 12:14 PM. Staff #115 stated that the certified nursing assistants (CNAs) and all staff can submit work order. He used an app that gave weekly and monthly task and work orders. Staff #115 stated that he viewed and checked the work orders in his phone. After viewing and checking the work orders he had received, he communicated with the nursing team. For example, he communicated a work order for a low air mattress and issues with lighting for a resident.

Another interview was conducted with Resident #274 on May 9, 2024 at 9:37 AM. Resident #274 stated that it was still hot in her room. The portable fan was turned on in her room. She added that her roommate was discharged yesterday and she left her the portable fan to use. In addition, Resident #274 stated that her room felt hot since she arrived on May 1st. During the interview, the resident's room had a sliding door and she stated that she felt the sun heat was coming in from the door all day. The sliding door had a shade and the shade was rolled up from the bottom and closed about two thirds from the top. Resident stated that she did not messed with the shade because it was not in her side of the room.

On May 9, 2024 at 9:58 AM, a temperature check was performed using a laser temperature gun. The temperature by the window hallway outside the Resident #274 's room was 74.5-75 degrees Fahrenheit. The temperature in the resident's room just outside the resident's bathroom door was 75 degrees Fahrenheit with a portable fan turned on.

An interview was conducted with a certified nursing assistant (CNA)/Staff #108 on May 9, 2024 at 2:01 PM. Staff #108 stated that the temperature in the rooms are pretty much even. And, if residents say that their rooms were warm, she will have the maintenance staff check the room. She further stated that the thermostats were controlled in the hallways.

An interview was conducted with the Maintenance Director/Staff #115 on May 9, 2024 at 2:06 PM. Staff #115 stated that the facility had 16 units total and each unit controls 7 to 8 rooms with the common area or office per unit. He stated that the back end where the Director of Nursing (DON) and rooms 5 through 18 use unit 12 or 13 to control the temperature. He further added that the thermostat was set between 71 through 74 degrees Fahrenheit. He stated that he checked the temperature every morning. He also felt the vents to make sure that cool temperature was coming out and this is done every weekly. He further added that when he checked the thermostat in the room, he carried his temperature check gun. If the temperature is hot, he will offer a fan to the resident and then communicate the issue with the DON and admission so the resident can be moved to another room. Furthermore, he stated that there was a thermostat issue a week ago or so and a technician was called.

On May 9, 2024 at 3:45 PM, Resident #274 stated that it was cooler today but it had been hot. With laser temperature gun, the temperature at vent was 91 degrees Fahrenheit, and the floor fan was on high setting.

On May 9, 2024 at 3:52 PM, another interview was conducted with the Director of Maintenance. Staff #115 took temperatures in room 15. Staff #115 used two temperature guns and the first one read 88.2 degrees Fahrenheit. The second reading was 87 degrees Fahrenheit. The temperature in room 14 was 61 degrees Fahrenheit, in room 13 was 49 - 52 degrees Fahrenheit depending on the thermometer. He further stated that maybe the vents need to be adjusted. He also added that the resident had originally said that it was hot on May 2nd when he was in Resident #274's room fixing a television. He agreed that it was very warm. He added that the thermostat was installed on that unit in May, but did not include the vents, ducts, or actual air conditioning. He added a floor fan in her room. One thermostat will control 7 rooms approximately and it cannot be adjusted for her.

On May 9, 2024 at 4:15 PM, an interview with the Director of maintenance was conducted. The administrator/Staff #72 was present during the interview. The Director of maintenance stated that a comfortable environment temperature is between 72 thru 73 degrees Fahrenheit. The administrator added that the temperature range is 71 thru 82 degrees is the safe temperature range but certain resident had a preference for warmer and cooler temperatures.

A review of the facility policy titled, Temperature, Rise in Environment and in the Facility, with a reviewed date of May 2022 revealed an acceptable environmental temperature ranges from 71-81 degrees to ensure a home like environment the resident has the right to request adjustment to room temperature for comfort.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure medication services are provided according to accepted standards of clinical practice for one resident (#177). The deficient practice could place residents at risk for developing illness.

Findings included:

Resident #177 was admitted at the facility on April 18, 2024 with diagnoses of acute on chronic systolic congestive heart failure, generalized edema, and acute kidney failure.

An admission Minimum Data Set (MDS) assessment dated April 24, 2024 revealed a Brief Interview of Mental Status (BIMS) score of 15 which meant the resident was cognitively intact.

Review of Resident #177 care plan initiated on April 18, 2024 revealed a focus for potential fluid deficit related to diuretic use. The goals included that the resident will be free of symptoms of dehydration and will maintain moist mucous membranes, good skin turgor. The interventions included to administer medications as ordered.

On May 7, 2024 at 7:23 AM the medication administration observation pass was conducted with licensed practical nurse (LPN)/Staff #200, she stated that the process of administering medication included the right person and right dose. Resident #177 was amongst the residents observed for medication administration observation pass.

During Resident #177's medication preparation on May 7, 2024 at 7:55 AM, Staff #200 stated that the staff noticed two orders for potassium medication and stated that she was holding the potassium 10 mEq (Milliequivalent).

Review of Resident #177 record revealed following two physician orders for Potassium Chloride ER medication:
-Potassium Chloride ER (Extended Release) Oral Tablet 10 mEq, give 1 tablet by mouth three times a day for supplement
-Potassium Chloride ER Oral Tablet 20 mEq, give 40 mEq by mouth one time a day for diuresis

A review of Resident #177's Medication Administration Record (MAR) revealed on May 7, 2024 for 0800 Hours, Potassium Chloride ER Oral Tablet 20 mEq, give 40 mEq by mouth one time a day for diuresis, was administered by Staff #200 and Potassium Chloride ER Oral Tablet 10 MEQ, give 1 tablet by mouth three times a day for supplement, was marked held/see nurse notes by Staff #200.

A follow up interview was conducted with Staff #200 on May 7, 2024 at 3:40 PM. Staff #200 stated that she informed her charge nurse and she stated that the potassium medication was a duplicate order. She stated that if she did not understand something about the medication then she will go to the charge nurse or the director of nursing (DON) or the physician if readily available.

A review of Resident #177 clinical record on May 7, 2024 at 3:57 PM revealed a documentation under electronic medication administration record (eMAR)-medication administration note dated May 7, 2024 at 8:04. The note stated that the Potassium Chloride ER Oral Tablet 10 mEq, give 1 tablet by mouth three times a day for supplement, was held for duplicate order. In addition, a review of Resident #177 laboratory results dated April 22, 2024 at 17:16 revealed a potassium of 3.9 millimoles per liter (mmol/L).

An interview was conducted with registered nurse RN/Staff #11 on May 8, 2024 at 10:32 AM regarding physician orders. He stated that for an order that he had a question with, he stated that he double checked with the provider. He contacted the provider by using the provider numbers located in the station phone. The station phone included the provider's number and their office numbers. Furthermore, he stated that for medications that needed clarification such as sometimes orders are transcribed in a wrong way for instance the nurses transcribed by mouth instead of enteral feeding. He called the doctor to confirm route. Another example, for same medication with two orders that looked like maybe a mistake, he reads the actual order. An example was a vitamin C order 500 mg everyday but certain days of the week there was an order for vitamin C 1000 mg. He stated that he wondered why he was signing the medication vitamin C twice. He stated He did not hold the order and only gave the medications after the order was confirmed by talking to the provider.

An interview was conducted with the director of nursing (DON)/Staff #14 on May 9, 2024 at 2:44 PM and she stated that when preparing medication, she anticipated the nurse to call the provider for clarification and her expectation for her staff was to clarify and notify. The nurse is using her judgement that she will review order and then notify provider.

Review of Medication Administration Policy revised 05/2017; last Reviewed 10/2023 revealed the facility to accurately prepare, administer and document oral medications. In addition, "Essential Points: 13. Any irregularity in pouring or administering must be reported to the doctor. 14. If there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage".

Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure staff provided meals according to regulations to one resident (#76). The deficient practice could result in residents not meeting dietary needs.

Findings include:

Resident #76 was admitted to the facility on 4/15/2023 and discharged on 4/27/2023 with diagnoses that included left tibia fracture, chronic obstructive pulmonary disease, heart failure, and chronic kidney disease.

Resident #76 had an order dated 4/15/2023 for regular diet with regular texture and thin liquids. There were also orders for once daily dietary supplements; Glucerna 8 ounces and Prostat 30 milliliters, dated 4/19/202 and 4/22/2023 respectively.

Medicare Minimum Data Set (MDS) dated 4/21/23 shows Brief Interview of Mental Status (BIMS) of 15 which indicated no cognitive impairment.

The care plan initiated on 4/16/2023 reflected a goal related to resident being malnourished. The goal for resident #76 was to maintain adequate nutritional status as evidenced by consuming more than 75% of meals and supplements. Interventions included diet as ordered by the physician and monitor and report to the physician any decreased appetite, unexpected weight loss,

A nutritional screening dated 4/18/24 revealed the resident was malnourished due to being bed bound and experiencing rapid weight loss. Recommendations were to provide dietary supplement Ensure.

A review of the facility grievance log for April 2023 showed resident #76 had brought up meal concerns with the kitchen and the Assistant Director of Nursing on 4/17/2023.

Review of the Plan of Care (POC) task documentation shows one shift on 4/18/2023 and 4/20/2023 each, show no documentation of meals being provided to resident #76.

In an interview on 05/09/2024 at 1:41pm with a Certified Nursing Assistant (CNA/Staff #40), Staff #40 stated that activity of daily living (ADL) care is always documented in the electronic health record (EHR) and CNAs document under POC tasks. They stated that ADL's like meals, baths, brief changes, and dressing is documented each time it is completed.

In an interview with CNA (Staff #24), she stated ADL care is always documented in the EHR including refusals of care which are also reported to the nurse. Each time they provide the ADL service it is documented in the system. Some of them are required the one time and then it will be as needed. For bowel movements for example, a new entry can be created for each time a brief change is done. Each meal is also a new entry. She reviewed the print out of POC tasks for resident #76 and when asked what the blanks meant, she stated that meant it was not completed.

In an interview with the Director of Nursing (DON/ Staff #14) on 05/09/2024 at 2:10pm, she reviewed a print out of the POC tasks for Resident #76 and stated that the blanks are not indicative of the services not being completed. They just mean that it was not documented. There are areas that show that if a service was completed after midnight, then they will roll over to the next day, but it was still completed. Review of Resident #76's chart shows that eating was not documented for 2 days and she indicated this was not due to the midnight rollover glitch. The DON stated that the facility had intitated the following measures after the April 12, 2023 abbreviated survey:

-staff to be in-serviced on accuracy and completion of daily Point of Care/Activities of Daily (POC/ADL) Living with a completion date of 06/21/2023.
-staff to be in-serviced on recognizing and reporting changes in ADL activity/ability. The completion date was 06/21/2023.
-DNS or designee will conduct a daily review Monday through Friday of POC/ADL documentation completion x 4 weeks to ensure substantial compliance. 06/21/2023.
-DNS or designee will ensure that the nutrition report will be discussed and reviewed at the weekly nutrition meeting for the Interdisciplinary Team (IDT) to recognize declines or changes in eating patterns and respond proactively to the changes as indicated x4 weeks. The completion date was 06/21/2023.
-DNS or designee will report findings of reviewes to the QAPI committee with additioanl follow-up and recommendation as needed until substantial compliance is achieved and maintained. The completion date was 06/21/2023.

In a policy titled "Documentation and Charting" last reviewed 07/2023, it stated that facility will provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc. as well as the progress of the resident's care.

Based on clinical record review, staff interviews, and review of facility policies and practices, the facility failed to ensure nursing documentation reflect care and medical services provided for Resident # 36 according to professional standards. The deficient practice may result in incomplete and/or inaccurate clinical records, and suboptimal care due to the absence of pertinent clinical information.

Findings include:

Resident # 36 was admitted to the facility on March 27, 2024 with diagnoses that included hypothyroidism, depression, and generalized anxiety disorder.

The comprehensive minimum data set (MDS) assessment dated May 08, 2024 revealed a brief interview for mental status (BIMS) score of 15, which indicated the resident was cognitively intact.

On May 06, 2024 at 10:02 AM, an observation of Resident # 36 revealed discoloration surrounding her left eye darkened at an unknown stage of bruising. An interview conducted with Resident # 36 stated that this was due to a recent fall injury inside the facility which resulted in a left sided-orbital fracture.

On May 07, 2024 at 3:39 PM, electronic medical record (EMR) nursing progress notes reviewed from the day of fall dated April 29, 2024 at 3:03 PM, revealed no information detailing how the fall had occurred:

Nurse was notified that resident was found on the floor, resident was bleeding from her eyebrow, pressure was applied to site followed by steri strips, and provider notified and advised staff to send resident to emergency department via 911.

On May 07, 2024 at 04:45 PM, an interview was conducted with Director of Nursing (DON/Staff # 14) regarding completing and accurately documenting the fall incident. Staff # 14 stated Resident # 36 was found on the floor, alert and oriented, and the fall was not suspected to be a result of neglect or abuse. Staff # 14 stated that the call light was not used by the resident and believed she had tripped over her oxygen tubing. Staff # 14 stated that although these details were not found on the nursing progress notes, this was documented on the facility's risk assessment notes. Staff # 14 attempted to locate the documentation on the facility risk assessment, however realized the documentation was never created and that this information about the incident was just being recalled. Staff # 14 requested that Assistant Director of Nursing (ADON/Staff # 64) join in the interview because she had discussed the incident with her. Staff # 64 joined the interview, but could not recall the incident details or explain accurately when a fall should be reported to the Department of Health Services (DHS). Staff # 64 stated that since she was hired as ADON she was unaware if falls were reported and confirmed she had not reported any falls to DHS. Staff # 14 stated she would like to educate Staff # 64 at this time, and proceeded to explain which falls must be reported to DHS.

On May 08, 2024 at 08:45 AM, a list of residents who had previous falls with major injury in the last 6 months was requested. The list revealed a single individual or Resident # 36.

On May 08, 2024 at 09:24 AM, Staff # 14 stated that the facility had made an error by failing to document how the fall had occurred, however that the notes were created last night as a late entry through risk management documentation. Staff # 14 stated she was there when it happened, and should have documented or made sure that staff documented. Staff # 14 stated not only was she there and failed to document, but she failed to make sure that her staff documented what happened. She stated that did not meet professional standards.

Review of the facility's policy titled, "Fall Management System" revision date of July 2023 revealed,

-review of the fall incident will include investigation to determine probably causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall.
-the investigation will be reviewed by the interdisciplinary team (IDT). Results of the investigation will be documented in the resident's clinical record.

Review of the facility's policy titled, "Documentation and Charting" revision date of July 2022 revealed, it is the policy of this facility to provide:

-a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc.
-the facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident.
-nursing service personnel with a record of the physical and mental status of the resident.
-the elements of quality medical nursing care
-legal record that protects the resident, physician, nurse and the facility.

Based on clinical record review, staff interviews, and review of facility policies and practices, the facility failed to ensure nursing documentation reflect care and medical services provided for Resident # 36 according to professional standards.

Findings include:

Resident # 36 was admitted to the facility on March 27, 2024 with diagnoses that included hypothyroidism, depression, and generalized anxiety disorder.

The comprehensive minimum data set (MDS) assessment dated May 08, 2024 revealed a brief interview for mental status (BIMS) score of 15, which indicated the resident was cognitively intact.

On May 06, 2024 at 10:02 AM, an observation of Resident # 36 revealed discoloration surrounding her left eye darkened at an unknown stage of bruising. An interview conducted with Resident # 36 stated that this was due to a recent fall injury inside the facility which resulted in a left sided-orbital fracture.

On May 07, 2024 at 3:39 PM, electronic medical record (EMR) nursing progress notes reviewed from the day of fall dated April 29, 2024 at 3:03 PM, revealed no information detailing how the fall had occurred:

Nurse was notified that resident was found on the floor, resident was bleeding from her eyebrow, pressure was applied to site followed by steri strips, and provider notified and advised staff to send resident to emergency department via 911.

On May 07, 2024 at 04:45 PM, an interview was conducted with Director of Nursing (DON/Staff # 14) regarding completing and accurately documenting the fall incident. Staff # 14 stated Resident # 36 was found on the floor, alert and oriented, and the fall was not suspected to be a result of neglect or abuse. Staff # 14 stated that the call light was not used by the resident and believed she had tripped over her oxygen tubing. Staff # 14 stated that although these details were not found on the nursing progress notes, this was documented on the facility's risk assessment notes. Staff # 14 attempted to locate the documentation on the facility risk assessment, however realized the documentation was never created and that this information about the incident was just being recalled. Staff # 14 requested that Assistant Director of Nursing (ADON/Staff # 64) join in the interview because she had discussed the incident with her. Staff # 64 joined the interview, but could not recall the incident details or explain accurately when a fall should be reported to the Department of Health Services (DHS). Staff # 64 stated that since she was hired as ADON she was unaware if falls were reported and confirmed she had not reported any falls to DHS. Staff # 14 stated she would like to educate Staff # 64 at this time, and proceeded to explain which falls must be reported to DHS.

On May 08, 2024 at 08:45 AM, a list of residents who had previous falls with major injury in the last 6 months was requested. The list revealed a single individual or Resident # 36.

On May 08, 2024 at 09:24 AM, Staff # 14 stated that the facility had made an error by failing to document how the fall had occurred, however that the notes were created last night as a late entry through risk management documentation. Staff # 14 stated she was there when it happened, and should have documented or made sure that staff documented. Staff # 14 stated not only was she there and failed to document, but she failed to make sure that her staff documented what happened. She stated that did not meet professional standards.

Review of the facility's policy titled, "Fall Management System" revision date of July 2023 revealed,

-review of the fall incident will include investigation to determine probably causal factors considering environmental factors, resident medical condition, resident behavioral manifestations, and medical or assistive devices that may be implicated in the fall.
-the investigation will be reviewed by the interdisciplinary team (IDT). Results of the investigation will be documented in the resident's clinical record.

Review of the facility's policy titled, "Documentation and Charting" revision date of July 2022 revealed, it is the policy of this facility to provide:

-a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc.
-the facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident.
-nursing service personnel with a record of the physical and mental status of the resident.
-the elements of quality medical nursing care
-legal record that protects the resident, physician, nurse and the facility.

Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure medication services are provided according to accepted standards of clinical practice for one resident (#177).

Findings included:

Resident #177 was admitted at the facility on April 18, 2024 with diagnoses of acute on chronic systolic congestive heart failure, generalized edema, and acute kidney failure.

An admission Minimum Data Set (MDS) assessment dated April 24, 2024 revealed a Brief Interview of Mental Status (BIMS) score of 15 which meant the resident was cognitively intact.

Review of Resident #177 care plan initiated on April 18, 2024 revealed a focus for potential fluid deficit related to diuretic use. The goals included that the resident will be free of symptoms of dehydration and will maintain moist mucous membranes, good skin turgor. The interventions included to administer medications as ordered.

On May 7, 2024 at 7:23 AM the medication administration observation pass was conducted with licensed practical nurse (LPN)/Staff #200, she stated that the process of administering medication included the right person and right dose. Resident #177 was amongst the residents observed for medication administration observation pass.

During Resident #177's medication preparation on May 7, 2024 at 7:55 AM, Staff #200 stated that the staff noticed two orders for potassium medication and stated that she was holding the potassium 10 mEq (Milliequivalent).

Review of Resident #177 record revealed following two physician orders for Potassium Chloride ER medication:
-Potassium Chloride ER (Extended Release) Oral Tablet 10 mEq, give 1 tablet by mouth three times a day for supplement
-Potassium Chloride ER Oral Tablet 20 mEq, give 40 mEq by mouth one time a day for diuresis

A review of Resident #177's Medication Administration Record (MAR) revealed on May 7, 2024 for 0800 Hours, Potassium Chloride ER Oral Tablet 20 mEq, give 40 mEq by mouth one time a day for diuresis, was administered by Staff #200 and Potassium Chloride ER Oral Tablet 10 MEQ, give 1 tablet by mouth three times a day for supplement, was marked held/see nurse notes by Staff #200.

A follow up interview was conducted with Staff #200 on May 7, 2024 at 3:40 PM. Staff #200 stated that she informed her charge nurse and she stated that the potassium medication was a duplicate order. She stated that if she did not understand something about the medication then she will go to the charge nurse or the director of nursing (DON) or the physician if readily available.

A review of Resident #177 clinical record on May 7, 2024 at 3:57 PM revealed a documentation under electronic medication administration record (eMAR)-medication administration note dated May 7, 2024 at 8:04. The note stated that the Potassium Chloride ER Oral Tablet 10 mEq, give 1 tablet by mouth three times a day for supplement, was held for duplicate order. In addition, a review of Resident #177 laboratory results dated April 22, 2024 at 17:16 revealed a potassium of 3.9 millimoles per liter (mmol/L).

An interview was conducted with registered nurse RN/Staff #11 on May 8, 2024 at 10:32 AM regarding physician orders. He stated that for an order that he had a question with, he stated that he double checked with the provider. He contacted the provider by using the provider numbers located in the station phone. The station phone included the provider's number and their office numbers. Furthermore, he stated that for medications that needed clarification such as sometimes orders are transcribed in a wrong way for instance the nurses transcribed by mouth instead of enteral feeding. He called the doctor to confirm route. Another example, for same medication with two orders that looked like maybe a mistake, he reads the actual order. An example was a vitamin C order 500 mg everyday but certain days of the week there was an order for vitamin C 1000 mg. He stated that he wondered why he was signing the medication vitamin C twice. He stated He did not hold the order and only gave the medications after the order was confirmed by talking to the provider.

An interview was conducted with the director of nursing (DON)/Staff #14 on May 9, 2024 at 2:44 PM and she stated that when preparing medication, she anticipated the nurse to call the provider for clarification and her expectation for her staff was to clarify and notify. The nurse is using her judgement that she will review order and then notify provider.

Review of Medication Administration Policy revised 05/2017; last Reviewed 10/2023 revealed the facility to accurately prepare, administer and document oral medications. In addition, "Essential Points: 13. Any irregularity in pouring or administering must be reported to the doctor. 14. If there is any question in regard to dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage".

Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure staff provided meals according to regulations to one resident (#76).

Findings include:

Resident #76 was admitted to the facility on 4/15/2023 and discharged on 4/27/2023 with diagnoses that included left tibia fracture, chronic obstructive pulmonary disease, heart failure, and chronic kidney disease.

Resident #76 had an order dated 4/15/2023 for regular diet with regular texture and thin liquids. There were also orders for once daily dietary supplements; Glucerna 8 ounces and Prostat 30 milliliters, dated 4/19/202 and 4/22/2023 respectively.

Medicare Minimum Data Set (MDS) dated 4/21/23 shows Brief Interview of Mental Status (BIMS) of 15 which indicated no cognitive impairment.

The care plan initiated on 4/16/2023 reflected a goal related to resident being malnourished. The goal for resident #76 was to maintain adequate nutritional status as evidenced by consuming more than 75% of meals and supplements. Interventions included diet as ordered by the physician and monitor and report to the physician any decreased appetite, unexpected weight loss,

A nutritional screening dated 4/18/24 revealed the resident was malnourished due to being bed bound and experiencing rapid weight loss. Recommendations were to provide dietary supplement Ensure.

A review of the facility grievance log for April 2023 showed resident #76 had brought up meal concerns with the kitchen and the Assistant Director of Nursing on 4/17/2023.

Review of the Plan of Care (POC) task documentation shows one shift on 4/18/2023 and 4/20/2023 each, show no documentation of meals being provided to resident #76.

In an interview on 05/09/2024 at 1:41pm with a Certified Nursing Assistant (CNA/Staff #40), Staff #40 stated that activity of daily living (ADL) care is always documented in the electronic health record (EHR) and CNAs document under POC tasks. They stated that ADL's like meals, baths, brief changes, and dressing is documented each time it is completed.

In an interview with CNA (Staff #24), she stated ADL care is always documented in the EHR including refusals of care which are also reported to the nurse. Each time they provide the ADL service it is documented in the system. Some of them are required the one time and then it will be as needed. For bowel movements for example, a new entry can be created for each time a brief change is done. Each meal is also a new entry. She reviewed the print out of POC tasks for resident #76 and when asked what the blanks meant, she stated that meant it was not completed.

In an interview with the Director of Nursing (DON/ Staff #14) on 05/09/2024 at 2:10pm, she reviewed a print out of the POC tasks for Resident #76 and stated that the blanks are not indicative of the services not being completed. They just mean that it was not documented. There are areas that show that if a service was completed after midnight, then they will roll over to the next day, but it was still completed. Review of Resident #76's chart shows that eating was not documented for 2 days and she indicated this was not due to the midnight rollover glitch. The DON stated that the facility had intitated the following measures after the April 12, 2023 abbreviated survey:

-staff to be in-serviced on accuracy and completion of daily Point of Care/Activities of Daily (POC/ADL) Living with a completion date of 06/21/2023.
-staff to be in-serviced on recognizing and reporting changes in ADL activity/ability. The completion date was 06/21/2023.
-DNS or designee will conduct a daily review Monday through Friday of POC/ADL documentation completion x 4 weeks to ensure substantial compliance. 06/21/2023.
-DNS or designee will ensure that the nutrition report will be discussed and reviewed at the weekly nutrition meeting for the Interdisciplinary Team (IDT) to recognize declines or changes in eating patterns and respond proactively to the changes as indicated x4 weeks. The completion date was 06/21/2023.
-DNS or designee will report findings of reviewes to the QAPI committee with additioanl follow-up and recommendation as needed until substantial compliance is achieved and maintained. The completion date was 06/21/2023.

In a policy titled "Documentation and Charting" last reviewed 07/2023, it stated that facility will provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc. as well as the progress of the resident's care.

Based on observations, interviews, facility document reviews, and facility policy, the facility failed to ensure a comfortable and safe temperatures were maintained in one resident room (Resident #274).

Findings included:

Resident #274 was admitted on May 1, 2024 with diagnoses of osteomyelitis, urinary tract infection, chronic systolic heart failure.

The resident's Brief Interview for Mental Status (BIMS) dated May 1, 2024 revealed a score of 15 that indicated resident was cognitively intact.

During an initial screening on May 6, 2024 at 9:34 AM, Resident #68 stated that the room was hot, she had been in that same room for a month, and staff were aware of her concerns. Resident #68 added that the second week she got there that she almost passed out. She stated she was not used to hot temperatures since she was living in a different state. She further added that the staff brought her lots of ice and cool rags because she was very hot and she felt like she was going to pass out. Resident #274, who shared the same room with Resident #68, stated that the air conditioner did not work and the maintenance staff were aware that the air conditioning was not working.

An interview was conducted with Maintenance Director/Staff #115 on May 8, 2024 at 12:14 PM. Staff #115 stated that the certified nursing assistants (CNAs) and all staff can submit work order. He used an app that gave weekly and monthly task and work orders. Staff #115 stated that he viewed and checked the work orders in his phone. After viewing and checking the work orders he had received, he communicated with the nursing team. For example, he communicated a work order for a low air mattress and issues with lighting for a resident.

Another interview was conducted with Resident #274 on May 9, 2024 at 9:37 AM. Resident #274 stated that it was still hot in her room. The portable fan was turned on in her room. She added that her roommate was discharged yesterday and she left her the portable fan to use. In addition, Resident #274 stated that her room felt hot since she arrived on May 1st. During the interview, the resident's room had a sliding door and she stated that she felt the sun heat was coming in from the door all day. The sliding door had a shade and the shade was rolled up from the bottom and closed about two thirds from the top. Resident stated that she did not messed with the shade because it was not in her side of the room.

On May 9, 2024 at 9:58 AM, a temperature check was performed using a laser temperature gun. The temperature by the window hallway outside the Resident #274 's room was 74.5-75 degrees Fahrenheit. The temperature in the resident's room just outside the resident's bathroom door was 75 degrees Fahrenheit with a portable fan turned on.

An interview was conducted with a certified nursing assistant (CNA)/Staff #108 on May 9, 2024 at 2:01 PM. Staff #108 stated that the temperature in the rooms are pretty much even. And, if residents say that their rooms were warm, she will have the maintenance staff check the room. She further stated that the thermostats were controlled in the hallways.

An interview was conducted with the Maintenance Director/Staff #115 on May 9, 2024 at 2:06 PM. Staff #115 stated that the facility had 16 units total and each unit controls 7 to 8 rooms with the common area or office per unit. He stated that the back end where the Director of Nursing (DON) and rooms 5 through 18 use unit 12 or 13 to control the temperature. He further added that the thermostat was set between 71 through 74 degrees Fahrenheit. He stated that he checked the temperature every morning. He also felt the vents to make sure that cool temperature was coming out and this is done every weekly. He further added that when he checked the thermostat in the room, he carried his temperature check gun. If the temperature is hot, he will offer a fan to the resident and then communicate the issue with the DON and admission so the resident can be moved to another room. Furthermore, he stated that there was a thermostat issue a week ago or so and a technician was called.

On May 9, 2024 at 3:45 PM, Resident #274 stated that it was cooler today but it had been hot. With laser temperature gun, the temperature at vent was 91 degrees Fahrenheit, and the floor fan was on high setting.

On May 9, 2024 at 3:52 PM, another interview was conducted with the Director of Maintenance. Staff #115 took temperatures in room 15. Staff #115 used two temperature guns and the first one read 88.2 degrees Fahrenheit. The second reading was 87 degrees Fahrenheit. The temperature in room 14 was 61 degrees Fahrenheit, in room 13 was 49 - 52 degrees Fahrenheit depending on the thermometer. He further stated that maybe the vents need to be adjusted. He also added that the resident had originally said that it was hot on May 2nd when he was in Resident #274's room fixing a television. He agreed that it was very warm. He added that the thermostat was installed on that unit in May, but did not include the vents, ducts, or actual air conditioning. He added a floor fan in her room. One thermostat will control 7 rooms approximately and it cannot be adjusted for her.

On May 9, 2024 at 4:15 PM, an interview with the Director of maintenance was conducted. The administrator/Staff #72 was present during the interview. The Director of maintenance stated that a comfortable environment temperature is between 72 thru 73 degrees Fahrenheit. The administrator added that the temperature range is 71 thru 82 degrees is the safe temperature range but certain resident had a preference for warmer and cooler temperatures.

A review of the facility policy titled, Temperature, Rise in Environment and in the Facility, with a reviewed date of May 2022 revealed an acceptable environmental temperature ranges from 71-81 degrees to ensure a home like environment the resident has the right to request adjustment to room temperature for comfort.

Based on clinical record review, staff interviews and review of policies and procedures, the facility failed to ensure identify and address the risk factors for the nutritional status for one resident (#1). The deficient practice could result in residents not meeting dietary needs.

Findings include:

Resident #1 was admitted on January 13, 2023 with diagnoses of transient ischemic attack (TIA), cerebral infarction without residual deficits, gastro-esophageal reflux disease (GERD) without esophagitis and type 2 diabetes mellitus.

A care plan initiated on January 14, 2023 revealed the resident had ADL (activities of daily living) self-care performance deficit. Goal was that the resident would maintain current level of function in eating. Interventions included to discuss feelings about self-care deficit, participate to the fullest extent possible, and use mobility bars.

The nutrition care plan dated January 14, 2023 included resident had malnutrition. Goal was that the resident will maintain adequate nutritional status as evidence by consuming more than 65% of meals and supplements. Interventions included to monitor and report to physician as needed for any signs or symptoms of decreased appetite, RD (registered dietician) to evaluate and make diet change recommendations, and provide supplements as ordered.

A nursing note dated January 14, 2023 revealed the resident was alert and oriented times 1-2, was able to answer yes or no questions only and continued to refuse medications; and that, the nurse educated the resident on the importance of the medications.

The weight on January 14, 2023 was 135 lbs. (pounds).

The speech therapy note dated January 16, 2023 included the resident was at baseline for cognition and had a history of TBI (traumatic brain injury) with a decline over the past several months.

Review of the admission minimum data set (MDS) assessment dated January 20, 2023 included the resident had a brief interview for mental status (BIMS) score of indicating the resident had severe cognitive impairment.

A nursing note dated February 8, 2023 included the resident refused medications during the first medication pass and 45 minutes later; and that, the staff attempted another time right before lunch and the resident stated that he was "not taking them today."

The weights record for February and March 2023 were recorded as follows:
-February 1 was 126.4 lbs. which was significant weight loss 6.37% from January 14, 2023;
-March 6 was 128.6 lbs.

Review of the Documentation Survey report from February 1 through March 31, 2023 revealed that there were multiple dates that the meal intake percentages boxes were blank and not marked. The report also revealed multiple dates that documented resident had meal intake of less than 50%.

The clinical record revealed no evidence that the resident was provided with meals on the dates that were not marked in the report.

Further, the clinical record revealed no evidence that the provider was notified for the missed meals or intake of less than 50% for February and March 2023.

During an interview with a certified nursing assistant (CNA/staff #22) conducted on April 12, 2023 at 10:19 a.m., the CNA stated that resident #1 required adaptive silverware because his grips had gotten weak. Staff #22 stated resident #1 was not on a feeding program and no one was assisting the resident with feeding. Staff #22 stated she would go to the kitchen to get "big" silverware so the resident could feed himself.

An interview was conducted on April 12, 2023 at 10:53 a.m. with a registered dietitian (RD/staff #45) who stated the resident does not use an adaptive equipment; and that, if the resident had a consistent decline in intake and required assistive devices, she would want to be notified to complete a nutritional assessment and work with therapy to meet the resident's need. Regarding resident #1, the RD stated that based on their assessment, resident #1 had an average oral meal intake of 38% and was placed on supplements. The RD said she was never notified of missed meals, lack of intake, or any use of adaptive equipment.

An interview with a registered nurse (RN) conducted on April 12, 2023 at 11:52 a.m. The RN stated that if a resident has supplements then there was a required intake percentage of the supplement. The RN said that if the resident's food intake was consistently low, she would inform the Director of Nursing (DON) or the RD. Regarding resident #1, the RN stated that the resident was receptive to care, could follow enough to understand, was thin but not emancipated. The RN further stated that she could not recall the resident having an adaptive utensil/assistive device for eating.

In an interview with the DON (staff #70) conducted on April 12, 2023 at 12:55 p.m., the DON stated that the expectation was that staff would set up meal trays when they are delivered to the room. The DON stated that meal percentages are documented in to the electronic chart and some residents eat less than 50% of their meals. The DON stated that the expectation was that if a staff see a "regular pattern" of eating less than 50%, the nurse should be notified; and, the nurse should notify the dietary manager. The DON stated that a regular pattern was defined as what was normal for that resident and if the intake was less and was a deviation from the regular pattern it should be reported. The DON also stated that if a resident needs adaptive equipment, occupational therapy should screen the resident prior to use of the adaptive equipment.

A facility policy titled "Change of Condition Reporting" (revised 7/2022) included that all changes in resident conditions will be communicated to the physician and documented. The change of condition and response will be documented in the nursing progress notes and the resident's care plan will be updated.

Based on clinical record review, staff interviews and review of policies and procedures, the facility failed to ensure identify and address the risk factors for nutritional status for one resident (#1).

Findings include:

Resident #1 was admitted on January 13, 2023 with diagnoses of transient ischemic attack (TIA), cerebral infarction without residual deficits, gastro-esophageal reflux disease (GERD) without esophagitis and type 2 diabetes mellitus.

A care plan initiated on January 14, 2023 revealed the resident had ADL (activities of daily living) self-care performance deficit. Goal was that the resident would maintain current level of function in eating. Interventions included to discuss feelings about self-care deficit, participate to the fullest extent possible, and use mobility bars.

The nutrition care plan dated January 14, 2023 included resident had malnutrition. Goal was that the resident will maintain adequate nutritional status as evidence by consuming more than 65% of meals and supplements. Interventions included to monitor and report to physician as needed for any signs or symptoms of decreased appetite, RD (registered dietician) to evaluate and make diet change recommendations, and provide supplements as ordered.

A nursing note dated January 14, 2023 revealed the resident was alert and oriented times 1-2, was able to answer yes or no questions only and continued to refuse medications; and that, the nurse educated the resident on the importance of the medications.

The weight on January 14, 2023 was 135 lbs. (pounds).

The speech therapy note dated January 16, 2023 included the resident was at baseline for cognition and had a history of TBI (traumatic brain injury) with a decline over the past several months.

Review of the admission minimum data set (MDS) assessment dated January 20, 2023 included the resident had a brief interview for mental status (BIMS) score of indicating the resident had severe cognitive impairment.

A nursing note dated February 8, 2023 included the resident refused medications during the first medication pass and 45 minutes later; and that, the staff attempted another time right before lunch and the resident stated that he was "not taking them today."

The weights record for February and March 2023 were recorded as follows:
-February 1 was 126.4 lbs. which was significant weight loss 6.37% from January 14, 2023;
-March 6 was 128.6 lbs.

Review of the Documentation Survey report from February 1 through March 31, 2023 revealed that there were multiple dates that the meal intake percentages boxes were blank and not marked. The report also revealed multiple dates that documented resident had meal intake of less than 50%.

The clinical record revealed no evidence that the resident was provided with meals on the dates that were not marked in the report.

Further, the clinical record revealed no evidence that the provider was notified for the missed meals or intake of less than 50% for February and March 2023.

During an interview with a certified nursing assistant (CNA/staff #22) conducted on April 12, 2023 at 10:19 a.m., the CNA stated that resident #1 required adaptive silverware because his grips had gotten weak. Staff #22 stated resident #1 was not on a feeding program and no one was assisting the resident with feeding. Staff #22 stated she would go to the kitchen to get "big" silverware so the resident could feed himself.

An interview was conducted on April 12, 2023 at 10:53 a.m. with a registered dietitian (RD/staff #45) who stated the resident does not use an adaptive equipment; and that, if the resident had a consistent decline in intake and required assistive devices, she would want to be notified to complete a nutritional assessment and work with therapy to meet the resident's need. Regarding resident #1, the RD stated that based on their assessment, resident #1 had an average oral meal intake of 38% and was placed on supplements. The RD said she was never notified of missed meals, lack of intake, or any use of adaptive equipment.

An interview with a registered nurse (RN) conducted on April 12, 2023 at 11:52 a.m. The RN stated that if a resident has supplements then there was a required intake percentage of the supplement. The RN said that if the resident's food intake was consistently low, she would inform the Director of Nursing (DON) or the RD. Regarding resident #1, the RN stated that the resident was receptive to care, could follow enough to understand, was thin but not emancipated. The RN further stated that she could not recall the resident having an adaptive utensil/assistive device for eating.

In an interview with the DON (staff #70) conducted on April 12, 2023 at 12:55 p.m., the DON stated that the expectation was that staff would set up meal trays when they are delivered to the room. The DON stated that meal percentages are documented in to the electronic chart and some residents eat less than 50% of their meals. The DON stated that the expectation was that if a staff see a "regular pattern" of eating less than 50%, the nurse should be notified; and, the nurse should notify the dietary manager. The DON stated that a regular pattern was defined as what was normal for that resident and if the intake was less and was a deviation from the regular pattern it should be reported. The DON also stated that if a resident needs adaptive equipment, occupational therapy should screen the resident prior to use of the adaptive equipment.

A facility policy titled "Change of Condition Reporting" (revised 7/2022) included that all changes in resident conditions will be communicated to the physician and documented. The change of condition and response will be documented in the nursing progress notes and the resident's care plan will be updated.

Based on closed clinical record review, interviews, and policy, the facility failed to ensure that medications were available as ordered for one resident (#261).

Findings include:

Resident #261 was admitted to the facility on 1/29/22 with diagnoses that included dementia, heart disease, encephalopathy, hypotension, breast cancer, and lung cancer.

The resident's pain care plan, dated 1/29/22, revealed a goal to manage pain related to cancer and risk of impaired cognition related to dementia.

Review of the physician's orders dated 1/30/22 revealed an order for anastrozole (used to treat breast cancer) 1 milligram (mg) per day.

The admission Minimum Data Set (MDS) assessment dated 2/4/22 revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating cognitive impairment.

Review of the Medication Administration Record (MAR) for January and February 1 through 8, 2022 revealed that the resident did not receive the anastrozole 1 mg on any occasion.

Review of the nursing notes indicated that the anastrozole was not administered because the prescription was not filled and was on order with the pharmacy. The nursing notes did not indicate that the physician had been notified that the medication was not available.

The resident discharged from the facility on 2/8/22.

During an interview with a Registered Nurse (RN/staff #2) on 1/4/23 at 2:03 PM, she stated that if a medication is not available when a resident is admitted to the facility, the next steps would be to contact the physician, contact the pharmacy, and inform the Director of Nursing (DON) and the resident. She said that depending on the medication, pharmacy may be able to give them a code to get it from the medication dispenser. She said she would document all of these things in the clinical record. She stated that for anastrozole specifically, it would not be available in the medication dispenser or the emergency kit, so they would need to continue to follow-up with the pharmacy.

In an interview with the facility's pharmacist (consultant staff #129) on 1/5/22 at 9:57 AM, she stated she could not say what risks or side effects there would be for going so many days without anastrozole, due to it being a maintenance medication for the suppression of cancer. She said that she could see that other medications were dispensed and administered for the resident during the same timeframe. She stated the initial prescription was received for anastrozole on 1/29/22 but it was not filled. She said there may have been some confusion because the resident received a 14-day supply on 1/24/22 when she was at another facility. She said that she could see that the medication was not given and that this was confusing because this would have been an easy fix with one call or message. She stated that the pharmacy keeps records of all communications, and for this resident there weren't any records of the facility contacting them for follow-up.

During an interview with the DON (staff #7) on 1/6/23 at 12:33 PM, she stated her expectation when medications are not available for a resident on admission is that the nurses notify the provider who may put the medication on hold while they figure out what is going on. She said that if the medications continues to not be available for multiple days, they should follow up with the provider as often as necessary and the provider will usually give guidance on the next steps. Her expectations for documentation of these actions is that it always is put in a nursing note in the resident's clinical record. She said she did not see any notes to show that the process was followed.

Review of the facility's physician orders policy, dated 8/22, revealed that drugs must be ordered before administering the last dose. The policy included that any irregularity in administering must be reported to the doctor.

Based on closed clinical record review, interviews, and policy, the facility failed to ensure that medications were available as ordered for one resident (#261). The deficient practice could result in residents not receiving needed medications.

Findings include:

Resident #261 was admitted to the facility on 1/29/22 with diagnoses that included dementia, heart disease, encephalopathy, hypotension, breast cancer, and lung cancer.

The resident's pain care plan, dated 1/29/22, revealed a goal to manage pain related to cancer and risk of impaired cognition related to dementia.

Review of the physician's orders dated 1/30/22 revealed an order for anastrozole (used to treat breast cancer) 1 milligram (mg) per day.

The admission Minimum Data Set (MDS) assessment dated 2/4/22 revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating cognitive impairment.

Review of the Medication Administration Record (MAR) for January and February 1 through 8, 2022 revealed that the resident did not receive the anastrozole 1 mg on any occasion.

Review of the nursing notes indicated that the anastrozole was not administered because the prescription was not filled and was on order with the pharmacy. The nursing notes did not indicate that the physician had been notified that the medication was not available.

The resident discharged from the facility on 2/8/22.

During an interview with a Registered Nurse (RN/staff #2) on 1/4/23 at 2:03 PM, she stated that if a medication is not available when a resident is admitted to the facility, the next steps would be to contact the physician, contact the pharmacy, and inform the Director of Nursing (DON) and the resident. She said that depending on the medication, pharmacy may be able to give them a code to get it from the medication dispenser. She said she would document all of these things in the clinical record. She stated that for anastrozole specifically, it would not be available in the medication dispenser or the emergency kit, so they would need to continue to follow-up with the pharmacy.

In an interview with the facility's pharmacist (consultant staff #129) on 1/5/22 at 9:57 AM, she stated she could not say what risks or side effects there would be for going so many days without anastrozole, due to it being a maintenance medication for the suppression of cancer. She said that she could see that other medications were dispensed and administered for the resident during the same timeframe. She stated the initial prescription was received for anastrozole on 1/29/22 but it was not filled. She said there may have been some confusion because the resident received a 14-day supply on 1/24/22 when she was at another facility. She said that she could see that the medication was not given and that this was confusing because this would have been an easy fix with one call or message. She stated that the pharmacy keeps records of all communications, and for this resident there weren't any records of the facility contacting them for follow-up.

During an interview with the DON (staff #7) on 1/6/23 at 12:33 PM, she stated her expectation when medications are not available for a resident on admission is that the nurses notify the provider who may put the medication on hold while they figure out what is going on. She said that if the medications continues to not be available for multiple days, they should follow up with the provider as often as necessary and the provider will usually give guidance on the next steps. Her expectations for documentation of these actions is that it always is put in a nursing note in the resident's clinical record. She said she did not see any notes to show that the process was followed.

Review of the facility's physician orders policy, dated 8/22, revealed that drugs must be ordered before administering the last dose. The policy included that any irregularity in administering must be reported to the doctor.

Based on closed clinical record review, interviews, and policy, the facility failed to ensure continence care was adequately documented for one resident (#266). The deficient practice could result in residents' clinical records not being accurate and complete.

Findings include:

Resident #266 was admitted to the facility on 1/19/22 with diagnoses that included fracture of right leg, dislocation of a joint in right foot, epilepsy, dementia, and major depressive disorder.

The resident's incontinence care plan, dated 1/19/22, revealed the resident had bowel and bladder incontinence with the goal to remain free from skin breakdown. Interventions included washing and drying perineum and changing clothing as needed after incontinence episodes.

A bowel and bladder evaluation dated 1/22/22 showed that the was always incontinent of bowel and bladder.

Review of a Minimum Data Set (MDS) assessment dated 2/13/22 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The assessment included that the resident was not on a toileting program and was frequently incontinent.

Review of the bowel and bladder continence documentation from 1/20 through 2/18/22 revealed more than 10 occasions where incontinence care was not documented for an entire shift. This included four day shifts in a row where continence care was not documented.

The resident was discharged from the facility on 2/18/22.

The clinical record did not include any further information regarding continence care during the times that the continence documention was not documented.

Review of facility documentation revealed that the problem of documenting Activity of Daily Living (ADL) care had been identified in the March 2022 Quality Assurance (QA) committee and the facility began working on the problem as part of their Quality Assurance and Performance Improvement (QAPI) process. The goal was to improve CNA documentation, specifically with ADL documentation. The information provided included evidence of staff education and monitoring with improvement noted from 57% in January 2022 to 88-90% in November and December 2022. Review of current practice revealed no evidence of deficient practice.

An interview was conducted with a Certified Nursing Assistant (CNA/staff #34) on 1/5/23 at 12:10 PM. She stated that residents are changed every two hours and as needed unless they are care planned for something different. She said that the CNAs document the continence care in the record. She said that it is typical to document throughout the shift as it can be a lot to try to catch up on at the end of a shift.

The Director of Nursing (DON/staff #57) was interviewed on 1/5/23 at 12:20 PM. She reviewed the continence documentation for the resident and stated that the facility does not track brief changes. She stated she could not locate any further documentation for the resident's continence care. She said that documentation for incontinence care was done once for a whole shift, but that each brief change was not documented. She stated that the issue of missed documentation was identified and addressed in the QA process.

Review of the facility's incontinent care policy, revised on 5/2022, revealed that the policy of the facility was to check for incontinent episodes routinely and as needed.

Based on closed clinical record review, interviews, and policy, the facility failed to ensure continence care was adequately documented for one resident (#266).

Findings include:

Resident #266 was admitted to the facility on 1/19/22 with diagnoses that included fracture of right leg, dislocation of a joint in right foot, epilepsy, dementia, and major depressive disorder.

The resident's incontinence care plan, dated 1/19/22, revealed the resident had bowel and bladder incontinence with the goal to remain free from skin breakdown. Interventions included washing and drying perineum and changing clothing as needed after incontinence episodes.

A bowel and bladder evaluation dated 1/22/22 showed that the was always incontinent of bowel and bladder.

Review of a Minimum Data Set (MDS) assessment dated 2/13/22 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. The assessment included that the resident was not on a toileting program and was frequently incontinent.

Review of the bowel and bladder continence documentation from 1/20 through 2/18/22 revealed more than 10 occasions where incontinence care was not documented for an entire shift. This included four day shifts in a row where continence care was not documented.

The resident was discharged from the facility on 2/18/22.

The clinical record did not include any further information regarding continence care during the times that the continence documention was not documented.

Review of facility documentation revealed that the problem of documenting Activity of Daily Living (ADL) care had been identified in the March 2022 Quality Assurance (QA) committee and the facility began working on the problem as part of their Quality Assurance and Performance Improvement (QAPI) process. The goal was to improve CNA documentation, specifically with ADL documentation. The information provided included evidence of staff education and monitoring with improvement noted from 57% in January 2022 to 88-90% in November and December 2022. Review of current practice revealed no evidence of deficient practice.

An interview was conducted with a Certified Nursing Assistant (CNA/staff #34) on 1/5/23 at 12:10 PM. She stated that residents are changed every two hours and as needed unless they are care planned for something different. She said that the CNAs document the continence care in the record. She said that it is typical to document throughout the shift as it can be a lot to try to catch up on at the end of a shift.

The Director of Nursing (DON/staff #57) was interviewed on 1/5/23 at 12:20 PM. She reviewed the continence documentation for the resident and stated that the facility does not track brief changes. She stated she could not locate any further documentation for the resident's continence care. She said that documentation for incontinence care was done once for a whole shift, but that each brief change was not documented. She stated that the issue of missed documentation was identified and addressed in the QA process.

Review of the facility's incontinent care policy, revised on 5/2022, revealed that the policy of the facility was to check for incontinent episodes routinely and as needed.

Based on observation and staff interview the facility failed to provide a record of electrical equipment tests, repairs, and modifications. Failing to conduct maintenance on patient care appliances could cause harm to the residentt if the appliance malfunctions.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements
"The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training."

Findings include:

Observation, record review and staff interview on January 5th, 2023, revealed the facility was unable to produce documentation to identify all electrical equipment tests, repairs, and modifications. The facility had blood pressure monitors (4) through out the facility with Preventitive maint stickers reading expired on Sept 2022.

Facility management acknowledged during the exit conference on January 5th, 2023, the facilty failed to preform PM's on some electrical equipment