Mission Palms Post Acute

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#2) was reported to the State Agency.

Findings include:

Resident #2 was admitted to the facility on January 3, 2024 with diagnoses that included metabolic encephalopathy, acute kidney failure, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated January 8, 2024, revealed a Brief Interview for Mental Status score of 2, which suggests moderate cognitive impairment. The MDS also included the resident had verbal behaviors towards others 1-3 days a week.

She was also care planned for behaviors problems on her care plan initiated on January 10, 2024, with interventions that included administering medications as ordered and consulting with Pastoral Care, Social Services, and Psych services.

A physician's order dated January 13, 2024 indicated she would be transferred to the hospital. Her discharge paperwork for the same day revealed she was transferred to the hospital for altered mental status.

In a nursing progress note time stamped January 13, 2024 at 1:46 PM, a Licensed Practical Nurse (LPN/Staff #23) documented the resident had alleged that night staff had tried to "finger fuck her." The note further documents behaviors of yelling at, attempting to bite, and throwing things at staff.

In a follow up progress note at 2:00 PM the same day, the patient was sent out to the hospital per the provider to get a psychiatric evaluation done due to behaviors. The patient's son and power of attorney were notified of the change in condition.

On January 15, 2024 a Social Services note entered at 1:12 PM by the Social Service Supervisor and the Assistant Director of Nursing indicated they had followed up regarding Resident #2's statements of being sexually assaulted. The resident denied making these statements.

During an interview conducted on January 18, 2024 at 12:15 PM, with the Charge Nurse, (Staff #23) on the phone, she stated that on the night of the incident, she was made aware by the nurse that the patient was refusing all medications, and stating that the staff was trying to rape her. Staff #23 called the ADON for support, and ultimately the patient was sent out for a psychiatric evaluation.

During an interview with the ADON, (Staff #67), on January 18, 2024 at 12:41 PM, she stated she had received a call from the charge nurse the day of the incident about Resident #2 "making weird comments and concerning statements." She denies that the charge nurse told her the resident reported sexual assault. She further stated that she and the Social Services Supervisor, (Staff #89) immediately came into the building to investigate. When they interviewed Resident #2, she denied she had alleged sexual assault. The Director of Nursing (DON) was notified of the situation.

During an interview conducted on January 18, 2024 at 12:47 PM with the DON, when asked if the facility is required to report before investigating, she stated they investigate immediately on the spot and it is a very fast process. In this instance she would not have reported because she stated she did not know what the patient was alleging.

In the facility policy entitled "Abuse: Prevention of and Prohibition Against" last reviewed on 10/2022, it states "Residents also have the right to be free from verbal, sexual, physical, and mental abuse ..." Under section H. Reporting/Response it states "All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State of Federal agencies in the applicable timeframes, as per this policy and applicable regulations. "

Based on closed clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of abuse for one resident (#2) was reported to the State Agency.

Findings include:

Resident #2 was admitted to the facility on January 3, 2024 with diagnoses that included metabolic encephalopathy, acute kidney failure, and heart failure. Review of the admission Minimum Data Set (MDS) assessment dated January 8, 2024, revealed a Brief Interview for Mental Status score of 2, which suggests moderate cognitive impairment. The MDS also included the resident had verbal behaviors towards others 1-3 days a week.

She was also care planned for behaviors problems on her care plan initiated on January 10, 2024, with interventions that included administering medications as ordered and consulting with Pastoral Care, Social Services, and Psych services.

A physician's order dated January 13, 2024 indicated she would be transferred to the hospital. Her discharge paperwork for the same day revealed she was transferred to the hospital for altered mental status.

In a nursing progress note time stamped January 13, 2024 at 1:46 PM, a Licensed Practical Nurse (LPN/Staff #23) documented the resident had alleged that night staff had tried to "finger fuck her." The note further documents behaviors of yelling at, attempting to bite, and throwing things at staff.

In a follow up progress note at 2:00 PM the same day, the patient was sent out to the hospital per the provider to get a psychiatric evaluation done due to behaviors. The patient's son and power of attorney were notified of the change in condition.

On January 15, 2024 a Social Services note entered at 1:12 PM by the Social Service Supervisor and the Assistant Director of Nursing indicated they had followed up regarding Resident #2's statements of being sexually assaulted. The resident denied making these statements.

During an interview conducted on January 18, 2024 at 12:15 PM, with the Charge Nurse, (Staff #23) on the phone, she stated that on the night of the incident, she was made aware by the nurse that the patient was refusing all medications, and stating that the staff was trying to rape her. Staff #23 called the ADON for support, and ultimately the patient was sent out for a psychiatric evaluation.

During an interview with the ADON, (Staff #67), on January 18, 2024 at 12:41 PM, she stated she had received a call from the charge nurse the day of the incident about Resident #2 "making weird comments and concerning statements." She denies that the charge nurse told her the resident reported sexual assault. She further stated that she and the Social Services Supervisor, (Staff #89) immediately came into the building to investigate. When they interviewed Resident #2, she denied she had alleged sexual assault. The Director of Nursing (DON) was notified of the situation.

During an interview conducted on January 18, 2024 at 12:47 PM with the DON, when asked if the facility is required to report before investigating, she stated they investigate immediately on the spot and it is a very fast process. In this instance she would not have reported because she stated she did not know what the patient was alleging.

In the facility policy entitled "Abuse: Prevention of and Prohibition Against" last reviewed on 10/2022, it states "Residents also have the right to be free from verbal, sexual, physical, and mental abuse ..." Under section H. Reporting/Response it states "All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to the appropriate State of Federal agencies in the applicable timeframes, as per this policy and applicable regulations. "

Based on record review, staff and family interviews, as well as policy and facility documentation, the facility failed to ensure a resident's privacy during medication administration.

Findings include:

Resident #331 was admitted on March 22, 2023 with diagnosis including metabolic encephalopathy, fracture of the left femur, congestive heart failure, atherosclerotic heart disease, chronic obstructive pulmonary disease, dysphagia and cognitive communication deficit.

A review of the MDS (minimum data set) dated March 29, 2023 revealed a BIMS (brief interview of mental status) score of 6, indicating severe cognitive impairment.

A review of the consents section in the electronic medical record revealed a communication method request form dated March 22, 2023, noting the following: "I do not want information regarding my condition to be given to any of my friends/ family members." The document was noted to be signed by telephonic consent by the resident's spouse, who was observed to have signed all other admission consent forms telephonically.

A review of the grievance log for May 2023, noted a grievance for resident #331 logged by the case manager at the Veterans Administration on May 25, 2023, citing lost items. However, further review of the grievance resolution form, noted an additional concern regarding the resident's protected health information. The grievance resolution form addressed a question regarding the resident's PHI (protected health information), stating that it had not been given to an unauthorized person. It further stated that the nurse was telling the resident which medications were being administered while a family member was visiting at bedside. The grievance investigation further revealed that the nurse asked the resident if it was okay to give him his medications with a visitor in the room. The resident was stated to have given his permission; however, the resident is noted to have BIMS score of 6.

An interview was conducted on November 14, 2023 at 12:50 P.M. with the spouse (#205) of resident #331. The spouse stated that the resident's nurse (LPN, #36) had admitted that she had relayed information regarding the resident's medication to the sister-in-law, who was not authorized to receive the information. She stated that she had advised the director of nursing but had not heard back from the facility.

An interview was conducted on November 15, 2023 at 7:30 A.M. with the director of nursing, staff #70. Staff #70 stated that she was aware of the incident where the nurse had advised resident #331 of the medications she was administering with the resident's sister-in-law in the room. She stated that it was likely that the nurse was unaware of the communication method preference noted in the resident's electronic health record. She stated that the expectation is that staff be aware of the resident's privacy preferences. She stated that the risk would be that information would be shared with unauthorized individuals.

An interview was conducted on November 15, 2023 at 8:25 A.M. with staff #63, medical records supervisor and HIPAA compliance officer for the facility. She stated that HIPAA breaches can occur in a number of different ways, to include: incoming faxes if observed by non-authorized personnel, mail delivered to the wrong room, giving out information to unauthorized individuals over the phone or in person. She stated that staff can discern who is authorized to have a resident's information by the facesheet. She stated that if someone is not listed on the facesheet, outside of staff, they are not authorized to obtain information on the resident or their medical record. When staff #63 reviewed the electronic medical record for resident #331, she stated that only the spouse and wife were noted to be authorized to receive the resident's medical information; however, the information had been shared with the resident's sister-in-law, per facility documentation and staff interviews. She stated that if there is a HIPAA violation, the staff would report it her, she would discuss it with the administrator and it would then be sent to the compliance team. She stated that she was not made aware that medication information for resident #331 had been shared with an unauthorized individual. She stated that the risk could be a barrier to trust and information could be taken out of context.

An interview was conducted on November 15, 2023 at 8:47 A.M with the administrator, staff #90. Staff #90 stated that communication regarding the resident and their medical record occurs only with the resident and their approved family members and stated that the expectation is that no information is shared forward to those not designated in the medical record.

A review of the HIPPA compliance policy dated May 2022 revealed that all staff, volunteers and vendors must not disclose any potential medical information about a resident, either verbally, written or electronically; however, medication information for resident #331 was revealed to the resident's sister-in-law, who was not an authorized person, per the medical record.

Based on record review, staff and family interviews, as well as policy and facility documentation, the facility failed to ensure a resident's privacy during medication administration. Failure to respect privacy has the potential to erode trust, dignity, and a sense of well-being.

Findings include:

Resident #331 was admitted on March 22, 2023 with diagnosis including metabolic encephalopathy, fracture of the left femur, congestive heart failure, atherosclerotic heart disease, chronic obstructive pulmonary disease, dysphagia and cognitive communication deficit.

A review of the MDS (minimum data set) dated March 29, 2023 revealed a BIMS (brief interview of mental status) score of 6, indicating severe cognitive impairment.

A review of the consents section in the electronic medical record revealed a communication method request form dated March 22, 2023, noting the following: "I do not want information regarding my condition to be given to any of my friends/ family members." The document was noted to be signed by telephonic consent by the resident's spouse, who was observed to have signed all other admission consent forms telephonically.

A review of the grievance log for May 2023, noted a grievance for resident #331 logged by the case manager at the Veterans Administration on May 25, 2023, citing lost items. However, further review of the grievance resolution form, noted an additional concern regarding the resident's protected health information. The grievance resolution form addressed a question regarding the resident's PHI (protected health information), stating that it had not been given to an unauthorized person. It further stated that the nurse was telling the resident which medications were being administered while a family member was visiting at bedside. The grievance investigation further revealed that the nurse asked the resident if it was okay to give him his medications with a visitor in the room. The resident was stated to have given his permission; however, the resident is noted to have BIMS score of 6.

An interview was conducted on November 14, 2023 at 12:50 P.M. with the spouse (#205) of resident #331. The spouse stated that the resident's nurse (LPN, #36) had admitted that she had relayed information regarding the resident's medication to the sister-in-law, who was not authorized to receive the information. She stated that she had advised the director of nursing but had not heard back from the facility.

An interview was conducted on November 15, 2023 at 7:30 A.M. with the director of nursing, staff #70. Staff #70 stated that she was aware of the incident where the nurse had advised resident #331 of the medications she was administering with the resident's sister-in-law in the room. She stated that it was likely that the nurse was unaware of the communication method preference noted in the resident's electronic health record. She stated that the expectation is that staff be aware of the resident's privacy preferences. She stated that the risk would be that information would be shared with unauthorized individuals.

An interview was conducted on November 15, 2023 at 8:25 A.M. with staff #63, medical records supervisor and HIPAA compliance officer for the facility. She stated that HIPAA breaches can occur in a number of different ways, to include: incoming faxes if observed by non-authorized personnel, mail delivered to the wrong room, giving out information to unauthorized individuals over the phone or in person. She stated that staff can discern who is authorized to have a resident's information by the facesheet. She stated that if someone is not listed on the facesheet, outside of staff, they are not authorized to obtain information on the resident or their medical record. When staff #63 reviewed the electronic medical record for resident #331, she stated that only the spouse and wife were noted to be authorized to receive the resident's medical information; however, the information had been shared with the resident's sister-in-law, per facility documentation and staff interviews. She stated that if there is a HIPAA violation, the staff would report it her, she would discuss it with the administrator and it would then be sent to the compliance team. She stated that she was not made aware that medication information for resident #331 had been shared with an unauthorized individual. She stated that the risk could be a barrier to trust and information could be taken out of context.

An interview was conducted on November 15, 2023 at 8:47 A.M with the administrator, staff #90. Staff #90 stated that communication regarding the resident and their medical record occurs only with the resident and their approved family members and stated that the expectation is that no information is shared forward to those not designated in the medical record.

A review of the HIPPA compliance policy dated May 2022 revealed that all staff, volunteers and vendors must not disclose any potential medical information about a resident, either verbally, written or electronically; however, medication information for resident #331 was revealed to the resident's sister-in-law, who was not an authorized person, per the medical record.

Based on observation, staff interviews, and facility policy and procedures, the facility failed to ensure one resident's (#93) environment was free from hazards. The deficient practice could result in accidents occurring.

Findings include:

Resident #93 was admitted to the facility on April 1, 2023 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinsonism unspecified, seizure disorder, and hypertension.

The minimum data set (MDS) dated October 25, 2023 included a brief interview for mental status score of 15 indicating the resident was cognitively intact.

Review of the fall risk evaluation dated August 3, 2023 revealed that the resident had fallen 2 times in the past three months and was a high risk for falling.

A nurse progress note dated September 27, 2023 at 7:14 p.m. revealed that a loud noise was heard coming from the resident's room along with the resident's roommate yelling for help. Upon entering the resident's room, she was found lying on her left side between the bed and the nightstand. A very small lesion was found on the left brow with minimal bleeding and no pain. The resident was assessed from head to toe. The resident was experiencing pain in the left shoulder, trapezius, scapula area. Upon palpation, a hard bump was found on the scapula area with no pain. An X-ray was ordered to rule out a fracture. Passive range of motion (ROM) was performed on left side due to history of a stroke causing hemiplegia. Pain was experienced at full point of (ROM) with the upper left extremity. The resident stated that she was having muscle spasm in right mid back that causes all pain to worsen. Vitals were taken and the resident was transferred to bed. The nurse practitioner (NP) was notified and ordered Baclofen 5 mg three times a day for muscle spasms and an X-ray. The resident's daughter and Director of Nursing were notified. An ice pack and pain medications were given as needed, neurological assessment sheet was started as of 5:40 p.m. and resident is stable.

A nurse progress note dated September 27, 2023 at 11:44 p.m. revealed that the resident was sent out to the hospital.

A nurse progress note dated September 28, 2023 at 11:50 a.m. revealed that the resident returned from the hospital with a fractured shoulder.

A fall committee interdisciplinary team meeting note dated September 28, 2023 revealed that the resident is alert and oriented with a brief interview for mental status score of 15 and is able to make needs known. The resident requires extensive to total assistance for safety with bed mobility, toileting, and transfers. On September 27, 2023 a loud noise was heard coming from the resident's room, followed by the resident being heard yelling out for help along with the resident's roommate. The nurse entered the room and found the resident lying on her left side between the bed and the nightstand. The resident had her bed in the high position. The resident stated that she was attempting to reach for an item from the nightstand, but the item was too far to reach and she fell off of the bed. The resident complained of pain in her left shoulder. A full head to toe assessment was performed by the nurse and noted a small lesion by brow, hard lump found on the left shoulder. The provider was notified and ordered an X-ray of the left shoulder. The X-ray showed a fracture to the left clavicle. The provider was informed and ordered for the resident to be sent to the hospital for further evaluation and treatment. The resident returned from the hospital on September 28, 2023 with a sling. New interventions for the fall care plan: bed in low position, resident educated to use call-light and ask for assistance when reaching for items not within reach.

Review of a physician progress note dated November 15, 2023 at 8:38 AM revealed that the resident was seen and examined after a fall on September 27, 2023. The resident was sent to the emergency room (ER) where she was evaluated. A X-ray of the left shoulder showed acromioclavicular (ac) distal left clavicle fracture and was placed in sling and sent back to facility September 28, 2023. The resident complained of pain and is on oxycodone. Pain is controlled with medications.

An interview was conducted on November 15 2023 at 8:44 AM with resident #93, who stated that - she fell off the bed, while reaching in the drawer of her nightstand for her arthritis cream, Blue Emu, and broke her collarbone. During the interview, a jar of Blue Emu was observed on the resident's mobile tray.

During an interview was conducted on November 15, 2023 at 8:52 AM with a hospitality aide (staff #113), staff observed the Blue Emu on the resident's mobile tray; she picked jar up, read the label, and she stated she would have to ask the nurse if the cream needed to be locked up. Staff #113 went to get a licensed practical nurse (LPN/staff #180), who stated that he would need to check with the supervisor to see if the Blue Emu needed to be locked up. After talking to his supervisor, (LPN/staff #180) stated that the Blue Emu needed to be removed and he would be reaching out to the physician to get an order for the Blue Emu.

An interview was conducted on November 17, 2023 at 8:09 AM with the Director of Nursing (DON/staff #70), who stated that an evaluation would need to be completed to determine if resident #93 can self-administer the Blue Emu, which was not done. She stated that the Blue Emu was removed and there is now an order in place for the nurse to administer. Also, staff #70 stated that the resident fell on September 27, 2023 and broke her collarbone, while reaching for something. She stated that the team met after the fall on September 28, 2023 to determine the reason for the fall and it was determined that the resident had her bed in the high position and the resident stated that she went to reach for an item. Staff #70 stated that the fall care plan was updated to include ensuring the bed is in the lowest position.

The facility's policy "Incidents and Accidents" stated that it is the policy of this facility to implement and maintain measures to avoid hazards and accidents.

Based on observation, interview, and record review, the facility did not ensure that a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections.

Findings include:

Resident #37 was admitted to the facility January 10, 2023 with several diagnosis including dysphasia and aphasia following cerebral infarction, neuromuscular dysfunction of the bladder, depression, bipolar disorder, post traumatic stress disorder, schizoaffective disorder, and anxiety disorder. A review of the medical record revealed that the resident had an indwelling catheter. Review of the most recent MDS assessment revealed that Resident #37 had a BIMS (brief interview of mental status) score of 15, indicating no cognitive impairment but was dependent on staff for all activities of daily living. Initial physician's order written on January 11, 2023 read "may change suprapubic catheter PRN (as needed) for malfunctioning or dislodged. Suprapubic catheter care every shift and PRN". Further review of the medical record revealed Resident #37 was being treated for a UTI (urinary tract infection) during the dates of November 9, 2023 through November 16, 2023.

Review of the physician's order sheet revealed an order dated January 17, 2023 that read "irrigate suprapubic catheter with 60 mL sterile water every day shift".

Review of the medical record revealed Resident #37 was seen by Southeast Valley Urology on February 3, 2023 to change the catheter. A note from Southeast Valley Urology was returned to facility after Resident #37 appointment stating "catheter hole in her stomach was dirty and smelly. Please help keep it clean by cleaning when undergarment is changed daily and put a new bandage on it. Thank you. Next appointment is March 3, 2023 at 1:00 PM. Please schedule transportation. Daughter will meet her there. Thank you".

Further review of the medical record revealed Resident #37 was seen by Southeast Valley Urology on
March 3, 2023 for catheter change.

Review of the physician's orders written on April 3, 2023 read "suprapubic catheter # 16 FR/ 10 ML (LATEX) to closed drainage system".

Review of medical record revealed on April 14, 2023 for catheter change. A note was returned to facility following Resident #37 appointment stating "The catheter was filthy. The bandage has not been cleaned in a very long time. The bandage needs cleaned daily to avoid infection. She needs ointment on the skin to reduce redness and irritation. The bandage needs cleaned AGAIN TONIGHT due to A LOT of blood. NEXT APPOINTMENT May 12, 2023 at 1:00 PM".

Review of medical record revealed physician's order written on July 5, 2023 5:00 PM read "cleanse suprapubic catheter site with wound cleanser or normal saline, pat dry, cover with split gauze, secure with tape. every night shift.

Review of of medical record revealed Resident #37 was seen by Southeast Valley Urology on May 12, 2023 for catheter change, and June 13, 2023 for catheter change. Resident #37 had a scheduled appointment at Southeast Valley Urology on July 21, 2023 that had to be canceled.

On November 16, 2023 at 12:12 PM an interview was conducted with the Director of Nursing, (DON staff #70), revealed that best practice is to change a catheter every 30 days unless there is specific order for prn (as needed). Staff #70 revealed that the Assistant Director of Nursing, (ADON staff #47), monitors catheter care and if the catheters are changed monthly.

On November 17, 2023 at 09:23 AM an interview was conducted with the Unit Secretary, (staff #171), who stated "the patient goes to urology monthly. It can be the facility scheduler who schedules the appointments or residents family. When the patient returns she usually has a packet with her from urology that has her next appointment on it. Sometimes she doesn't have the packet but we call to get the notes and the next appointment". Staff #171 also stated that "sometimes the patient's daughter calls and tell us when the next appointment is. The appointment on July 21, 2023 had to be canceled because patients daughter called a day or two before the appointment and we did not have enough time to schedule for transportation". When further questioned to why Resident #37 did not have any scheduled urology appointments in August 2023, September 2023, Staff #171 did not know why. Medical record revealed that Resident #37 did attend her October 27, 2023 Southeast Valley Urology appointment and did have an appointment on November 17, 2023 at 1:00 PM and was scheduled for transportation.

On November 17, 2023 at 09:10 AM an interview was conducted with Licensed Practical Nurse, (LPN staff #46), who stated "there is an order to flush or clean the catheter every day or every shift. We check for any redness or signs of infection. If there are signs we notify the Dr. If the catheter needs changed and we do not have an order to change it monthly, or if there are concerns, we call the Urology Doctor. I know that the catheter has been changed but I don't know where the documentation is".

Review of the record revealed that the catheter had not been changed July 2023, and resident #37 had her Southeast Valley Urology appointment canceled. Further record review revealed that Resident #37 did not have a scheduled urology appointment in August 2023, September 2023 or October 2023. In a progress note dated September 18, 2023 that the catheter had been changed by a nurse at the facility. More documentation revealed that a nurse at the facility also changed the catheter on October 20, 2023 and October 25, 2023.

Review of the facilities policy states, "It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN for soiling to promote hygiene, comfort and decrease the risk of infection for catheterized residents.

Based on clinical review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident's (#66) pain medication was administered within parameters. The deficient practice could result in residents being overly medicated.

Findings include:

Resident #66 was admitted to the facility on October 12, 2023 with diagnoses that included dementia, wedge compression fracture, and hypertensive heart and chronic kidney disease.

The minimum data set (MDS) dated October 19, 2023 included a brief interview for mental status score of 15 indicating the resident was cognitively intact.

Review of the order summary report revealed an order dated October 13, 2023 for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB Refer to NPI

Review of the medication administration record (MAR) dated October 2023 revealed that Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB was administered on October 15,2023 for a pain level of 2 and on October 23, 2023 for a pain level of 3.

Review of the care plan dated October 16, 2023 revealed that the resident is currently prescribed an opioid for pain management; potential for adverse outcomes form opioid use. Interventions included to administer opioid as prescribed and to provide education to the resident on the potential risks, adverse outcomes, complications, and medication interactions associated with opioid use including death.

An interview was conducted on November 16, 2023 with the licensed practical nurse/MDS Coordinator (LPN/staff #110), who stated that an order for a pain mediation as needed requires a pain scale. She reviewed the MAR dated October 2023 and stated that the Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB was administered on October 15, 2023 for a pain level of 2 and on October 23, 2023 for a pain level of 3. She stated that administering pain medication outside of the parameters can result in overmedicating the resident and sedation.

An interview was conducted on November 17, 2023 at 8:05 AM with the Director of Nursing (DON/staff #70), who stated that pain medication prescribed as needed requires a pain scale on the order and the risk to not following the pain scale parameters depends on the type of medication. She stated that she wasn't sure if there was a risk to administering an opioid outside of the parameters because some residents have been on opioids for long periods.

The facility's policy "Physician Orders" states that It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on observation, the clinical record, staff and resident interviews, and the policy and procedures, the facility failed to obtain dental services to meet the needs of one resident (#14). The deficient practice could result in tooth decay, pain, and affect nutrition.

Findings include:

Resident #14 was admitted to the facility on January 24, 2023 and readmitted on February 3, 2023 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysphagia oropharyngeal phase, obstructive and reflux uropathy.

The minimum data set (MDS) dated January 31, 2023 included a staff assessment for mental status score of 2 indicating the resident had a moderate cognitive impairment. It also included that the the resident didn't have obvious or a likely cavity or broken natural teeth and the resident needed a one-person supervised assistance for hygiene tasks.

Review of the care plan for activities of daily living (ADL) performance deficit related to decreased mobility, weakness, and fatigue included the interventions to explain all procedures/tasks before starting, encourage to participate to the fullest extent possible with each interaction, and to converse with resident while providing care.

Review of a progress note dated November 16, 2023 revealed that an oral cavity/dental assessment was performed in the resident's room with the resident's permission. The resident had visible tooth/teeth decay, missing teeth, broken teeth with complaints of occasional pain not occurring on a daily basis. The resident expressed no or discomfort during the assessment. The patient is currently on a regular texture diet.

Review of the clinical record did not reveal that the resident was scheduled or attended any dental appointments.

During an interview conducted on November 14, 2023 at 9:41 AM with resident #14), multiple teeth were observed to be dark brown in some places and multiple teeth were missing. The resident stated that her bottom teeth are rotted and she has requested to see a dentist because she had a toothache, but the nurse never followed up with her. She stated that the top teeth are still hurting and she experiences sharp pain, but it doesn't hurt all the time. She wasn't sure when she made the request, but thinks that it was sometime between now and last January. She stated that the dentist has been here and cleaned her roommate's teeth and pulled her tooth, but she has not received dental care.

An interview was conducted on November 16, 2023 at 12:11 PM with the Social Services Supervisor (staff #144) and the Social Services Supervisor (staff #25). Staff #144 stated that the resident has dental coverage and she would have scheduled dental appointment if knew there was a problem. She stated that the dentist comes to the facility on average of every two to three months and agreed that resident should have seen the dentist at least once. Staff #25 stated that she has no knowledge about the resident complaining of a toothache. During the interview, neither staff was able to provide any documention showing that the resident was scheduled to see the dentist or that the resident was seen by the dentist on any prior dates and stated that they would need to review the clinical record.

An interview was conducted on November 16, 2023 at 12:42 PM with a certified nursing assistant (CNA/staff #121), who stated that the resident requires assistance with brushing her teeth on one side because she doesn't have full use of her arm. Staff #121 has assisted the resident with brushing her teeth and did notice a little tooth decay on the bottom teeth, some brown areas, but not too much on the top. The staff stated that the CNAs are supposed to report the tooth decay to the nurse on the shift and he doesn't think he let the nurse know about the tooth decay or documented the concern in the clinical record. Staff #121 has no knowledge of the resident reporting tooth pain.

An interview was conducted on November 16, 2023 at 12:49 PM with a licensed practical nurse/MDS Coordinator (LPN/staff #406), who stated that it is her expectation that the CNAs assist the residents with brushing their teeth if needed, which would include observing any concerns related to the teeth/mouth. She stated that the CNAs should report tooth decay and any discomfort the residents are experiencing to the nurse on duty. She stated that it is the nurse's responsibility to document the concern in a progress note and follow up on the problem. She stated that a full mouth assessment would have been completed during the annual MDS, which was completed in January 2023. Then she reviewed the annual MDS and stated the resident had no cavities at that time.

On November 16, 2023 at 1:10 PM, (LPN/staff #406) was observed assessing the resident's teeth and stated she observed multiple cavities and multiple missing teeth. During the assessment, the resident stated that she has experienced discomfort and thinks that she saw a dentist approximately one and half years ago.

An interview was conducted on November 17, 2023 8:21 AM with the Director of Nursing (DON/staff #70), who stated that resident #14 has insurance coverage for dental care and the resident should see the dentist at least once a year. It is her expectation that if a CNA sees something concerning the resident's teeth, such as tooth decay, it should be reported to the nurse.

The facility's policy "Referrals (Dental Appointments)" reviewed February 2023 stated that if the facility does not employ a qualified professional to furnish a specific service ordered by the physician, the facility will make necessary arrangements for services to be furnished to the resident by a person or agency outside the facility.

Based on observation, staff interviews, and facility policy and procedures, the facility failed to ensure that one staff (#113) sanitized her hands prior to handling the one resident's (#93) food/container. The deficient practice could result in food being contaminated.

Findings include:

Resident #93 was admitted to the facility on April 1, 2023 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinsonism unspecified, seizure disorder, and hypertension.

The minimum data set (MDS) dated October 25, 2023 included a brief interview for mental status score of 15 indicating the resident was cognitively intact.

During an interview conducted on November 15, 2023 at 8:44 AM with resident #93, she asked the hospitality aide (staff #113), to get her peanut butter. Staff #113 was observed retrieving a large jar of peanut butter from the resident's cupboard. Staff #113 twisted the plastic lid off and removed the seal covering the peanut butter from the jar. As she removed the seal, her fingers were observed touching the lip of the jar. Then, she handed the jar to the resident, who spread the peanut butter on her toast. Staff #113 was not observed sanitizing her hands before or after opening the jar.

During an interview was conducted on November 15, 2023 at 8:57 AM with a hospitality aide (staff #113), she stated that she received training on hand hygiene. She stated that she did not wash/sanitize hands before opening the resident's jar of peanut butter and did not clean around the lip of jar before replacing the lid and putting it back in the resident's cupboard. She stated that there was a risk of cross contamination.

An interview was conducted on November 17, 2023 at 11:42 AM with the Director of Nursing (DON/staff #70), who stated that staff should sanitize hands during food service and if the staff touched the lip of the container, staff should get a new container because the jar is potentially contaminated.

The facility's policy "Hand Hygiene" states that It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff.

Based on clinical review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident's (#66) pain medication was administered within parameters. The deficient practice could result in residents being overly medicated.

Findings include:

Resident #66 was admitted to the facility on October 12, 2023 with diagnoses that included dementia, wedge compression fracture, and hypertensive heart and chronic kidney disease.

The minimum data set (MDS) dated October 19, 2023 included a brief interview for mental status score of 15 indicating the resident was cognitively intact.

Review of the order summary report revealed an order dated October 13, 2023 for Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB Refer to NPI

Review of the medication administration record (MAR) dated October 2023 revealed that Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB was administered on October 15,2023 for a pain level of 2 and on October 23, 2023 for a pain level of 3.

Review of the care plan dated October 16, 2023 revealed that the resident is currently prescribed an opioid for pain management; potential for adverse outcomes form opioid use. Interventions included to administer opioid as prescribed and to provide education to the resident on the potential risks, adverse outcomes, complications, and medication interactions associated with opioid use including death.

An interview was conducted on November 16, 2023 with the licensed practical nurse/MDS Coordinator (LPN/staff #110), who stated that an order for a pain mediation as needed requires a pain scale. She reviewed the MAR dated October 2023 and stated that the Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) give 0.25 ml by mouth every 2 hours as needed for Pain 4-10/SOB was administered on October 15, 2023 for a pain level of 2 and on October 23, 2023 for a pain level of 3. She stated that administering pain medication outside of the parameters can result in overmedicating the resident and sedation.

An interview was conducted on November 17, 2023 at 8:05 AM with the Director of Nursing (DON/staff #70), who stated that pain medication prescribed as needed requires a pain scale on the order and the risk to not following the pain scale parameters depends on the type of medication. She stated that she wasn't sure if there was a risk to administering an opioid outside of the parameters because some residents have been on opioids for long periods.

The facility's policy "Physician Orders" states that It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on observation, the clinical record, staff and resident interviews, and the policy and procedures, the facility failed to obtain dental services to meet the needs of one resident (#14).

Findings include:

Resident #14 was admitted to the facility on January 24, 2023 and readmitted on February 3, 2023 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysphagia oropharyngeal phase, obstructive and reflux uropathy.

The minimum data set (MDS) dated January 31, 2023 included a staff assessment for mental status score of 2 indicating the resident had a moderate cognitive impairment. It also included that the the resident didn't have obvious or a likely cavity or broken natural teeth and the resident needed a one-person supervised assistance for hygiene tasks.

Review of the care plan for activities of daily living (ADL) performance deficit related to decreased mobility, weakness, and fatigue included the interventions to explain all procedures/tasks before starting, encourage to participate to the fullest extent possible with each interaction, and to converse with resident while providing care.

Review of a progress note dated November 16, 2023 revealed that an oral cavity/dental assessment was performed in the resident's room with the resident's permission. The resident had visible tooth/teeth decay, missing teeth, broken teeth with complaints of occasional pain not occurring on a daily basis. The resident expressed no or discomfort during the assessment. The patient is currently on a regular texture diet.

Review of the clinical record did not reveal that the resident was scheduled or attended any dental appointments.

During an interview conducted on November 14, 2023 at 9:41 AM with resident #14), multiple teeth were observed to be dark brown in some places and multiple teeth were missing. The resident stated that her bottom teeth are rotted and she has requested to see a dentist because she had a toothache, but the nurse never followed up with her. She stated that the top teeth are still hurting and she experiences sharp pain, but it doesn't hurt all the time. She wasn't sure when she made the request, but thinks that it was sometime between now and last January. She stated that the dentist has been here and cleaned her roommate's teeth and pulled her tooth, but she has not received dental care.

An interview was conducted on November 16, 2023 at 12:11 PM with the Social Services Supervisor (staff #144) and the Social Services Supervisor (staff #25). Staff #144 stated that the resident has dental coverage and she would have scheduled dental appointment if knew there was a problem. She stated that the dentist comes to the facility on average of every two to three months and agreed that resident should have seen the dentist at least once. Staff #25 stated that she has no knowledge about the resident complaining of a toothache. During the interview, neither staff was able to provide any documention showing that the resident was scheduled to see the dentist or that the resident was seen by the dentist on any prior dates and stated that they would need to review the clinical record.

An interview was conducted on November 16, 2023 at 12:42 PM with a certified nursing assistant (CNA/staff #121), who stated that the resident requires assistance with brushing her teeth on one side because she doesn't have full use of her arm. Staff #121 has assisted the resident with brushing her teeth and did notice a little tooth decay on the bottom teeth, some brown areas, but not too much on the top. The staff stated that the CNAs are supposed to report the tooth decay to the nurse on the shift and he doesn't think he let the nurse know about the tooth decay or documented the concern in the clinical record. Staff #121 has no knowledge of the resident reporting tooth pain.

An interview was conducted on November 16, 2023 at 12:49 PM with a licensed practical nurse/MDS Coordinator (LPN/staff #406), who stated that it is her expectation that the CNAs assist the residents with brushing their teeth if needed, which would include observing any concerns related to the teeth/mouth. She stated that the CNAs should report tooth decay and any discomfort the residents are experiencing to the nurse on duty. She stated that it is the nurse's responsibility to document the concern in a progress note and follow up on the problem. She stated that a full mouth assessment would have been completed during the annual MDS, which was completed in January 2023. Then she reviewed the annual MDS and stated the resident had no cavities at that time.

On November 16, 2023 at 1:10 PM, (LPN/staff #406) was observed assessing the resident's teeth and stated she observed multiple cavities and multiple missing teeth. During the assessment, the resident stated that she has experienced discomfort and thinks that she saw a dentist approximately one and half years ago.

An interview was conducted on November 17, 2023 8:21 AM with the Director of Nursing (DON/staff #70), who stated that resident #14 has insurance coverage for dental care and the resident should see the dentist at least once a year. It is her expectation that if a CNA sees something concerning the resident's teeth, such as tooth decay, it should be reported to the nurse.

The facility's policy "Referrals (Dental Appointments)" reviewed February 2023 stated that if the facility does not employ a qualified professional to furnish a specific service ordered by the physician, the facility will make necessary arrangements for services to be furnished to the resident by a person or agency outside the facility.

Based on observation, interview, and record review, the facility did not ensure that a resident with an indwelling catheter received appropriate care and services to prevent urinary tract infections.

Findings include:

Resident #37 was admitted to the facility January 10, 2023 with several diagnosis including dysphasia and aphasia following cerebral infarction, neuromuscular dysfunction of the bladder, depression, bipolar disorder, post traumatic stress disorder, schizoaffective disorder, and anxiety disorder. A review of the medical record revealed that the resident had an indwelling catheter. Review of the most recent MDS assessment revealed that Resident #37 had a BIMS (brief interview of mental status) score of 15, indicating no cognitive impairment but was dependent on staff for all activities of daily living. Initial physician's order written on January 11, 2023 read "may change suprapubic catheter PRN (as needed) for malfunctioning or dislodged. Suprapubic catheter care every shift and PRN". Further review of the medical record revealed Resident #37 was being treated for a UTI (urinary tract infection) during the dates of November 9, 2023 through November 16, 2023.

Review of the physician's order sheet revealed an order dated January 17, 2023 that read "irrigate suprapubic catheter with 60 mL sterile water every day shift".

Review of the medical record revealed Resident #37 was seen by Southeast Valley Urology on February 3, 2023 to change the catheter. A note from Southeast Valley Urology was returned to facility after Resident #37 appointment stating "catheter hole in her stomach was dirty and smelly. Please help keep it clean by cleaning when undergarment is changed daily and put a new bandage on it. Thank you. Next appointment is March 3, 2023 at 1:00 PM. Please schedule transportation. Daughter will meet her there. Thank you".

Further review of the medical record revealed Resident #37 was seen by Southeast Valley Urology on
March 3, 2023 for catheter change.

Review of the physician's orders written on April 3, 2023 read "suprapubic catheter # 16 FR/ 10 ML (LATEX) to closed drainage system".

Review of medical record revealed on April 14, 2023 for catheter change. A note was returned to facility following Resident #37 appointment stating "The catheter was filthy. The bandage has not been cleaned in a very long time. The bandage needs cleaned daily to avoid infection. She needs ointment on the skin to reduce redness and irritation. The bandage needs cleaned AGAIN TONIGHT due to A LOT of blood. NEXT APPOINTMENT May 12, 2023 at 1:00 PM".

Review of medical record revealed physician's order written on July 5, 2023 5:00 PM read "cleanse suprapubic catheter site with wound cleanser or normal saline, pat dry, cover with split gauze, secure with tape. every night shift.

Review of of medical record revealed Resident #37 was seen by Southeast Valley Urology on May 12, 2023 for catheter change, and June 13, 2023 for catheter change. Resident #37 had a scheduled appointment at Southeast Valley Urology on July 21, 2023 that had to be canceled.

On November 16, 2023 at 12:12 PM an interview was conducted with the Director of Nursing, (DON staff #70), revealed that best practice is to change a catheter every 30 days unless there is specific order for prn (as needed). Staff #70 revealed that the Assistant Director of Nursing, (ADON staff #47), monitors catheter care and if the catheters are changed monthly.

On November 17, 2023 at 09:23 AM an interview was conducted with the Unit Secretary, (staff #171), who stated "the patient goes to urology monthly. It can be the facility scheduler who schedules the appointments or residents family. When the patient returns she usually has a packet with her from urology that has her next appointment on it. Sometimes she doesn't have the packet but we call to get the notes and the next appointment". Staff #171 also stated that "sometimes the patient's daughter calls and tell us when the next appointment is. The appointment on July 21, 2023 had to be canceled because patients daughter called a day or two before the appointment and we did not have enough time to schedule for transportation". When further questioned to why Resident #37 did not have any scheduled urology appointments in August 2023, September 2023, Staff #171 did not know why. Medical record revealed that Resident #37 did attend her October 27, 2023 Southeast Valley Urology appointment and did have an appointment on November 17, 2023 at 1:00 PM and was scheduled for transportation.

On November 17, 2023 at 09:10 AM an interview was conducted with Licensed Practical Nurse, (LPN staff #46), who stated "there is an order to flush or clean the catheter every day or every shift. We check for any redness or signs of infection. If there are signs we notify the Dr. If the catheter needs changed and we do not have an order to change it monthly, or if there are concerns, we call the Urology Doctor. I know that the catheter has been changed but I don't know where the documentation is".

Review of the record revealed that the catheter had not been changed July 2023, and resident #37 had her Southeast Valley Urology appointment canceled. Further record review revealed that Resident #37 did not have a scheduled urology appointment in August 2023, September 2023 or October 2023. In a progress note dated September 18, 2023 that the catheter had been changed by a nurse at the facility. More documentation revealed that a nurse at the facility also changed the catheter on October 20, 2023 and October 25, 2023.

Review of the facilities policy states, "It is the policy of this facility that each resident with an indwelling catheter will receive catheter care daily and PRN for soiling to promote hygiene, comfort and decrease the risk of infection for catheterized residents.

Based on observation, staff interviews, and facility policy and procedures, the facility failed to ensure that one staff (#113) sanitized her hands prior to handling the one resident's (#93) food/container. The deficient practice could result in food being contaminated.

Findings include:

Resident #93 was admitted to the facility on April 1, 2023 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinsonism unspecified, seizure disorder, and hypertension.

The minimum data set (MDS) dated October 25, 2023 included a brief interview for mental status score of 15 indicating the resident was cognitively intact.

During an interview conducted on November 15, 2023 at 8:44 AM with resident #93, she asked the hospitality aide (staff #113), to get her peanut butter. Staff #113 was observed retrieving a large jar of peanut butter from the resident's cupboard. Staff #113 twisted the plastic lid off and removed the seal covering the peanut butter from the jar. As she removed the seal, her fingers were observed touching the lip of the jar. Then, she handed the jar to the resident, who spread the peanut butter on her toast. Staff #113 was not observed sanitizing her hands before or after opening the jar.

During an interview was conducted on November 15, 2023 at 8:57 AM with a hospitality aide (staff #113), she stated that she received training on hand hygiene. She stated that she did not wash/sanitize hands before opening the resident's jar of peanut butter and did not clean around the lip of jar before replacing the lid and putting it back in the resident's cupboard. She stated that there was a risk of cross contamination.

An interview was conducted on November 17, 2023 at 11:42 AM with the Director of Nursing (DON/staff #70), who stated that staff should sanitize hands during food service and if the staff touched the lip of the container, staff should get a new container because the jar is potentially contaminated.

The facility's policy "Hand Hygiene" states that It is the policy of this facility to cleanse hands to prevent transmission of possible infectious material and to provide clean, healthy environment for residents and staff.

Based on observation, staff interviews, and facility policy and procedures, the facility failed to ensure one resident's (#93) environment was free from hazards. The deficient practice could result in accidents occurring.

Findings include:

Resident #93 was admitted to the facility on April 1, 2023 with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Parkinsonism unspecified, seizure disorder, and hypertension.

The minimum data set (MDS) dated October 25, 2023 included a brief interview for mental status score of 15 indicating the resident was cognitively intact.

Review of the fall risk evaluation dated August 3, 2023 revealed that the resident had fallen 2 times in the past three months and was a high risk for falling.

A nurse progress note dated September 27, 2023 at 7:14 p.m. revealed that a loud noise was heard coming from the resident's room along with the resident's roommate yelling for help. Upon entering the resident's room, she was found lying on her left side between the bed and the nightstand. A very small lesion was found on the left brow with minimal bleeding and no pain. The resident was assessed from head to toe. The resident was experiencing pain in the left shoulder, trapezius, scapula area. Upon palpation, a hard bump was found on the scapula area with no pain. An X-ray was ordered to rule out a fracture. Passive range of motion (ROM) was performed on left side due to history of a stroke causing hemiplegia. Pain was experienced at full point of (ROM) with the upper left extremity. The resident stated that she was having muscle spasm in right mid back that causes all pain to worsen. Vitals were taken and the resident was transferred to bed. The nurse practitioner (NP) was notified and ordered Baclofen 5 mg three times a day for muscle spasms and an X-ray. The resident's daughter and Director of Nursing were notified. An ice pack and pain medications were given as needed, neurological assessment sheet was started as of 5:40 p.m. and resident is stable.

A nurse progress note dated September 27, 2023 at 11:44 p.m. revealed that the resident was sent out to the hospital.

A nurse progress note dated September 28, 2023 at 11:50 a.m. revealed that the resident returned from the hospital with a fractured shoulder.

A fall committee interdisciplinary team meeting note dated September 28, 2023 revealed that the resident is alert and oriented with a brief interview for mental status score of 15 and is able to make needs known. The resident requires extensive to total assistance for safety with bed mobility, toileting, and transfers. On September 27, 2023 a loud noise was heard coming from the resident's room, followed by the resident being heard yelling out for help along with the resident's roommate. The nurse entered the room and found the resident lying on her left side between the bed and the nightstand. The resident had her bed in the high position. The resident stated that she was attempting to reach for an item from the nightstand, but the item was too far to reach and she fell off of the bed. The resident complained of pain in her left shoulder. A full head to toe assessment was performed by the nurse and noted a small lesion by brow, hard lump found on the left shoulder. The provider was notified and ordered an X-ray of the left shoulder. The X-ray showed a fracture to the left clavicle. The provider was informed and ordered for the resident to be sent to the hospital for further evaluation and treatment. The resident returned from the hospital on September 28, 2023 with a sling. New interventions for the fall care plan: bed in low position, resident educated to use call-light and ask for assistance when reaching for items not within reach.

Review of a physician progress note dated November 15, 2023 at 8:38 AM revealed that the resident was seen and examined after a fall on September 27, 2023. The resident was sent to the emergency room (ER) where she was evaluated. A X-ray of the left shoulder showed acromioclavicular (ac) distal left clavicle fracture and was placed in sling and sent back to facility September 28, 2023. The resident complained of pain and is on oxycodone. Pain is controlled with medications.

An interview was conducted on November 15 2023 at 8:44 AM with resident #93, who stated that - she fell off the bed, while reaching in the drawer of her nightstand for her arthritis cream, Blue Emu, and broke her collarbone. During the interview, a jar of Blue Emu was observed on the resident's mobile tray.

During an interview was conducted on November 15, 2023 at 8:52 AM with a hospitality aide (staff #113), staff observed the Blue Emu on the resident's mobile tray; she picked jar up, read the label, and she stated she would have to ask the nurse if the cream needed to be locked up. Staff #113 went to get a licensed practical nurse (LPN/staff #180), who stated that he would need to check with the supervisor to see if the Blue Emu needed to be locked up. After talking to his supervisor, (LPN/staff #180) stated that the Blue Emu needed to be removed and he would be reaching out to the physician to get an order for the Blue Emu.

An interview was conducted on November 17, 2023 at 8:09 AM with the Director of Nursing (DON/staff #70), who stated that an evaluation would need to be completed to determine if resident #93 can self-administer the Blue Emu, which was not done. She stated that the Blue Emu was removed and there is now an order in place for the nurse to administer. Also, staff #70 stated that the resident fell on September 27, 2023 and broke her collarbone, while reaching for something. She stated that the team met after the fall on September 28, 2023 to determine the reason for the fall and it was determined that the resident had her bed in the high position and the resident stated that she went to reach for an item. Staff #70 stated that the fall care plan was updated to include ensuring the bed is in the lowest position.

The facility's policy "Incidents and Accidents" stated that it is the policy of this facility to implement and maintain measures to avoid hazards and accidents.

Based on observation the facility failed to ensure rated doors were maintained. Failing to have proper rated doors and maintain the the self-closing hardware on the door and frame to a hazardous room could cause harm to patients in time of a fire if the door does not close and latch secure.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.1, Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Chapter 8, 8.7.1. 1 Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: 1. Enclosing the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.3 2. Protecting the area with automatic extinguishing systems in accordance with Section 9.7 3. Applying both 8.7.1.1 (1) and (2) where the hazard is severe or where otherwise specified by Chapters 11 through 43. Section 8.7.1.3 Doors in barriers required to have a fire resistance rating shall have a minimum 3/4-hour fire protecting rating and shall be self or automatic closing in accordance with 7.2.1.8. Section 7.2.1.8.1 A door leaf normally required to be kept closed shall not be secured in the open position at any time and shall be self or automatic closing in accordance with 7.2.1.8.2.

Findings include:

Observations made while on tour on November 20, 2023, revealed the following;

1) the rated door between the kitchen and dining room failed to close. The door was rubbing on the floor. The facility had an estimate for a new door dated September 28, 2023, with no further documentation
2) the door for the janitors closet in the kitchen had an over 1/2 inch gap on the lower handle side

During the exit conference on November 20, 2023,, the above findings were again acknowledged by the management team.

Based on observation, the facility failed to ensure patient safety by allowing an extension cord to be utilized in a patient room. The use of extension cords in a patient care area could malfunction and could cause injury or death to a patient if overloaded.

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2, "All Patient Care Areas," Sections 6.3.2.2.6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. NFPA 1 11.1.5. Multiplug Adapters 11.1.5.2 Multiplug adapters shall not be used as a substitute for permanent wiring or receptacles.

NFPA 101 2012 Edition. 9.1 Utilities. 9.1.2 Electrical Systems.
Electrical wiring and equipment shall be in accordance with NFPA 70 National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. NEC 70 2011 Edition. 400.8 Uses Not Permitted. Unless specifically permitted in 400.7 flexible cords and cables shall not be used for the following:
1. As a substitute for the fixed wiring of a structure
2. Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
3. Where run through doorways, windows, or similar openings
4. Where attached to building surfaces. Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
5. Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
6. Where installed in raceways, except as otherwise permitted in this Code
7. Where subject to physical damage

Findings include:

Observations made while on tour on November 20, 2023, revealed the facility allowed the use of a white extension cord in patient room 228. The cord was under the bed and two charging cords were plugged into it.

During the exit conference on November 20, 2023, the above findings were again acknowledged by the management team.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that one resident (#1) was not administered an unnecessary medication. The sample size was 5. The deficient practice could result in resident receiving unnecessary medication.

Findings include:

Resident #1 was admitted on April 22, 2023 with diagnoses of metabolic encephalopathy, left femur fracture, ventricular tachycardia, congestive heart failure, and chronic obstructive pulmonary disease.

The clinical record revealed no documentation that the resident had diagnosis of type I or type II diabetes.

The physician order summary included an order dated May 4, 2023 to monitor blood sugar levels every shift for 3 days, due to change in condition related to a wrong medication administration.

The electronic medical record (EMAR) from May 4 thorough 7, 2023 revealed to monitor the resident's blood sugar levels every shift for 3 days due to change of condition regarding a wrong medication administration; and that, the resident's blood sugar levels from May 4 through 7 were recorded as between 134-205.

A review of medication error investigation report dated May 4, 2023 revealed that on May 4, resident #1 had been administered 50 units of Glargine (insulin) subcutaneously, without a physician order; and that, a licensed practical nurse (LPN/staff #161) had been identified as the staff making the error.

A telephone interview was conducted on May 24, 2023 at 12:05 p.m. with the LPN (staff #161) who stated that on May 4, 2023 at approximately 9:00 a.m., resident #1 was administered 50 units of Glargine subcutaneously. Staff #161 stated that she had drawn the insulin to administer to a resident in another room; however, she said she got distracted by two residents requesting pain medications. Staff #161 stated that she then went into the room of resident #1 and administered the insulin. Staff #161, stated she immediately realized she had administered the insulin to the wrong resident; had explained to resident #1 what happened and then went and notified the charge nurse, director of nursing (DON), physician and resident's family. Staff #161 stated that monitoring of resident's blood sugar levels began every shift and the resident's blood sugar levels did not drop to a critical level, below 100. Further, staff #161 stated she should have been paying attention to her EMAR and verified the resident and medication to be administered prior to giving the medication. Staff #161 also said that she met with the DON (staff #171) and she was counseled on minimizing distractions from other residents during the medication pass by acknowledging requests or concerns, documenting them, redirecting the residents back to their rooms or away from the medication cart, and to focus on completing the medication administration.

In an interview conducted with the DON (staff #171) on May 24, 2023 at 12:20 p.m., the DON stated she met with the LPN (staff #161) on May 4, 2023 regarding the medication error. The DON stated that staff #161 administered Glargine 50 units subcutaneously to resident #1 in error; and that, the resident's blood sugar levels were monitored every shift per the physician orders and no adverse drug reactions were observed. The DON said that the LPN was counseled regarding focusing on medication administration pass and to minimize distraction during the medication administration pass; and that, there were no further disciplinary actions taken.

The facility policy on Medication Administration revealed that medications were to be administered as prescribed by the attending physician. Further, the policy included that identification of the resident must be made prior to administering the medication to the resident and that medications were to be administered according to appropriate indication/diagnosis.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that one resident (#1) was not administered an unnecessary medication.

Findings include:

Resident #1 was admitted on April 22, 2023 with diagnoses of metabolic encephalopathy, left femur fracture, ventricular tachycardia, congestive heart failure, and chronic obstructive pulmonary disease.

The clinical record revealed no documentation that the resident had diagnosis of type I or type II diabetes.

The physician order summary included an order dated May 4, 2023 to monitor blood sugar levels every shift for 3 days, due to change in condition related to a wrong medication administration.

The electronic medical record (EMAR) from May 4 thorough 7, 2023 revealed to monitor the resident's blood sugar levels every shift for 3 days due to change of condition regarding a wrong medication administration; and that, the resident's blood sugar levels from May 4 through 7 were recorded as between 134-205.

A review of medication error investigation report dated May 4, 2023 revealed that on May 4, resident #1 had been administered 50 units of Glargine (insulin) subcutaneously, without a physician order; and that, a licensed practical nurse (LPN/staff #161) had been identified as the staff making the error.

A telephone interview was conducted on May 24, 2023 at 12:05 p.m. with the LPN (staff #161) who stated that on May 4, 2023 at approximately 9:00 a.m., resident #1 was administered 50 units of Glargine subcutaneously. Staff #161 stated that she had drawn the insulin to administer to a resident in another room; however, she said she got distracted by two residents requesting pain medications. Staff #161 stated that she then went into the room of resident #1 and administered the insulin. Staff #161, stated she immediately realized she had administered the insulin to the wrong resident; had explained to resident #1 what happened and then went and notified the charge nurse, director of nursing (DON), physician and resident's family. Staff #161 stated that monitoring of resident's blood sugar levels began every shift and the resident's blood sugar levels did not drop to a critical level, below 100. Further, staff #161 stated she should have been paying attention to her EMAR and verified the resident and medication to be administered prior to giving the medication. Staff #161 also said that she met with the DON (staff #171) and she was counseled on minimizing distractions from other residents during the medication pass by acknowledging requests or concerns, documenting them, redirecting the residents back to their rooms or away from the medication cart, and to focus on completing the medication administration.

In an interview conducted with the DON (staff #171) on May 24, 2023 at 12:20 p.m., the DON stated she met with the LPN (staff #161) on May 4, 2023 regarding the medication error. The DON stated that staff #161 administered Glargine 50 units subcutaneously to resident #1 in error; and that, the resident's blood sugar levels were monitored every shift per the physician orders and no adverse drug reactions were observed. The DON said that the LPN was counseled regarding focusing on medication administration pass and to minimize distraction during the medication administration pass; and that, there were no further disciplinary actions taken.

The facility policy on Medication Administration revealed that medications were to be administered as prescribed by the attending physician. Further, the policy included that identification of the resident must be made prior to administering the medication to the resident and that medications were to be administered according to appropriate indication/diagnosis.