rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,550,E,1,1,TYBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and medical record review, the facility failed to ensure residents were treated in a dignified manner. This failure affected 4 of 37 sample residents (#24, #62, #112, #220). The findings were: 1. Review of the 2/1/19 annual MDS assessment showed resident #24 had moderate cognitive impairment; required supervision with ambulation; and required extensive assistance with toileting, dressing, and personal hygiene. Review of the care plan, revised 12/27/18, showed the resident was at risk for ADL self-care performance deficit related to [DIAGNOSES REDACTED]. Further review showed care plan interventions included directions for staff to assist the resident with choosing simple comfortable clothing that enhanced his/her ability to dress self and provide supervised assistance with dressing. The following concerns were identified: a. Observation on 4/7/19 from 4:45 PM to 9:30 PM showed the resident wore his/her shirt inside out. Continuous observation showed the shirt seams were visible and the buttons were interiorly positioned against his/her chest. Further observation showed the resident ambulated independently throughout the halls and dining area. b. Observation on 4/8/19 from 8:50 AM to 2:30 PM showed the resident wore the same shirt inside out. c. Observation on 4/9/19 at 10 AM showed the resident continued to wear the same shirt inside out. At that time the DON was observed walking with the resident to his/her room to change the shirt. Continued observation showed the resident was compliant and allowed the DON to assist him/her without resistance. 2. Observation on 4/8/19 at 9:56 AM showed resident #62 had visibly wet pants and was taken to the toilet by CNA #2. After toileting the resident the CNA redressed the resident in the wet pants and returned him/her to the dining room. During interview with the CNA at that time the CNA stated It's probably just juice . 3. Observation in the second floor dining room on 4/7/19 at 6:03 PM showed resident #112 had vomited down the front of his/her shirt and pants, and a staff member took the resident to his/her room. Observation in the hallway near the resident's room on 4/7/19 at 7:44 PM showed the resident was wearing a different shirt, however, his/her pants remained the same and had a stain on the left upper pant leg. 4. Review of the 4/2/19 admission MDS assessment showed resident #220 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 12/15 (moderate cognitive impairment); had an indwelling catheter; required the extensive assistance of one staff member for transfers, locomotion, dressing, toilet use, and personal hygiene; and required supervision for eating. The following concerns were identified: a. Observation on 4/8/19 at 5:52 PM showed the resident was in the dining room for the evening meal. CNA #1 was seated across from the resident using her cell phone and not interacting with the resident. Interview with the CNA at that time revealed the resident required assistance back to his/her room and she was waiting for the resident to complete his/her meal. b. Observation on 4/8/19 at 8:04 AM showed the resident was in the dining room with his/her catheter bag hanging uncovered from the right side of his/her wheelchair. c. Observation on 4/8/19 at 10:58 AM showed the resident was in the therapy room with his/her catheter bag uncovered. There were 10 additional residents and staff present in the therapy room at that time. d. Observation on 4/8/19 at 12:16 PM showed the resident was in the dining room for the noon meal with his/her catheter bag uncovered. e. Interview on 4/10/19 at 9:11 AM with the DON revealed it was her expectation catheter bags be placed in a privacy bag to promote dignity. In addition, she stated it was the facility's policy that staff not use their personal cell phones during working hours, except for an emergency.",2020-09-01
2,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,584,D,1,1,TYBQ11,"> Based on observation and family and staff interview, the facility failed to implement measures to effectively eliminate odors in 1 of 37 sample resident rooms (#24) observed for environmental concerns. The findings were: During observation on 4/7/19 at 4:45 PM an odor was detected emanating from a room shared by resident #24 and his/her roommate. Inside the room the strong odor was a mixture of urine and neglected personal hygiene. The odor was present again on 4/8/19 and 4/9/19. Observation of the room every day from 4/7/19 to 4/11/19 showed a Caution Wet Floor sign was positioned in the hall near the entrance door. Interview on 4/8/19 at 2 PM with a visiting family member revealed s/he and other family members were concerned about the offensive odor emanating from the room. Interview on 4/9/19 at 10:55 AM with the special care director revealed one of the residents who resided in the room was confused and frequently urinated in inappropriate areas of the room and the roommate was noncompliant with scheduled baths/showers. She also stated the Caution Floor Wet sign was permanently posted outside the room due to the confused resident's behavior of voiding in inappropriate areas. At that time, the special care director stated she would have to talk with the housekeeping staff about doing something more than the usual room cleaning for this room.",2020-09-01
3,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,657,D,1,1,TYBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review, family and staff interview, and policy review, the facility failed to revise the care plan to reflect resident needs for 3 of 37 residents (#63, #71, #108) reviewed. The findings were: 1. Review of the 2/9/19 quarterly MDS assessment and the 3/1/19 significant change MDS assessment showed resident #63 wandered 4 to 6 days of the 7-day look-back period. The following concerns were identified: a. Observation on 4/8/19 at 9:25 AM showed the resident had a WanderGuard (device to alert staff of possible elopement) attached to his/her right ankle. b. Review of a nurse's note dated 3/22/19 revealed the resident was exit seeking and a WanderGuard and been placed. c. Review of the care plan, last revised 2/19/19, failed to show interventions to address the resident's wandering or the use of the WanderGuard. d. Interview on 4/11/19 at 11:18 AM with the DON confirmed the care plan did not address the resident's wandering or the use of the WanderGuard. 2. Review of the 3/5/19 quarterly MDS assessment showed resident #71 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Further review showed the resident required the extensive assistance of 2 staff for bed mobility, transfers, and toileting. The following concerns were identified: a. Observation on 4/7/19 at 5:44 PM showed the resident had a bruised area on the right side of his/her face. b. Interview on 4/8/19 at 10:27 AM with the resident's son revealed the resident had fallen twice since admission; the first time the resident sustained [REDACTED]. The son stated the resident was sleeping in the recliner and fell out. c. Review of a nurse progress note dated 4/2/19 showed the resident had been sleeping in the recliner and at 3:45 AM the resident was found on the floor in front of the recliner the resident sustained [REDACTED]. Additional review of the nurse progress note showed the resident was transferred to the hospital on [DATE] at 10 AM and returned during the evening. d. Interview with LPN #1 revealed the resident was kept safe by providing 1:1 care to the resident. e. Interview on 4/11/19 at 9:09 AM with CNA #3 revealed the resident slept in the recliner and the staff reclined the chair back because the resident was unable to. The CNA further stated the resident did not sleep in his/her bed and had not slept in the bed since admission. f. Interview on 4/11/19 at 2:27 PM with HSA #1 revealed when staff tried to lay the resident down in bed s/he immediately tried to crawl out. She stated staff transferred the resident to the recliner, provided a pillow and blanket and s/he fell asleep. She further stated when the resident needed something s/he yelled out. g. Review of the care plan showed 4-2-16 fall from recliner with laceration above right eyebrow .keep pillows on each side in recliner to increase comfort-anticipate and meet needs Interview on 4/10/19 at 10:35 AM with LPN #2 revealed she added the statement to the care plan on the evening of 4/9/19. She further stated staff were educated to add pillows while the resident was in the recliner, due to resident's size and dry elbows. Further review of the care plan failed to show planning related to the resident's preference to sleep in the recliner and attempts to crawl out of bed. h. Review of the Fall Evaluation and Management policy dated 3/18 showed .Reviews and updates the care plan with newly identified interventions as needed . 3. Review of the 3/8/19 admission MDS assessment showed resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 14/15 (cognitively intact). The following concerns were identified: a. Review of a physician communication form dated 3/24/19, from a RN at the facility, showed the resident had bilateral lower extremity [MEDICAL CONDITION] (BLE) and the resident had reported when s/he was at home that his/her legs were wrapped every day. The RN requested an order for [REDACTED]. b. Review of the resident's care plan last revised 3/14/19 showed the resident had a [DIAGNOSES REDACTED]. Further review of the interventions showed no evidence the use of the ACE wraps was addressed. c. Interview on 4/11/19 at 1:45 PM with the MDS coordinator revealed she was unaware of the addition to the resident's treatment plan and verified the care plan had not been revised.",2020-09-01
4,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,659,D,1,1,TYBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and staff interview, the facility failed to ensure services were provided by qualified persons for 1 random observation which affected resident #14. The findings were: Review of the 4/4/19 quarterly MDS assessment showed resident #14 had a BIMS score of 15/15 (cognitively intact) and had [DIAGNOSES REDACTED]. Further review showed the resident received oxygen therapy. The following concerns were identified: a. Observation on 4/8/19 at 10:35 AM showed CNA #4 and CNA #5 in the resident's room adjusting the oxygen concentrator flow regulator. The CNAs brought in 2 different 5 liter concentrators and attempted to adjust the oxygen flow to 5 liters on each one. CNA #5 stated to unit manager #2 the liter dose won't turn up past 3 liters. b. Interview with unit manager #2 on 4/8/19 at 11 AM revealed the resident had a history of [REDACTED]. c. Interview on 4/11/19 at 11:30 AM with the DON revealed the oxygen liter dose was a physician order [REDACTED].",2020-09-01
5,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,677,E,1,1,TYBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and resident and staff interview, the facility failed to provide services to maintain personal and/or oral hygiene to 15 of 37 sample residents (#5, #11, #24, #50, #51, #54, #67, #75, #80, #88, #91, #103, #108, #109, #112), reviewed. The findings were: 1. Review of the 2019 (MONTH) and (MONTH) Resident Functional Performance bathing documentation for resident #5 showed the resident received a shower on 3/7, and did not receive another shower until s/he received a bed bath on 4/3 (28 days). There was documentation the resident refused showers on 3/19 and 3/26. 2. Review of the 1/8/19 quarterly MDS assessment showed resident #11 had a BIMS score of 8/15 (moderately impaired cognition) and required the extensive assist of 1 for personal hygiene and bathing. The following concerns were identified: a. Observation on 4/8/19 at 4:46 PM showed the resident's teeth were coated with a white substance. Interview with the resident at that time revealed s/he did not brush his/her teeth. b. Review of the care plan revised on 7/23/18 showed the resident was at risk for dental health problems and interventions included monitor/document report PRN any s/sx of oral/dental problems needing attention. Further review of the care plan showed the resident required assistance with bathing/showering. c. Review of the (MONTH) 2019 Functional Performance Record showed the resident went from 3/2 to 3/13 without a bath or shower (11 days). Further review showed the resident went from 3/1 to 3/21 without oral care (20 days). d. Interview on 4/11/19 at 11:31 AM with the DON revealed she had educated staff about baths and resident refusals and confirmed the baths were not clearly documented. She further stated staff were educated on oral care and was not sure why residents were not receiving it. 3. Review of the 2/1/19 annual MDS assessment showed resident #24 had moderate cognitive impairment; required supervision with ambulation; required extensive assistance with dressing and was totally dependent on staff for bathing and showering. Review of the care plan, revised 12/27/18, showed s/he was at risk for ADL self-care performance deficit due to dementia, change in cognitive status, vision problems and incontinence. Review of the shower schedule showed the resident was scheduled to receive 2 showers/baths weekly. Review of the 3/1/19 to 4/8/19 Resident Functional Performance Record showed the resident did not receive a bath or shower from 3/9/19 to 3/16/19 (7 days). Further review showed no documented refusals. 4. Review of the 2/19/19 quarterly MDS assessment showed resident #50 required the physical assistance of one staff member for bathing. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation showed the resident had a shower on 3/19 and did not receive another until 3/29 (10 days). Further review showed no evidence the resident had refused a shower during that timeframe. 5. Review of the 2/19/19 quarterly MDS assessment showed resident #51 had severe cognitive impairment and required extensive assistance with bathing and personal hygiene care. Review of the care plan, revised 12/28/18, showed the resident had ADL self-care performance deficit due to dementia; and staff were directed to provide a sponge bath when the resident could not tolerate a full bath or shower. Review of the shower schedule showed the resident was scheduled to receive 2 showers/baths weekly. Review of the 3/1/19 to 4/8/19 Resident Functional Performance Record showed the resident did not receive a sponge bath or shower from 3/7/19 to 3/15/19 (8 days). Further review showed no documented refusals. 6. Review of the 2019 (MONTH) and (MONTH) Resident Functional Performance bathing documentation for resident # 54 showed the resident had a shower on 3/1 and did not receive another until 3/12 (11 days); a shower on 3/18 and did not receive another until 3/24 (6 days); and from 3/24 the resident did not receive a shower again until 4/11 (18 days). 7. Review of the 3/13/19 admission MDS assessment showed resident #67 was admitted to the facility on [DATE]; had a BIMS score of 15/15 (cognitively intact); and required the total assistance of two staff members for bed mobility and transfers, and the extensive assistance of one staff member for personal hygiene. The following concerns were identified: a. Interview on 4/8/19 at 11:30 AM with the resident revealed s/he was using mouthwash for oral care because no one had offered to assist him/her with brushing his/her teeth. In addition the resident stated s/he had not brushed his/her teeth since admission and my mouth feels horrible and my breath stinks. b. Review of the ADL care plan, initiated on 3/17/19, showed the resident required assistance with grooming/hygiene. c. Review of the dental care plan, initiated on 3/17/19, showed the resident was at risk for potential dental issues related to decreased/limited mobility. The resident was to remain free of infection, pain or bleeding in the oral cavity by review date. However, there were no interventions regarding routine oral care. d. Review of the CNA's Care Directive Form showed the resident had his/her own teeth and required extensive assistance with grooming. In addition, the CNAs were to encourage independence with upper body ADLs. e. Interview on 4/10/19 at 9:22 AM with the DON revealed she expected oral care to be offered after each meal and the resident assisted as needed. 8. Random observation of resident care on 4/7/19 at 7:32 PM showed CNA #6 transferred resident #75 to bed without providing oral care and left the room. Interview with the CNA at that time revealed the resident was in bed for the night. 9. Review of the 2019 (MONTH) Resident Functional Performance bathing documentation for resident #80 showed the resident went without a shower from admission on 3/8/19 until discharge on [DATE] (20 days). 10. Review of the 2/28/19 admission MDS assessment showed resident #88 required the physical assistance of one staff member for bathing. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation showed the resident had a shower on 3/16 and did not receive another until 3/26 (10 days). Further review showed no evidence the resident had refused a shower during that timeframe. 11. Review of the 2/19/19 admission MDS assessment showed resident #91 required the physical assistance of one staff member for bathing. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation showed the resident had a shower on 3/10 and did not receive another until 3/25 (15 days). Further review showed no evidence the resident had refused a shower during that timeframe. 12. Review of the 2019 February, March, and (MONTH) Resident Functional Performance bathing documentation for resident #103 showed the resident had a shower on 2/15 and did not receive another until 3/5 (17 days); received a shower on 3/7 and did not receive another until 3/18 (11 days). Interview with resident #103 on 4/7/19 at 5:12 PM revealed s/he was supposed to have received a shower that day, but did not. S/he stated the hot water must have went out. 13. Review of the 3/8/19 admission MDS assessment for resident #108 showed the resident was admitted on [DATE] and did not receive a bath during the 7-day look-back period. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation for the resident showed the resident had a shower on 3/10 and did not receive another until 3/25 (15 days). Further review showed no evidence the resident had refused a shower during that timeframe. 14. Review of the (MONTH) 2019 Resident Functional Performance bathing documentation for resident #109 showed the resident had a shower on 3/1 and did not receive another until 3/9 (8 days). Further review showed the resident's next shower was on 3/26 (17 days). There was no evidence the resident had refused a shower during the gaps between shower days. 15. Review of the 2019 (MONTH) and (MONTH) Resident Functional Performance bathing documentation for resident #112 showed the resident had a shower on 3/1 and did not receive another until 3/17 (16 days); and received a shower on 4/1 and did not receive another until 4/8 (7 days). 16. Interview on 4/10/19 at 12:41 PM with CNA #7 revealed she was the bath aide for the first floor. In addition, during the timeframe in (MONTH) when the showers were not being completed she had been pulled to work in other areas of the building and no one had showered the residents in her absence. 17. Interview with the DON on 4/10/19 at 3:25 PM revealed the facility's expectation was for staff to offer residents a shower or bed bath twice a week and document it. If a resident refused 3 times the staff were to notify the nurse. 18. Interview on 4/11/19 at 11:13 AM with the DON revealed she was aware of the gaps between showers and had implemented new shower schedules.",2020-09-01
6,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,684,E,1,1,TYBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review, and resident and staff interview, the facility failed to ensure anti-embolism hose were applied as ordered for 3 of 4 sample residents (#8, #52, #108) with bilateral lower extremity (BLE) [MEDICAL CONDITION] (swelling). The findings were: 1. Review of the 1/17/19 significant change MDS assessment showed resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review showed s/he had severe cognitive impairment and required extensive to total assistance with all ADLs. Review of the physician's orders [REDACTED]. The following concerns were identified: a. Observations on 4/7/19 from 4:45 PM to 8:40 PM, on 4/8/19 from 8:50 AM to 2:30 PM, and on 4/9/19 at 10:58 AM showed the resident did not wear anti-embolism hose. Further observation showed the resident's legs appeared [MEDICAL CONDITION]. b. Interview on 4/9/19 at 10:58 AM with the DON revealed the hose should have been applied because they usually were provided for the resident within 2 or 3 days of the order. She further stated she did not know why the resident did not have the anti-embolism hose. 2. Review of the 2/19/19 annual MDS assessment showed resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review showed s/he had severe cognitive impairment and required extensive assistance with dressing. Review of the physician's orders [REDACTED]. The following concerns were identified: a. Observations on 4/7/19 from 4:45 PM to 8:40 PM, on 4/08/19 from 8:50 AM to 2:30 PM, and on 4/9/19 at 10:58 AM showed the resident sat in his/her wheelchair and did not wear anti-embolism hose. During the observations the resident's lower legs appeared [MEDICAL CONDITION]. b. Review of (MONTH) 2019 TAR showed the nurses documented the hose were removed at bedtime on 4/3, 4/6, 4/7, 4/8, and 4/9. Further review showed no evidence the anti-embolism hose were applied on the on 4/3, 4/6, 4/7 and 4/9. c. Interview on 4/10/19 at 3:50 PM with the DON revealed the staff should not document they were applying and removing the hose if they were not. She further stated staff needed to determine whether the resident did or did not need the hose, because if the resident needed them they should be applied as ordered. 3. Review of the 3/8/19 admission MDS assessment showed resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a BIMS score of 14/15 (cognitively intact). The following concerns were identified: a. Observation of the resident on 4/7/19 at 5:22 PM showed the resident was lying in bed and the resident's lower legs appeared [MEDICAL CONDITION]. The resident was not wearing compression stockings nor were they wrapped with ACE wraps (bandages used to control swelling). b. Observation of the resident on 4/8/19 at 2:24 PM showed the resident was sitting in his/her recliner. The resident's legs appeared swollen and s/he was not wearing compression stockings nor were the resident's legs wrapped with ACE wraps. c. Review of a physician communication form dated 3/24/19 showed the resident had bilateral lower extremity [MEDICAL CONDITION] (BLE) and the resident had reported when s/he was at home his/her legs were wrapped every day. The facility requested an order for [REDACTED]. d. Observation of the resident on 4/10/19 at 12:12 PM showed the resident's legs were wrapped with ACE wraps. Interview with the resident at that time revealed s/he had to belly-ache about the wraps and then staff had wrapped his/her legs yesterday afternoon and again this morning. e. Review of the (MONTH) 2019 TAR showed documentation the ACE wraps had been donned and doffed, as ordered, on 3/30 and 3/31. Review of the (MONTH) 2019 TAR showed documentation the ACE wraps were donned and doffed, as ordered, from 4/1 AM through 4/10 AM. f. Review of an (MONTH) 2019 clarification TAR showed the ACE wraps were not applied during the month of (MONTH) until the morning of 4/10/19. g. Interview with unit manager #1 on 4/10/19 at 12:17 PM revealed the resident's [MEDICAL CONDITION] was a chronic problem and was worse when s/he was up in a chair all day. In addition, she stated the resident was on medication for the [MEDICAL CONDITION], had orders for ACE wraps, and was encouraged to elevate his/her feet when sitting. h. Interview with the DON on 4/11/19 at 11:18 AM revealed she was unsure why there was a discrepancy between the TAR and surveyor observations. Further, she stated a new nurse was orienting on the first floor and she had attempted to contact the nurse for clarification. Interview with the DON on 4/11/19 at 4:28 PM revealed the orientating nurse had been contacted and verified the ACE wraps had not been applied as ordered.",2020-09-01
7,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,686,D,1,1,TYBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review and staff interview, the facility failed to ensure 1 of 12 sample residents with pressure ulcers (#8) consistently received treatments in accordance with physician orders. The findings were: Review of the 1/17/19 significant change MDS assessment showed resident #8 had severe cognitive impairment, required extensive or total assistance with all ADLs and was at risk for developing pressure ulcers. Further review showed the resident was always incontinent of bladder and bowel and did not have pressure ulcers. Review of the care plan interventions, revised 8/29/18, showed staff were directed to check the resident frequently, assist with toileting as needed, and complete weekly and as needed skin assessments. The following concerns were identified: a. Observation on 4/7/19 from 4:45 PM to 8:40 PM (almost 4 hours) showed the resident sat in his/her wheelchair in the dining/common area. During the continuous observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care. Observation at 8:40 PM showed CNA #6 and CNA #8 transferred the resident to bed, removed his/her urine- and feces-soiled disposable brief, then provided incontinence care. At that time, an uncovered pressure ulcer on the resident's coccyx area was observed. This area was moist, pink and approximately dime-sized. b. Continuous observation on 4/8/19 from 8:50 AM to 2:30 PM (5 hours and 50 minutes) showed the resident sat in his/her wheelchair in the dining/common area. During the observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care until the resident was transferred to bed at 2:30 PM. At that time CNA #2 and CNA #9 removed the urine-soaked disposable brief and exposed the uncovered pressure ulcer on the resident's coccyx area. c. Review of the wound care treatments showed the current treatment was to cleanse the area with wound cleanser, pat dry, apply skin prep, cover with [MEDICATION NAME] and change every 3 days and as needed. Further review showed this treatment was ordered on [DATE] for the area assessed as an unstageable pressure injury. d. Review of the (MONTH) 2019 to (MONTH) 2019 nursing daily progress notes showed the area remained unchanged. e. Interview on 4/9/18 at 11:21 AM with the wound care nurse revealed the pressure ulcer should have been covered with the [MEDICATION NAME] dressing. She also stated the facility had a system for reporting and documenting changes in wounds and pressure ulcers, but did not have a system for ensuring the nurses provided the treatments consistently as ordered.",2020-09-01
8,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,690,E,1,1,TYBQ11,"> Based on observation, medical record review, and staff interviews, the facility failed to ensure toileting and incontinence care were provided as needed for 4 of 6 sample residents (#8, #40, #52, #110) reviewed for incontinence. The findings were: 1. Review of the 1/17/19 significant change MDS assessment showed resident #8 had severe cognitive impairment and required extensive or total assistance with all ADLs including toileting and personal hygiene care. Further review showed the resident was always incontinent of bladder and bowel. Review of the care plan interventions, revised 8/29/18, showed staff were directed to check the resident frequently and assist with toileting as needed. The following concerns were identified: a. Observation on 4/7/19 from 4:45 PM to 8:40 PM (almost 4 hours) showed the resident sat in his/her wheelchair in the dining/common area. During the continuous observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care. Observation at 8:40 PM showed CNA #6 and CNA #8 transferred the resident to bed, removed his/her urine- and feces-soiled disposable brief, then provided incontinence care. At that time, an uncovered pressure ulcer on the resident's coccyx area was observed. b. Continuous observation on 4/8/19 from 8:50 AM to 2:30 PM (5 hours and 50 minutes) showed the resident sat in his/her wheelchair in the dining/common area. During the observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care until the resident was transferred to bed at 2:30 PM. At that time CNA #2 and CNA #9 removed the urine-soaked disposable brief and exposed the uncovered pressure ulcer on the resident's coccyx area. 2. Review of the 3/21/19 quarterly MDS assessment showed resident #110 had severe cognitive impairment and required extensive or total assistance with all ADLs including toileting and personal hygiene care. Further review showed the resident was always incontinent of bladder and bowel. Review of the care plan interventions for ADL self-care performance deficit, revised 2/1/19 showed the resident required assistance with toilet use and grooming/hygiene. The following concerns were identified: a. Observation on 4/7/19 from 4:45 PM to 9:45 PM, showed the resident rested in bed. During the observation staff fed the resident and periodically offered fluids. However, during the 5 hour observation, staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care until 9:45 PM. At that time, incontinence care provided by CNA #6 and CNA #8 included removing the disposal brief worn by the resident and changing the urine-soiled bed linen. b. Observation on 4/8/19 from 8:50 AM to 1 PM (over 4 hours) showed the resident rested in bed without being provided incontinence care or toileting assistance. At 1 PM, continuous observation showed CNA #2 and CNA #9 removed the urine-soiled disposable brief and bed linen when they provided incontinence care for the resident. 3. Review of the 2/19/19 annual MDS assessment showed resident #52 had a BIMS score of 5 (indicating cognitive impairment); required extensive assistance with toileting and personal hygiene care; and was always incontinent of bowel and bladder. Review of the care plan, revised 1/5/19, showed the resident had ADL self-care performance deficit due to weakness and required assistance with personal hygiene care and toileting. Observation on 4/7/19 from 4:45 PM to 9:30 PM (over 5 hours) showed the resident sat in his/her wheelchair in the dining/common area. During the continuous observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care. Observation at 9:30 PM showed CNA #6 and the DON transferred the resident to bed, removed his/her urine- and feces-soiled disposable brief, and provided incontinence care. 4. Review of the 2/14/19 quarterly MDS assessment showed resident #40 had severe cognitive impairment and required limited assistance with transfers, toileting, and personal hygiene care. Further review showed the resident had frequent urine incontinence and occasional bowel incontinence. Review of the care plan interventions for bladder incontinence due to dementia and decreased mobility, revised 2/25/19, showed staff were directed to clean peri-area with each incontinence episode and ensure the resident had an unobstructed path to the bathroom. Further review showed instructions to monitor for signs and symptoms of a urinary tract infection. Observation on 4/8/19 at 8:50 AM showed the resident was sitting on the bedside. At that time wet urine-stained areas on the groin and buttocks areas were observed on his/her pajamas. Continuous observation showed the resident wore the wet pajamas until 10:34 AM. At that time CNA #2 and CNA #9 assisted the resident to the bathroom and removed his/her wet brief and pajamas. 5. Interview on 4/8/19 at 2:30 PM with CNA #2 and CNA #9 revealed they tried to check and toilet residents every two hours, but they were unable to get to all the residents in a prompt manner when there was an insufficient number of staff on duty. Interview on 4/9/19 at 10:55 AM with the Special Care Director revealed she routinely helped the CNAs, but she was not a nurse and could not assist with toileting or personal care needs.",2020-09-01
9,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,725,F,1,1,TYBQ11,"> Based on observation, resident and family interviews, staff interview, review of the facility assessment, and review of facility staffing documentation, the facility failed to ensure an adequate number of staff was provided to meet resident needs. The census was 118. The findings were: Review of the facility assessment staffing plan showed the total number of nurses and CNAs required to meet basic staffing needs was 10 licensed nurses and 18 CNAs. Non-licensed and non-certified staff were not separately accounted for. The following concerns were identified: 1. Review of the facility staffing sheets from 2/1/19 through 2/28/19 revealed the facility failed to have the minimum required nurse staffing on 22 of the 28 days (78%). 2. Review of the facility staffing sheets from 3/1/19 through 3/31/19 revealed the facility failed to have the minimum required nurse staffing on 28 of the 31 days (90%). 3. Review of the facility staffing sheets from 4/1/19 through 4/7/19 revealed the facility failed to have the minimum required nurse staffing on 5 of the 7 days (71%). 4. Review of the facility staffing sheets from 2/1/19 through 4/7/19 revealed the facility failed to have the minimum required CNA staffing on all days reviewed (100%). 5. Interview on 4/8/19 at 3:30 PM with 7 residents revealed they had concerns about lengthy wait times for call lights to be answered, and lack of showers. 6. Interview on 4/8/19 at 2:26 PM with a family member of resident #77 revealed there was no system for getting residents up and the only time the resident's face was washed was during a bath. She further stated there was only 1 CNA for 19 residents. 7. Interview on 4/10/19 at 2:11 PM with a family member of resident #15 revealed the resident did not receive a bath during the first two weeks after s/he was admitted . The family member stated s/he felt the staff was overwhelmed with care, especially in the evening, when they were getting residents to bed and other residents were unattended in the dining room. The spouse also stated the resident's room had not been cleaned in 3 days. 8. Interviews with facility staff revealed the following: a. Interview on 4/9/19 at 4:07 PM with LPN #1 revealed only 2 CNAs provided care for each hall and no bath aide. She stated baths got missed , fluids were not passed to residents, and residents were not assisted with meals. She stated she did not understand the staffing related to the numbers, and why resident acuity did not factor into staffing. She added there were residents who required total care, were a total lift for transfers, and those residents took additional time and extra staff. She further stated there were nights when only one CNA worked in the secure unit. b. Interview on 4/9/19 at 4:46 PM with HSA #1 revealed she was scheduled with a CNA in the secure unit, but when the CNA took a break she was left alone with the residents. She stated if an unsafe situation occurred she pressed the HELP button, which is located by the nurse's station by the clock. She stated she had been alone in a room with an upset resident, and she had to wait for the resident to calm down, because she had no way to get help. c. Interview on 4/10/19 at 4:08 PM with HSA #1 revealed she was vomiting and tried to call in sick and the facility told her she had to work. She added she talked to the DON who told her to find her own coverage if she was sick. The HSA stated she did not have any of the other staff phone numbers at home. d. Interview on 4/8/19 at 2:30 PM with CNA #2 and CNA #9 revealed they tried to check and toilet residents every two hours, but they were unable to get to all the residents in a prompt manner when there was an insufficient number of staff on duty. e. Interview on 4/11/19 at 8:28 AM with the infection control nurse revealed she had been working on the floor and had not been able to devote time to all of the infection control nurse duties. She stated she started the surveillance and periodic audit system for monitoring dressing changes, ADLs, and hand hygiene, but the most current audits were completed in (MONTH) (YEAR). She stated she started developing the antibiotic stewardship program, but it had not been fully implemented. f. Interview on 4/10/19 at 12:41 PM with CNA #7 revealed she was the bath aide for the first floor. During the timeframe in (MONTH) when the showers were not being done she had been pulled to work in other areas of the building and no one had showered the residents in her absence. 9. Staff inability to respond promptly to residents's toileting and incontinence needs was noted during the following observations: a. Observation on 4/7/19 from 4:45 PM to 8:40 PM (almost 4 hours) showed resident #8 sat in his/her wheelchair in the dining/common area. During the continuous observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care until 8:40 PM when CNA #6 and CNA #8 provided urine and fecal incontinence care. Continuous observation on 4/8/19 from 8:50 AM to 2:30 PM (5 hours and 50 minutes) showed the resident sat in his/her wheelchair in the dining/common area. During the observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care until 2:30 PM. b. Observation on 4/7/19 from 4:45 PM to 9:45 PM, showed resident #110 rested in bed. During the observation staff fed the resident and periodically offered fluids. However, during the 5 hour observation, staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care until 9:45 PM. Observation on 04/08/19 from 8:50 AM to 1 PM (over 4 hours) showed the resident rested in bed without being provided incontinence care or toileting assistance. At 1 PM, continuous observation showed CNA #2 and CNA #9 removed the urine-soiled disposable brief and bed linen when they provided incontinence care for the resident. c. Observation on 4/7/19 From 4:45 PM to 9:30 PM (over 5 hours) showed resident #52 sat in his/her wheelchair in the dining/common area. During the continuous observation staff did not offer or provide toileting assistance, check for incontinence, or provide incontinence care. Observation at 9:30 PM showed CNA #6 and the DON transferred the resident to bed, removed his/her urine- and feces-soiled disposable brief, and provided incontinence care. d. Observation on 4/8/19 at 8:50 AM showed resident #40 was sitting on the bedside. At that time wet urine-stained areas on the groin and buttocks areas were observed on his/her pajamas. Continuous observation showed the resident wore the wet pajamas until 10:34 AM. At that time CNA #2 and CNA #9 assisted the resident to the bathroom and removed his/her wet brief and pajamas. 10. Please refer to F677 for details of concerns regarding resident showers and oral hygiene. 11. Interview with the staffing coordinator on 4/11/19 at 12:21 PM revealed the PPD was determined by the facility's corporation and the NHA and they gave her the number. She stated HSA (non-licensed, non-certified staff members) hours were figured in with the nursing hours. She confirmed the facility was short-staffed, and the past couple months had been terrible because of illness. She also stated the management staff helped on the resident units. 8. Interview on 4/11/19 at 2:15 PM with the NHA confirmed HSA hours were counted with nursing hours. She also stated when staffing was critical all managers were pulled to work on the resident units. She stated they have had turnover due to holding staff accountable to the attendance policy. She stated the facility currently had 9 CNA position openings and 4 full-time nursing position openings. She stated they monitored potential admissions and did not accept residents with higher acuity.",2020-09-01
10,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,755,D,1,1,TYBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, medical record review, and staff interview, the facility failed to provide medications to meet resident needs for 1 of 37 sample residents (#108). The findings were: 1. Review of the [DATE] admission MDS assessment showed resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The following concerns were identified: a. Review of a nurse's note dated [DATE] and timed 3:15 AM showed the resident was found unresponsive with a blood glucose level of 58 mg/dl. The physician was notified; one dose of [MEDICATION NAME] was administered, and the resident regained consciousness. b. Review of a nurse's note dated [DATE] and timed 5:45 PM showed the resident was lethargic at 5 PM and had a blood glucose level of 35 mg/dl. [MEDICATION NAME] was administered. c. Review of a nurse's note dated [DATE] and timed 6:10 PM showed the resident was unresponsive with a blood sugar of 44 mg/dl. The physician was called and one dose of [MEDICATION NAME] was administered. After the [MEDICATION NAME] was administered the resident was still unresponsive and his/her blood glucose level was 53 mg/dl. The physician was notified and an additional dose of [MEDICATION NAME] was ordered. However, no [MEDICATION NAME] was available and the resident was sent to the emergency department. d. Observation of the 2nd floor medication storage room on [DATE] at 10:47 AM showed 1 expired emergency kit dated ,[DATE]. Interview at that time with the LPN #3 confirmed the medication was expired, and was available for resident use. She revealed it was the [MEDICATION NAME] in the kit that had expired. 2. Interview on [DATE] at 10:42 AM with unit manager #1 revealed the facility had identified a problem with the nurses not ordering medications properly. She further stated the error was in the process of being corrected. 3. Interview on [DATE] at 11:13 AM with the DON revealed she had recognized there was a problem with the availability of the [MEDICATION NAME]. She had obtained new physician orders [REDACTED]. In addition some of the new nurses, including herself, had not been granted access to the Cubex, but this had been corrected. 4. Interview with DON on [DATE] at 11:39 AM revealed it was the expectation of the facility for nursing staff to get the medication from the Cubex, if needed, or call the backup pharmacy to get the medication until the order arrived.",2020-09-01
11,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,761,D,1,1,TYBQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure medications were labeled in accordance with professional principles in 1 of 3 medication carts (1st floor medication cart). The findings were: Observation on 4/10/19 at 11 AM of the 1st floor medication cart showed one [MEDICATION NAME] container without a pharmacy label on it. The container showed white residue where a label appeared to have been. Interview at that time with unit manager #1 revealed the [MEDICATION NAME] belonged to a resident that had been discharged , and confirmed it was unlabeled.",2020-09-01
12,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,812,E,1,1,TYBQ11,"> Based on observation, staff interview, manufacturer's instructions, and review of the (YEAR) food code, the facility failed to ensure proper dating and labeling of pre-thickened beverage products in 4 of 5 food storage areas (kitchen, first floor, third floor, Reflections unit). The findings were: 1. Observation on 4/7/19 at 4:35 PM of the Victory refrigerator in the main kitchen and again with the certified dietary manager on 4/9/19 at 4:05 PM showed 7 open cartons of pre-thickened beverages and 2 open containers of thickened dairy drink were not labeled with an open date. 2. Observation on 4/7/19 at 6:22 PM of the refrigerator located on the first floor showed 2 open cartons of pre-thickened liquid containers and 1 open container of thickened dairy drink were not labeled with an open date. 3. Observation on 4/10/19 at 4:55 PM of the refrigerator located in the Reflections unit showed 2 open cartons of thickened dairy drink were not labeled with an open date. 4. Observation on 4/10/19 at 5 PM of the refrigerator located on the third floor showed 1 open carton of thickened dairy drink was not labeled with an open date. 5. Interview on 4/9/19 at 4:05 PM with the certified dietary manager confirmed the open cartons of thickened beverages were not labeled with an open date. 6. Review of the product label of the pre-thickened beverages showed the product was good for 7 days after opening if refrigerated. In addition, review of the manufacturer's instructions for the thickened dairy drink showed once opened, recap, refrigerate and use within 48 hours. 7. According to Food Code (YEAR), U.S. Public Health Service: 3-501.17 (A) .refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days.",2020-09-01
13,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,880,F,1,1,TYBQ11,"> Based on observation, and staff interview, the facility failed to ensure effective infection control practices were followed during for 1 random observation. The findings were: Observation on 4/10/19 at 2:32 PM showed the wound nurse performed a dressing change on resident #103's pressure injury. The following concerns were identified: a. Observation showed after the nurse finished the removal of the old dressing and cleaned her hands to do the clean dressing. The nurse then pulled clean gloves out of her pocket and donned them. b. The wound nurse picked up a packet of skin prep off of the over-bed table and then reached into her pocket and retrieved a pair of scissors to cut the packet. She then put the scissors down on the table. c. The wound nurse dropped a skin prep towelette on floor; picked it up and threw it in the trash bag. She proceeded, with the same gloves, to pack the open wound with wet gauze. d. The wound nurse then picked up the scissors to cut the gauze and set them back down on the table. e. While holding the gauze in place with the same gloves, the nurse retrieved a flashlight from her pocket to look at the skin. The nurse put the flashlight back in her pocket and finished dressing the wound. Interview at that time with the nurse revealed it did not occur to her the pocket was not clean. f. Interview with the DON on 4/10/19 at 3:25 PM revealed it was the facility's expectation for wound care to be completed in a clean procedure.",2020-09-01
14,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-04-11,881,E,1,1,TYBQ11,"> Based on review of the antibiotic stewardship policy and procedure and staff interview, the facility failed to develop and implement an active and effective antibiotic stewardship program. The census was 118. The findings were: Interview on 4/11/19 at 8:28 AM with the infection preventionist revealed she had been working on the floor and had not been able to devote time to all of the infection control duties. She stated she started the surveillance and periodic audit system for monitoring wound dressing changes, ADLs, and hand hygiene, but the most current audits were completed in (MONTH) (YEAR). She stated she started developing the antibiotic stewardship program, but it had not been fully implemented. She also confirmed the program did not include active participation from prescribing practitioners and pharmacist. Review of the antibiotic stewardship program forms, documentation, and monitoring records showed an effective system for tracking and identifying appropriate antibiotics and reviewing laboratory sensitivity reports. However, the infection control nurse was unable to provide evidence the following sections of the Antibiotic Stewardship Program policy and procedure, published (MONTH) (YEAR), had been operationalized: a. Protocols that identify what infection assessment tools or management algorithms to be used for one or more infections. b. A process for a periodic review of antibiotic use by prescribing practitioners: c. A system for the provision of feedback reports on antibiotic use, antibiotic resistance patterns based on laboratory data, and prescribing practices for the prescribing practitioner.",2020-09-01
15,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-08-21,760,D,1,0,OB2411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, medication error report review, staff interview, and quality assurance information review, the facility failed to ensure residents were free of significant medication errors for 2 of 11 sample residents (#1, #3) reviewed for medication regimen. Corrective measures were implemented by the facility prior to the survey and substantial compliance was determined to be achieved on 7/17/19. The findings were: 1. Review of the 6/27/19 admission orders [REDACTED]. The resident also had an order for [REDACTED]. Review of the 5/22/19 admission orders [REDACTED]. The following concerns were identified: a. Review of the (MONTH) 2019 MAR (medication administration record) showed the resident did not receive scheduled [MEDICATION NAME] for the 8 AM dose on 7/4/19, 7/5/19, and 7/6/19. In addition, the resident did not receive the scheduled [MEDICATION NAME] for the 8 PM dose on 7/1/19, 7/3/19, 7/5/19, and 7/6/19. The review showed no documented explanation for the omitted medication. Review of the corresponding medication error report dated 7/8/19 and timed 7:36 AM showed Upon review of MAR and MD orders = noted a total of 7 doses of [MEDICATION NAME] missed since 7/1/19. b. Review of an order communication from the nurse practitioner on 7/6/19 at 4:21 PM showed Is (the resident) still on [MEDICATION NAME]? Increase [MEDICATION NAME] to 7.5 mg tonight and Tuesday, recheck next Saturday. Review of an interdisciplinary progress note dated 7/7/19 and timed 6AM-6PM showed Clarification order written for [MEDICATION NAME] order. Spoke with (nurse practitioner). Review of the (MONTH) 2019 MAR showed the order to increase the resident's [MEDICATION NAME] to 7.5 mg was not started until 7/7/19 at 4 PM, 23 hours and 39 minutes after the order was written. Review of the corresponding medication error report dated 7/7/19 timed 2:30 PM showed When going thru faxes on the desk found orders that hadn't been taken off regarding new [MEDICATION NAME] orders from pt/inr results from 7/5/19. This nurse also found [MEDICATION NAME] had not been given. This nurse called on call relayed what I had found and obtained new orders and carried them out. c. Review of the 6/27/19 admission orders [REDACTED]. Review of a 7/9/19 interdisciplinary progress note timed 6 AM-6 PM revealed the nurse discovered an order for [REDACTED]. Review of a medication error report dated 7/9/19 and timed at 4:35 PM showed the nurse discovered an order dated 7/5/19 to increase the resident's [MEDICATION NAME] to 10 mg QID. Review of the (MONTH) 2019 MAR showed the facility failed to increase the [MEDICATION NAME] to 10 mg QID until 7/9/19 at 12 AM. d. Interview with the administrator and the director of nursing (DON) on 8/20/19 at 10:40 AM confirmed the facility failed to administer all doses of [MEDICATION NAME] as ordered, and failed to follow the nurse practitioner's order to increase the resident's [MEDICATION NAME] in a timely manner. In addition, they confirmed the resident's [MEDICATION NAME] order was not revised to reflect the increase in dosage in a timely manner. 2. Review of a fax from a nurse practitioner dated 6/13/19 and signed at 11:48 AM for resident #3 showed [MEDICATION NAME] (antibiotic) 1 gm for two doses was ordered. The following concerns were identified: a. Review of an interdisciplinary progress note dated 6/19/19 and signed at 11:20 AM showed Order clarified and received to give [MEDICATION NAME] 1 gm IM (intramuscular injection) times 2 doses. First dose given today for UTI (urinary tract infection) with no adverse reactions . Review of the (MONTH) 2019 MAR showed the [MEDICATION NAME] was administered on 6/19/19 and 6/20/19. b. Interview with the administrator and DON on 8/20/19 at 10:40 AM confirmed the facility failed to administer the resident's [MEDICATION NAME] in a timely manner. 3. Interview with the administrator and DON on 8/20/19 at 10:40 AM confirmed the facility had identified issues with the medication system. On 7/15/19 the facility addressed the issue with a Quality Assurance Performance Improvement (QAPI) Action Plan. The actions taken were as follows: a. Review of the 7/15/19 QAPI Action Plan to address medication errors showed transcription of medication from fax orders to telephone orders to the MAR/treatment administration record (TAR) was identified as the main issue. The plan identified specific staff members as having issues with orders, and the DON would address these issues with specific staff members, and also provide general staff education. The DON and the unit managers, along with other staff members designated by the DON, would be responsible for conducting audits. b. Review of the 7/17/19 Mandatory Nurses Meeting documentation showed nurses were educated on issues regarding medication errors and delay of transcription of orders. Nineteen nurses signed the attendance form. c. Review of the completed Medication Errors Audit forms showed a variety of nurses participated in the audits and all units were included. The audit dates were from 7/17/19 to 8/22/19. The 3 categories on the form included, Medication orders include dosage, route, time, and diagnosis, Medication transcribed to MAR/TAR, and Medication signed as given on the MAR/TAR. At the top of the forms the requirement was, 10 residents 3 times per week. 4. Review of the medical record for 11 sample residents showed no medication issues were identified after the 7/17/19 education was provided to nurses and the audit process began.",2020-09-01
16,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,167,E,1,1,GX9L11,"> Based on observation and staff interview, the facility failed to protect confidential identifying information in regard to resident names for 3 of 3 years reviewed (2014, (YEAR), (YEAR)) in the survey binder which was available for public viewing. The findings were: 1. Observation on 10/2/17 at 9:35 PM of the facility survey activity binder located near the main entrance showed the binder contained the confidential for facility use only resident sample list which listed resident names and corresponding identification numbers. The following concerns were identified: a. Review of the 4/23/14 survey showed the confidential resident sample list contained 30 resident names and identifying numbers. b. Review of the 8/1/14 survey showed the confidential resident sample list contained 45 resident names and identifying numbers. c. Review of the 10/17/14 survey showed the confidential resident sample list contained 25 resident names and identifying numbers. d. Review of the 3/19/15 survey showed the confidential resident sample list contained 11 resident names and identifying numbers. e. Review of the 2/5/16 survey showed the confidential resident sample list contained 14 resident names and identifying numbers. f. Review of the 11/7/16 survey showed the confidential resident sample list contained 13 resident names and identifying numbers. g. Review of the 11/10/16 survey showed the confidential resident sample list contained 4 resident names and identifying numbers. h. Review of the 12/8/16 survey showed the confidential resident sample list contained 48 resident names and identifying numbers. 2. Interview on 10/2/17 at 9:45 PM with the DON confirmed the presence of these documents and at that time the DON removed them from the binder.",2020-09-01
17,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,208,B,1,1,GX9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the facility's admission agreement and staff interview, the facility failed to ensure admission agreements did not request or require residents to waive potential facility liability for losses of personal property for 5 of 6 sample residents (#3, #14, #47, #65, #94) admitted after 11/28/16. The findings were: 1. Review on 10/4/17 at 10 AM of the facility's admission agreement, under section 11: Elections and Designations, last published 3/29/16 showed section 11.7 Laundry Services. The Center provides residents with laundry services .The Resident Group understands that the Center may lose or damage the Resident's clothing and the Resident Group agrees that the Center is not responsible for such loss or damage, except as required by law. Further review showed the resident or resident representative was asked to initial whether to Authorizes the Center to clean and mark with the Resident's name the Resident's laundry. The Center will not be responsible for lost or damaged laundry, except as required by law . or Do not authorize the Center to clean the Resident's laundry . The following concerns were identified: a. Review of resident #3's 7/6/17 quarterly MDS assessment showed the resident was admitted to the facility on [DATE]. Review of section 11.7 of the resident's admission agreement showed the resident initialed the section which authorized the facility to provide laundry services. b. Review of resident #14's 9/26/17 quarterly MDS assessment showed the resident was admitted to the facility on [DATE]. Review of section 11.7 of the resident's admission agreement showed the resident initialed the section which authorized the facility to provide laundry services. c. Review of the resident #47's 9/6/17 quarterly MDS assessment showed the resident was admitted to the facility on [DATE]. Review of section 11.7 of the resident's admission agreement showed the resident initialed the section which authorized the facility to provide laundry services. d. Review of resident #65's 8/18/17 quarterly MDS assessment showed the resident was admitted to the facility on [DATE]. Review of section 11.7 of the resident's admission agreement showed the resident's representative initialed the section which authorized the facility to provide laundry services. e. Review of resident #94's 8/31/17 annual MDS assessment showed the resident was admitted to the facility on [DATE]. Review of section 11.7 of the resident's admission agreement showed the resident's representative initialed the section which authorized the facility to provide laundry services. 2. Interview on 10/4/17 at 10:10 AM with the admissions coordinator verified she used the admission agreement when admitting a new resident, however, she was unable to explain what the section that stated The Center will not be responsible for lost or damaged laundry, except as required by law meant.",2020-09-01
18,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,225,D,0,1,GX9L11,"Based on employee file review and staff interview, the facility failed to ensure pre-hire screening was completed for 2 of 2 employees (CNA #1, CNA #2). The findings were: 1. Review of the employee file for CNA #2 showed a 8/30/17 hire and start date. Further review showed no documentation to determine if the CNA registry was checked from hire to the survey timeframe of 10/1/17 to 10/5/17. 2. Review of the employee file for CNA #1 showed a 8/16/17 hire and start date. Further review showed no documentation to determine if the CNA registry was checked from hire to the survey timeframe of 10/1/17 to 10/5/17. 3. Interview with the administrator on 10/5/17 at 10 AM revealed it was her expectation for staff to check the CNA registry prior to hiring CNAs, and confirmed the facility failed to document this process was completed for CNAs #1 and #2.",2020-09-01
19,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,244,E,1,1,GX9L11,"> Based on observation, family and staff interview, review of policy and procedures, and grievance log, the facility failed to effectively act on grievances for 4 of 4 months reviewed (June, July, August, (MONTH) of (YEAR)) to improve handling of resident's personal laundry. The findings were: Observation of the laundry room on 10/4/17 at 10:51 AM revealed there was a portable laundry rack in the laundry room which contained clothing whose ownership was not identifiable due to not being labeled or the labeling was too faded. Interview at that that time with facility laundry manager #1 revealed they let the cart fill up then every couple of months the clothing rack was brought to the resident floors to see if the clothing could be identified by staff, residents or family members. Clothing not identified was discarded. The laundry room had a heat press to affix permanent labels to clothing. Staff indicated that this was used when nurses sent laundry that specifically needed a label affixed, such as dark clothing where markers would not show. Further,the laundry manager stated there were markers specifically made to withstand high heat up to 500 degrees, however, these were not commonly used by the nurses. He confirmed the regular sharpie markers used by staff to mark clothing was not ideal and lasted only 3-4 months. Review of grievance logs for (MONTH) (YEAR) through (MONTH) (YEAR) showed complaints laundry was not returned within 72 hours. These complaints included 5 of 12 laundry grievances in June, 12 of 19 laundry grievances in July, 13 of 22 laundry grievances in (MONTH) (YEAR), and 10 of 22 laundry grievances in (MONTH) (YEAR). Two instances occurred in (MONTH) and (MONTH) (YEAR), where items were not located and reimbursement was offered. Interview with a family member on 10/4/17 at 11:04 AM revealed she was frustrated with the facility's laundry service. S/he revealed s/he ironed on identification labels which had been lost in the laundry. Interview on 10/4/17 at 10:55 AM with the social services staff revealed the facility's standard turn around time for clothing being laundered was 72 hours. She stated the facility has attempted to educate residents about the turn around time to lessen the amount of grievances. Further, she confirmed when residents were admitted to the facility, nurses use a standard Sharpie marker to mark resident's clothing. Interview on 10/4/17 at 11:27 AM with RN #2 revealed nurses marked all clothing and filled out an inventory sheet of personal items when residents were admitted . She stated nurses used a regular old sharpie to mark the clothing, unless it was dark clothing, in which case a label was affixed, after asking the resident or family it it was OK to be done. She stated most everybody just stops and lets you know if new clothing was brought into the facility. Interview on 10/4/17 at 1:29 PM with the administrator revealed the facility had provided education to residents regarding the facility policy of a 72 hour turn around time for laundry. She stated the facility called family to bring in more clothes when it was noticed a resident didn't have enough of a supply of clothing. She confirmed that the facility holds a shopping party every couple of months where the rack of unidentified clothing was brought to the resident floors to see if the clothing could be identified by staff, residents or family members. Review of policy and procedure for processing resident personal clothing showed All clothing for residents must be labeled in a manner that is both practical and respects the dignity of the resident,. A small, permanent tag or label with the resident's name, placed in an inconspicuous place on each article of clothing, is key. It further stated Follow-up is needed to ensure that any clothing brought in by families for holidays or birthdays is also labeled properly before going to the resident's unit. Additionally, assigned staff needs to remember to check for lost labels or faded writing on a regular basis.",2020-09-01
20,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,253,E,1,1,GX9L11,"> Based on observation and staff interview, the facility failed to maintain a clean and sanitary environment on 3 of 3 floors (1st floor, 2nd floor, 3rd floor) and failed to maintain one randomly observed resident's wheelchair (#35) in a clean manner. The findings were: 1. Observation on 10/3/17 at 10:02 AM showed the horizontal molding at a 12 inch height in the hallway of the third floor was visibly dusty, this was noted near rooms 302, 314, 316, and 319. Observation at 10:41 AM showed the horizontal molding at a 12 inch height in the hallway of the second floor was visibly dusty, near rooms 224, 225, 226, and 227. Further observation at 11:18 AM showed the horizontal molding at a 12 inch height in the hallway of the first floor was visibly dusty, near rooms 113 and 114. 2. Observation on 10/1/17 at 4:38 PM showed resident #35 sitting in a wheelchair in the second floor hallway. The wheelchair had visible debris and dirt on the wheelchair wheel spokes and brake system. There was an unidentified green substance stuck to the brake system as well. Further observation on 10/4/17 at 11:35 AM showed the same resident sitting at a table in the dining room. The wheelchair was noted as having debris and dirt on the wheels and brake system, and the green substance noted on 10/1/17 remained stuck to the brake system. 3. Observation on 10/3/17 at 10:26 AM showed an Invacare Reliant RPS 350 sit-to-stand lift, located on the second floor, had flaky, light-colored particles covering the footboard. Observation of the same lift on 10/4/17 showed the footboard to be in the same condition. 4 .Observation on 10/4/17 at 9:42 AM showed an Invacare Platinum 10 oxygen concentrator in room 224 had a cabinet air filter visibly covered in dust. 5. Interview on 10/4/17 at 11:38 AM with housekeeping staff #1 revealed the janitorial staff was primarily responsible for the cleaning of the hallway floors and surfaces, and it was not a regular part of the housekeeping routine. 6. Interview on 10/4/17 at 11:30 AM with RN #2 revealed staff was expected to clean lifts after every use, wiping the surfaces with bleach wipes. She further confirmed that none of the lifts were for single resident use. 7. Interview on 10/4/17 at 11:48 AM with the DON revealed wheelchairs were supposed to be cleaned on each resident's shower day, and the task was performed by hospitality aides on the evening shift. She confirmed resident #35's wheelchair did not appear to have been recently cleaned. She further confirmed the Invacare Reliant RPS 350 sit-to-stand lift was not clean and the expectation was for equipment including lifts to be cleaned after every use. Finally, she concurred the horizontal molding in the hallway was dusty and required cleaning.",2020-09-01
21,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,278,E,1,1,GX9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of the Resident Assessment Instrument User's Manual, and staff interview, the facility failed to ensure the MDS assessment was certified as complete in a timely manner for 9 of 18 sample residents (#9, #17, #23, #36, #47, #64, #65, #83, #90). The findings were: Review of timeliness criteria in Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14 (section 5.2), by the Centers of Medicare and Medicaid Services, showed the MDS completion date (item Z0500B) must be no later than the 14th calendar day of the resident's admission for an admission assessment and no later than the assessment reference date (ARD) plus 14 days for an annual assessment. For a significant change assessment, the completion date must be no later than 14 days after the determination that a significant change has occurred. The following concerns were identified: 1. Review of the admission MDS assessment, with an ARD of 5/23/17, revealed resident #65 was admitted on [DATE]. Further review of section V showed the RN certified the assessment as being complete on 6/8/17 (the 23rd day after admission). 2. Review of the annual MDS assessment for resident #83 revealed an ARD of 3/31/17. Review of section V showed the RN had not certified the assessment as being complete until 4/17/17 (17 days after the ARD). 3. Review of the annual MDS assessment for resident #64 revealed an ARD of 10/20/16. Review of section V showed the RN had not certified the assessment as being complete until 11/16/17 (28 days after the ARD). Review of the significant change MDS assessment with an ARD of 6/21/17 for the same resident showed it was not certified as complete until 7/11/17 (20 days after the ARD). 4. Review of the significant change MDS assessment for resident #23 showed an ARD of 5/16/17. Further review revealed the RN failed to sign the assessment as complete on section Z until 6/8/17 (23 days after the ARD). 5. Review of the annual MDS assessment for resident #17 showed an ARD of 12/22/16. Further review revealed the RN failed to sign the assessment as complete on section Z until 2/20/17 (60 days). 6. Review of the significant change MDS assessment for resident #9 showed an ARD of 1/20/17 and a completion date of 2/23/17 (34 days after the ARD). Review of the significant change MDS assessment for resident #9 showed an ARD of 8/22/17 and a completion date of 9/18/17 (27 days after the ARD). 7. Review of the annual MDS assessment for resident #90 showed an ARD of 1/18/17. Further review revealed the RN failed to sign the assessment as complete on section Z until 2/27/17 (40 days). 8. Review of the admission MDS assessment for resident #36 showed an ARD of 1/19/17. Further review revealed the RN failed to sign the assessment as complete on section Z until 2/20/17 (23 days). 9. Review of the admission MDS assessment for resident #47 showed an ARD of 1/20/17. Further review revealed the RN failed to sign the assessment as complete on section Z until 2/20/17 (22 days). 10. Interview on 10/4/17 at 9:55 AM with the MDS coordinator revealed she was aware of the 14 day completion deadline and verified the MDS assessments were not completed within the correct timeframe.",2020-09-01
22,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,309,G,0,1,GX9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, family, and hospital case manager interviews, and policy and procedure review, the facility failed to ensure physician orders [REDACTED].#113) who had a significant change in condition. This failure resulted in delayed treatment and further decline in condition that required transport to the emergency room . In addition, the facility failed to ensure effective pain management for 1 of 7 sample residents (#114) who were assessed as needing pain management to help maintain his/her highest practicable level of well-being. This failure resulted in a decline in health status and inability to participate in activities and bedside therapy. The findings were: 1. Review of the medical record for resident #113 showed an admission date of [DATE] with a discharge date of [DATE]. The resident had [DIAGNOSES REDACTED]. The following concerns were identified: a. An interdisciplinary progress note dated 2/19/17 and timed 12:30 AM noted the resident had a pulse of 89 beats per minute (bpm), an oxygen saturation level of 86%, and expiratory wheeze noted in RLL (right lower lung) and LLL (left lower lung), more significant wheeze in LLL. Audible crackles without stethoscope (sic). Resident displays/reports no SOB (shortness of breath). Asked resident to deep breathe and cough multiple times. Resident attempted each time but struggled to produce a productive cough. Resident is in no acute distress .left resident in bed in the lowest position, to go back to sleep. Will continue to monitor. Further review of progress notes showed the next entry was dated three days later, on 2/22/17 and timed 2 PM, and showed the resident was started on [MEDICATION NAME] (an inhalation solution that dilates lung cells) every 6 hours for 5 days and [MEDICATION NAME] (an antibiotic) for 5 days with a [DIAGNOSES REDACTED]. No evidence was provided to show the resident was assessed during the three days between progress notes, or that the resident's signs/symptoms were addressed prior to 2/22/17. b. Review of an SBAR communication form showed the medical doctor was notified of the resident's condition on 2/19/17 at 4:15 AM by fax. A faxed response dated 2/20/17 showed an order for [REDACTED]. c. Review of a progress note, dated 2/23/17 and timed 3:45 PM showed the resident had a pulse of 131 bpm and temperature of 101.1 Fahrenheit (F). d. Review of the progress note dated 2/24/17 and timed at 4 AM showed the resident had a pulse of 124, temperature of 101.6 F and oxygen saturation of 87% on 3L (liters of oxygen). The note showed the resident was short of breath and sweating. The note further showed the doctor had contacted the facility, and thought the resident may have had pneumonia and may have been going septic, and ordered for the resident to be transferred to the hospital for evaluation and treatment. The resident was transferred to the emergency department on 2/24/17. e. Interview on 10/4/17 at 3:02 PM with the DON revealed the facility had reviewed the charting and assessments for resident #113 and confirmed it was not sufficient. The DON stated the nurse who had made the progress note entry on 2/19/17 was new and had not placed the resident on alert charting for follow up from her assessment. The facility provided education to staff on 3/8/17 regarding charting requirements. f. Review of inservice education attendance sheets dated 3/8/17 indicated education was provided to staff which included 24 hour documentation. Handouts included the facility policy for Alert Charting Guidelines which stated the following for upper and lower respiratory infections: Alert charting Q (every) shift until condition improves or resolves. Vital Signs Q shift - Allow to sleep on 3rd shift unless condition warrants interruption. Lung sounds Q shift or as condition warrants. Characteristics of sputum. Activity tolerance. Oxygen use, Oxygen saturation. Dietary tolerance, fluid intake. For exacerbation of cardiac/respiratory condition, the guideline stated Alert charting Q shift. VS Q shift. Heart & lung sounds. Circulatory changes, [MEDICAL CONDITION]. Daily weight. Activity tolerance. Oxygen use, oxygen saturations. medications: [REDACTED] 2. Review of the medical record showed resident #114 was admitted from the hospital on [DATE] and [DIAGNOSES REDACTED]. Further review showed at the hospital the resident's pain was effectively managed with a [MEDICATION NAME], [MEDICATION NAME], and [MEDICATION NAME] (all are medications for pain). Review of the nursing admission assessment revealed the resident did not have cognitive impairment and required assistance with toileting and transfers. This review also revealed the resident had constant pain in his/her lower back. Review of the physician admission orders [REDACTED]. Review of nursing notes dated 8/30/17 showed the resident received a neuromuscular block injection in the lumbar area of the spine. According to the nursing notes the resident reported the procedure greatly improved the pain, but s/he continued to need the [MEDICATION NAME] pain medication every 4 hours. Review of the physician orders, dated 8/31/17, showed an order to apply a [MEDICATION NAME] to the lower back each day for lumbar stenosis pain. The following concerns were identified regarding ineffective pain management: a. Review of the narcotic book sign out sheet for the resident showed after receiving the daily [MEDICATION NAME] the resident continued to need [MEDICATION NAME] for pain. This review revealed 25 doses of [MEDICATION NAME] were administered after the [MEDICATION NAME] was started on 8/31/17 and before the facility obtained an order for [REDACTED]. b. Review of the nursing assessments before and after administering the pain medication showed the medication was effective only for a short time. Interview with LPN #1 on 10/4/17 at 3 PM revealed the resident had a lot of pain and it was never completely controlled. The LPN stated the resident was unable to participate in a lot of activities and bedside therapy due to the pain. He further stated it was difficult to get the physician to prescribe additional medications. c. Interview with the hospital case manager on 10/9/17 at 9:10 AM revealed she visited the resident at the hospital prior to the transfer to the nursing home and was concerned when she saw the resident at the nursing home on 9/5/17 because there was a noticeable decline in health status and the resident complained of severe back pain. d. Interview with the family on 10/10/17 at 5:45 PM and again on 10/13/17 at 9:50 AM revealed the family visited 1 to 2 times daily and verbalized their concerns about the resident's pain to the nursing staff. During the interview the family member described the resident's pain as s/he was always hurting and the resident remained in bed most of the time due to the pain. e. Review of the admission and nutrition hydration status care plans, developed on 8/24/17, showed pain was an identified problem, but there were no documented interventions for this problem. The facility was unable to provide evidence of an individualized plan for managing the resident's pain, an initial pain assessment to establish desirable goals, and evaluation of this effectiveness of non-pharmacological approaches. f. Interview with the DON on 10/4/17 at 10:30 AM revealed staff talked with the physician about the resident's pain, but the physician was reluctant to prescribe different medications. Review of the documentation provided by the facility revealed the nursing staff contacted the physician on 8/31/17 and 9/5/17 to report the pain medication was not effective. This review also revealed additional efforts to report the ineffective pain management to the physician and/or request for involvement from other practitioners were lacking g. Review of hospital records showed the resident was admitted on [DATE]. Review of the hospital physicians progress note dated 9/11/17, revealed the resident had a lumbar burst fracture with retropulsion causing severe canal stenosis and impinging conus. h. Review of Pain Management Policy -495, updated (MONTH) (YEAR), showed the following procedures were included in the measures for effective pain management: When pain is not adequately controlled by current regiment, l, or if there is newly identified pain, the Licensed Nurse (LN) contacts the physician for consideration of new or modified treatment orders. The information on the Pain Evaluation Record is used in conjunction with the Center's other evaluation and data collection tools to develop an individualized care plan including non-pharmacological interventions, if appropriate.",2020-09-01
23,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,329,D,0,1,GX9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medication regimen for 1 of 20 sample residents (#90) was free from unnecessary drugs. The findings were: 1. Review of the 7/18/17 quarterly MDS assessment showed resident #90 had severe cognitive impairment and [DIAGNOSES REDACTED]. Review of the care plan, revised on 8/1/17, showed problems included dementia, feelings of depression, self isolation and verbal outbursts of screaming when ambulating or with cares. This review also showed interventions included interdisciplinary team and physician review for reduction of dosage every 3 months and report new behaviors, and worsening or violent behaviors. Review of the quarterly Psychoactive Drug and Behavior Medication Review Form, dated 6/20/17, showed the interdisciplinary team noted the resident had increased outbursts with agitation and anxiety. Review of the psychotherapy progress notes, dated 8/25/17, 9/1/17, 9/7/17, and 9/15/17 showed the resident reported depressed mood daily, little to no interest in most things, and has feelings of worthlessness. Review of the physician's orders [REDACTED]. Review of the Consultant Pharmacist Medication Regimen Reviews dated 2/13/17 - 2/21/17 and 9/25/17-9/26/17 showed the pharmacist recommended the physician review the medications for a gradual dose reduction and document a risk versus benefits rationale if the physician determined the reduction should not be done. Review of the pharmacy consultation report, dated 2/27/17, and the Psychoactive Drug and Behavior Medication Review Form dated 6/20/17 showed the physician response each time was for the medication review to be done by the psychiatrist. Interview with the DON on 10/4/17 at 11:10 AM revealed a psychiatrist was not available at the time the pharmacist made his initial recommendation. She further stated the review for the gradual dose reduction had not been done because they did not have a psychiatrist until (MONTH) (YEAR).",2020-09-01
24,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,356,B,0,1,GX9L11,"Based on record review and staff interview the facility failed to ensure the posted 24 nursing staff information was maintained and updated to reflect the correct number of staff and actual hours worked for 16 of 16 days. The following concerns were identified: 1. Review of the POS [REDACTED]. 2. Interview with the nurse scheduler on 10/4/17 at 1:55 PM confirmed the posted daily staffing schedule was not updated. She stated, I post the sheet at the beginning of the day and on Friday evenings for the weekend. I don't update the numbers at the beginning of each shift, based on actual staff on duty. She revealed the accurate staffing numbers are on her master nursing schedule. Both the nurse scheduler and DON stated they did not know the posted staffing sheets must be updated when staff numbers or hours changed.",2020-09-01
25,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,371,E,0,1,GX9L11,"Based on observation, staff interview, review of food temperature logs, and policies and procedures, the facility failed to ensure hot food temperatures were at a safe level prior to service during observation of food service on 1 of 4 facility units. The findings were: Observation on 10/2/17 at 4:10 PM in the kitchen showed 2 small containers of pureed food were on the prep table and remained there until they were covered and placed on the delivery food cart at 4:55 PM. Cook #1 and the CDM made periodic observations of the pizza in the oven, the pureed food on the prep table, and the hamburger patties in the warmer without checking the temperature of the foods. At 4:30 PM Cook #1 and the CDM removed the cooked pizza from the oven, used a spatula to move individual slices into a serving pan, covered the pan and placed it on the food delivery cart. The cook removed the cooked hamburger patties from the warmer. He then removed the bowls of lettuce salad and sliced tomatoes from the cooler and placed them on the food delivery cart. Staff were observed performing the tasks with gloves and appropriate hand hygiene, however during the observation they did not check the temperature of the hot foods. Review of the food temperature log for this meal revealed it was blank. Continued observation revealed the food was wheeled to the nursing unit and nursing staff assisted the dietary staff in preparing the food items for service. The hot items including the pureed foods were placed on the steam table and the cold items in the iced pan that was set aside. Observation of the steam table revealed the gauges on the controls were worn making it impossible to know the temperature setting. At 5:30 PM the dietary aide donned gloves after hand hygiene and began to serve the food. Review of the food temperature log book for this meal revealed no documented food temperatures. Interview with the CDM on 10/2/17 at 5:45 PM revealed the policy required all dietary staff to ensure food items were at a safe temperature prior to meal service. He further stated he needed to provide additional staff education to ensure this is done consistently. Review of the Policy titled Food Temperature Policy-785, dated (MONTH) 2009, showed food temperatures were to be taken and documented daily prior to meal service.",2020-09-01
26,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,428,E,1,1,GX9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, pharmacy drug regimen review, and staff interview, the facility failed to ensure pharmacist recommendations were addressed for 8 of 16 sample residents (#3, #9, #17, #22, #64, #65, #82, #90). The findings were: 1. Review of the 8/28/17 to 8/29/17 Consultant Pharmacist Medication Regimen Review for resident #3 showed the pharmacist recommended the resident's scheduled Synthroid 25 micrograms (mcg) be changed from being given in the AM to being given at 6 AM or at HS (bedtime) in order to ensure the medication would be given on an empty stomach for optimal absorption. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the medical record showed that the pharmacist recommendation had not been addressed. Continued review of the Consultant Pharmacist Medication Regimen Review showed the pharmacist noted that the resident's ordered eyedrops were scheduled to be given together. The eyedrop orders were for brimonidine 0.1% scheduled at HS (bedtime), timolol 0.5% scheduled at HS, and dorzolmide 2% scheduled at 8 AM, 2 PM, and 8 PM. The pharmacist made the recommendation to separate administration of each eye drop by at least 3 to 5 minutes. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record showed that the recommendation had not been addressed. 2. Review of the 8/28/17 to 8/29/17 Consultant Pharmacist Medication Regimen Review for resident #17 showed the pharmacist recommended that the resident's scheduled Synthroid 50 mcg be changed from being given in the AM to being given at 6 AM or at HS (bedtime) in order to ensure the medication would be given on an empty stomach for optimal absorption. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record showed that the recommendation had not been addressed. 3. Review of the 7/24/17 to 7/26/17, 8/28/17 to 8/29/17, and 9/25/17 to 9/26/17 Consultant Pharmacist Medication Regimen Reviews for resident #22 showed the pharmacist recommended that the resident's scheduled Flomax be changed from being given in the AM to being given approximately 30 minutes after the same meal each day since taking this drug on an empty stomach may increase risk of side effects such as blood pressure drop and dizziness. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record showed that the recommendation had not been addressed. Continued review of the Consultant Pharmacist Medication Regimen Review showed the pharmacist recommended on 9/26/17 that the resident's 1/22/17 order for Seroquel 50 mg (milligrams) be given in the AM and be considered for a GDR (gradual dose reduction). Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record showed that the recommendation had not been addressed. 4. Review of the 7/24/17 to 7/26/17 and 8/28/17 to 8/29/17 Consultant Pharmacist Medication Regimen Review for resident #64 showed the pharmacist recommended the resident's scheduled Prilosec 20 mg be changed from being given in the AM to being administered approximately 30 minutes before the meal to achieve optimal therapeutic effect. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record showed the recommendation had not been addressed. Continued review of the Consultant Pharmacist Medication Regimen Review for 8/28/17 to 8/29/17 and 9/25/17 to 9/26/17 showed the pharmacist recommended the resident's scheduled Synthroid 25 mcg be changed from being given in the AM to being given at 6 AM or at HS in order to ensure the medication would be given on an empty stomach for optimal absorption. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record revealed the recommendation had not been addressed. 5. Review of the 8/28/17 to 8/29/17 and 9/25/17 to 9/26/17 Consultant Pharmacist Medication Regimen Review for resident #65 showed the pharmacist recommended the resident's scheduled Synthroid 50 mcg be changed from being given in the AM to being given at 6 AM or at HS in order to ensure the medication would be given on an empty stomach for optimal absorption. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record showed the recommendation had not been addressed. 6. Review of the 8/28/17 to 8/29/17 and 9/25/17 to 9/26/17 Consultant Pharmacist Medication Regimen Review for resident #82 showed the pharmacist recommended the resident's scheduled Synthroid 25 mcg be changed from being given in the AM to being given at 6 AM or at HS in order to ensure the medication would be given on an empty stomach for optimal absorption. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the medical record showed the recommendation had not been addressed. 7. Review of the Consultant Pharmacist Medication Regimen Review dated 9/25/17-9/26/17 showed Resident #9 had a prescription for Ativan since 6/17/17. Further review showed the resident had received zero doses in 4 months. The pharmacist recommendation was to provide a risk versus benefit assessment if the current therapy was to be continued. Interview on 10/4/17 at 11:30 AM with the DON revealed The medication should have been discontinued but it hasn't been. 8. Review of the physician's orders [REDACTED].#90 showed Buspar (anti-anxiety medication)15 milligrams (mg) 3 times a day was ordered on [DATE], Guanfacine (for treatment of [REDACTED]. Review of the Consultant Pharmacist Medication Regimen Reviews dated 2/13/17-2/21/17 and 9/25/17-9/26/17 showed the pharmacist recommended the physician review the medications for a possible gradual dose reduction and document a risk versus benefits rationale if the physician determined the reduction should not be done. Review of the pharmacy consultation report, dated 2/27/17, and the Psychoactive Drug and Behavior Medication Review Form dated 6/20/17 showed the physician response on both was for the medication review to be done by the psychiatrist. Interview with the DON on 10/4/17 at 11:10 AM revealed a psychiatrist was not available at the time the pharmacist made his initial recommendation. She further stated the review for the gradual dose reduction had not been done because they did not have a psychiatrist until (MONTH) (YEAR). 9. Interview on 10/4/17 at 12 PM with the consultant pharmacy revealed he had identified the concern with the physician's not acting upon the recommendations and had recently presented it to the facility's quality assurance committee.",2020-09-01
27,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,431,E,0,1,GX9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to ensure medications for resident use were not past their expiration date in 6 of 6 medication carts. The findings were: 1. Observation of medication cart A located on first floor on 10/3/17 at 10:20 AM revealed clortrimazole TRO 10 milligram (mg) did not have an expiration date on the label. Interview with RN # 1 revealed the medications in the cart were for resident use. 2. Observation of medication cart B located on the first floor on 10/3/17 at 10:33 AM revealed Klor-Con 20 milliequivalent (meq) did not have an expiration date on the label. Interview with LPN # 3 revealed the medications in the cart were for resident use. 3. Observation of the medication cart located on the second floor on 10/3/17 at 11:35 AM revealed Zofran 4 mg with an expiration date of 5/26/17 on the label. Interview with RN # 2 revealed the medications in the cart were for resident use. The RN also stated the Zofran came from the home of a resident's who was admitted [DATE]. The RN further stated the resident had not received that medication since admission. 4. Observation of medication cart B located on the third floor on 10/3/17 at 2:25 PM revealed 4 vials of lidocaine 1% 20 milliliters (ml) did not have the date opened recorded on the label. Interview with LPN # 2 revealed the vials were used for residents. Review of the Vials and Ampules of Injectable Medications policy showed The date opened and initials of the first person to use the vial are recorded on multidose vials on the vial label . 5. Observation of medication cart A located on the third floor on 10/3/17 at 3:00 PM revealed Dulcolax suppository had an expiration date of 5/15/17 and oxycodone/acetaminophen 0.5mg/325mg had an expiration date of 7/18/17. Interview with LPN # 1 revealed the medications were for resident use and were past their expiration date. 6. Observation of the medication cart located in the secure unit on the third floor on 10/3/17 at 2:40 PM revealed multiple vitamin with iron with an expiration date of 9/17. Interview with LPN # 1 revealed the medications were for resident use.",2020-09-01
28,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,502,D,0,1,GX9L11,"Based on observation, staff interview and manufacturer instructions, the facility failed to ensure the accuracy of finger stick blood sugar levels obtained by staff. The findings were: 1. Observation of the medication cart located on the secure unit on the third floor on 10/3/17 at 2:40 PM revealed a bottle of Assure Blood Glucose Strips had an expiration date of 8/17. 2. Interview with LPN # 1 revealed the glucose strips in the medication cart were for resident use and the bottle was beyond its expiration date. 3. Review of the Assure Prism multi blood glucose test strips manufacturer's instructions (www.arkrayusa.com/, pg.10, retrieved 10/10/17) showed Do not use Assure Prism multi Blood Glucose Test Strips beyond the expiration date as this may cause inaccurate results.",2020-09-01
29,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2017-10-04,520,E,0,1,GX9L11,"Based on staff interview, review of the CMS (Centers for Medicare and Medicaid) 2567 Statement of Deficiencies, and review of the facility's quality assessment and assurance information, the facility failed to ensure the quality assessment and assurance program developed and implemented appropriate interventions to effectively resolve and sustain compliance with previously identified deficient practice. The facility census was 110. The findings were: 1. Review of the of the 9/9/16 CMS 2567 Statement of Deficiencies, and quality assessment and assurance program showed the facility failed to resolve and/or maintain compliance with the following deficient practices: a. Issues with the facility's grievance resolution measures were cited during the 9/9/16 survey. A plan of correction was developed and monitored through the facility's quality assessment and assurance program, but the facility was unable to sustain compliance. Issues related to grievance resolution were again cited during the current survey (F244). b. Issues with failing to maintaining a clean environment were cited during the 9/9/16 survey. A plan of correction was developed and monitored through the facility's quality assessment and assurance program, but the facility was unable to sustain compliance regarding environmental issues. This issue was again cited during the current survey (F253). c. Issues with failing to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being address, specifically failure to complete timely assessments, were cited during the 9/9/16 survey. A plan of correction was developed and monitored through the facility's quality assessment and assurance program, but the facility was unable to sustain compliance. Issues related to this failure were again cited during the current survey (F309). d. Issues with the food service not provided accordance with professional standards for food service safety were cited during the 9/9/16 survey. A plan of correction was developed and monitored through the facility's quality assessment and assurance program, but the facility was unable to sustain compliance. Issues related to food temperatures were cited during the current survey (F371). 2. Interview with the administrator on 10/4/17 at 2 PM revealed the facility had been working to address problems they had identified through the quality assessment and assurance process; and determined one of the reasons they were unable to effectively resolve recurrent problems was possibly due to resident and family perceptions. She further stated the plan was to utilize the quality assessment and assurance process to implement measures that would improve resident and family perceptions.",2020-09-01
30,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,550,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and medical record review, the facility failed to maintain dignity for 1 of 6 sample residents (#8) with incontinence. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #8 had [DIAGNOSES REDACTED]. Further review showed the resident required extensive assistance of one person for transfer, dressing, toilet use, and personal hygiene. Review of the incontinence care plan last revised on 10/4/18 showed check for incontinence . Review of the ADL care plan last revised on 10/4/18 showed nursing to provide assist with bed mobility, transfers, locomotion in w/c, dressing, toilet use, personal hygiene, and bathing. The following concerns were identified: a. Observation on 10/08/18 at 4:21 PM showed resident #8 was assisted off the elevator on the second floor unit and into his/her room by another unidentified resident. Resident #8's pants were visibly soiled from the upper inner thighs down to the bottom of the pant leg. Interview with the resident at that time revealed the wet area was urine and s/he had just returned to the second floor after being downstairs. b. Interview with the DON on 10/11/18 at 3:54 PM revealed the resident traveling through the facility with urine-soaked clothing could be undignified for the resident.",2020-09-01
31,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,561,D,1,1,P2JJ11,"> Based on medical record review and resident and staff interview, the facility failed to promote resident choices with 2 of 4 sample residents (#24, #91). The findings were: 1. Interview with resident #24 on 10/8/18 at 4:42 PM revealed residents go without a bath or shower for weeks. The resident stated, We are supposed to have one twice a week. It would be nice to have one twice a week. a. Review of the resident's 2nd floor shower schedule showed the resident was scheduled for showers on Tuesdays and Fridays. b. Review of the care plan showed the resident preferred to take his/her showers after breakfast. c. Review on 10/10/18 of the resident functional performance record for (MONTH) (YEAR) showed the resident did not receive a shower for 9 days between 10/1/18 and 10/9/18. 2. Observation on 10/8/18 at 10:15 AM showed resident #91 had visible facial hair on his/her chin. Interview with CNA #1 at that time revealed the residents were shaved when they get their bath. The following concerns were identified: a. Review on 10/10/18 of the resident functional performance record for (MONTH) (YEAR) showed the resident did not receive a shower for 9 days between 10/1/18 and 10/9/18. 3. Interview with the DON on 10/12/18 at 10:25 AM confirmed the residents were to receive a shower/bath 2 times a week.",2020-09-01
32,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,578,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical record accurately reflected resident advance directive preferences for 2 of 7 sample residents (#2, #16) reviewed for advance directives. The findings were: 1. Review of the WyoPOLST (Providers Orders for Life Sustaining Treatment) dated [DATE] showed resident #2 elected a do not attempt resuscitation (DNR) with selective treatment designation. Review of the nurses 24 hour staff report sheet showed the resident had a code status of DNR. Review of the resident care plan dated [DATE] showed the code status as cardiopulmonary resuscitation (CPR) requested. 2. Review of the WyoPOLST dated [DATE] showed resident #16 elected a DNR status with full treatment. Review of the nurses 24 hour staff report showed only DNR. Review of resident care plan dated [DATE] showed the code status was full code. 3. Interview with CNA #2 on [DATE] at 11:12 AM revealed that, regardless of resident code status, she would call for help if a resident was unresponsive and begin CPR. 4. Interview with RN #1 on [DATE] at 10:03 AM stated he would go to the resident medical record and check the POLST to determine the resident's code status as the nurses 24 hour report sheet did not accurately identify resident code status. 5. Interview with the DON on [DATE] at 10:25 AM stated the facility would expect staff to follow the resident's POLST election at all times.",2020-09-01
33,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,604,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to ensure a physical restraint had been assessed and was the least restrictive for 1 of 1 sample resident (#72) who was restrained. The findings were: 1. Review of the quarterly MDS assessment dated [DATE] showed resident #72 had [DIAGNOSES REDACTED]. Further review showed the resident had short term and long term memory problems, no coded behaviors, and required extensive assistance of two or more people for toilet use, transfers, walking in room and corridor, locomotion, and dressing. Review of the behavior care plan last revised on 9/11/18 showed the resident had potential for unprovoked aggressive behaviors toward others and interventions included assessment for basic needs, eliminate causes of distress, handling situations as calmly as possible, unrushed and constant routine, and diversional activities geared toward the resident's interest. The following concerns were identified: a. Observation on 10/8/18 at 11:11 AM showed resident #72 attempted to stand from his/her wheelchair and HSA #1 stood behind the resident. At that time, the HSA placed her arms around the resident, placed her hands on the resident's forearms, and applied pressure while stating (resident's name) you can't stand up in an attempt to get the resident to return to sitting in the wheelchair. The resident stated stop pushing me. The HSA remained behind the resident, and when the resident attempted to stand again, she placed her hands on the resident's shoulders and applied pressure to get the resident to sit in his/her chair. The HSA stated, You have to sit down (resident's name). The resident said, Stop it. The HSA remained behind the resident and when the resident attempted to stand a third time, the HSA placed her hands on the resident's hips and applied pressure. The resident said, Stop it, leave me alone. Stop pushing me. The HSA responded to the resident You have to sit down (resident's name). b. Interview with HSA #2 on 10/11/18 at 3:18 PM revealed when the resident tried to get up it was best to talk to (him/her) and maybe rub (his/her) back. The HSA revealed if staff tried to apply pressure to the resident's arms or shoulders it agitated him/her more and resulted in increased behaviors. Further, she confirmed applying pressure to the resident's extremities in an attempt to get him/her to sit down prevented the resident from moving independently. c. Interview with the DON and unit manager #1 on 10/11/18 at 3:38 PM revealed staff should allow the resident to stand and ensure s/he was safe. Further, it was revealed the resident became agitated when people were hovering over (him/her) or applying pressure to try and get him/her to sit down.",2020-09-01
34,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,606,D,0,1,P2JJ11,"Based on review of employee files and staff interview, the facility failed to ensure employed CNAs were entered into the nurse aide registry for 1 of 2 CNAs reviewed (CNA #4). The findings were: Review of the employee file showed CNA #4 had a date of hire of 9/12/18. Further review showed no evidence the CNA was entered into the state nurse aide registry. Interview on 10/12/18 at 9:10 AM with administrative assistant #1 confirmed the facility did not enter the CNA into the nurse aide registry. She further stated that action was usually completed on orientation.",2020-09-01
35,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,623,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a transfer notice was issued to 2 of 7 sample residents (#36, #37) with hospital transfers. The findings were: 1. Review of the medical record for resident #36 showed the resident was transferred to the hospital on [DATE] and returned on 6/18/18. Further review showed no evidence the facility issued a written notice of transfer to the resident or resident representative. 2. Review of the medical record for resident #37 showed the resident was transferred to the hospital on [DATE] and returned on 4/17/18. Further review showed no evidence the facility issued a written notice of transfer to the resident or resident representative. 3. Interview with the admission/discharge coordinator on 10/10/18 at 10:13 AM confirmed the facility had identified a failure to issue written notices of transfer, and had started education of staff in August.",2020-09-01
36,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,625,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a notice of bed-hold policy was issued to 2 of 7 sample residents (#36, #37) who transferred to the hospital. The findings were: 1. Review of the medical record for resident #36 showed the resident was transferred to the hospital on [DATE] and returned on 6/18/18. Further review showed no evidence the facility issued a written notice of the bed-hold policy to the resident or resident representative. 2. Review of the medical record for resident #37 showed the resident was transferred to the hospital on [DATE] and returned on 4/17/18. Further review showed no evidence the facility issued a written notice of the bed-hold policy to the resident or resident representative. 3. Interview with the admission/discharge coordinator on 10/10/18 at 10:13 AM confirmed the facility had failed to issue written notices to the resident or resident representative concerning the bed-hold policy for hospital transfers.",2020-09-01
37,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,645,D,1,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, and staff interview, and review of Wyoming Medicaid PASRR guidelines, the facility failed to ensure residents with categorical determinations had a PASRR Level II completed within the identified time frames for 1 of 3 sample residents (#81) reviewed. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #81 was admitted to the facility on [DATE], had physical behaviors 4 to 6 days and verbal behaviors 1 to 3 days during the look back period, and [DIAGNOSES REDACTED]. The following concerns were identified: a. Review of a PASRR Level I dated 5/21/18 showed the resident had a psychiatric [DIAGNOSES REDACTED]. Further review showed the categorical 6 determination qualified the resident for convalescent care after acute hospital stay, not to exceed 120 days and the facility was to attach current LT101, current history and physical, and comprehensive drug history. An individual Level II determination will be required on 121st day, please plan accordingly. b. Review of a PASRR Level II determination completed on 5/23/18 showed the determination was requested on 5/18/18, prior to the resident's hospitalization . The determination was completed 2 days following the resident's admission to the facility, however there was no evidence a PASRR Level II was requested after the resident had been at the facility for 30 days. c. Review of the Wyoming MEDICAID PASRR Update dated 8/2017 showed .Categorical 6- A medical condition following a discharge from an acute care hospital, for which convalescent care is expected to require less than 120 days in a NF (nursing facility) .If the individual will continue to require NF placement, past the day limit stated above, he/she MUST have a full Level II PASRR evaluation completed BEFORE the end of the exempted period. (A new PASRR Level I needs to be repeated in the portal and PASRR II packet faxed to Optum). The earliest a provider can submit a request for an expiring Categorical Determination PASRR II is 30 days after admission . d. Interview with the admissions coordinator on 10/11/18 at 4:05 PM revealed the resident was going to be admitted from another skilled nursing facility which resulted in the facility initiating the PASRR II on 5/18/18; however, the resident was hosptalized on [DATE] and required the completion of a PASRR Level I which resulted in the categorical 6 determination.",2020-09-01
38,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,656,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the comprehensive care plan addressed all required areas for 1 of 30 sample residents (#30) who required a care plan. The findings were: Review of the 7/27/18 quarterly MDS assessment showed resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. Review of the care plan showed the facility failed to address the resident's hospice services on the plan, and no delineation between facility services and hospice services was addressed. Interview with unit manager #1 on 10/11/18 at 12:02 PM confirmed the facility failed to address hospice services on resident #30's care plan.",2020-09-01
39,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,689,D,0,1,P2JJ11,"Based on observation, medical record review, family and staff interview, the facility failed to ensure the care plan was followed concerning safety interventions for 1 of 4 sample residents (#30) identified with fall issues. The findings were: Observation on 10/8/18 at 4:46 PM showed resident #30 was in bed in a low position with a fall mat by the bed. Interview with a family member of the resident at that time showed the resident had fallen in the past, and the fall mat was a safety intervention the facility had added to lessen the risk of injury if the resident fell out of bed. Review of the care plan showed a 1/1/18 plan that addressed the resident's risk of falls. The plan had been revised several times, and included the intervention Lip mattress on floor by bedside to set parameters when in bed. The following concerns were identified: a. Observation on 10/11/18 from 2:09 PM through 5:51 PM showed the resident was asleep in bed with the bed in a low position. However, the required lip mattress was not on the floor. A fall mat was behind the bed against the wall and not on the floor by the bedside. There were no visitors or staff with the resident during the observation period. b. Interview with unit manager #1 on 10/11/18 at 5:51 PM confirmed the resident's lip mattress (or fall mat) should have been on the floor beside the bed for safety as per the care plan.",2020-09-01
40,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,690,E,1,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident and staff interview, and medical record review, the facility failed to ensure residents received appropriate services and treatment for 5 of 7 sample residents (#8, #46, #72, #81, #322) who were incontinent. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #8 had [DIAGNOSES REDACTED]. Further review showed the resident required extensive assistance of one person for transfer, dressing, toilet use, and personal hygiene. Review of the incontinence care plan last revised on 10/4/18 showed check for incontinence . Review of the ADL care plan last revised on 10/4/18 showed nursing to provide assist with bed mobility, transfers, locomotion in w/c, dressing, toilet use, personal hygiene, and bathing. The following concerns were identified: a. Observation on 10/08/18 at 4:21 PM showed resident #8 was assisted off the elevator on the second floor unit and into his/her room by another unidentified resident. Resident #8's pants were visibly soiled between his/her upper inner thighs down to the bottom of his/her pant leg. Interview with the resident at that time revealed the wet area was urine and s/he had just returned to the second floor after being downstairs. b. Observation on 10/11/18 beginning at 8:41 AM showed the resident was sitting at a table in the second floor unit dining room. The resident left the unit and rode the elevator to the first floor at 10:29 AM. The resident returned to the dining room table on the second floor unit at 10:56 AM. Interview with CNA #3 on 10/11/18 at 1:09 PM revealed the resident had not been offered or assisted to use the restroom since s/he got up for the day. Further the CNA revealed she was going to ask the resident at that time. Continued observation showed the resident remained at the dining table until 1:11 PM, 4 hours and 30 minutes after the observation began. Interview with CNA #3 at 1:13 PM confirmed the resident's brief was wet and had to be changed. 2. Review of the significant change MDS assessment completed on 8/23/18 showed resident #46 had [DIAGNOSES REDACTED]. Further the resident required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of the bladder incontinence care plan last revised on 8/10/18 showed .Brief Use: (resident's name) uses disposable briefs. Change after each incontinent episode and prn (as needed) . Review of the ADL care plan last revised on 8/24/18 showed .Toilet USE: (resident's name) requires assistance by staff for toileting. Review of the high risk for falls care plan last revised on 10/9/18 showed .Toilet before and after meals and PRN. Provide assistance with toileting needs . The following concerns were identified: a. Observation beginning on 10/10/18 at 8:58 AM showed the resident was in the common area during exercise activity. The resident was sleeping in his/her wheelchair. At 9:25 AM CNA #7, CNA #8 and CNA #9 assisted the resident into his/her room and into bed without assisting him/her to the bathroom or performing incontinence care. The resident remained in bed until 12:21 PM. Observation at that time showed unit manager #1, LPN #2, and CNA #9 assisted the resident out of bed and did not offer toileting or perform incontinence care. The resident was assisted to a dining table and LPN #2 stated We will take you to the bathroom in a little bit when the resident attempted to leave the table. At 12:26 PM the resident left the table and went to his/her room to use the bathroom. At that time CNA #9 assisted the resident onto the toilet (3 hours and 28 minutes later). b. Interview with CNA #9 on 10/10/18 at 12:29 PM revealed the resident's brief was wet when s/he was assisted to the bathroom. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #72 had [DIAGNOSES REDACTED]. Further review showed the resident had short term and long term memory problems, no coded behaviors, and required extensive assistance of two or more people for toilet use, transfers, walking in room and corridor, locomotion, and dressing. Review of the Bowel Incontinence care plan last revised 5/21/18 showed interventions that included Observe for pattern of incontinence and initiate toileting schedule if indicated. Review of the Bladder Incontinence care plan last revised on 5/21/18 showed (resident's name) uses disposable briefs. Clean peri-area with each incontinence episode. The following concerns were identified: a. Observation beginning on 10/10/18 at 9:06 AM showed the resident was in bed sleeping. At 10 AM CNA #7 assisted the resident out of bed and assisted him/her to a dining table without offering to use the bathroom or performing incontinence care. The resident remained at the dining table until 1:09 PM when CNA #9, CNA #7, and LPN #2 assisted the resident to bathroom (4 hours and 3 minutes later). b. Interview with CNA #9 on 10/10/18 at 1:15 PM revealed the resident's brief was wet with urine and further it was confirmed the resident was not toileted or provided incontinence care when s/he was assisted out of bed. 4. Review of the significant change MDS assessment dated [DATE] showed resident #81 had [DIAGNOSES REDACTED]. Further review showed the resident required extensive assistance of two or more people for bed mobility, transfers, dressing, and toilet use. The resident required extensive assistance of one person for personal hygiene. Review of the ADL care plan last revised on 6/3/18 showed .Toilet USE: (resident's name) requires extensive assistance for transfers . The following concerns were identified: a. Observation beginning on 10/10/18 at 8:57 AM showed the resident was in the common area participating in exercises. At 9:40 AM CNA #7 assisted the resident to his/her room to perform hair care and did not offer to take the resident to the bathroom or perform incontinence care. The CNA assisted the resident to return to a dining table in the common area. The resident remained in the common area until s/he asked to use the bathroom at 12:36 PM. CNA #7 assisted the resident to the bathroom at that time (3 hours and 39 minutes later). b. Interview with CNA #7 on 10/10/18 at 12:41 PM revealed the residents brief was soiled. 5. Review of the 48-Hour Baseline Plan of Care Form, dated 10/4/18, showed resident #322 had [DIAGNOSES REDACTED]. Further review showed the resident required 2-person extensive assist with toileting, was incontinent, and utilized incontinence products. Review of a Bladder Evaluation form, dated 10/4/18, showed the resident had functional incontinence related to physical or cognitive limitations and was dependent on caregivers for toileting. The following concerns were identified: a. Interview with the resident on 10/08/18 at 5:33 PM revealed concerns with receiving the assistance s/he needed to toilet. The resident stated s/he had wet the bed through his/her incontinence products while waiting for assistance. Additionally, the resident stated diuretic medication made him/her urinate large amounts. b. Interview on 10/10/18 at 2:50 PM with CNA #5 revealed the resident was usually continent of bladder, unless we don't get to (him/her) in time. c. Interview on 10/10/18 at 6:22 PM with CNA #6 revealed the resident was normally continent, adding the resident will tell you when (s/he) has to go, you just have to help (him/her). d. Review of the resident's bladder function record from 10/3/18 through 10/11/18 showed the resident was continent of bladder 38 times and was incontinent of bladder 19 times. e. Interview on 10/11/18 at 3:54 PM with the DON confirmed the resident required assistance for toileting. She further revealed the resident was usually continent and was able to ask for assistance. 6. Interview with unit manager #1 and DON on 10/11/18 at 3:35 PM revealed the facility expectation was for residents to be taken to the bathroom upon rising, before and after meals, and as needed and the residents should not go longer than 3 hours without toileting.",2020-09-01
41,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,755,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy and procedure review the facility failed to ensure medications were not expired in 1 of 6 medication storage areas (2nd floor A medication cart). The findings were: 1. Observation of the 2nd floor A medication cart on [DATE] at 4:09 PM showed the following concerns: a. One multiple-dose bubble pack of [MEDICATION NAME]/[MEDICATION NAME] (Narcotic pain medication) ,[DATE] milligram tablets which expired on [DATE]. b. One multiple-dose bubble pack of [MEDICATION NAME] HCL (narcotic pain medication) 50 mg tablets which expired [DATE]. 2. Interview with LPN #1 on [DATE] at 4:18 PM revealed the medications would have been administered to the residents even though the medications were expired. 3. Review of the Medication storage in the facility policy and procedure included .M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures .",2020-09-01
42,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,758,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure appropriate medication use for 2 of 5 sample residents (#62, #81) reviewed for [MEDICAL CONDITION] medications. The findings were: 1. Review of the significant change MDS assessment date 8/4/18 showed resident #62 had [DIAGNOSES REDACTED]. Further review showed the resident rejected care and wandered 1 to 3 days during the look back period. Review of the depression and anxiety care plan last revised on 5/21/18 showed interventions included Administer medications as ordered, monitor/document for side effects and effectiveness .Monitor/document/report PRN (as needed) any risk for harm to self: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, refusing to eat or drink, refusing med or therapies, sense of hopelessness, impaired judgement or safety awareness. Monitor/document/report PRN any s/sx (signs or symptoms) of depression, including: hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing, (sic) negative statements, repetitive anxious or health-related complaints, tearfulness. Monitor/record/report to MD prn risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons . Review of the Medication Administration Record [REDACTED]. The following concerns were identified: a. Review of a Behavior Monitoring Flowsheet dated 10/2018 showed the monitored behavior was aggression directed at others, the identified trigger was Dx (diagnosis) of dementia, and interventions included 1. Redirect as able 2. Offer (him/her) something to hold onto 3. Involve family 4. R/O (rule out) unmet needs. Further review showed the monitoring did not include specific target behaviors identified for the use of individual medications and did not include specific target behaviors identified on the resident's care plan. 2. Review of the significant change MDS assessment dated [DATE] showed resident #81 had [DIAGNOSES REDACTED]. Further review showed the resident had physical behavioral symptoms directed at other on 4 to 6 days and verbal behavioral symptoms directed towards others on 1 to 3 days during the look back period. Review of the depression care plan last revised on 6/3/18 showed interventions which included .Monitor/document/report PRN any s/sx of depression, including: hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing, (sic) negative statements, repetitive anxious or health-related complaints, tearfulness . Review of the mood problem care plan last revised on 9/17/18 showed .Anticipate (resident's name) impulsive behavior and attempt to keep others at least an arm length's away .Monitor for signs of increased anxiety, change in mood, aggression,. Keep (him/her) away from other residents during those times .(resident's name) can be intrusive and wander into others personal space and room .(resident's name) can be resistive to care-hit, kick, and throw items. Offer reassurance, take to quiet area . Review of the MAR for (MONTH) (YEAR) showed the resident received duloxetine [MEDICATION NAME] (antidepressant) 60 mg capsule by mouth in the morning for major [MEDICAL CONDITION], [MEDICATION NAME] (anti-anxiety) [MEDICATION NAME] ([MEDICATION NAME]) [MEDICATION NAME] (antipsychotic) [MEDICATION NAME] (anti-emetic) (ABHR) gel 1 ml (milliliter) [MEDICATION NAME] on the wrists every morning and at bedtime for pain/aggression, and [MEDICATION NAME] (antipsychotic) 0.25 mg by mouth at bedtime. The following concerns were identified: a. Review of a Behavior Monitoring Flowsheet dated 10/2018 showed the monitored behavior was aggression directed at others, the identified trigger was 1. Dx of dementia 2. DX of depression 3. Over stimulation, and interventions included 1. Redirect as able 2. Involve family 3. 1:1 conversation 4. R/O (rule out) unmet needs. Further review showed the monitoring did not include specific target behaviors identified for the use of individual medications and did not include specific target behaviors identified on the resident's care plan. 3. Interview with the DON on 10/12/18 at 9:15 AM confirmed the behavior monitoring did not identify specific behaviors for individual medications, the behaviors on the care plan did not match the behaviors the facility was monitoring for medication use, and the rational for effectiveness of medications could not be determined from the behavior monitoring. 4. Review of the policy titled Behavior Management last revised 10/2017 showed .5. If a resident exhibits a new behavior symptom, staff implements the Behavior Monitor Flowsheet and notifies Social Services Director (SSD) and the IDT via the 24-hour Report. 6. The Behavior Monitor Flowsheet (number of behaviors, trigger, intervention, and outcome) is completed as the indicated behaviors are exhibited. 7. The IDT reviews the resident's record and Behavior Monitoring Flowsheet (as applicable) to evaluate whether the current plan is effective. If the plan is effective, the IDT makes a note in the medical record. If further evaluation is is needed, modification, including adding changes to care plan and Behavior Monitoring Flowsheet using non-medication interventions, are implemented .",2020-09-01
43,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,812,E,0,1,P2JJ11,"Based on observation, review of the Ice Machine PM Task Sheet, and staff interview, the facility failed to ensure food was stored/prepared under sanitary conditions in 1 of 1 kitchens. In addition, the facility failed to ensure 1 of 2 ice machines were sanitary. The findings were: 1. Observation on 10/10/18 at 10:12 AM in the kitchen showed 14 of 34 available serving trays were damaged with the metal underneath showing through and starting to rust. Interview with the CDM on 10/10/18 confirmed the food trays were damaged. 2. Observation on 10/10/18 at 11:39 AM showed two ice machines in the beverage area. The ice machine on the left had paint chipped on the left of the door. Further, there were whitish mineral deposit stains on the bottom right side of the door, and above the door area on the right side of the machine that went the length of the machine. Inside the ice machine where ice collected for use there was a thumb-sized deposit of a dark substance that appeared hardened on the right wall. 3. Interview with the CDM on 10/11/18 at 5:45 PM confirmed the dirty ice machine. He stated the maintenance department cleaned the ice machines, and the kitchen staff did not have a schedule to observe the ice machines. 5. Interview with the maintenance director on 10/12/18 at 8:44 AM revealed the maintenance department emptied and cleaned both ice machines inside and out once a month. He then provided a copy of the (YEAR) Ice Machine PM Task Sheet that the subsequent review showed the last date the ice machines were cleaned as 9/24/18. According to Food Code (YEAR), U.S. Public Health Service: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch.",2020-09-01
44,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2018-10-12,880,D,0,1,P2JJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and policy and procedure review, the facility failed to ensure appropriate infection control practices were followed during 2 random observations of wound care which affected 2 sample residents (#70, #88). The findings were: 1. Review of an SBAR (Situation, Background, Assessment, Request) Communication Form showed resident #88 began showing signs and symptoms of abdominal pain and diarrhea on 9/29/18. Review of the Contact Isolation Care Plan showed it was initiated on 9/30/18. The plan showed the resident required contact isolation precautions related to a [DIAGNOSES REDACTED]. Approaches included Inservice direct staff on contact isolation techniques. The following concerns were identified: a. Observation of the wound care nurse on 10/11/18 at 9:09 AM showed the nurse finished wound care for the resident and exited the resident's room without performing hand hygiene, and while wearing a gown and mask. Further observation showed the wound nurse walked to the second floor dining area and removed the gown, using an ungloved hand, by grabbing the gown on the exterior surface and pulling the gown away from her body. The wound nurse discarded the PPE in a trash can on the medication cart, walked to a cart outside the isolation room, and handled items in and on the cart without performing hand hygiene. b. Interview with the staff development coordinator on 10/11/18 at 4:56 PM revealed donning of PPE should be performed prior to resident care and doffing PPE should be completed prior to leaving the resident's room. Further she revealed PPE used during treatment of [REDACTED]. c. Review of the policy titled Personal Protective Equipment (PPE) Work Practices dated 09/2017 showed .8. All PPE is removed prior to leaving the work area. a. Contaminated garments are removed immediately or as soon as feasible. b. Removed PPE are placed in a designated or (sic)container for storage, washing, decontamination, or disposal .Contact Precautions: .c. Gloves and Handwashing .iii. Remove gloves before leaving the room and perform hand hygiene .d. Gown i. wear a disposable gown upon entering Contact Precautions room or cubicle. ii. After removing the gown, do not allow clothing to contact potentially contaminated environmental surfaces . 2. Observation of the wound care nurse on 10//11/18 at 9:21 AM showed the nurse gathered supplies needed for wound care for resident #70, then moved the trash can close to the bed. The nurse donned gloves and removed the dressing on the resident's heel using both hands. Hand hygiene was not performed prior to donning gloves. The nurse gathered the dressing in her left hand and discarded it. She removed her left glove and replaced it. The dressing change was completed and the nurse removed both gloves. The nurse left the room without performing hand hygiene at 9:36 AM. The nurse returned to the room at 9:39 AM and donned gloves without performing hand hygiene. She performed wound care to the resident's buttock area, removed her gloves, and washed her hands. 3. Interview with the DON on 10/12/18 at 10:17 AM revealed it was the facilities expectation for staff to perform hand hygiene upon entry to a room and exit of a room. In addition hand hygiene should be performed after removal of dirty gloves and prior to applying new dressing. 4. Review of the Handwashing/Hand Hygiene policy and procedure included the following: .6.Wash hands with soap and water for the following situations: . b. After contact with a resident with known or suspected with infectious diarrhea including, but not limited to infections caused by norovisus, salmonella, shigella, and [DIAGNOSES REDACTED]icile .7. g. Before handling clean or soiled dressings, gauze pads, etc.; .k. After handling used dressings, contaminated equipment, etc. m. After removing gloves. n. Before and after entering isolation precaution settings.",2020-09-01
45,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-10-25,600,G,1,0,GM1D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, facility investigation review, facility incident report review, review of policy and procedures, and review of professional standards, the facility failed to provide services to a resident that were necessary to avoid physical harm. Specifically, the facility failed to implement advance directives for 1 of 1 sample residents (#2) who experienced cardiopulmonary arrest in the facility and had elected to receive CPR in such an event. This failure resulted in harm to resident #2 who was found unresponsive, staff failed to initiate CPR, and the resident expired. Corrective measures were implemented by the facility, and compliance was determined to be met on [DATE]. The findings were: 1. Review of the WyoPOLST (Wyoming Providers Orders for Life Sustaining Treatment) form dated [DATE] (and signed by the physician on what appeared to be [DATE]) revealed resident #2 requested to be resuscitated in the event of no pulse and is not breathing. Further review showed the POLST form was reviewed with the resident on [DATE], [DATE], [DATE], and [DATE] and the resident elected to maintain a full code status. The following concerns were identified: a. Review of a progress note created by RN #1 dated [DATE] at 2:18 AM showed At 0110 (1:10 AM) this morning Resident was found not breathing, unresponsive, no pulse and no heartbeat with auscultation. Pupils nonreactive (physician name) notified and Resident pronounced dead at 0120 (1:20 AM). There was no evidence staff initiated CPR. b. Review of an Investigator's Interview Statement of Event, signed by the DON and dated [DATE], showed CNA #1 was interviewed by the facility, and described the event. The CNA told the facility she had answered the resident's call light and had started to help him/her when she was called to assist another CN[NAME] Upon returning to the resident's room ,[DATE] minutes later she found the resident unresponsive and attempted to rouse (him/her) with no response. The CNA then ran out of the room to go find the nurse. Ran up and down halls calling out for nurse and couldn't find her. Finally found her in the bathroom. Nurse finished up going to the bathroom and than (sic) went down to (the resident's) room. (The resident) was unresponsive when CNA found (him/her) + 15 min/20 min later the nurse went to the room (By the time CNA tried to arouse (him/her) and find the nurse). c. Review of an Investigator's Interview Statement of Event signed by the DON and dated [DATE], showed RN #1 was interviewed by the facility and described the event. She told the facility the CNA looked for me and I was in the restroom. Further review showed the nurse went to the resident's room to check the resident's status and noted color changes, no heartbeat, no lung sounds, was unresponsive, and was not warm to the touch. The nurse stated she immediately called the physician. In addition, RN #1 recalled receiving POLST education, however she had misunderstood the parameters with following through with the POLST. d. Review of the medical record and the investigation documentation provided by the facility showed no evidence CNA #1 or RN #1 had used the intercom system to activate Code Blue or made an attempt to contact a nurse on a different floor on [DATE] between 12:55 AM and 1:20 AM. e. Interview with LPN #1 on [DATE] at 6:07 PM revealed she was working on the third floor the night the incident occurred and Code Blue had not been activated. Further, RN #1 had contacted her approximately 30 minutes after the resident had expired, informed her the physician had been notified, orders had been received for transport, and then requested information in regard to where to find mortuary papers. LPN #1 asked the RN about the resident's code status and was informed the resident had been a Full Code; however the resident had expired before interventions had been instigated. The LPN stated she never set eyes on the resident. f. Interview on [DATE] at 2 PM with the DON, administrator, and the corporate district DON confirmed the CNA had not called Code Blue, however the CNA had gone down every hall two times until she found the nurse in the bathroom. Further, the nurse did not check the resident's chart to establish the resident's CPR status until after she had completed her assessment. The DON revealed the investigation had determined it was definitely between 10 and 15 minutes from when the CNA found the resident unresponsive until the nurse arrived in the resident's room. g. Review of the facility's incident report submitted to the State Survey Agency on [DATE] showed the incident was documented as Failure to Provide Services. The report showed the resident had elected to receive CPR in the event of cardiopulmonary arrest, and confirmed the facility failed to initiate CPR. 2. Review of the Advance Directive policy, last updated (MONTH) (YEAR), showed a policy statement of The Center relates information regarding advance directive to each resident and honors each advance directive that is given to it. Review of the Cardiopulmonary Resuscitation policy, last updated (MONTH) (YEAR), showed .CPR is initiated for those residents who: a. Have requested, through advanced directive or POLST/POST, to have CPR initiated when cardiac or respiratory arrest occurs . 3. According to Perry, Potter, and Ostendorf in Nursing Interventions and Clinical Skills, 7th edition, 2020, page 812 .Immediate recognition of [MEDICAL CONDITION] and activation of emergency medical response are critical. Early CPR and recommended health care team-level coordination that switches the provider who performs chest compressions every 2 minutes improves the performance of high-quality CPR (AHA, (YEAR)). 4. According to the American Heart Association Emergency Cardiovascular Care website found at https://eccguidelines.heart.org; (retrieved [DATE]), Part 3: Ethical Issues, Withholding and Withdrawing CPR, Out-of-Hospital [MEDICAL CONDITION] (OHCA), Terminating Resuscitative Efforts in Adult OHCA, BLS out-of-hospital system showed Rescuers who start BLS should continue resuscitation until one of the following occurs: a. Restoration of effective, spontaneous circulation b. Care is transferred to a team providing advanced life support c. The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy d. Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met. 5. Review of the facility's action plan in response to this incident showed the root cause was determined to be: Nursing staff will verbalize how a code status is verified via POLST form and procedure to carry out based upon full code or DNR status. All charts will have current and updated POLST forms in place. 1) Licensed Nurses will verbalize Advanced Directives choice and explanation of full code versus DNR details. Corrective actions taken were provide education to nursing staff in regard to the POLST form, verification of code status before initiation of interventions if resident is unresponsive, full code versus DNR status and procedure to carry out accordingly. In addition, an audit was conducted on [DATE] of current resident's charts to ensure the POLST forms were complete. Monitoring included weekly random audits for nursing staff for 4 weeks on identification of how to verify code status and initiate a code status according to the policy and procedure. a Interview on [DATE] at 3:05 PM with the staff development coordinator (SDC) revealed she had educated the licensed nurses on [DATE] following the incident. Review of an Inservice Education Summary form dated [DATE] showed 26 nurses (RNs and LPNs) had received training on the topic of POLST/CPR/Full code protocol. b. Review of the facility's audit documentation showed 26 licensed nurses responded accurately to facility interviews regarding the facility's POLST/CPR/Full Code protocol. c. Review of the facility's audit documentation showed the audit of all current resident charts for completed POLST forms was concluded on [DATE].",2020-09-01
46,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-10-25,678,K,1,0,GM1D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, review of policy and procedures, facility incident report review, review of the facility's Standards for Code Blue and review of professional standards, the facility failed to ensure basic life support was administered to 1 of 1 sample resident (#2) who required emergency life support, and failed to ensure staff were familiar with facility policies related to CPR. The facility failed to implement the advance directive for 1 of 1 sample resident (#2) that expired in the facility that had elected to receive CPR in the event of cardiopulmonary arrest. At the time of the survey 53 out of 117 residents had elected to receive CPR in the event of cardiopulmonary arrest. This resulted in a determination of an immediate jeopardy situation and substandard quality of care for these residents. The findings were: 1. Review of the WyoPOLST (Wyoming Providers Orders for Life Sustaining Treatment) form dated [DATE] (and signed by the physician on what appeared to be [DATE]) revealed resident #2 requested to be resuscitated in the event of no pulse and is not breathing. Further review showed the POLST was reviewed with the resident on [DATE], [DATE], [DATE], and [DATE] and the resident elected to maintain a full code status. Review of an unsigned and undated Standards for Code Blue provided by the facility on [DATE] at 9:40 AM showed Any person who discovers that a resident is unresponsive should immediately notify the employee in charge. Steps to take immediately: 1. Activate the Code Blue a. To activate the Code Blue in your Center: i. Announce Code Blue and the location of the unresponsive resident by shouting or paging overhead (#39) at least three times .ii. Establish the Resident's Code status . Interview with the administrator on [DATE] at 1:15 PM revealed the Standards for Code Blue was a process the facility had been using forever. The following concerns were identified: a. Review of a progress note created by RN #1 dated [DATE] at 2:18 AM showed At 0110 (1:10 AM) this morning Resident was found not breathing, unresponsive, no pulse and no heartbeat with auscultation. Pupils nonreactive (physician name) notified and Resident pronounced dead at 0120 (1:20 AM). There was no evidence staff initiated CPR. b. Review of an Investigator's Interview Statement of Event, signed by the DON and dated [DATE], showed CNA #1 was interviewed by the facility, and described the event. The CNA told the facility she had answered the resident's call light and had started to help him/her when she was called to assist another CN[NAME] Upon returning to the resident's room ,[DATE] minutes later she found the resident unresponsive and attempted to rouse (him/her) with no response. The CNA then ran out of the room to go find the nurse. Ran up and down halls calling out for nurse and couldn't find her. Finally found her in the bathroom. Nurse finished up going to the bathroom and than (sic) went down to (the resident's) room. (The resident) was unresponsive when CNA found (him/her) + 15 min/20 min later the nurse went to the room (By the time CNA tried to arouse (him/her) and find the nurse). c. Review of an Investigator's Interview Statement of Event signed by the DON and dated [DATE], showed RN #1 was interviewed by the facility and described the event. She told the facility the CNA had looked for me and I was in the restroom. Further review showed the nurse went to the resident's room to check the resident's status and noted color changes, no heartbeat, no lung sounds, was unresponsive, and was not warm to the touch. The nurse stated she immediately called the physician. In addition, RN #1 recalled receiving POLST education, however she had misunderstood the parameters with following through with the POLST. d. Review of the medical record and the investigation documentation provided by the facility showed no evidence CNA #1 or RN #1 had used the intercom system to activate Code Blue or made an attempt to contact a nurse on a different floor on [DATE] between 12:55 AM and 1:20 AM. e. Interview with LPN #1 on [DATE] at 6:07 PM revealed she was working on the third floor the night the incident occurred and Code Blue had not been activated. Further, RN #1 had contacted her approximately 30 minutes after the resident had expired, informed her the physician had been notified, orders had been received for transport, and then requested information in regard to where to find mortuary papers. LPN #1 asked the RN about the resident's code status and was informed the resident had been a Full Code; however the resident had expired before interventions had been instigated. The LPN stated she never set eyes on the resident. f. Interview on [DATE] at 2 PM with the DON, administrator, and the corporate district DON confirmed the CNA had not called Code Blue, however the CNA had gone down every hall two times until she found the nurse in the bathroom. Further, the nurse did not check the resident's chart to establish the resident's CPR status until after she had completed her assessment. The DON revealed the investigation had determined it was definitely between 10 and 15 minutes from when the CNA found the resident unresponsive until the nurse arrived in the resident's room. g. Review of the incident report submitted to the State Survey Agency on [DATE] showed the incident type was documented as Failure to provide Services and stated the resident was a Full Code, and confirmed the facility staff failed to initiate CPR. The documentation further showed RN #1 was immediately educated regarding Wyoming POLST and full code. The facility developed a plan of action and as part of the action plan had started educating all licensed nurses and implemented random daily nurse interviews regarding the POLST and full code status. h. Review of the facility's action plan in response to this incident showed the root cause was determined to be Nursing staff will verbalize how a code status is verified via POLST form and procedure to carry out based upon full code or DNR status. All charts will have current and updated POLST forms in place. 1) Licensed Nurses will verbalize Advanced Directives choice and explanation of full code versus DNR details. Corrective actions taken were provide education to nursing staff in regard to the POLST form, verification of code status before initiation of interventions if resident is unresponsive, full code versus DNR status and procedure to carry out accordingly. In addition, an audit was conducted on [DATE] of current resident's charts to ensure the POLST forms were complete. Monitoring included weekly random audits for nursing staff for 4 weeks on identification of how to verify code status and initiate a code status according to the policy and procedure. However, the action plan failed to address the unavailability of the nurse and the CNA's failure to activate a Code Blue to obtain assistance. i. Review of an Inservice Education Summary form dated [DATE] showed 26 nurses (RNs and LPNs) had received training on the topic of POLST/CPR/Full code protocol. j. Interview on [DATE] at 3:05 PM with the staff development coordinator (SDC) revealed she had educated the licensed nurses on [DATE] following the incident; however she had realized in the last week CNAs also needed to be educated. This education was to include the corporation's policy of only licensed nurses being allowed to perform CPR; and if a resident was found unresponsive they were to find a nurse, call code blue, retrieve the resident's chart, and return to the resident's room. The intercom system was activated by dialing #39 on the telephone. Further, she had begun the process to educate the CNAs individually and planned to finish at the all-staff in-service which was to be held on [DATE]. k. Review of an undated Inservice Education Summary form provided by the SDC showed the topic was CPR, codes, POLST. Further review showed 15 CNAs and 2 HSAs had completed the education. Review of the facility's personnel roster (updated on [DATE]) showed the facility employed 50 CNAs (31 full-time, 3 part-time, 13 PRN, 1 unspecified, 2 restorative aides) and 13 hospitality aides. l. Interviews with 9 CNAs on [DATE] between 1:20 PM and 4:08 PM revealed how they would respond if they found an unresponsive resident. Seven of the 9 CNAs described a response that was inconsistent with the facility's Standards for Code Blue, as evidenced by the following: i. CNA #2 stated she would yell for help, try CPR, and if no one came would run out of the room to get help. ii. CNA #3 stated she would check on the resident and then go get a nurse. iii. CNA #4 stated she would yell code and then find a nurse. iv. CNA #5 stated she would yell code blue and find a nurse. In addition, if she was unable to find a nurse she would call 911 and start CPR. v. CNA #7 stated she would notify the nurse, call a different floor if a nurse was not available, and check the resident's code status in their chart. vi. CNA #9 stated she would push the call light, find a nurse, and start compressions. In addition, if she could not find a nurse she would ask another CNA for assistance. vii. CNA #10 stated she would look for signs of life, call for a nurse, stay in the resident's room, and start CPR. In addition, she thought #39 was used to activate the intercom, however she was not sure. m. Review of the Advance Directive policy, last updated (MONTH) (YEAR), showed a policy statement of The Center relates information regarding advance directive to each resident and honors each advance directive that is given to it. Review of the Cardiopulmonary Resuscitation policy, last updated (MONTH) (YEAR), showed .CPR is initiated for those residents who: a. Have requested, through advanced directive or POLST/POST, to have CPR initiated when cardiac or respiratory arrest occurs . n. Interview with the administrator on [DATE] at 4:52 PM revealed the facility did not have a policy in regard to the procedure to follow if a resident, visitor, or staff member was found unresponsive. In addition, the administrator stated the Advance Directive policy and the CPR policy were sufficient and a policy that outlined the steps to take when a resident was found unresponsive was not necessary because it was a standard of care. o. Review of the POLST/Code Status/Full Code audit sheets updated on [DATE] showed 53 of the 117 residents had a code status of Full Code. This number was confirmed on [DATE] at 5:30 PM by the district DON 2. According to Perry, Potter, and Ostendorf in Nursing Interventions and Clinical Skills, 7th edition, 2020, page 812 .Immediate recognition of [MEDICAL CONDITION] and activation of emergency medical response are critical. Early CPR and recommended health care team-level coordination that switches the provider who performs chest compressions every 2 minutes improves the performance of high-quality CPR (AHA, (YEAR)). 3. According to the American Heart Association Emergency Cardiovascular Care website found at https://eccguidelines.heart.org; (retrieved [DATE]), Part 3: Ethical Issues, Withholding and Withdrawing CPR, Out-of-Hospital [MEDICAL CONDITION] (OHCA), Terminating Resuscitative Efforts in Adult OHCA, BLS out-of-hospital system showed Rescuers who start BLS should continue resuscitation until one of the following occurs: a. Restoration of effective, spontaneous circulation b. Care is transferred to a team providing advanced life support c. The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitative efforts places others in jeopardy d. Reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met. 4. On [DATE] at 6 PM, the administrator was notified of the immediate jeopardy related to the facility's failure to initiate CPR for resident #2, and failure to ensure facility staff were familiar with facility policies or standards of care related to CPR. The facility's removal plan included the following corrective actions: a. Education will be provided to all staff including nursing, dietary, activities, and housekeeping in regard to the WyoPOLST form, verification of code status before initiation of interventions if a resident was unresponsive, Full Code versus DNR status, announcement of the standards for code blue, and CPR initiated by a licensed nurse only. The education was to begin on [DATE] at 6 PM and continue until all staff had been educated prior to work. b. An audit was conducted on [DATE] of all current residents to verify their code status and physician signature. c. An audit was conducted on [DATE] on all current employees to verify current CPR/BLS certification. d. A Mock Code Blue Drill was conducted on [DATE] at 7 AM and would continue every shift for the next 24 hours and then one time per week for 4 weeks, monthly for two months, and once per quarter. e. A monitoring system was put into practice to ensure staff were able to identify code status and initiate a code. In addition, audits would be conducted to ensure current residents' POLST forms were complete; licensed staff had current CPR/BLS certification, and a CPR-certified nurse was on duty at all times. The removal plan was accepted on [DATE] at 1:44 PM, and the immediate jeopardy was removed on [DATE] at 2:40 PM. However, deficient practice remained at a scope and severity of G (Actual harm that is not immediate jeopardy).",2020-09-01
47,GRANITE REHABILITATION AND WELLNESS,535013,3128 BOXELDER DRIVE,CHEYENNE,WY,82001,2019-10-30,684,D,1,0,MTHS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interview, and policy and procedure review, the facility failed to complete wound assessments for 1 of 9 residents (#1) reviewed for wound care. The findings were: 1. Review of the medical record showed resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment, dated 6/24/19 showed the resident had a surgical wound that required surgical wound care. The following concerns were identified: a. Review of the Admission/Readmission Nursing Evaluation, not dated, showed a diagram of the human body with documentation that [MEDICAL CONDITION] lesion removed. The evaluation failed to show any documentation of the surgical site, including location, size, wound appearance, odor, and dressing. b. Review of the care plan showed an initiation date of 6/25/19, and interventions included observe/assess surgical site every shift per MD order until healed. Review of the nursing progress notes revealed a late entry documentation dated 10/11/19, which showed (the [MEDICAL CONDITION] ) began to get larger and getting an odor . Continued review of the nursing progress notes for (MONTH) failed to show any assessments of the wound site. Further review of the medical record failed to show an assessment of the surgical wound. c. Interview with the director of nursing on 10/30/19 at 12:00 PM revealed the facility had no additional information on wound assessments for this resident. d. Review of the Skin Integrity Policy, updated (MONTH) 2019, showed .6. For skin impairment identified with admission, the LN (licensed nurse) completes the following: a.documents skin impairment that includes measurements of size, color, presence of odor, exudates, and presence of pain associated with the skin impairment in Nurse's Notes and on the Weekly Wound Evaluation .9. Wounds are evaluated weekly by Center clinicians .surgical wounds .are evaluated, measured and findings documented in the medical record .",2020-09-01
48,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2017-02-02,226,E,0,1,W1N011,"Based on review of facility investigation documentation, staff interview, and policy review, the facility failed to implement written policies related to reporting for 2 of 3 allegations of abuse or neglect (involving residents #20 and #30) reviewed. In addition, the facility failed to revise policies related to reporting to ensure compliance with federal regulations. The findings were: 1. Review of facility investigation documentation revealed the following: a. An allegation of verbal abuse by a staff member to resident #30 on 3/5/16 was not reported to Healthcare Licensing and Surveys (HLS) until 3/7/16. b. An allegation of neglect involving resident #20 which was dated 8/30/16 was not reported to HLS until 9/7/16. During an interview on 2/1/17 at 3:30 PM the administrator confirmed the dates of the notification to HLS for the two allegations. She stated she was out of the office when the written allegation involving resident #20 was received. She stated the staff person who handled the allegation involving resident #30 no longer worked in the facility, so she was unsure why it was reported late. 2. Review of the facility's policy Procedure to handle suspected abuse, neglect and misappropriation of funds (reviewed 12/2016) showed Allegations are to be reported immediately (within 24 hours) to the following agencies and actions taken to prevent recurrence: The Department of Healthcare Licensing and Survey . 3. During an interview on 2/1/17 at 3:30 PM the administrator stated she was unaware of new federal regulations for nursing homes effective (MONTH) 28, (YEAR). Specifically, she was not aware that allegations of abuse and other allegations involving harm were to be reported within 2 hours. She stated the facility's policies had not been updated.",2020-09-01
49,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2017-02-02,253,E,0,1,W1N011,"Based on observation and staff interview, the facility failed to ensure 3 of 4 resident areas (100 hall, 200 hall, 300 hall) were in good repair. The findings were: 1. Observation of the 100 hall on 2/1/17 showed the following: a. Observation on 2/1/17 at 5:30 PM revealed the emergency doors had a worn area 26 1/2 inches up from the floor that measured 3 feet by 2 inches and exposed the underlying metal which created surface that could not be cleaned effectively. b. Observation of the shower room at 5:35 PM showed the lower 3 inches of the doorway protector was broken off and left a rough sharp surface. The corner wall by the sink had an area where the plaster was broken away and exposed the underlying metal above the wall trim. The wall opposite of the sink had 2 damaged areas 9 inches up from the floor. The first was 30 inches from the wall and measured 4 inches, and the second was 43 inches from the wall, and measured 14 inches where the underlying material was exposed. Further, the wall had 3 areas 9 inches up from the floor that were 58 inches from the wall, 60 inches from the wall, and 62 inches from the wall where the surface had been damaged and the underlying drywall tape was exposed. The damaged areas created a surface that could not be cleaned effectively. c. Observation at 5:45 PM in room #102 showed open holes around the door edge on the top and left side of the metal trim that were rough to the touch and could not be cleaned effectively. 2. Observation of the 200 hall on 2/1/17 showed the following: a. Observation of the main entrance at 5:48 PM showed there was chipped paint measuring 2 1/2 inches by 1/2 inch near the wander guard box that could not be cleaned effectively. b. Observation of the hall in front of room #203 at 5:57 PM showed the carpet had 3 black spots that measured 1/2 inch by 1/2 inch, 3 inches by 1/2 inch, and 1 inch by 1/4 inch. c. Observation of the hall carpet between room #205 and #207 at 6 PM showed 3 gray stains that measured 4 inches by 4 inches each. 3. Observation of the 300 hall on 2/1/17 showed the following: a. Observation of the housekeeping door at 5:50 PM showed chips in the paint that exposed the underlying surface and could not be cleaned effectively. 4. Interview with the maintenance director on 2/2/17 at 9:30 AM verified the identified areas were in need of repair.",2020-09-01
50,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2017-02-02,276,D,0,1,W1N011,"Based on medical record review, staff interview, and review of the Resident Assessment Instrument User's Manual, the facility failed to ensure quarterly MDS assessments were completed no less than every 3 months for 1 of 9 sample residents (#21) with quarterly MDS assessments. The findings were: 1. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, (MONTH) (YEAR), by the Centers for Medicare and Medicaid Services, showed a quarterly assessment should have an assessment reference date (ARD) of no later than 92 days from the ARD of the previous federally mandated assessment. 2. Review of the admission MDS assessment for resident #21 showed an ARD of 7/4/16. Review of the subsequent quarterly MDS assessment revealed an ARD of 10/28/16 (116 days after the ARD of the admission assessment). During an interview on 2/2/17 at 9:15 AM the DON confirmed the quarterly MDS assessment was completed more than 92 days after the admission assessment.",2020-09-01
51,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2017-02-02,309,E,0,1,W1N011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's elimination protocol, staff interview, and medical record review, the facility failed to ensure interventions were implemented for lack of bowel movements (BMs) in accordance with the elimination protocol for 6 of 10 sample residents (#3, #21, #25, #27, #30, #35) reviewed. The findings were: Review of the facility's Elimination Protocol showed .3rd Day (72 hours without a BM) 2 [MEDICATION NAME] (laxative) tabs along with walking and fluids. Document senna on MAR comment sheet. 4th Day-Day Shift: [MEDICATION NAME] (stool softener) with walking and fluids. Assess bowel sounds. Document [MEDICATION NAME] on MAR comment sheet and follow up on BM (yes/no). Document in chart. EVE (evening) shift: MOM (Milk of Magnesia - a laxative) with walking and fluids. Assess bowel sounds. Document MOM on MAR comment sheet and follow up on BM (yes/no). Document in chart. N[NAME] (night) Shift: Bisocodyl suppository. Assess bowel sounds. Document suppository on MAR comment sheet and follow up on BM (yes/no). Document in chart. 5th Day- Assess bowel sounds- Fleets Enema- Notify physician and document in chart. The following concerns were identified regarding failure to follow the protocol: 1. Review of the BM record and MARs for resident #3 revealed the following: a. According to the (MONTH) (YEAR) BM record, the resident did not have a BM from 1/12 through 1/16 (5 days), 1/18 through 1/22 (5 days), and 1/24 through 1/30 (7 days). Review of the MAR and nursing notes showed no PRN (as needed) interventions in accordance with the elimination protocol were administered. b. Review of the (MONTH) (YEAR) BM record showed the resident did not have a BM 11/28 through 12/3 (6 days), and 12/15 through 12/19 (5 days). According to the MAR and nursing notes, there were no interventions for constipation documented on those dates. 2. Review of the (MONTH) (YEAR) BM record showed resident #21 did not have a BM documented from 1/18 through 1/21 (4 days), or on 1/25 through 1/28 (4 days). Review of the MAR and nursing notes showed no interventions were documented during those time frames in accordance with the elimination protocol. 3. Review of the (MONTH) (YEAR) BM record revealed resident #35 did not have a BM documented from 1/13 through 1/16 (4 days), 1/19 through 1/22 (4 days), and 1/24 through 1/27 (4 days). Review of the MAR and nursing notes failed to show any interventions related to the elimination protocol. 4. Review of the (MONTH) (YEAR) BM record showed resident #27 did not have a BM documented 1/26 through 1/29 (4 days). Review of the MAR and nursing notes showed no interventions related to the elimination protocol were documented. 5. Review of the (MONTH) (YEAR) BM record showed resident #30 did not have a BM documented 1/3 through 1/7 (5 days), 1/9 through 1/13 (5 days), 1/16 through 1/19 (4 days). Review of the MAR and nursing notes showed no interventions for constipation were administered during those timeframes. 6. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) BM records showed resident #25 did not have a BM documented 12/13 through 12/21 (9 days), or 1/8 through 1/12 (5 days). According to the MAR and nursing notes showed no interventions were documented during those time frames in accordance to the elimination protocol. 7. During an interview on 2/2/17 at 9:15 AM the DON stated nursing staff should follow the elimination protocol and document interventions on the MAR. She stated she had copies of the elimination protocol sheets that nurses used to track days without a BM and interventions given, which she kept in her office. The facility provided copies of the documentation for the above mentioned residents, but the documentation failed to show any constipation interventions for the applicable dates.",2020-09-01
52,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2017-02-02,425,E,0,1,W1N011,"Based on observation and staff interview the facility failed to ensure expired medications were not available for use in 2 of 2 medication carts and 1 medication room. The findings were: 1. Observation of the East/West medication cart on 2/1/17 at 2:30 PM showed benzonatate 200 mg capsules expired 8/24/16, ondansetron HCl 4 mg tablets expired 8/24/16, and ondansetron HCl 4 mg expired 11/5/16. 2. Observation of the North medication chart showed 3 bottles of carbamide peroxide 6.5% (Ear drop wax removal) two of which expired 7/16, and one which expired 12/16. 3. Observation of the Medication room showed 1 milliliter bottle of 0.9% sodium chloride irrigation solution expired 7/1/16. 4. Interview with RN #1 on 2/1/17 at 4:00 PM verified the medications were available for resident use and were past the expiration date.",2020-09-01
53,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2017-02-02,514,D,0,1,W1N011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of elimination protocol documentation, the facility failed to ensure the medical record was accurate and complete for 2 of 10 sample residents (#3, #35). The findings were: 1. During an interview on 2/2/17 at 9:15 AM the DON stated nursing staff should document interventions administered in accordance with the elimination protocol on the MAR. However, during an interview on 2/2/17 at 9:42 AM the medical records/CNA manager and DON stated nursing staff also documented on the elimination protocol sheets, which the DON kept in her office. She stated that information was not part of the medical record. 2. Review of the elimination protocol sheets and medical record for resident #3 for (MONTH) (YEAR) revealed the following: a. The resident was given [MEDICATION NAME] (stool softener), [MEDICATION NAME] (stool softener), and MOM (Milk of Magnesia - a laxative) on 1/5/17. Review of the MAR and nursing notes showed no documentation related to this. b. The resident was given [MEDICATION NAME], senna (laxative), and MOM on 1/9/17-1/10/17. Review of the MAR and nursing notes showed no documentation related to this. 3. Review of the elimination protocol sheets for (MONTH) (YEAR) showed resident #35 was administered senna on 1/10-1/11. Review of the MAR and nursing notes showed no documentation related to this.",2020-09-01
54,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2018-02-15,576,E,0,1,3QMW11,"Based on resident interview, staff interview, and post office employee interview, the facility failed to provide residents the right to send and receive mail on Saturday. The facility census was 35. The findings were: 1. Interview with 9 residents on 2/13/18 at 9:42 AM revealed they received mail on weekdays only, and they did not receive mail on Saturdays. 2. Interview on 2/13/18 at 12:42 PM with the office manager revealed she retrieved mail from the facility's post office box at the post office Monday through Friday. She further stated the mail was delivered only to rural areas on the weekends, and the post office was only open until 10:30 AM on Saturday. She further stated she didn't pick up the mail on Saturday because the business office was closed and no one was available to get the mail. She further stated she picked up Saturday's mail with Monday's mail, and there typically wasn't much mail for those two days. 3. Interview on 2/15/18 at 10:30 AM with the CNA manager revealed the post office delivered packages and boxes on Saturday, and mail was delivered to rural areas only on Saturdays. 4. Interview on 2/20/18 at 10:42 AM employee #1 of the local post office revealed the post office was open on Saturdays from 9 AM to 11 AM. She further revealed that all town residents who lived in town had a post office box and mail was delivered only to rural areas. The employee also stated the nursing home's mail was placed in their post office box on Saturday, and most of the time there was a decent amount of mail.",2020-09-01
55,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2018-02-15,641,D,0,1,3QMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review, review of facility policy, and review of the CMS Resident Assessment Instrument (RAI) version 3.0 manual, the facility failed to ensure MDS assessments were accurately completed for 1 of 12 sample residents (#133). The findings were: 1. Medical record review showed resident #133 was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. Interview with the resident on 2/13/18 at 10:25 AM revealed s/he developed a pressure ulcer on his/her buttock while in the hospital. Observation on 2/14/18 at 1:35 PM showed resident had a 1.1 cm area of healing skin on the coccyx covered with a dressing dated 2/12/18. Review of the nursing admission evaluation and interim care plan showed a diagram of the human body with the coccyx area circled and 1 cm black escar (sic) documented. Review of a nurse's note dated 1/30/18 at 5:30 PM showed, Resident also has 1 cm escar (sic) to coccyx. Allevyn dressing applied for protection. Review of a nurse's note dated 2/12/18 at 8:30 PM showed, Resident has a sore at top of butt crack that (s/he) reports (s/he) got while in the hospital. This RN placed Alevyn on site. The following concerns were identified: a. Interview on 2/14/18 at 3 PM with the MDS coordinator confirmed she considered the wound a pressure ulcer. b. Review of the admission MDS assessment revealed Section M Skin Conditions lacked documentation related to the pressure ulcer. The MDS was signed as completed on 2/8/18. Interview with MDS coordinator on 2/15/19 at 8:45 AM revealed the MDS was complete. c. Review of the facility policy titled Pressure Ulcer Prevention with a revision date of 12/17 stated, Nursing staff upon admission is to . identify the presence of pressure ulcers. d. Review of the RAI 3.0 User's Manual dated (MONTH) (YEAR) showed under Section M .Steps for Assessments .1. Review the medical record .including skin care flow sheets, and nurses' notes. 2. Speak with the treatment nurse and direct care staff on all shifts to confirm conclusions from the medical record review and observations of the resident . Continued review showed .Pressure ulcers that eschar (tan, black or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized .should be classified as unstageable . Further review showed .For each pressure ulcer, determine if the pressure ulcer was present at the time of admission .and not acquired while the resident was in the care of the nursing home .",2020-09-01
56,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2018-02-15,686,D,0,1,3QMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, medical record review and policy review, the facility failed to provide necessary services and treatment to promote healing of a pressure ulcer for 1 of 1 sample resident (#133) with a pressure ulcer. The findings were: 1. Medical record review showed resident #133 was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. Interview with the resident on 2/13/18 at 10:25 AM revealed s/he had developed a pressure ulcer on his/her buttock while in the hospital. Further interview revealed the facility staff placed a dressing on it. Observation on 2/14/18 at 1:35 PM showed the resident had a 1.1 cm area of healing skin on the coccyx covered with a dressing dated 2/12/18. Review of the nursing admission evaluation showed a diagram of the human body with the coccyx area circled and 1 cm black escar(sic) documented. Review of a nurse's note dated 1/30/18 and timed 5:30 PM showed resident also has 1 cm escar (sic) to coccyx. Alevyn dressing applied for protection. Review of a nurse's note dated 2/12/18 and timed 8:30 PM showed resident has a sore at top of butt crack that (s/he) reports (s/he) got while in hospital. This RN placed Alevyn on site. Interview on 2/14/18 at 3 PM with the MDS coordinator confirmed she considered the wound a pressure ulcer. The following concerns were identified: a. There lacked evidence the physician was notified of the pressure ulcer. Review of the medical record showed no physician's orders or documentation related to the pressure ulcer. Interview on 2/14/18 at 3:00 PM with the MDS coordinator revealed the chart lacked physician documentation and orders related to the pressure ulcer. b. Medical record review on 2/14/18 failed to show consistent nursing documentation related to the wound or wound treatment. c. Review of the facility policy titled Pressure Ulcer Prevention, last revised 12/17 showed Nursing staff upon admission .is to identify the presence of pressure ulcers .Nursing staff will then develop and implement a comprehensive care plan that reflects each resident's needs the nurse should monitor the impact of the interventions . the pressure ulcer must be reassessed at least weekly and the healing progress documented .",2020-09-01
57,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2018-02-15,842,D,0,1,3QMW11,"Based on observation, medical record review and staff interview, the facility failed to ensure the medical record was complete for 1 of 12 sample residents (#18). The findings were: Observation on 2/12/18 at 5:17 PM revealed CNA #1 and LPN #1 transferred resident #18 from bed to wheelchair. At the time the LPN revealed the resident had a skin tear on his/her arm. Further observation at that time showed a white bandage on the resident's left arm, above the wrist. Observation on 2/13/18 at 9:56 AM revealed the resident still had a bandage on the left arm. Review of the medical record on 2/14/18 showed no documentation related to a skin tear on the resident's arm. During an interview on 2/14/18 at 2:49 PM the MDS coordinator confirmed there was no documentation related to a skin tear or the bandage on the resident's arm. She stated she spoke with the resident's nurse and looked under the bandage. She stated it was a small area that the resident picked/scratched.",2020-09-01
58,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2018-02-15,865,E,0,1,3QMW11,"Based on review of the facility's written QAPI plan and staff interview, the facility failed to ensure the plan contained all the required elements. The findings were: Review of the facility's plan titled QAPI Policy showed it did not describe the process for identifying and correcting quality deficiencies. The policy listed the members of the QAPI oversight team and listed the frequency of meetings. Specifically, the plan lacked the following: a. Tracking and measuring performance. b. Establishing goals and thresholds for performance measurement. c. Identifying and prioritizing quality deficiencies. d. Analyzing underlying causes of systemic quality deficiencies. e. Developing and implementing corrective action or performance improvement activities. f. Monitoring the effectiveness of corrective action, and revising as needed. During an interview on 2/15/18 at 8:07 AM the QAPI coordinator stated the facility was in the process of revising the written QAPI plan/policy and confirmed the current policy/plan did not contain all the required elements.",2020-09-01
59,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2019-03-14,604,D,0,1,68ZB11,"Based on observation, medical record review, and staff and resident interviews, the facility failed to ensure restraints were used to treat a medical condition, that the restraint was the least restrictive intervention, and that there was on-going evaluation for 1 of 6 sample residents (#18) with restraints. The findings were: 1. Review of the 2/6/19 quarterly MDS assessment revealed resident #18 had a BIMS score of 14 (intact cognition). Observation on 3/12/19 at 8:50 AM revealed CNA #1 and CNA #2 transferred the resident into a recliner in his/her room. The CNAs used the control for the recliner to recline the chair and elevate the resident's feet. The CNAs then disconnected the control, and placed it in a drawer across the room. During an interview at the time, the CNAs stated they removed the control so the resident would not use it to lower his/her feet and try to walk. During an interview on 3/12/19 at 12:53 PM the resident stated s/he was unable to change his/her position in the recliner if s/he wanted because staff removed the control because they didn't want him/her to use the control to lower the foot of the recliner. During an interview on 3/13/19 at 3:50 PM RN #1 stated staff removed the control for the recliner so the resident could not use it to lower the foot of the recliner and try to get up. The following concerns were identified: a. Review of the medical record showed no documentation of any medical symptoms related to staff removing the control for the recliner, nor was there evidence of on-going assessment to determine the continued need to remove the control for the recliner. d. On 3/13/19 at 4:19 PM the administrator stated that staff removing the control for the recliner would be considered a restraint because it restricted freedom of movement (positional change), and confirmed the facility had not gone through the normal assessment process for restraints.",2020-09-01
60,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2019-03-14,623,E,0,1,68ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a transfer notice was issued for 3 of 3 sample residents (#1, #8, #20) with hospital transfers. The findings were: 1. Review of the medical record for resident #1 showed s/he was transferred to the hospital on [DATE] for an evaluation. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 2. Review of the medical record for resident #8 showed s/he was transferred to the hospital on [DATE]. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 3. Review of the medical record for resident #20 showed s/he was transferred to the hospital on [DATE]. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 4. Interview with the administrator 3/13/19 2:52 PM revealed the facility had not issued written notices of transfer with all the required information to the residents or the residents' representative.",2020-09-01
61,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2019-03-14,625,E,0,1,68ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written information on the bed-hold policy for 3 of 3 sample residents (#1, #8, #20) with hospital transfers. The findings were: 1. Review of the medical record for resident #1 showed s/he was transferred to the hospital on [DATE] for an evaluation. Further review showed no evidence the facility issued a written notice of bed-hold policy to the resident or the resident's representative. 2. Review of the medical record for resident #8 showed s/he was transferred to the hospital on [DATE]. Further review showed no evidence the facility issued a written notice of bed-hold policy to the resident or the resident's representative. 3. Review of the medical record for resident #20 showed s/he was transferred to the hospital on [DATE]. Further review showed no evidence the facility issued a written notice of bed-hold policy to the resident or the resident's representative. 4. Interview with the administrator on 3/13/19 at 2:52 PM revealed the facility had not issued written notices of the bed-hold policy to the residents or the residents' representative.",2020-09-01
62,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2019-03-14,660,D,0,1,68ZB11,"Based on medical record review and staff interview, the facility failed to ensure the development and implementation of a discharge plan for 1 of 2 sample residents (#29) who were discharged . The findings were: 1. Review of the medical record for discharged resident #29 on 3/13/19 10:22 AM showed that a comprehensive discharge plan had not been developed. An Interdisciplinary Discharge Summary that was used as documentation was not complete, and did not include elements necessary to prevent unnecessary readmissions such as a reconciliation of pre and post discharge medications. There was no indication of where the resident planned to live, nor was there documentation that pertinent labs, prescriptions, or new home medications had been forwarded to the resident's primary care provider. 2. In an interview on 3/13/19 04:45 PM, the administrator and medical records staff #1 confirmed that the Interdisciplinary Discharge Summary was the only documentation in use and acknowledged it did not meet all of the requirements.",2020-09-01
63,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2019-03-14,661,D,0,1,68ZB11,"Based on medical record review and staff interview, the facility failed to provide the necessary elements of a discharge summary for 1 of 2 sample residents (#29) discharged . The findings were: 1. Review of the medical record for discharged resident #29 showed that the form with the heading Interdisciplinary Discharge Summary did not include diagnoses, pertinent lab results, a reconciliation of all pre-discharge medications with post-discharge medications, or a post-discharge plan of care indicating where the individual planned to reside. There was no documentation of arrangements for follow up care, ordered lab work, or continued medication oversight. Review of the Medication Administration Record [REDACTED]. These changes and future dosing plans were not addressed in the Interdisciplinary Discharge Summary. 2. Interview with the administrator and medical records staff #1 on 3/13/19 4:45 PM confirmed that the Interdisciplinary Discharge Summary was the only form in use for discharges and they acknowledged it was incomplete.",2020-09-01
64,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2019-03-14,755,D,0,1,68ZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy and procedure review, the facility failed to ensure medications available for use were not expired in 1 of 2 medication carts (North medication cart). The findings were: 1. Observation during medication pass on [DATE] at 4:25 PM of the North medication cart showed the following concerns: a. One vial of [MEDICATION NAME] R 100 units/milliliter (ml) insulin showed no written expiration date. b. Three [MEDICATION NAME] flex touch insulin pens 100 unit/ml showed no written expiration date. c. One Humalog injection insulin pen 100 unit/ml showed no written expiration date. Interview with RN #2 at that time confirmed the medications had no written date, and were available for use. 2. Interview with the DON on [DATE] at 3:58 PM revealed it was the facility expectation that the medications were labeled with expiration dates, and they were to be discarded when expired. 3. Review of the policy named Administering Medication established on ,[DATE] showed .7. a .Insulin must have expiration date from date of opening labeled on the outside of the bottle.",2020-09-01
65,SUBLETTE CENTER,535017,333 N BRIDGER AVE,PINEDALE,WY,82941,2019-03-14,880,D,0,1,68ZB11,"Based on observation, medical record review and staff interview, the facility failed to ensure staff utilized infection prevention techniques for 1 of 2 sample residents (#1) with a urinary catheter. The findings were: 1. Observation of resident #1 on 3/12/19 at 5 PM showed the resident was on contact isolation for extended spectrum beta-lactamases (ESBL) in the urine. Continued observation showed the resident's Foley catheter bag was uncovered and lying on the floor. a. Interview on 3/12/19 at 5:14 PM with RN #2 revealed the Foley bag should always be off the floor and covered. b. During an interview on 3/13/19 at 2 PM the infection control nurse stated the expectation was that catheter bags should be covered and not laying on the ground.",2020-09-01
66,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2020-01-22,678,E,1,0,EOG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of training records and the nurse schedule, staff interview, and review of facility policy and nurse job descriptions, the facility failed to ensure nurses were trained/certified in Basic Life Support (BLS), including cardiopulmonary resuscitation (CPR) for 1 of 7 nurses (RN #1) to ensure staff were present at all times to provide CPR. The findings were: 1. Review of the facility's policy emergency room /Trauma (#[DATE], undated) revealed it applied to all nurses within the(NAME)Bluejacket Skilled Nursing facility. The policy read .In the absence of a physician, nurses may initiate cardiopulmonary resuscitation on patients who have sudden unexpected cardiac or respiratory arrest, unless contraindicated. 2. During an interview on [DATE] at 11:42 AM the DON stated nurses were required to have CPR training. 3. Review of the job description for the RN (issued [DATE]) showed BLS certification is required. Review of the job description for the LPN (issued [DATE]) showed BLS certification is required. 4. Review of the [DATE] nursing schedule showed 7 nurses worked in the facility. The training records were reviewed for evidence of BLS or CPR certification for the 7 nurses. No documentation was found for RN #1. 5. During an interview on [DATE] at 12:39 PM the DON stated she was unable to provide evidence of current BLS or CPR certification for RN #1.",2020-09-01
67,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2020-01-22,805,D,1,0,EOG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of the menu, staff interview, and medical record review, the facility failed to provide food in a form to meet the resident's needs for 1 of 5 sample residents (#1) with a mechanically altered diet during 1 of 1 meals observed. The findings were: 1. Review of the annual MDS assessment, with an assessment reference date of 4/15/19, showed resident #1 received a mechanically altered diet. Review of the current care plan, dated 7/10/19, showed the resident was supposed to receive a mechanical-soft diet. Review of physician's orders [REDACTED]. The following concerns were identified: a. Observation on 1/21/20 at 5:20 PM showed the resident was served a bowl of soup and a cup of whole grapes by cook #1. b. Review of the menu for the evening meal on 1/21/20 revealed residents with a mechanical soft diet were not supposed to receive grapes. They were supposed to receive soft chopped fruit (mechanical-soft chopped diet) or mashed fruit (mechanical-soft ground diet) instead. c. During an interview on 1/22/20 at 10:19 AM cook #1 stated the resident should not have received the grapes, because he is on a mechanical-soft diet. She stated I should have been more aware.",2020-09-01
68,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2018-03-01,554,D,0,1,52NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure residents were safe to self-administer medications for 1 of 11 residents (#4) observed during medication pass. The findings were: Observation on 2/27/18 at 11:29 AM showed resident #4 self-administered [MEDICATION NAME] acetate eye drops with one drop to each eye after LPN #1 gave the bottle to the resident. Medical record review showed the facility failed to document an assessment to determine if the resident was safe to self-administer medication. Interview with the CNO on 2/28/18 at 1:46 PM confirmed that the resident self-administered some of his/her medications. She further confirmed the facility failed to assess the resident to ensure s/he was safe to self-administer his/her medications.",2020-09-01
69,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2018-03-01,638,D,0,1,52NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure quarterly assessment MDS assessments were completed every three months for 1 of 12 sample residents (#13). The findings were: Review of the MDS assessments for resident #13 showed a quarterly assessment with an assessment reference date (ARD) of 7/3/17. The next MDS assessment was a quarterly assessment dated [DATE] (5 months after the previous quarterly MDS assessment). During an interview on 2/27/18 at 3:59 PM the CNO confirmed the quarterly MDS assessment was late and should have been done in October. She stated she started in (MONTH) and the assessment must have slipped through the crack.",2020-09-01
70,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2018-03-01,640,D,0,1,52NN11,"Based on medical record review, staff interview, and review of CMS MDS submission data, the facility failed to ensure MDS assessments were transmitted for 2 of 2 non-sample residents (#125, #126). The findings were: 1. Review of CMS MDS submission data showed two facility residents did not have current MDS assessments. Resident #125 had one assessment listed: a 6/5/17 annual MDS assessment. Resident #126 had one assessment listed: a 6/5/17 admission MDS assessment. 2. Review of the medical records showed the following: a. Resident #125 had two quarterly MDS assessments dated 9/6/17 and 12/5/17. b. Resident #126 had two quarterly MDS assessments dated 9/6/17 and 12/5/17. 3. During an interview on 3/1/18 at 11:32 AM the social services director, who transmits the MDS assessments, stated she was not able to provide evidence the quarterly MDS assessments dated 9/6/17 and 12/5/17 for residents #125 and #126 had been transmitted to CMS. She stated she was unable to locate submission folders on her computer for the MDS assessments.",2020-09-01
71,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2018-03-01,657,E,0,1,52NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff and resident interview, the facility failed to ensure the care plan was revised as needed for 3 of 12 sample residents (#1, #12, #23). The findings were: 1. During an interview on 2/27/18 at 9:08 AM resident #1 stated s/he currently had a urinary tract infection [MEDICAL CONDITION] and frequently had UTIs. Review of a physician's note dated 2/27/18 showed the resident had frequent UTIs, .nearly monthly for past 4-5 months. However, review of the care plan, last reviewed 1/10/18, showed frequent UTIs was not addressed. 2. Review of the care plan for resident #12, last reviewed 2/21/18, showed diet as ordered and .will maintain 171# or less through next review. However, review of the 2/20/18 quarterly MDS assessment showed the resident weighed 150#. In addition, review of a 2/14/18 registered dietitian (RD) note showed the resident received Ensure as a supplement. A 1/10/18 physician note documented the resident said s/he wasn't eating, but received a supplement. Observation on 2/28/18 at 12:46 PM showed the resident was drinking a supplement in the dining room. Review of physician orders [REDACTED]. The resident's care plan was not updated to reflect the resident's current weight or the supplement. 3. During an interview on 2/28/18 at 10:52 AM the RD stated resident #23 had weight loss and received Carnation Instant Breakfast once per day, a Breeze drink two times per day, and a nutritional shake two times per day. A note by the RD dated 1/17/18 showed the resident received supplements multiple times daily. Observation on 2/28/18 at 5:45 PM in the dining room showed the resident had a Breeze drink and a nutritional shake. Observation in the kitchen on 2/28/18 at 4:02 PM showed a list for specialty drinks. Resident #23 was listed for Mighty Shakes for breakfast, lunch, dinner and Breeze drink for breakfast, lunch and dinner. In addition, it was posted that the resident received Carnation Instant Breakfast for breakfast. However, review of the care plan, last reviewed 1/23/18, showed only the Breeze supplement was included. The care plan did not include the nutritional shake or the Carnation Instant Breakfast. 4. During an interview on 3/1/18 at 11:30 AM the CNO confirmed the care plans for residents #1, #12, and #23 were not updated regarding UTIs and nutritional interventions.",2020-09-01
72,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2018-03-01,710,D,1,1,52NN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on former employee interview, observation, medical record review, and staff interview, the facility failed to ensure the resident's physician wrote orders for medications for 1 of 12 sample residents (#21). The findings were: 1. Review of physician progress notes [REDACTED].#21 established care with a new physician. The progress note read .all other treatments and meds will continue as before with no changes. However, there lacked evidence of an physician order [REDACTED]. The following concerns were identified: a. Interview 3/1/18 at 8:45 AM with former employee PA #1 revealed she became aware on 2/28/18 that medication, specifically [MEDICATION NAME], was still being filled under her name for this resident, and she was no longer the provider for this resident. The PA stated she left in (MONTH) (YEAR). b. Observation of medications for resident #21 with RN #1 on 3/1/18 at 9:42 AM showed the label on the [MEDICATION NAME] and [MEDICATION NAME] had PA #1 as the current practitioner for the medication orders. c. Review of the Medications Report provided by the facility on 3/1/18 at 9:27 AM showed PA #1 was still listed as the ordering practitioner for 10 routine and as needed (PRN) medications for resident #21. d. Interview with the CNO on 3/1/18 at 9:27 AM revealed the physician did not write new orders when he took over care of the resident. She stated some medications were still under the previous provider's name.",2020-09-01
73,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,565,E,0,1,GU4111,"Based on review of resident council meeting minutes and resident and staff interview, the facility failed to ensure grievances from the resident council were acted upon and followed through to resolution for 3 of 3 months reviewed (January 2019, (MONTH) 2019, (MONTH) 2019). The findings were: 1. Review of the resident council minutes for (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 showed concerns with the dietary, nursing, and housekeeping departments. The following concerns were identified: a. Review of the (MONTH) 2019 resident council minutes showed 3 concerns related to dietary and 5 concerns related to nursing. The concern in regard to staffing from 2 PM through supper showed a follow-up of In-service staff. The follow-up section to the remaining 7 concerns was left blank. b. Review of the (MONTH) 2019 resident council minutes showed 2 concerns related to nursing and 2 concerns related to housekeeping. The 2 nursing concerns were in regard to call lights and waiting for assistance from staff; the follow-up section was left blank. One housekeeping concern about missing blankets showed a follow-up of In-service staff. The additional housekeeping concern identified had a follow-up section that was left blank. c. Review of the (MONTH) 2019 resident council minutes showed 3 nursing concerns related to call light response time and the manner in which staff communicated when they responded. The follow-up to these concerns was marked as In-service. 2. Interview with 11 residents on 3/25/19 at 1:30 PM revealed they were told the issues had been addressed; however the identified nursing concerns continued to occur. 3. Interview with the social service director on 3/25/19 at 2:13 PM revealed the concerns identified at the resident council meeting were given to the appropriate department for resolution. She stated the nursing department was then educated at their monthly staff meeting. In addition the resident council minutes used to include the resolution of the concerns; however she thought that was no longer a requirement. 4. Interview with the DON on 3/27/19 at 12:03 PM revealed she educated staff in regard to the identified concerns, but had not investigated them. In addition she stated she had not attended a resident council meeting since becoming the DON in (MONTH) of 2019.",2020-09-01
74,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,575,B,0,1,GU4111,"Based on observation and staff interview, the facility failed to post the mailing and email addresses of all pertinent State agencies and advocacy groups and include a statement that the resident may file a complaint with the State Survey Agency. The census was 29. The findings were: Observation of the information board located in the main area of the facility during the survey timeframe showed the posting failed to include the mailing and email addresses of all pertinent State agencies and advocacy groups. In addition the posting failed to include the required statement pertaining to the resident's right to file a complaint with the State Survey Agency. Interview with the social service director on 3/26/19 at 5 PM revealed she was unaware of the information that must be included in the required posting.",2020-09-01
75,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,578,E,0,1,GU4111,"Based on medical record review and staff interview, the facility failed to ensure residents' advance directive preferences were accurately documented in the electronic medical record for 4 of 16 sample residents (#10, #23, #26, #81) reviewed. The findings were: 1. Review of the advance directive for resident #10 showed the resident's preference was DNR (do not resuscitate); no nutrition or hydration by intravenous line; and chose to have pain medication, a blood transfusion, and transfer to the hospital if appropriate. Review of the resident's face sheet on the EMR (electronic medical record) showed the resident's preference was Full Code. 2. Review of the advance directive for resident #23 showed the resident's preference was DNR; chose not to have hydration or nutrition by feeding tube or intravenous line; and chose to have pain medication, a blood transfusion and transfer to the hospital if appropriate. Review of the resident's face sheet on the EMR showed the resident's preference was Full Code. 3. Review of the advance directive for resident #26 showed the resident's preference was DNR; no nutrition or hydration by intravenous line; and chose to have pain medication, a blood transfusion, and transfer to the hospital if appropriate. Review of the resident's face sheet on the EMR showed the resident's preference was Full Code. 4. Review of the advance directive for resident #81 showed the resident's preference was DNR; no nutrition or hydration by intravenous line; and chose to have pain medication, a blood transfusion, and transfer to the hospital if appropriate. Review of the resident's face sheet on the EMR showed the resident's preference was Full Code. 5. Interview with the DON on 3/26/19 at 9:34 AM confirmed the EMR had not been updated to reflect the resident's advance directive preferences.",2020-09-01
76,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,585,B,0,1,GU4111,"Based on observation, review of policy and procedure, and staff interview, the facility failed to ensure the grievance policy contained all required information. The census was 29. The findings were: 1. Observation of the facility during the survey timeframe showed Resident/Family Grievance forms were located next to the information board in the main area of the facility. However, the grievance policy and contact information for the grievance official were not posted. 2. Review of the policy and procedure entitled Resident Grievance Policy last revised 4/25/16 showed the policy failed to contain required information including the contact information of the grievance official and the contact information of independent entities with whom a grievance could also be filed. Further, the policy did not address the residents' right to file a grievance anonymously. 3. Interview with the social service director on 3/26/19 at 5 PM verified the policy did not contain the required information and the residents had not been informed individually or through postings.",2020-09-01
77,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,623,D,0,1,GU4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a transfer notice was issued for 2 of 2 residents with facility-initiated transfers (#4, #27). The findings were: 1. Review of the medical record for resident #4 showed s/he was admitted to the hospital for an acute change of condition on 2/26/19 and was readmitted to the facility on [DATE]. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 2. Review of the medical record for resident #27 showed s/he was admitted to the hospital for an acute change of condition on 3/19/19 and remained hospitalized at the end of the survey on 3/27/19. Further review showed no evidence the facility issued a written notice of transfer to the resident or the resident's representative. 3. Interview with the DON on 3/26/19 at 9:49 AM verified transfer notices had not been issued to the resident or the resident's representative. Further, she stated a policy had recently been developed, however it had not been implemented.",2020-09-01
78,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,625,D,0,1,GU4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a notice of the bed-hold policy was issued for 2 of 2 residents with facility-initiated transfers (#4, #27). The findings were: 1. Review of the medical record for resident #4 showed s/he was admitted to the hospital for an acute change of condition on 2/26/19 and was readmitted to the facility on [DATE]. Further review showed no evidence the facility issued a written notice of the bed-hold policy to the resident or the resident's representative. 2. Review of the medical record for resident #27 showed s/he was admitted to the hospital for an acute change of condition on 3/19/19 and remained hospitalized at the end of the survey on 3/27/19. Further review showed no evidence the facility issued a written notice of the bed-hold policy to the resident or the resident's representative. 3. Interview with the DON on 3/26/19 at 9:49 AM verified the written notice of the bed-hold policy had not been issued to the resident or the resident's representative. Further, she stated a policy had recently been developed, however it had not been implemented.",2020-09-01
79,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,641,D,0,1,GU4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure MDS assessment information was an accurate reflection of resident status for 2 of 16 sample residents (#1, #26). The findings were: 1. Observation on 3/25/19 at 9:44 AM showed 1/2 side rails on both sides of the bed for resident #1. Review of the quarterly MDS assessment dated [DATE] showed the side rails were used as a restraint. The following concerns were identified: a. Interview on 3/26/19 at 9:33 AM with LPN #1 revealed the resident had never been in restraints and the side rails were used for repositioning. b. Interview on 3/26/19 at 2:48 PM with the DON revealed the side rails were used for repositioning and not as a restraint. She further stated she was not sure where to document the side rails on the MDS. 2. Review of the 2/4/19 quarterly MDS assessment showed resident #26 had no falls since the prior assessment completed on 11/12/18. The following concerns were identified: a. Review of a Post Fall Assessment and Intervention form dated 11/22/18 showed the resident had an unwitnessed fall on 11/21/18. b. Interview with the DON on 3/26/19 at 4:52 PM revealed an incident report had not been completed after the fall and submitted to administration, and as a result the fall was not recognized and recorded on the MDS assessment. According to the MDS 3.0 RAI Manual version 1.15, page 395: Determine the number of falls that occurred since admission/entry or reentry or prior assessment (OBRA or Scheduled PPS) and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury. According to the MDS 3.0 RAI Manual version 1.15, page 531: Section P: Restraints and Alarms: .the intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used at any time during the day or night during the 7-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories .",2020-09-01
80,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,657,E,0,1,GU4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and resident, family and staff interview, the facility failed to ensure the individualized person-centered care plan was revised as needed to reflect the resident's current needs for 5 of 16 sample residents (#1, #14, #15, #23, #26). The findings were: 1. Review of the medical record showed resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 3/25/19 at 9:44 AM showed the resident was resting in bed. Interview with the resident at that time revealed s/he did not get out of bed due to arthritis and pain. S/he further stated s/he was not receiving therapy. The following concerns were identified: a. Review of physical therapy notes dated 2/26/19 showed the resident became agitated and refused care when they saw her/him. b. Interview on 3/26/19 at 3:03 PM with LPN #1 revealed the resident refused to get of out bed and refused to move his/her legs and left arm. She added the resident refused repositioning. c. Review of the MDS showed a quarterly assessment was completed on 3/11/19. Review of the care plan showed a review date of 11/14/19; 4 months prior to latest quarterly assessment. Further review of the care plan failed to show interventions to address the resident's pain. 2. Review of the medical record showed resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. The following concerns were identified: a. Interview on 3/25/19 at 11:36 AM with the resident's brother revealed the resident had constant pain in his/her neck and was unable to take the bus because it hurt too much. The facility was going to get a special pillow to support the resident's neck. He further stated s/he had a hearing aid that caused pain, and he thought the facility was going to fix it but was not sure. b. Review of the MDS showed a quarterly assessment was completed on 3/4/19. Further review showed the resident had a pain level of 5 on a scale of 10 (with 1 being the least pain and 10 being the most), and received as needed pain medication, the resident also had a hearing aid. c. Review of the care plan showed it was last reviewed 12/17/18, and failed to show interventions that would help decrease the pain, and what made the pain worse. d. Review of the Care Plan Meeting Summary dated 3/4/19 showed the facility purchased a neck pillow to ease some of the vehicle motion. Review of the care plan failed to show this intervention. e. Interview with LPN #1 on 3/26/19 at 3:53 PM revealed the resident had a hearing aid which caused him/her pain. She stated the facility had it fitted to the ear, and had cleaned the ear, but the resident could only wear it for a couple days before s/he complained of pain. Review of the care plan failed to have a plan for the hearing aid. 3. Review of the medical record showed resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. Continued observations showed staff redirected the resident to the common area and included him/her in the activities. Interview on 3/26/19 at 11:30 AM with LPN #1 revealed the resident wandered but had not tried to walk out the door. She added they tried to place a wander guard multiple times but the resident removed it. When staff saw the resident walk towards the hospital they walked with the resident and redirected him/her. She further stated staff sat with the resident during meals and encouraged him/her to eat. The following concerns were identified: a. Review of the MDS showed a quarterly assessment was completed on 2/4/19. b. Review of the care plan showed the last review date was 11/29/18. Further review of the care plan showed wander alarm check every shift, and failed to show interventions used when resident removed the wander guard. 4. Review of the medical record showed resident #23 was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 3/25/19 at 3:29 PM showed the resident had an ace wrap dressing and heel protector to the right lower leg. Interview with the resident at this time revealed s/he had pressure ulcer on his/her heel and was seeing a physician who managed the wound. Review of the care plan with a review date of 1/18/19 failed to show evidence of a wound. Interview on 3/26/19 at 10 AM with the DON revealed the care plan was not revised to reflect the wound and wound care. 5. Review of the 2/4/19 MDS assessment showed resident #26 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Further review showed the resident had a BIMS score of 6/15 (severe cognitive impairment); required the extensive assistance of one staff member for bed mobility, transfers, dressing, and toilet use; required the limited assistance of one staff member for locomotion on the unit using a wheelchair or walker; and used a bed and chair alarm daily. The following concerns were identified: a. Observation on 3/25/19 at 3:01 PM showed an alarm was attached to the resident's wheelchair. b. Interview with CNA #1 on 3/26/19 at 2:08 PM revealed the resident used a chair and bed alarm daily. c. Review of a nursing note dated 11/28/18 showed NDO (new doctor order) for bed & chair alarms d/t (due to) res (resident) crawling out of bed on (resident) own and falling out of bed. d. Review of the falls care plan, last reviewed 11/26/18, did not show the use of a bed or chair alarm. e. Interview with the DON on 3/26/19 at 9:34 AM confirmed the care plan did not include the use of the chair or bed alarm. 6. Interview with the DON on 3/26/19 at 10 AM revealed some interventions were written in the care plans, but they had not been updated with the last MDS assessments.",2020-09-01
81,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,661,D,0,1,GU4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a discharge summary which included a recapitulation of the resident's stay for 1 of 1 residents (#29) reviewed for discharge to the community. The findings were: Review of the medical record for resident #29 showed s/he was admitted to the facility on [DATE] for respite care. The resident was discharged to the community on 3/11/19. Further review showed no evidence a discharge summary which included a recapitulation of the resident's stay had been completed. Interview with the DON on 3/27/19 at 11:46 AM verified the discharge summary had not been completed.",2020-09-01
82,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,684,D,0,1,GU4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and policy and procedure review, the facility failed to perform neurological assessments and post-fall reviews for 1 of 2 (#26) sample residents with falls. The findings were: 1. Review of the 2/4/19 MDS assessment showed resident #26 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Further review showed the resident had a BIMS score of 6/15 (severe cognitive impairment); required the extensive assistance of one staff member for bed mobility, transfers, dressing, and toilet use; required the limited assistance of one staff member for locomotion on the unit using a wheelchair or walker; and used a bed and chair alarm daily. The following concerns were identified: a. Review of a Post Fall Assessment and Intervention form dated 11/22/18 showed the resident had an unwitnessed fall on 11/21/18 when the resident was found lying on his/her left side under the his/her walker. Neurological checks were initiated; however, the neurological section of the form was left blank. b. Review of a nurse's note dated 11/22/18 and timed 10:44 AM showed Neuro checks intact. Further review of the progress notes showed no further neurological assessments had been completed. 2. Review of the policy and procedure Care Following a Fall last revised 10/3/14 failed to address the procedure following an unwitnessed fall or a fall with a head injury. 3. Interview with the DON on 3/26/19 at 4:52 PM revealed it was her expectation that any unwitnessed fall or head injury be followed per standard of practice and verified only one neurological assessment had been completed after the resident's fall. In addition she confirmed the policy and procedure did not include the standard of practice and was in the process of being revised.",2020-09-01
83,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,727,F,0,1,GU4111,"Based on observation, review of staffing schedules, staff interview, review of the CNO/DON job description, and review of the facility assessment staffing matrix, the facility failed to ensure the services of a registered nurse were utilized for 8 hours a day 7 days a week. In addition the facility failed to ensure the director of nursing served the facility on a full time basis. The census was 29. The findings were: 1. Multiple observations from 3/25/19 to 3/27/19 showed the DON was not readily available in the facility. 2. Interview with the DON on 3/26/19 at 5:08 PM revealed she oversaw both the nursing home and the hospital. She stated the facility had hired a registered nurse as the manager of the facility who will report to her, however that person had not yet started work at the facility. She further stated she was available during the day shift to help with issues. 3. Review of the CNO/DON position description, issued 4/2/15, showed .the Chief Nursing Officer (CNO) assumes full time administrative authority, responsibility and accountability of the delivery of nursing services for south Big Horn County Hospital and[NAME]Blue[NAME]et Nursing Home . 4. Review of the (MONTH) nurse staffing schedule revealed 9 days where an RN was not scheduled (3/1, 3/13, 3/15, 3/18, 3/19, 3/20, 3/22, 3/23, 3/24). Interview on 3/26/19 at 10:50 AM with the DON revealed on weekends the facility was staffed with LPNs. She stated when an RN was not scheduled, there were 2 charge RNs on the hospital side who were immediately available to help as needed. She further added during the week she was always available to help. Review of the facility assessment (YEAR) showed the staffing matrix was to have one RN or LPN for each shift.",2020-09-01
84,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,756,D,0,1,GU4111,"Based on medical record review and staff interview, the facility failed to ensure the pharmacist recommendations were submitted on a separate written report to the attending physician and the physician's response maintained in the medical record for 1 of 5 sample residents (#11) reviewed for unnecessary medications. In addition the facility failed to develop policies and procedures related to the monthly drug regimen review. The findings were: Review of the pharmacist's medication regimen reviews for resident #11 showed the monthly reviews were being completed, however there was no evidence a separate written report listing irregularities or recommendations was submitted to the physician. Interview with the pharmacist on 3/27/19 at 8:31 AM revealed he had developed a system on his personal computer for completing the monthly reviews and would then transfer the information into the resident's medical record. However, he did not generate a separate report with any irregularities or recommendations to the required facility personnel. Interview with the DON on 3/27/19 at 9:14 AM verified the required information was not in the medical record. In an additional interview on 3/27/19 at 2:44 PM the DON stated a policy and procedure for the monthly medication review had not been developed.",2020-09-01
85,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,880,E,0,1,GU4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy and procedure review, the facility failed to implement infection control processes to prevent transmission of infection in 2 random observations and in 2 of 2 laundry rooms. The findings were: 1. Observation on 3/25/19 at 4:24 PM showed CNA #2 transferred resident #23 to the toilet using the sit-to-stand lift. The CNA donned gloves, removed the resident's briefs; removed her gloves and left the bathroom without performing hand hygiene. The CNA came back, donned gloves, and performed peri-care. The CNA touched the clean briefs and the sit-to-stand lift without changing gloves. The CNA removed her gloves, transferred the resident to the wheelchair, positioned the resident's legs with pillows, and then performed hand hygiene. 2. Observation on 3/26/19 at 12 PM of medication pass for multiple residents showed LPN #1 failed to perform hand hygiene between residents. The LPN also failed to perform hand hygiene after obtaining a blood glucose from a resident. 3. Interview with the DON on 3/27/19 at 2:30 PM revealed the expectation was for staff to perform hand hygiene prior to putting gloves on, after removing gloves, and after resident contact. 4. Observation on 3/27/19 at 12:20 PM of laundry room [ROOM NUMBER] showed a washer and dryer next to a double sink and a rack of clean clothes which hung over part of the sink. The following concerns were identified: a. Interview on 3/27/19 at 12:20 PM with the housekeeping manager revealed the resident's clothes were brought to the laundry room in a bag and soiled clothes were rinsed in the sink prior to going into the washing machine. She further stated the only personal protective equipment staff wore was gloves; she denied wearing a gown or eye protection. b. Observation on 3/27/19 at 12:20 PM of both laundry rooms failed to show a supply of gowns and eye protection. Interview at this time with the housekeeping manager revealed both laundry rooms were used to sort dirty clothes, wash the clothes and hang the clean clothes. c. Observation on 3/27/19 at 12:20 PM showed the soap dispenser to wash hands was hidden by the side of a cabinet behind the clean rack of clothes and the paper towel dispenser was behind the clean rack of clothes. Interview with the housekeeping manager stated staff had to move the clothes to obtain soap for hand hygiene. d. Interview with the Infection Preventionist on 3/27/19 at 2:10 PM revealed gowns, gloves, and eye protection should be readily available, and she was not aware staff wore only gloves to sort the laundry. 5. Review of the Facility Infection Control Policy, revised 4/5/17, showed .wash hands before and after contact with each patient. Wash hands before gloves are donned and after gloves are removed. Eye and mucus membrane protective devices must be worn if splashing is likely. Moisture resistant cover gowns or aprons must be worn when splashing or clothing contamination is likely .",2020-09-01
86,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2019-03-27,943,D,0,1,GU4111,"Based on employee record review, staff interview, and policy review, the facility failed to provide evidence of abuse training in 4 of 4 new employee records (#1, #2, #3, #4). The findings were: 1. Review of employee records showed the following: employee #1 (CNA) was hired on 12/17/18, employee #2 (CNA) was hired on 2/18/19, employee #3 (CNA) was hired on 1/14/19, and employee #4 (dietary aide) was hired on 12/14/18. Further review of the employee records failed to show evidence abuse training was provided. 2. Interview on 3/27/19 at 10:18 AM with director of human resources revealed new staff were to read policies and procedures on abuse, but there was no process in place to verify employee acknowledgment of training. She stated all employees receive abuse training in September. 3. Interview on 3/27/19 at 10:18 AM with the DON confirmed all employees receive abuse training in September, but the facility did not have a process for newly hired employees. 4. Review of the Patient Abuse/Unknown Cause Injury Investigating/Reporting policy, last revised 5/9/16 showed .Every new employee, upon hire, will receive a copy facility Abuse Policy.Prior to providing direct patient care, each new hire will have inservice regarding resident abuse .",2020-09-01
87,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,164,D,0,1,508H11,"Based on observation, staff interview, and review of facility policy, the facility failed to ensure medical records were secure during 2 random observations of the report room. The following concern was identified: 1. Observation of the report room on 04/05/17 from 1:35 PM to 1:51 PM (16 minutes) showed the electronic medical record for a facility resident was open on the computer and no staff were present. The room was located near the common area where residents and family were seated. The door to the room was open and the computer screen was facing the open door to the common area. The computer system identified CNA #1 as the user that was logged into the system. 2. Observation of the report room on 04/05/17 at 3:23 PM showed the medical record of a facility resident was open on the computer and no staff were present. The door to the room was open. The computer system identified CNA #1 as the user that was logged into the system. 3. Interview with the DON on 4/6/17 at 9:30 AM revealed staff are to log out of the computer charting system when they are not using it to ensure privacy of residents' personal information. 4. Review of Resident Rights received from the facility on 4/6/17 at 10:30 AM showed The facility shall protect and promote the rights as identified below. Each Resident, and his/her legal representative as appropriate, has the right: .14. To have clinical and personal records kept confidential .",2020-09-01
88,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,166,E,0,1,508H11,"Based on resident, family, and staff interview, and policy and procedure review, the facility failed to ensure grievances were resolved for 4 of 4 sample residents (#12, #17, #20, #21) who voiced grievances. The findings were: 1. Interview with the resident #17's family member on 4/5/17 at 9:40 AM revealed a concern had been reported to the DON about CNA #2. The family member stated the CNA is rude and rough with the resident and forces the resident to use his/her injured arm to transfer which causes the resident significant pain. The family member felt that if the CNA gets in trouble for not caring for the resident then the resident would be retaliated against by the CNA not answering his/her call light or not providing assistance. The family stated, nothing gets done about the concerns, however, the family member was concerned about reporting it again out of fear the facility would discharge the resident. 2. Interview with the resident #17 on 4/5/17 at 1:50 PM revealed s/he had previously reported concerns about rough treatment by CNA #2 to the nurse and was told the nurse would talk to the CNA about it. The behavior did not improve and the resident revealed s/he was afraid to bring it up again. The resident felt the CNA was impatient and tells him/her to get up without providing assistance and the CNA gets louder when she is upset with the resident. Further, the resident stated s/he felt uncomfortable, like a burden, embarrassed, and intimidated by the CN[NAME] There was no evidence a grievance form was completed related to the resident's concerns. 3. Interview with resident #21 on 4/4/17 at 9 AM revealed the resident had reported, to the nurses and DON, that CNA #2 is rude. Further, the resident said s/he reported concerns about staff and was told s/he can go someplace else. There was no evidence a grievance form was completed related to the resident's concerns. 4. Review of a nurse's note dated 1/11/17 and timed 12:42 AM showed resident #21 reported s/he did not like the CNA that was in here. The nurse talked to the resident 1 to 1 at that time. There was no evidence a grievance form was completed related to the resident's concerns. 5. Review of a nurse's note dated 1/13/17 and timed 11:30 AM showed resident #21 complained of care that was provided. The nurse told the resident s/he needed to express his/her concerns to the DON and if (s/he) is not happy in this facility (s/he) could always consider another facility. There was no evidence a grievance form was completed related to the resident's concerns. 6. Review of a nursing note dated 1/15/17 and timed 1:50 PM showed resident #21 reported that aides were not taking him/her to the bathroom during the shift and the previous night. Further, the note showed the CNAs stated the resident was visiting with family and was taken to the bathroom after the visit. There was no evidence a grievance form was completed related to the resident's concerns. 7. Interview with resident #12 on 4/4/17 at 3:30 PM revealed the resident had reported to facility staff s/he wanted a new wheelchair, and also that s/he was missing an afghan blanket. 8. Interview with resident #20 on 4/5/17 at 1:30 PM revealed s/he was missing 23 tops, and s/he had reported the missing items to several CNAs. 9. Review of the grievance log showed there had been no identified grievances since (MONTH) (YEAR). There was no evidence a grievance form was completed related to the residents' concerns. 10. Interview with the social services director on 4/6/17 at 8:15 AM revealed the facility had not received any formal grievances since 6/9/16 and had identified the grievance system as an area for improvement in (MONTH) (YEAR); however, she was not aware of the grievances for resident #17, #20, or #21. Further, she revealed the facility has tried different wheelchairs for resident #12 and the resident had concerns with all of them; however, she was not aware the resident was missing an afghan blanket or that the resident was unhappy with the current wheelchair. 11. Review of the policy titled Resident Grievance Policy last revised on 4/25/16 showed .3. Resident Grievances will be tracked by the Quality Improvement Committee [NAME] Social Services will be responsible for tracking and reporting Resident Grievances quarterly, or more often as required, to the Quality Improvement Committee. B. Social Services will be responsible to make the administrator aware of on-going concerns .Process .1. Notify the Social Services Person for assistance in resolving the problem. The Social Service Person serves as the facility's in-house ombudsman. An ombudsman investigates complaints on behalf of the administrator and reports findings/resolution to the Administrator. This report may either be done verbally or written. The Social Service Person will be happy to write concern for the resident. 2. If you are not satisfied notify the Director of Nursing. 3. Should you remain unsatisfied, please take the concern to the Administrator. You are welcome to present the problem verbally or in writing. You may expect a response at each level as quickly as possible, certainly within 5 working days . 12. Review of Resident Rights received from the facility on 4/6/17 at 10:30 AM showed The facility shall protect and promote the rights as identified below. Each Resident, and his/her legal representative as appropriate, has the right: .11. To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of restraint, interference, coercion, discrimination or reprisal. The facility shall listen to and act promptly upon grievances and recommendations received from Residents and family groups .",2020-09-01
89,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,167,B,0,1,508H11,"Based on observation, and resident and staff interview, the facility failed to ensure survey results and a notice of the availability of previous surveys were posted in an area readily accessible to residents. The census was 25. The findings were: 1. Observation on 4/4/17 at 9:26 AM showed a binder containing the most recent survey results was in a file wall pocket, behind the piano in the main lobby, not easily viewable or accessible to all residents. Further observation showed there was no posted notice that surveys from the preceding 3 years were available for review upon request. 2. Group interview on 4/4/17 at 1 PM with 11 residents present revealed that they did not know where the survey results were located. 3. Interview on 4/5/17 at 5:54 PM with the social services director confirmed that the survey results binder was behind the piano and not easily accessible to all residents, and that only the last survey is in the binder. She further revealed she had the prior year's surveys somewhere.",2020-09-01
90,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,221,D,0,1,508H11,"Based on observation, medical record review, staff interview, and policy and procedure review, the facility failed to ensure 1 of 25 sample residents (#24) was free from unnecessary physical restraints. The findings were: 1. Observation on 4/6/17 at 8:50 AM showed resident #24 was sitting in a recliner in the main lobby area with his feet elevated on the foot rest. A trash can was placed under the foot rest. The following concerns were identified: a. Review of the resident's history and physical dated 11/7/16 showed the resident had a left upper extremity amputation. b. Review of the resident's care plan showed that s/he had a care plan for ADLs with a goal to achieve maximum functional mobility. The fall/safety approaches included mobility alarm. There was no evidence a restraint assessment was performed related to the placement of the trash can under the recliner foot rest. 2. Interview on 4/6/17 at 8:54 AM with CNA #3 revealed the trash can was put under resident's recliner foot rest to prevent him/her from lowering his/her legs. 3. Interview with the DON on 4/6/17 at 9:20 AM revealed there was not a safety evaluation for placement of the trash can under the recliner while the resident's legs were elevated. Further, she revealed staff were not to place the trash can under the recliner because it prevented the resident from moving. 4. Review of facility policy and procedure on restraints with an issue date of 8/13/14 showed the purpose as, .to identify the need for a physical restraint and to ensure the safety of the resident .The DON or designee will complete the physical restraint consent form to determine if appropriate and safe.",2020-09-01
91,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,225,E,0,1,508H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family, and staff interview, medical record review, and policy and procedure review, the facility failed to ensure abuse allegations were investigated for 2 of 3 abuse allegations which involved 2 sample residents (#17, #21). Further the facility failed to ensure pre-hire screening was performed for 3 of 9 employees (CNA #2, CNA #4, RN #1) prior to resident contact. The findings were: 1. Review of the 3/27/17 significant change MDS assessment showed resident #17 had a BIMS (brief interview for mental status) score of 15 (cognitively intact), was able to understand and be understood and required extensive assistance of 2 or more people for bed mobility, transfers, dressing, and toilet use. The following concerns were identified: a. Interview with the resident's family member on 4/5/17 at 9:40 AM revealed the resident was afraid of CNA #2. The family member stated the CNA is rude and rough with the resident and forces the resident to use his/her injured arm to transfer which causes the resident significant pain. The family member stated the concern was taken to the DON; however, nothing gets done. The family member felt that if the CNA got in trouble for not caring for the resident then the resident would be retaliated against by the CNA not answering his/her call light or not providing assistance. Further, the family member was concerned about reporting the concern again out of fear the facility would discharge the resident. b. Interview with the resident on 4/5/17 at 1:50 PM revealed CNA #2 was physically rough with him/her during cares and it caused the resident pain. The resident felt the CNA was impatient and told him/her to get up without providing assistance and the CNA got louder when she was upset with the resident. Further, the resident stated s/he felt uncomfortable, like a burden, embarrassed, and intimidated by the CN[NAME] The resident revealed s/he had previously reported the CNA behaviors to the nurse and was told the nurse would talk to the CNA about it. The behavior did not improve and the resident revealed s/he was afraid to bring it up again. 2. Review of the admission assessment dated [DATE] showed resident #21 had [DIAGNOSES REDACTED]. Further the resident was able to understand and be understood, and required total assistance of one person for bed mobility, transfer, and toilet use. The following concerns were identified: a. Interview with the resident on 4/4/17 at 9 AM revealed s/he reported concerns about staff and was told s/he can go someplace else. Further, the resident revealed that CNA #2 was rude and rough when she provided care and the resident had expressed this to the nurses before. b. Review of a nurse's note dated 1/11/17 and timed 12:42 AM showed the resident reported s/he did not like the CNA that was in here. The nurse talked to the resident 1 to 1 at that time. c. Review of a nurse's note dated 1/13/17 and timed 11:30 AM showed the resident had complained about care that was provided. The nurse told the resident s/he needed to express his/her concerns to the DON and if (s/he) is not happy in this facility (s/he) could always consider another facility. d. Review of a nursing note dated 1/15/17 and timed 1:50 PM showed the resident reported that aides were not taking him/her to the bathroom during the shift and the previous night. Further, the note showed the CNAs stated the resident was visiting with family and the resident was taken to the bathroom after the visit. 3. Interview with the DON on 4/5/17 and timed 2:07 PM revealed she was not aware of any allegations related to resident treatment by CNA #2. Further she revealed an investigation had not been completed related to the allegations. 4. Review of the policy titled Patient Abuse/Unknown Cause of Injury Investigating/Reporting last revised on 5/9/16 showed .Abuse includes such actions as using derogatory language to a patient, rough handling, ignoring resident while giving care, directing patient who need toileting assistance to urinate or defecate in their bed, ignoring any request or need by a resident .2) Reporting: Any patient, family or staff who witness or suspect or have any concern about any resident who may be at risk of abuse will report such incident or concern to immediate floor supervisor on duty immediately. In the case of concern being related to immediate floor supervisor, another staff member may be notified. Immediate supervisor or staff member receiving report must determine most appropriate course of action for patient to ensure patient is removed from abusive situation immediately. Actions may include constant observation of patient by supervisor, staff perpetrator immediate suspension from cares, or other . 5. Review of the employee file for CNA #2 showed a 6/3/03 date of hire and start date. Further review showed evidence CNA registry placement was requested; however, there were no results. In addition there was no evidence of a background check being completed. 6. Review of the employee file for CNA #4 showed a 5/26/16 date of hire and start date. Further review showed there was no evidence of a background check and reference check being completed. 7. Review of the employee file for RN #1 showed a 3/7/11 date of hire and start date. Further review showed there was no evidence of a background check and reference check being completed. 8. Interview with human resources on 4/5/17 at 2:30 PM revealed that she had only been there since (MONTH) (YEAR). She also verified that the information on the three employees was not in the personnel files. 9. Review of the annual in-service for employees provided from HR showed a date of 1/26-1/28/16 for the facility's last annual employee abuse in-service. 10. Review of the policy and procedure titled Employment Verification last revised 5/20/16 showed the process for screening .3) Copies of all background information will be kept in personnel files. 6) No person will be hired for a position prior to licensure verification, background check, and all previous employment history references. 7) Background checks will include all Federal and State required checks, and past job reference. 8) No person with a criminal background related to abuse or theft will be employed in this facility.",2020-09-01
92,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,244,E,0,1,508H11,"Based on resident interview, staff interview, and review of resident council meeting minutes, the facility failed to ensure resident grievances were resolved for 1 of 4 months (December (YEAR)) reviewed. The findings were: 1. Review of the Resident Council Meeting Minutes dated 12/1/16 showed one of the residents was tired of his/her spouse's T-shirts getting lost. The spouse was also a resident at the facility. Review of the Resident Council Meeting Minutes Dated 3/2/17 showed Grievances from (MONTH) 1, (YEAR) and listed the missing T-shirts with a plan of action as communication book and the grievance was marked as resolved. 2. Group interview on 4/4/17 at 1 PM revealed 4 of 11 residents in attendance felt the facility was not providing feedback and resolution to their concerns. Further, the group felt missing clothing items continued be a concern. 2. Interview with resident #8 on 4/3/17 at 5:35 PM revealed s/he had been missing 23 T-shirts for months now. 3. Interview on 4/6/17 at 9:10 AM with the housekeeping supervisor revealed if residents' clothing is missing the facility performs a search for it and if it is not found the facility assumes it was sent out to a contracted cleaner. The facility attempts to call the vendor, however, they usually destroy the clothing if it goes through their wash. Further, the vendor will return items found before they go through the wash, and these items belongings are given to activities so they can be reclaimed. Further, she stated social services will replace the items if not found. 4. Interview on 4/6/17 at 9:48 AM with the social services director revealed the facility doesn't replace clothing.",2020-09-01
93,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,253,E,0,1,508H11,"Based on observation and staff interview, the facility failed to ensure 2 of 2 resident areas (100 hall, 200 hall) were clean and in good repair. The findings were: 1. Observations of the 100 hall beginning on 4/4/17 at 2:53 PM showed the following maintenance and housekeeping concerns: a. In the bathroom of room #101 the lower 7 inches on the door frames had chipped off paint exposing underlying material, which created a surface that could not be cleaned effectively. b. In room #104 the lower 12 inches of the door frame was damaged exposed underlying material which created a surface that could not be cleaned effectively. c. In room #109 the lower 23 inches of the door frame had chipped-off paint with exposed underlying material which created a surface that could not be cleaned effectively. d. In the toilet room next to the shower room the right side of the cabinet had 17 inches of broken trim which created a surface that could not be cleaned effectively. e. The entry to the 100 hall had three 4 foot by 2 foot ceiling tiles with black spots and holes in them. Two of the tiles also had small water spots on them. To the right by the wall there was a ceiling tile that had multiple cracks through it. f. The entry to the 100 hall had a 4 foot privacy wall with 3 spots with wallpaper peeled off. 2. Observation of the 200 hall beginning on 4/3/17 at 5:09 PM showed the following maintenance and housekeeping concerns: a. In room #205 in front of the bathroom the ceiling tile was cracked. b. The door frame at room #201 had chipped-off paint at the lower 12 inches that exposed underlying material which created a surface that could not be cleaned effectively. 3. Interview on 4/6/17 at 8:25 AM with the maintenance supervisor confirmed the identified areas needed to be fixed.",2020-09-01
94,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,309,E,0,1,508H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family, and staff interview, and medical record review, the facility failed to ensure pain monitoring was implemented for 3 of 3 sample residents (#17, #18, #21) with identified pain. Further, the facility failed to assess 1 of 3 sample residents (#12) after a fall. The findings were: 1. Review of the 3/27/17 significant change MDS assessment showed resident #17 had [DIAGNOSES REDACTED]. Further the resident had a BIMS score of 15 (cognitively intact), was able to understand and be understood, had scheduled and as needed pain medication, and reported occasional pain of 7 out of 10. Review of the Pain care plan dated 8/31/16 showed approaches for pain included 1. Monitor pain 2. Non-drug interventions 3. Administer pain medications as ordered. The following concerns were identified: a. Review of a nursing note dated 3/29/17 and timed 2:14 PM showed the resident received an order for [REDACTED]. There was no evidence the medication effectiveness was assessed after administration. b. Review of the MAR for (YEAR) showed no evidence the resident was routinely assessed for pain. c. Interview with the resident on 4/5/17 at 1:50 PM revealed s/he did not think the CNAs always reported it to the nurse when s/he asked for pain medication, because sometimes s/he would not get any pain medication. d. Interview with a family member of the resident on 4/5/17 at 9:40 AM revealed the resident requested pain medication at night and the CNA would not tell the nurse. The resident had to wait until the next shift arrived to receive the medication. Further, the family member stated the resident would turn on his/her call light and staff would take more than an hour to answer it or turn the call light off without assisting the resident. 2. Review of the 2/13/17 admission MDS assessment showed resident #18 had [DIAGNOSES REDACTED]. Further the resident had a BIMS score of 12 (cognitively intact), was able to understand and make self understood, and reported occasional pain of 6 out of 10. Review of the physician orders [REDACTED]. The following concerns were identified: a. Review of the Pain care plan last reviewed on 2/13/17 showed approaches for pain included 1. Monitor pain 2. Non-drug interventions 3. Administer pain medications as ordered. 4. Establish causative factors and ways to alleviate them b. Review of the MAR for (YEAR) showed no evidence the resident was routinely assessed for pain. 3. Review of the admission assessment dated [DATE] showed resident #21 had [DIAGNOSES REDACTED]. Further the resident had a BIMS score of 6 (severely impaired), was able to understand and make self understood, received as needed pain medication, and reported occasional pain of 6 out of 10. Review of the physician orders [REDACTED]. The following concerns were identified: a. Review of the Pain care plan last reviewed on 10/26/16 showed approaches for pain included 1. Monitor pain Chronic 2. Non-drug interventions Reposition, elevation, distraction 3. Administer pain medications as ordered. b. Review of the MAR for (MONTH) (YEAR) showed no evidence the resident was routinely assessed for pain. 4. Interview with the DON on 4/5/17 at 2:07 PM revealed staff should assess residents' medication effectiveness after administering as needed pain medications; however, the facility did not routinely monitor residents for pain. 5. Review of a nurse's note dated 3/31/17 and timed 7 AM showed resident #12 was found on (his/her) knees in (his/her) bathroom. The following concerns were identified: a. Review of the subsequent nursing notes showed no evidence the resident was monitored for injuries following the fall. Further, there was no evidence the resident was assessed for a possible head injury. b. Interview with the DON on 4/6/17 at 9:10 AM revealed the resident should have been monitored after the fall and neurological assessments should be completed after unwitnessed falls.",2020-09-01
95,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,323,D,0,1,508H11,"Based on observation, staff interview, and review of manufacturer's instructions the facility failed to ensure 1 of 4 mechanical lift transfers observed were done safely (which affected resident #22). The findings were: 1. Observation on 4/4/17 at 10:39 AM showed a single CNA had used the sit-to-stand lift to assist resident #22 up out of a recliner to his/her wheelchair. 2. Interview with the DON on 4/6/17 at 8:40 AM revealed staff were expected to follow manufacturer's recommendations when using the mechanical lift. 3. Review of the Lumex LF2020 Easy Lift Sit-to Stand user manual copyright dated 2005 showed .2 Safety Precautions .Important: Before using patient lift, read and adhere to the following safety precautions and warnings. Failure to do so could result in serious personal injury or damage to your patient lift Warnings .Warning: GF Health Products, Inc. strongly recommends that two caregivers take part in the lifting process .",2020-09-01
96,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,329,D,0,1,508H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure behavior monitoring was implemented for 2 of 5 sample residents (#12, #21) who received [MEDICAL CONDITION] medications. The findings were: 1. Review of the 3/27/17 significant change MDS assessment showed resident #12 had [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The following concerns were identified: a. Review of the medical record showed the facility had not identified specific target behaviors related to the medication use. Further, there was no evidence the facility was monitoring behaviors to identify or track the medication effectiveness. 2. Review of the 1/16/17 admission MDS assessment showed resident #21 had [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The following concerns were identified: a. Review of the medical record showed the facility had not identified specific target behaviors related to the medication use. Further, there was no evidence the facility was monitoring behaviors to identify or track the medication effectiveness. 3. Interview with the DON on 4/5/17 at 2:07 PM revealed the facility does not do daily monitoring of behaviors for [MEDICAL CONDITION] medication use.",2020-09-01
97,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,371,F,0,1,508H11,"Based on observation, staff interview, review of cleaning logs, and policy and procedure review, the facility failed to ensure a sanitary environment in 2 of 2 food storage and preparation areas (main kitchen, dining room kitchenette). These failures related to out-dated food items, an unsanitary ice machine, and food service equipment in poor condition. The findings were: 1. Observation of the walk-in cooler on 4/3/17 at 4:43 PM showed shredded cheese in an opened bag dated 3/16. 2. Observation of the main kitchen on 4/3/17 at 4:45 PM showed two 3.8 liter measuring pitchers that were visibly discolored and stained yellow from use and could not be cleaned effectively. 3. Observation of a plastic storage closet in the main kitchen on 4/3/17 at 4:49 PM showed a plastic rubbermaid container that was cracked on the bottom which created a fissure that could not be cleaned effectively. 4. Observation of the dining room kitchenette on 4/3/17 at 5:05 PM showed the ice machine had a thick, white film around the dispenser opening. 5. Observation of the dining room kitchenette refrigerator on 4/3/17 at 5:08 PM showed cheese slices with a use-by date of 3/28/17. 6. Observation of dinner service on 4/3/17 at 5:20 PM showed 6 of 17 water carafes in use had cracks and fissures which could not be effectively cleaned. 7. Observation of the walk-in cooler on 4/5/17 at 11:05 showed shredded cheese in an opened bag dated 3/16 and baby carrots in an opened bag with an opened date of 3/17. 8. Observation of the main kitchen equipment storage area on 4/5/17 at 11:08 AM showed an 8-ounce measuring cup with cracks and fissures and a 4-quart pitcher that was discolored, which could not be cleaned effectively. 9. Interview with the dietary manager on 4/5/17 at 11:15 AM revealed the food items were available for resident consumption and should have been discarded. Further, she confirmed the food containers were damaged and revealed they should have been replaced. 10. Review of ice machine cleaning log showed the dining room kitchenette ice machine was last cleaned on 7/18/16. 11. Interview with the maintenance director on 4/5/17 at 11:20 AM revealed he thought the ice machine had been cleaned more recently than 7/18/16 and the facility has issues with calcium build-up because of their water. Further, he confirmed the ice machine was visibly dirty. 12. Review of the policy titled Food Preparation and Storage issued 4/6/17 showed .Policy: Foods shall be prepared, served, and stored in a clean and sanitary manner. Foods shall be prepared using clean, sanitized, and damage free cooking pans, preparation utensils, and the like (sic) Foods shall be served using clean, sanitized, and damage free tableware and the like (sic) Foods shall be stored in clean, sanitized, and damaged free containers .Damaged pans, preparation utensils, tableware, and storage containers shall be removed from use when surfaces have cracks, scratches, gouges, worn surfaces that are deemed incapable of being sanitized suitably . 13. According to Food Code 2013, U.S. Public Health Service: 3-501.17 (A) .refrigerated, READY-TO-EAT, POTENTIALLY HAZARDOUS FOOD (TIME/TEMPERATURE CONTROL FOR SAFETY FOOD) prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days.",2020-09-01
98,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,441,D,0,1,508H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview, the facility failed to ensure infection prevention practices were followed during 1 random observation of linen handling and transportation. The findings were: Observation on 4/4/17 at 9:45 AM showed an unidentified CNA exited room [ROOM NUMBER] with unbagged linen held against her body, in her left hand. The CNA took the linen to the soiled utility room, discarded the linen, and then entered the clean utility room. The CNA obtained folded, unbagged, clean linen and carried it back to room [ROOM NUMBER]. The CNA held the clean linen against her body in her left hand. Interview with the infection preventionist on 4/16/17 at 8:40 AM revealed linen should be bagged during transportation and carrying unbagged soiled linen in the hallway was not acceptable. Further the clean linen could have been contaminated because it came in contact with the same area on the staff member as the soiled linen.",2020-09-01
99,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,514,F,0,1,508H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a complete, systematically organized electronic health record for each resident was accessible. The census was 25. The findings were: 1. Interview with the administrator during the entrance conference on 4/3/17 revealed that the facility was using an electronic health record (EHR) system for the resident records. The following concerns were identified: a. During the survey, the surveyors identified issues trying to access and review the residents' medical records. The surveyors were involuntarily logged out of the system on multiple occasions and had to ask staff for copies of the residents' medical record or parts of the records in order to complete the survey. b. Review of individual resident records showed that all residents had an admission date of [DATE]. Further, all physicians orders had a start date of 4/1/17. c. Interview with LPN #1 on 4/4/17 at 3:50 PM revealed she had to fight with the computer system because it would freeze and log out. d. Interview with the DON on 4/4/17 at 4:20 PM revealed all residents showed an admitted the first day of the current month because the computer system rolls over every month related to computer memory issues. Further, she revealed in order to identify the correct admission and physician order [REDACTED]. e. Interview with the administrator on 4/5/17 at 1:41 PM revealed the computer system is not the best and it frequently kicks you out. Further, it was revealed the facility had identified the concern and was working with some companies to change the system; however, there was not a date the system would be changed.",2020-09-01
100,BONNIE BLUEJACKET MEMORIAL NURSING HOME,535019,388 SOUTH US HWY 20,BASIN,WY,82410,2017-04-06,520,E,0,1,508H11,"Based on observation, staff interview, and record review, it was determined that the facility did not have a Quality Assessment and Assurance (QAA) committee that identified concerns, developed and implemented action plans to correct the concerns, and monitored the facility's effectiveness to maintain a minimum standard of care for residents residing in the facility. The facility census was 25. The findings were: 1. A review of the QAA (Quality Assessment & Assurance) program was done on 4/6/17 at 9:33 AM with the ADON. The areas identified for performance improvement by the facility included abuse investigations, and grievances. The following concerns were identified: a. The facility identified abuse investigations as an area in need of improvement. Since this identification, the facility failed to ensure identified allegations were investigated as referenced in F225. b. The facility identified the grievance procedure as an area in need of improvement. The identified problem was resident/family grievances were not being recorded and the plan included a log being kept to record all grievances turned in by residents and family. The facility failed to ensure identified grievances were logged and resolved as referenced in F166. c. Interview with the ADON on 4/6/17 at 9:33 AM confirmed the the QAA program was not effective related to abuse identification and investigation, and grievance identification and resolution.",2020-09-01