Chatuge Regional Nursing Home

Inspectors wroteBased on observations, record review, staff interview, and facility policy review, the facility failed to evaluate a resident's physical and cognitive ability to safely self- administer medication for one (Resident (R) 27) of six residents during medication administration observations out of a total sample size of 21 residents. This failure resulted in the resident administering the incorrect amount of medication.

Inspectors wroteBased on observations, family member and staff interviews, record review, and facility policy review, the facility failed to ensure the call button to activate the emergency call light was accessible for two (Resident (R) 3 and 87) of 21 residents in the sample. This failure placed the residents at risk for accident, injury, or unmet needs related to an inability to call for staff assistance.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure written notices for bed holds and transfers were provided to residents and/or resident representatives and that the Ombudsman was notified when residents transferred to the hospital for four of 21 sampled residents (Resident (R)1, R7, R83, and R94) reviewed for hospitalization. These failures had the potential to cause confusion for residents and their representatives regarding the reason for their hospitalization, their ability to return to the facility, and their ability to appeal the discharge.

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan directing interventions for positioning and feeding for two (Resident (R) 3 and R57) of a total sample of 21 residents. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure clinical criteria were met prior to prescribing and administering an antibiotic for a urinary tract infection (UTI) for two (Resident (R) 5 and R34) of six residents reviewed for unnecessary medications. This failure had the potential to cause antibiotic resistance, increased risk of Clostridioides difficile (C. diff) infection, and adverse drug reactions.

Inspectors wroteBased on observations, staff interviews, record review, facility policy review, and document review, the facility failed to ensure a medication error rate of less than five percent during observation of medication administration. The facility had three errors in 47 opportunities, which resulted in a six percent error rate. This affected three (Resident (R) 27, R42, and R87) out of six residents observed. Medication errors have the potential to result in adverse health outcomes.

Inspectors wroteBased on record review, interviews, review of the Administrator Job Description, and review of the policy titled Abuse Reporting and Investigation, the facility Administration failed to provide protective oversight to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to take appropriate action on allegations of employee-to-resident abuse, exploitation, and injury of unknown origin, which were reported to him. The failure of the Administrator to take appropriate action which was reported to him has the likelihood to lead to future allegations of abuse, exploitation, and injury of unknown origin that are not identified, reported, or investigated. [...]

Inspectors wroteBased on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protect the resident's right to be free from abuse from by facility staff. Specifically, the facility failed to protect two residents (R) (R78 and R107) of 27 total sampled residents from physical, mental, and verbal abuse from Certified Nursing Assistant (CNA) staff. Due to the vulnerable nature of the nursing home population and the likelihood of resident abuse in the facility, immediate action was required to prevent further events of abuse. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to protect one resident (R) (R71) out of a total sample of 27 from exploitation perpetrated by Certified Nurse Aide (CNA)1. Due to the vulnerable nature of the nursing home population, a potential for serious exploitation existed, and the likelihood of CNA 1 exploiting other residents in the facility required immediate action to prevent further events of exploitation. On 6/7/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of two Immediate Jeopardy's (IJ) on 6/7/2024 at 8:49 am. [...]

Inspectors wroteBased on record review, interviews, and review of policy titled Abuse Reporting and Investigation, the facility failed to ensure allegations of abuse, an injury of unknown origin that resulted in a hip fracture, and an allegation of employee to resident exploitation were reported to the State Survey Agency (SSA). Specifically, residents (R) (R71 and R107) were verbally abused by staff; R71 sustained an injury of unknown origin and potential exploitation by facility staff. The failure of the facility to report these incidents has the likelihood to lead to future unreported injuries of unknown origin, exploitation, and mental and verbal abuse against residents. The sample size was 27. [...]

Inspectors wroteBased on record review, interviews, and review of the policy titled Abuse Reporting and Investigation, the facility failed to ensure that allegations of abuse, allegations of exploitation, and an injury of unknown origin, were thoroughly investigated for three residents (R) (R78, R71, and R107) reviewed out of a total sample of 27 residents. Specifically, the facility failed to investigate allegations of employee to resident abuse for R78 and R107, perpetrated by Certified Nurse Aide (CNA) 2. In addition, the facility failed to investigate an injury of unknown origin that resulted in a hip fracture and failed to investigate allegations of exploitation for R71 perpetrated by CNA 1. The failure of the Administrator to investigate these incidents have the likelihood to lead to future unreported allegations of abuse and exploitation as well as injuries of unknown origin. [...]

Inspectors wroteBased on record review, interview, and review of the policy titled Grievance Policy, the facility failed to ensure that grievances were promptly and thoroughly resolved and/or responded to for one resident (R) (R107) out of 27 sampled residents. Additionally, the facility failed to have a process in place for residents to file a grievance anonymously. This had the potential to affect all of the residents of the facility.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure that informed consents were signed prior to the use of bedrails for four of 27 sampled residents (R) (R1, R45, R72, and R78) reviewed for bed rail use. The failure had the potential for risks of injury, entrapment, and/or death.

Inspectors wroteBased on observations, interviews, and review of the policy Titled Copy of 5.d Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure expired medications were removed from one of two medication carts, failed to remove expired phlebotomy supplies for one of two phlebotomy carts, and one of two medication rooms. This had the potential to affect any resident who might be administered expired medications/use of expired supplies. The census was 104.

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to ensure that meals were served according to resident preferences and designated meal times for 50 residents on the green and pink halls.

Inspectors wroteBased on interviews, review of facility's Nursing Home Inspection Report Upon Receipt of Equipment, review of the Food and Drug Administration (FDA) guidelines, and review of the policy titled Proper Use of Side Rails, the facility failed to ensure bed rails were inspected for safety to minimize the risks of possible entrapment or resident injury for 90 resident beds out of 104. This failure had the potential to cause serious injury to all 90 residents in the facility using a bed with bed rails attached.

Inspectors wroteBased on record review and interviews, the facility failed to assist one resident (R) (R56) in obtaining identification for voting purposes out of total sample of 27 residents reviewed for resident rights. This had the potential for a diminished quality of life and the failure to promote the resident's right to vote.

Inspectors wroteBased on record review, interviews, and review of the policy titled Resident Transfer and Discharge Rights Policy and Procedure, the facility failed to ensure three of five residents (R1, R72, and R101) and/or their representatives reviewed for facility initiated emergent hospital transfer were provided with written transfer notice that contained all required information. This failure has the potential to affect the resident and their representatives by not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired.

Inspectors wroteBased on record review, interviews, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to ensure an annual Minimum Data Set (MDS) assessment was submitted within 14 days of completion to Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for one resident (R) (R58) reviewed out of a total sample of 27. This failure had the potential to adversely affect the care planning and care provision for any resident that may not have received a comprehensive assessment.

Inspectors wroteBased on record review, interviews, and review of the policy titled Care Plan Meetings, the facility failed to ensure that three residents (R) (R56, R44, and R17) of 27 sampled residents had scheduled care plan conferences after each assessment. In addition, the facility failed to ensure updated interventions were included on the comprehensive care plan for one resident (R3). This failure had the potential for residents not to be involved with their care decisions and potential unmet care needs.

Inspectors wroteBased on observations, record review, staff interviews, and review of the policy titled Physician Orders Policy and Procedure, the facility failed to follow the physician orders for one resident (R) (R3) related to using body pillows for positioning. This failure had the potential to put the resident at risk of aspirating. The sample size was 27.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Departmental (Respiratory Therapy) - Prevention of Infection, the facility failed to provide respiratory care in accordance with professional standards for one resident (R) (R48) of two residents reviewed for respiratory care out of a total sample of 27 residents. Specifically, respiratory equipment was not stored in a sanitary manner. This had the potential for the resident to have possible respiratory infections.

Inspectors wroteBased on record review, staff interviews, and review of the policy titled 10.b Medication Regimen Review, the consultant pharmacist failed to identify and report irregularities regarding an order for PRN (as needed) lorazepam (antianxiety medication) beyond 14 days and to include a written rationale and duration for continuing its use, for one resident (R) (R24) reviewed for psychotropic medications from a total of 27 sampled residents.

Inspectors wroteBased on record review, staff interviews, and review of the policy titled Physician Orders Policy and Procedure, the facility failed to ensure that as needed (PRN) order for antianxiety medication was limited to 14 days and failed to document the rationale for the extended duration for the PRN order for one of five residents (R) (R24) reviewed for unnecessary medications.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure that the daily nurse staffing posted included the name of the facility, the facility census, and the total number and the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. display contained the required information for residents, visitors, and/or staff. This failure could affect the knowledge of the family members or representatives of the 104 residents in the facility.

Inspectors wroteBased on record review, family and staff interviews, and review of the policy titled Abuse Reporting and Investigation , the facility failed to report an injury of unknown source for one resident (R) of four residents, (R#25). Specifically, the facility failed to submit a report of an injury of unknown source involving R#25, to the State Agency within two hours of discovery.

Inspectors wroteBased on record review, family and staff interviews, and review of the facility policy titled, Abuse Reporting and Investigation , the facility failed to investigate and report an injury of unknown source for one of four residents (R) R#25. Specifically, the facility failed to conduct an investigation of an injury of unknown source for R#25 as required.

Inspectors wroteBased on record review, and staff interview the facility failed to ensure that one resident (R) of 25 residents, R#53, was referred to the appropriate state designated authority for a Preadmission Screening and Resident Review (PASARR) Level II for the evaluation and determination of specialized services. This deficient practice had the potential to affect the appropriate level of care and services provided for R#53.

Inspectors wroteBased on record review, observations, resident and staff interviews, and review of the facility policy titled, Initial admission Care Plan Policy and Procedure, the facility failed to follow the care plan for activities of daily living (ADLS), specifically related to showers and nail care, for one resident (R) (R#8), The sample size was 25. This deficient practice had the potential to affect the delivery of the proper care and services provided to R#8

Inspectors wroteBased on record review, observations, resident and staff interviews, and review of the facility policy, Activities of Daily Living Policy and Procedure, the facility failed to ensure activities of daily living (ADL) were provided for one resident (R) of 25 residents, R#8, reviewed for ADL care. Specifically, the facility failed to ensure that scheduled showers and nail care were completed for R#8.

Inspectors wroteBased on record review, and staff interviews, facility failed to provide restorative nursing services to maintain the highest practicable physical, mental, and psychosocial well- being for one resident (R) of 25 sample residents, (R#44). This failure had the potential to cause a decline in the resident's functional ability.

Inspectors wroteBased on record review, observations, and staff interview, the facility failed to ensure that one resident (R) of 25 sampled residents, R#15, was administered oxygen therapy in accordance with the physician orders. This deficient practice had the potential to affect the resident's ability to maintain an oxygen level of 90% or greater.

Inspectors wroteBased on observations, interviews, and review of the facility policy titled, Storage and Expiration of Medications, Biologicals, Syringes, and Needles, the facility failed to ensure that two of three medication carts were locked and secured when the carts were out of view of the nurse. The deficient practice had the potential to allow unauthorized residents, visitors, and staff access to unattended medications.