Arcadia Valley Skilled Nursing And Rehabilitation

Penalty

Inspection fine: $13,627

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide basic life support, including CPR, to a resident as per the resident's advance directives. The resident was found unresponsive and without a pulse, but the facility staff inaccurately identified the resident's code status as Do Not Resuscitate Comfort Care Arrest (DNRCC-A) based on an internal report sheet. This error occurred despite the resident's medical record indicating she was a full code, as per her advance directives upon admission. Consequently, CPR was not initiated, and Emergency Medical Services (EMS) were not called until approximately an hour and fifteen minutes after the resident was found unresponsive. The resident, who had a history of sepsis, urinary tract infection, pressure ulcer, chronic obstructive pulmonary disease (COPD), acute congestive heart failure (CHF), diabetes, atrial fibrillation, hypertension, history of pulmonary embolism, and malignant neoplasm of the endometrium, was admitted to the facility with a full code status. On the night of the incident, the resident was found unresponsive in her bed by a State Tested Nursing Assistant (STNA), who then called for nursing assistance. Two nurses verified the absence of vital signs but relied on an incorrect report sheet that listed the resident as DNRCC-A, leading to a delay in initiating CPR. The error was discovered later when a Licensed Practical Nurse (LPN) reviewed the resident's electronic medical record for next of kin information and found the correct full code status. The Director of Nursing (DON) was notified, and CPR was initiated, but it was too late to prevent the resident's death. The facility's failure to verify the resident's code status in the electronic medical record and reliance on an inaccurate report sheet were critical factors that led to the deficiency.

Removal Plan

• Licensed Practical Nurse (LPN) #150 was reviewing Resident #44's electronic medical record to obtain next of kin information and funeral home preference when she discovered Resident #44's code status was a full code. The DON was notified, and a directive was given to initiate CPR and to call 911. CPR was initiated and EMS were called.
• Resident #44 was transported out of facility via EMS.
• One Registered Nurse (RN), two LPNs, two State tested Nursing Assistants (STNAs) on site were re-educated by the DON on timely delivery of services and care, change of condition, and notification, and where to find code status orders (in Point Click Care (PCC)). RN #100 (the staff member identified to be responsible for the error in not initiating CPR timely) was suspended pending investigation.
• All staff re-education was initiated related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification by the DON, ADON, and Regional Quality Assurance Registered Nurse via in person or telephone. Staff trained included five RNs, nine LPNs, 19 STNAs, three housekeeping staff, three dietary staff, and one activity personnel.
• The Social Service Designee attempted to contact Resident #44's family without success. A voicemail was left. The Social Services Designee and preceptor began an audit of all 43 resident's advance directives' orders and advance directives on file in chart. Each was verified and cross-referenced for accuracy. Any identified findings were corrected upon discovery.
• The Human Resource Director verified CPR certification of RN #100 and LPN #150 and began audits of all licensed nurses (five RNs and nine LPNs) CPR certifications. Any identified findings were addressed immediately.
• All current report sheets were removed from the facility and replaced with new report sheets that did not include the resident's code status by Regional Director of Quality Assurance RN.
• The facility Medical Director was notified by the DON of the incident involving Resident #44 and the delay in CPR initiation and current process of correction.
• All staff on shift interviews were completed with RN #100, LPN #150, STNA #175, and STNA #200, who were all of the staff on duty when Resident #44 was found unresponsive and without an obtainable pulse. Re-education was provided related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification by the Regional Director of Quality Assurance RN.
• All licensed nurses not CPR certified (two RNs and three LPNs) were removed from direct patient care by the Administrator and not utilized in the role as a licensed nurse until their CPR certification was current.
• All staff re-education (which included five RNs, nine LPNs, 19 STNAs, three housekeeping staff, three dietary staff, and one activity personnel) was completed by the DON, ADON, and Regional QA nurse related to change in condition, timely delivery of care and services, documentation, where to find code status orders (in PCC), and notification.
• The advance directives/code status for all 43 facility residents was verified and cross-referenced, orders in PCC verified, and audit completed by Social Services Designee.
• A crash cart (cart with emergency supplies/equipment) audit was completed by the DON to ensure all required supplies were present on the cart and the cart was replenished.
• All licensed nurses (five RNs and nine LPNs) CPR certifications were current and valid. An Ad hoc Quality Assurance (QA) meeting was held. The facility implemented a plan for all licensed nursing staff CPR certifications to be verified upon hire, annually, and evaluated during annual performance evaluations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store and prepare food in a sanitary manner, potentially affecting all 42 residents. During an initial kitchen tour, two bags of salad with a best-by date of the previous day were found in the refrigerator. Continuous observations of the lunch tray line revealed multiple hygiene violations: a dietary aide rubbed her nose and forehead with her wrist without changing gloves or washing hands, and another aide wiped her hand on her pants before applying a new glove without hand hygiene. Additionally, a dietary cook licked her fingers to separate meal tickets, which were then placed on resident trays. Seven trays were sent out with bowls of grapes left open to air. The freezer temperature was also found to be at 14 degrees Fahrenheit, which was confirmed by the dietary cook. The facility's policies on hand hygiene and food storage were not followed, as confirmed by the dietary manager.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate liability notices to two residents when they were cut from Medicare Part-A services despite having benefit days remaining. Resident #40, admitted with diagnoses including acute bronchitis, muscle weakness, and altered mental status, was discharged from Medicare Part A on 02/18/24 without receiving an Advance Beneficiary Notice (ABN) form CMS-10055. Similarly, Resident #41, admitted with multiple sclerosis, cellulitis, and other conditions, was discharged from Medicare Part A on 04/20/24 without receiving the required ABN form. Both residents remained in the facility without being informed of their potential financial liability for services not covered by Medicare. The deficiency was attributed to a miscommunication between the therapy department and the facility regarding responsibility for completing the ABN forms. The Administrator, who was also the Business Office Manager, acknowledged the issue and indicated that a quality assurance/performance improvement (QAPI) plan was developed after the survey team entered the facility. However, the QAPI plan lacked comprehensive interventions, such as initial audits and staff education, to ensure compliance with the requirement to issue ABN forms. The facility's policy stated that the ABN should be provided two days prior to the termination of services, but this was not adhered to in the cases of Residents #40 and #41.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the privacy of Resident #38, who was admitted with diagnoses including hyperkalemia, gastrointestinal hemorrhage, acute kidney failure, and type II diabetes. Despite having intact cognition and no behaviors, Resident #38 experienced repeated invasions of privacy by her roommate, who rummaged through her belongings and even attempted to touch her food. Staff interviews confirmed that the roommate's behavior was a known issue, and although Resident #38 was offered room changes multiple times, she declined. The Director of Nursing (DON) acknowledged that no additional interventions were implemented to safeguard Resident #38's privacy apart from offering room changes. Additionally, the facility failed to maintain the confidentiality of Resident #38's medical records. Observations revealed that scripts for controlled substances prescribed to Resident #38 were left unsupervised and face-up on the nurses' station, making her personal information visible. The Medication Aide confirmed that the scripts should not have been left out, and the DON stated that new scripts are usually placed face down on a clip until the pharmacy picks them up. The facility did not provide a policy related to privacy when requested.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents were invited to participate in care planning upon admission and during quarterly reviews. This deficiency affected two residents, Resident #15 and Resident #22. Resident #22, who was admitted with diagnoses including metabolic encephalopathy, type II diabetes, and congestive heart failure, was not invited to participate in her care conference despite being cognitively intact and having no behaviors. Interviews with the resident and staff confirmed that Resident #22 was not aware of the care conference or the facility's social worker. The facility's policy stated that the interdisciplinary care team and the resident should meet and review the care plan upon admission, which was not followed in this case. Resident #15, admitted with multiple diagnoses including chronic obstructive pulmonary disease, cerebral infarction, and mild cognitive impairment, also experienced a lapse in care planning. The last documented care conference for Resident #15 was held with only the resident and an LPN present, and there was no evidence of a care plan meeting after that date. The Director of Nursing confirmed that a care plan meeting should have occurred in April 2024 but did not due to a transition period in the facility's social services department. The facility's policy required quarterly care plan meetings with the interdisciplinary team and the resident, which was not adhered to in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #247 was assessed and provided activities according to her preferences. Resident #247, who had multiple diagnoses including malignant neoplasm of bone, type two diabetes, diabetic retinopathy with macular edema, visual loss, anxiety, depression, spinal stenosis, arthritis, sleep disorder, and heart disease, was admitted and readmitted to the facility. The activity participation review for the resident was incomplete, and there was no evidence of a new assessment upon her readmission. The resident's activity participation was minimal, and her visual plan of care did not include provisions for large print materials, which she needed due to her vision impairment. Observations revealed that the resident spent most of her time in bed without access to large print reading materials, and interviews confirmed that the activity director was not qualified and had not completed the necessary assessments or provided appropriate activities for the resident's needs. The facility's policies required activity assessments to be completed on admission, readmission, and annually, with quarterly progress notes. However, these assessments were not properly conducted for Resident #247. The activity director admitted to not completing the resident's activity assessment and not documenting activity refusals. Additionally, the director of nursing confirmed that the resident's activity assessment was not comprehensive, and the activity plan of care was not individualized. The facility's failure to adhere to its policies and provide appropriate activities for Resident #247 led to the deficiency identified in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure fall interventions were in place per the resident plan of care, affecting one resident. Resident #10, who was admitted with diagnoses including muscle weakness, dementia, macular degeneration, difficulty walking, lack of coordination, and a fracture of the right humerus, experienced multiple falls on 07/17/23, 09/01/23, 01/20/24, and 04/25/24. The falls on 07/17/23 and 09/01/23 were not captured in the Minimum Data Set (MDS) assessment dated 10/03/23. The resident's fall plan of care included interventions such as a low bed with a mat on the floor, placement in a room closer to the nurse's station, nonskid socks, and a bright-colored tape on the call light. However, these interventions were not consistently implemented or maintained as observed on multiple dates in May 2024. Observations revealed that Resident #10 did not have mats at the bedside, the call light did not have a bright-colored tag, the resident was not wearing nonskid socks, and the resident's room was not close to the nurse's station. Interviews with the State tested Nurse's Aide (STNA) and Licensed Practical Nurse (LPN) confirmed these observations and noted that the resident refused to wear nonskid socks. The Director of Nursing (DON) confirmed that the falls on 07/17/23 and 09/01/23 were not captured in the MDS assessment. The facility's policy on Fall Management stated that the care plan should be updated routinely and with significant changes in the resident's condition, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident with a history of significant weight loss received the prescribed nutritional interventions. Resident #35, who had diagnoses including morbid obesity, moderate protein-calorie malnutrition, and dysphagia, was supposed to receive a consistent carbohydrate diet with super cereal and super mashed potatoes daily. However, observations during lunch and dinner on 05/15/24 revealed that the resident did not receive the super mashed potatoes as recommended by the dietitian. Additionally, the resident's meal ticket did not reflect the prescribed super cereal or super mashed potatoes, indicating a failure in communication and implementation of the dietary orders. Interviews with the Director of Nursing and the Dietary Manager confirmed that the resident had not been receiving the prescribed nutritional interventions since they were recommended on 04/10/24. The facility's policy on Immediate Temporary Interventions for Unintended Significant Weight Loss was not followed, as the resident did not receive the necessary nutrition interventions to prevent further weight loss. This deficiency was identified through record reviews, observations, and staff interviews, highlighting a lapse in ensuring the resident's nutritional needs were met as ordered by the dietitian.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide medically related social services to monitor behavioral health concerns for Resident #10, who was admitted with diagnoses including Alzheimer's disease, major depressive disorder, and anxiety disorder. The resident exhibited behaviors such as yelling out, crying, and refusing care, which were documented in the care plan. However, the last Social Service History assessment was completed on 09/27/23, and there was no evidence of medically related social services being provided since 10/07/22. Observations on multiple dates revealed the resident frequently yelling for help, with staff either not acknowledging the calls or addressing the behaviors with food, drink, or medication rather than social services interventions. Interviews with staff confirmed the lack of consistent social services staffing and the absence of social services interventions in the behavior management plan for the resident. The Director of Nursing (DON) and the Administrator acknowledged the deficiency, noting that social service assessments should be completed quarterly and that a social worker would be integral to behavior management. The facility's policy on Behavior and Psychoactive Management Program indicated that social service support should be provided as needed, with a social service representative evaluating and documenting changes in behaviors and communicating with the Behavior Committee. However, this protocol was not followed, leading to the deficiency in providing necessary social services to Resident #10.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs. Specifically, the facility did not include parameters for administering narcotic pain medication (Norco) and Acetaminophen on an as-needed (prn) basis, and administered Morphine Sulfate for pain instead of its intended use for dyspnea. This affected a resident with multiple diagnoses, including Parkinson's disease, congestive heart failure, dementia, emphysema, anxiety disorder, schizophrenia, and psychotic disorder with delusions. The resident's medical record showed that Norco was administered for pain levels between 3 to 5 on a 1-10 scale, and Morphine Sulfate was frequently given for pain despite being ordered for shortness of breath, with no documented complaints of dyspnea. Interviews with the resident's Power of Attorney and the Regional Quality Assurance Nurse confirmed the inappropriate use of medications. The Power of Attorney noted that the resident experienced chronic pain due to arthritic pain and compression fractures but did not regularly suffer from shortness of breath. The Regional Quality Assurance Nurse acknowledged the lack of parameters for the Norco order and confirmed that Morphine Sulfate was administered for pain instead of dyspnea, as ordered. The findings indicate a failure to adhere to proper medication administration protocols, leading to the inappropriate use of controlled narcotic medications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the medication error rate was less than 5%, resulting in a medication error rate of 7.69%. This deficiency was identified through record review, observation, interview, and policy review. Specifically, Resident #33, who was admitted with diagnoses including hypothyroidism, low back pain, chronic pain, and fractures, was affected. The resident had orders for Synthroid to be administered early in the morning and Diclofenac Sodium gel to be applied to specific areas for pain relief. However, the Licensed Practical Nurse (LPN) administered Synthroid at 8:11 A.M. instead of the prescribed early morning time and applied the Diclofenac gel incorrectly, both in terms of location and omission of certain areas. During the observation, the LPN confirmed the errors, acknowledging that Synthroid was administered outside the prescribed time window and that the Diclofenac gel was not applied to the ankles and feet as ordered. Additionally, the LPN applied the gel to the upper back, which was not included in the physician's order. The facility's policies on medication administration were reviewed, revealing that the physician's specific orders should supersede any routine schedule, and medications should be administered in an organized and safe manner. The failure to adhere to these policies contributed to the observed medication errors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure medications were stored properly and that expired medications were not administered. Specifically, a resident with type two diabetes did not receive their prescribed Humalog insulin from the specified dates. Upon inspection, it was found that the Humalog pen had been opened and was past its 28-day expiration period. Additionally, there were 15 loose pills found in the medication cart drawers, which were not properly stored or identified. An LPN confirmed the Humalog pen should have been discarded two days prior to the survey. The facility's medication storage policy mandates that insulin products should be stored in the refrigerator until opened and that the date of opening should be noted on the label. The policy also requires that medication storage areas be kept clean, well-lit, organized, and free of clutter. These guidelines were not followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain proper infection control practices while administering eye drops to a resident. The resident, who was admitted with diagnoses including macular degeneration and dry eyes, had orders for artificial tear solution to be administered twice daily. During an observation, an LPN administered the eye drops to the resident's left eye, removed her gloves, and applied a new pair of gloves without performing hand hygiene. She then administered the drops to the right eye and left the room without performing hand hygiene after removing the gloves or before exiting the room. The LPN confirmed in an interview that she did not perform hand hygiene as required. The facility's hand washing policy required the use of alcohol hand sanitizer before exiting a resident's room, and the medication administration policy did not specify when to apply or remove gloves or when to perform hand hygiene during the process.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all staff were checked against the Nurse Aide Registry (NAR) for a history of abuse, as required by their policy. Specifically, the personnel files for a Dietary Cook and an LPN revealed no evidence that they were checked against the NAR. This deficiency was confirmed by the Human Resources Manager during an interview. The lack of these checks had the potential to affect all 42 residents at the facility. The facility's undated policy titled 'Licensing Requirements' mandates that all required checks, including the Ohio Nurse Aide Registry and Office for Inspector General, be completed on anyone the facility is considering hiring.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the activities director was qualified, potentially affecting all 42 residents. The personnel file review revealed that the Activity Director (AD) was hired as a Dietary Manager and later assigned as the AD without meeting the required qualifications. The job description required the AD to be a qualified therapeutic recreation specialist, licensed activities professional, or have relevant experience or training. However, there was no evidence that the AD met these qualifications. Interviews confirmed that the AD was aware of her lack of qualifications and had informed the facility, which promised but failed to provide the necessary training until the day before the surveyor's interview. As of the interview date, the AD remained unqualified according to the job description and regulations.