Avir At Grapevine

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, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen. Observations on two separate occasions revealed that all four steamtable compartments contained food and debris floating in them while food was being held for meal service. The specific foods present included sausage jambalaya, capri vegetables, fortified mashed potatoes, mechanical soft sausage jambalaya, brown gravy, pureed vegetables, pureed bread, Salisbury steaks, and pureed jambalaya. These conditions were directly observed prior to and during meal service. Interviews with the Dietary Manager (DM) confirmed awareness of the food and debris in the steamtable compartments before lunch service, with the DM stating that cleaning typically occurred at the end of each shift, not between breakfast and lunch. The DM acknowledged that the expectation was for the steamtable compartments to be cleaned before food was placed in them and that all staff had been trained accordingly. Review of the facility's policy indicated a requirement for a routine cleaning schedule for all cooking equipment and surfaces.

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 the posted lunch menu was followed for one reviewed meal. On the observed date, the posted and planned menu listed sausage jambalaya, seasoned okra, cornbread, and a brownie. However, during meal service, residents were instead served sausage jambalaya, sliced bread, and capri vegetables (green beans, carrots, squash, and zucchini). The cornbread was not served because the delivered box appeared to be open and was deemed unusable, and there was no replacement available in time. The seasoned okra was also not served as it had been used earlier in the week, leaving insufficient quantity for the lunch meal. Interviews with two residents revealed that they were unsure of what would be served, as the menu often did not match the actual meal. The Dietary Manager (DM) confirmed the substitutions and acknowledged that the menu should match what is served, and that staff had been trained to ensure this. The facility's policy requires that menus be served as written unless changes are made for preference, unavailability, or special meals, and that menus are posted in relevant areas. In this instance, the posted menu was not updated to reflect the substitutions, leading to confusion among residents.

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 medication aides (MAs) and nurses followed physician orders for the administration and removal of a lidocaine patch for a resident with chronic pain and moderately impaired cognition. The resident, who had a diagnosis of age-related osteoporosis and was on a scheduled pain medication regimen, was observed to have two lidocaine patches on her right hip, one dated two days prior and another from the current day. Record review showed that staff had signed off on the removal and application of patches, but the old patch was not removed before the new one was applied, contrary to the physician's order. Interviews with staff revealed that both the MA and RN involved were aware of the requirement to remove the old patch before applying a new one, and both had attended in-service training on medication administration. However, neither noticed the previous patch during their respective shifts. The facility's policy on pharmacy services did not address the specific procedure for patch administration and removal, and the DON confirmed there was no policy in place for patch removal. The failure to remove the old patch before applying a new one was not identified until it was observed by surveyors.

Penalty

Inspection fine: $22,950

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

A deficiency occurred when facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, a male with a history of stroke, heart failure, hypertension, diabetes, aphasia, substance abuse, and cerebral ischemia, was found unresponsive on the floor with a reddish-purple face, weak pulse, and no obvious respirations. The resident's care plan indicated full code status, requiring initiation of CPR if the resident was without a heartbeat or not breathing. However, LVN A did not initiate CPR, instead placing the resident on oxygen and attempting to arouse him while checking the code status in the electronic chart. Staff believed the resident was a DNR based on information in the electronic chart and a hospital DNR form, but there was no valid Out of Hospital DNR or state-recognized advance directive on file. The facility's policy required CPR to be initiated if the code status was unclear, but staff did not apply the AED or begin resuscitation efforts. When EMS arrived, they found the resident pulseless and apneic, and began CPR after being unable to locate valid DNR documentation. The confusion over the resident's code status and the lack of appropriate paperwork led to a delay in life-saving interventions. Interviews with facility staff, including the DON, ADON, and Administrator, confirmed that CPR should have been initiated in the absence of a valid Out of Hospital DNR. The EMS Captain and the facility's physician also stated that, according to state requirements, the resident was a full code and resuscitation should have been performed. The incident revealed that staff were not adequately trained to distinguish between hospital and Out of Hospital DNRs, and did not follow facility policy regarding initiation of CPR when code status was unclear.

Removal Plan

• Complete a code status audit of all residents residing in the facility to ensure appropriate documentation in the chart listed as advanced directives or out of hospital DNRs.
• Complete a chart audit to double-check that no code statuses were missed.
• Start education on Code Status and CPR, with education ongoing.
• Educate the director of nursing and administrator on Code Status, Out of Hospital DNRs, when to initiate CPR, and when to apply the AED.
• Initiate new training for all nurses on identifying the appropriate code status including out of hospital DNR vs. Hospital DNR, when to initiate CPR, and how to use the AED correctly.
• Nursing staff checks all residents for orders and appropriate paperwork on code status upon admission/readmission to the facility.
• Nurse management team checks code status in the morning meeting, and the social worker in weekly audits.
• Continue to audit code statuses weekly.
• Discuss all audit results in QAPI.
• Notify the Medical Director of the deficiency (F678).
• Complete education for all staff, and remove any staff unable to be educated from the schedule until training is provided.

Penalty

Inspection fine: $22,950

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

A deficiency occurred when the facility failed to ensure that a resident was free from abuse, specifically when one resident pushed another, resulting in a fall and a pelvic fracture. The incident took place during a period when staff were present in the dining area, and both residents involved had severe cognitive impairment and a history of delusions. The resident who was pushed had previously been independently ambulatory and had recently completed physical therapy. After the incident, she experienced significant pain, was unable to ambulate as before, and required hospitalization, where imaging confirmed a pelvic fracture. Staff interviews revealed that the altercation was preceded by an argument between the two residents, with one becoming agitated and physically pushing the other. Although staff were nearby and attempted to intervene, they were unable to prevent the push. Initial assessments and x-rays did not reveal a fracture, but persistent pain led to further evaluation and the eventual diagnosis. Documentation and interviews confirmed that the staff recognized the event as a resident-to-resident altercation, which is considered abuse under facility policy. The facility's administration did not immediately conduct a thorough investigation into the incident. The administrator relied on secondhand accounts and did not interview all witnesses, including a CNA who directly observed the event. The administrator was initially unaware of the full details and did not report the incident as abuse to the appropriate authorities. The lack of immediate and comprehensive investigation and reporting contributed to the deficiency, as the facility did not ensure the resident's right to be free from abuse was upheld.

Removal Plan

• Notify the medical director of the Immediate Jeopardy (IJ).
• Care plan new behavior of aggressiveness towards other residents for Resident #7, with interventions of a psych consult and redirection when agitated.
• Provide education on de-escalation techniques to all staff.
• Call a psychiatric consult by the medical director for Resident #7 to review medications and behaviors.
• Educate the Administrator and Director of Nursing on abuse and neglect, resident-to-resident altercations, and de-escalation of resident behaviors.
• Train staff on abuse and neglect as well as de-escalation of resident behaviors by the administrator and DON and through facility training software.
• Continue education for new staff as they are hired.
• Start new education on abuse and neglect, resident-to-resident altercations, and de-escalation of resident behaviors for all staff prior to the start of their next shift.
• Hold an Ad Hoc QAPI meeting to inform all the management team.
• Review resident behaviors daily in morning clinical meetings while viewing the 24-hour report/EMR and then weekly in IDT; monitor this monthly in QAPI.
• Complete staff education; remove any staff member unable to be educated from the schedule until training has been provided.

Penalty

Inspection fine: $22,950

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 a safe, functional, sanitary, and comfortable environment for residents, as evidenced by persistent urine odors throughout the Memory Care Unit and unsanitary conditions in the rooms of five residents. Observations revealed dead bugs, food particles, dirt, and debris at the head of beds and between beds and walls in these rooms. Despite the presence of two housekeepers assigned daily to the unit, these issues were not addressed during routine cleaning. Interviews with housekeeping staff indicated that while high-touch surfaces, floors, trash, and bathrooms were cleaned regularly, furniture and beds were not routinely moved for cleaning unless a deep clean was specifically requested. The Housekeeping Supervisor confirmed that each housekeeper was expected to perform a deep clean in one room per day, which involved moving all furniture and beds, but there was no tracking system in place to ensure this was completed. The facility's Resident Rights policy emphasized the importance of a dignified existence, including a clean environment.

Penalty

Inspection fine: $22,950

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

A deficiency occurred when a certified nursing assistant (CNA) took a resident's debit card without consent and used it to make purchases at three different businesses. The resident, a female with diagnoses including diabetes, multiple sclerosis, and anxiety disorder, had an intact cognitive status as indicated by a BIMS score of 14. The resident typically kept her debit card in her purse, stored in the top drawer of her nightstand, and discovered it missing after her family noticed suspicious charges and contacted her. Additionally, $20 was reported missing from her purse. The facility's investigation revealed that the CNA, who had only been employed for about two weeks, was identified through business camera footage as the individual who used the stolen debit card. The administrator and other staff confirmed the CNA's identity after reviewing the footage provided by one of the businesses. The CNA was asked to provide a statement but refused and denied the allegations, despite being confronted with the evidence. The incident was reported to the police, and the resident's family took steps to freeze the debit card and press charges. Interviews with other alert and oriented residents and staff indicated that there were no additional concerns or reports of misappropriation or theft. The facility's policy strictly prohibits exploitation, theft, and misappropriation of resident property, defining misappropriation as the wrongful use of a resident's belongings or money without consent. The incident was limited to the single resident, and no other missing property was reported among other residents.

Penalty

Inspection fine: $22,950

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 implement its written policies and procedures to prohibit and prevent abuse and misappropriation, specifically in the case of a resident-to-resident altercation that resulted in significant injury. On the date of the incident, one resident with severe cognitive impairment and a history of delusions was pushed by another resident, also with severe cognitive impairment, during an argument in the dining area. The push caused the first resident to fall and sustain a pelvic fracture, which led to a significant decline in mobility and increased pain. Documentation and interviews confirmed that the incident was witnessed by staff, and the injured resident was assessed, given pain medication, and later sent to the hospital after continued complaints of pain, where the fracture was diagnosed. Despite the facility's policies requiring immediate reporting of suspected abuse, neglect, or exploitation to the Administrator (the designated Abuse Coordinator), the staff involved did not report the incident as abuse at the time. Both the LVN and CNA present during the incident acknowledged in interviews that they were aware of the reporting requirements but did not immediately notify the Administrator, either due to uncertainty about whether the incident constituted abuse or lack of experience. The Administrator was not made aware of the full details of the incident, including the intentional nature of the push, and therefore did not initiate an investigation or report the event to the appropriate state authorities as required by policy. The lack of immediate reporting and investigation meant that the incident was not properly classified or addressed as abuse, and the required notifications to the state health agency were not made. The Administrator only became aware of the full circumstances after the fact and acknowledged that, had she known the details, she would have conducted an investigation and reported the incident. The facility's failure to follow its own policies and procedures in this case resulted in a deficiency related to the prevention, identification, and reporting of abuse.

Penalty

Inspection fine: $22,950

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 alleged violations involving abuse were immediately reported, as required, to the Administrator and the State Survey Agency within two hours of the incident. Specifically, an incident occurred in which one resident pushed another, resulting in a fall and a pelvic fracture. Both the LVN and CNA who witnessed the event did not immediately report the incident to the Administrator, who also served as the Abuse Coordinator. The Administrator was not made aware of the full details of the incident in a timely manner and did not report the event to the appropriate authorities within the required timeframe. The resident who sustained the injury was an elderly female with severe cognitive impairment and a history of delusions, but no prior behavioral issues. She was previously independently ambulatory but, following the incident, required the use of a wheelchair due to the pelvic fracture. Documentation and interviews confirmed that the resident was assessed after the fall, pain medication was administered, and an x-ray was ordered. However, the initial x-ray did not reveal a fracture, and the resident was later sent to the hospital due to ongoing pain, where the fracture was diagnosed. The resident's responsible party was not initially aware of the circumstances of the fall and reported a significant decline in the resident's mobility following the incident. Interviews with staff revealed a lack of understanding regarding the definition of abuse, particularly in cases involving residents with cognitive impairment. The LVN and CNA both acknowledged knowing the reporting protocol but did not recognize the incident as abuse at the time, resulting in a delay in reporting. The Administrator did not conduct a thorough investigation or report the incident to the State Survey Agency, as she was not fully informed of the details. Facility policy required immediate reporting and investigation of all suspected abuse, including resident-to-resident incidents, but these procedures were not followed in this case.

Penalty

Inspection fine: $22,950

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 investigate and report an allegation of abuse after an incident in which a resident with severe cognitive impairment was pushed by another resident, resulting in a pelvic fracture. The incident occurred in a common area while staff were present, and was witnessed by both a CNA and an LVN. The LVN assessed the injured resident, administered pain medication, notified the DON, MD, and responsible party, and ordered a STAT x-ray. Despite these actions, the incident was not reported as abuse to the Administrator, who was the designated abuse coordinator, nor was a formal investigation initiated at that time. The resident who sustained the injury had a history of severe cognitive impairment, delusions, and depression, and was previously independently ambulatory. Following the incident, she experienced significant pain, was unable to ambulate, and was ultimately sent to the hospital, where a pelvic fracture was diagnosed. The resident's responsible party confirmed that the resident was pushed by another resident and that her mobility was significantly reduced as a result of the injury. The resident who pushed her also had severe cognitive impairment and a history of delusions but no prior physically aggressive behaviors toward other residents. Interviews with staff revealed that both the LVN and CNA present at the time of the incident did not immediately recognize the event as abuse, partly due to the cognitive status of the aggressor. The DON was notified of the incident but did not ensure that it was reported as abuse or that an investigation was conducted. The Administrator did not conduct an investigation or report the incident to the appropriate authorities, as required by facility policy, because she was not made aware of the full details. The facility's policy required immediate reporting and thorough investigation of all abuse allegations, but this was not followed in this case.

Penalty

Inspection fine: $22,950

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 full visual privacy for four residents in the Memory Care Unit, as observed during a survey. One resident's room had a privacy curtain that could not be fully extended around the bed due to a damaged track, while three other residents' rooms lacked privacy curtains entirely. At the time of observation, the residents were not present in their rooms and were being kept in the dining area for observation, and were unable to be interviewed. Interviews with the Housekeeping Supervisor revealed that the Floor Tech, responsible for changing privacy curtains, was on leave, and that maintenance would address damaged tracks if notified. The Director of Plant Operations stated that curtain issues were typically communicated verbally and was unaware of any current problems. Review of facility policy confirmed residents' rights to privacy and dignity.

Penalty

Inspection fine: $22,950

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 an effective pest control program, resulting in the presence of live and dead cockroaches and other bugs in the rooms of five residents. Observations revealed two live cockroaches in one resident's bathroom and dead cockroaches and other bugs at the head of beds between the bed and the wall in four other residents' rooms. The pest control log indicated that cockroaches had been reported every month since May 2024, with monthly treatments conducted by the pest control company, including the most recent treatment a week prior to the observation. During an interview, the Director of Plant Operations acknowledged that bugs in the facility were an ongoing problem, attributing it to the age of the building and multiple entry points for pests. He stated that the pest control company treated the entire facility and sealed any openings found during their visits. However, he was unaware of a specific pest control policy beyond the requirement to have a pest control program. The facility's Resident Rights policy emphasized the right to a dignified existence, which includes a pest-free environment.

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 the dignity and respect of two residents during mealtime. RN D was observed standing between two residents, alternately feeding them while standing, which did not promote a dignified environment. This action was contrary to the facility's policy and expectations, which require staff to sit at the same level as residents when assisting them with eating. The residents involved had severe cognitive impairments and required assistance with eating due to conditions such as Alzheimer's disease and dysphasia. Interviews with RN D revealed a lack of awareness regarding the importance of sitting while feeding residents to maintain their dignity. RN D admitted to not having received training on dignity, which was confirmed by the Director of Nursing (DON) who noted that RN D's name was absent from the in-service training record on dignity. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, 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 a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, during specific dates within the review period from May 25, 2024, to August 25, 2024. This deficiency was identified for five specific days: May 25, May 26, June 1, June 8, and June 15, 2024. On these days, the facility's Time Detail Reports showed that the RNs worked in shifts that did not meet the required eight consecutive hours. For instance, on May 25, 2024, RN C worked a total of 5.5 hours, RN E worked 5.5 hours, and RN D worked 5.5 hours, none of which met the eight-hour requirement. Interviews conducted on August 29, 2024, with the Director of Nursing (DON) and the Administrator revealed that the facility did not have a policy addressing RN coverage. The DON acknowledged that RNs usually doubled up on weekend shifts and expressed an expectation for RNs to work eight consecutive hours on weekends for coverage reasons. The Administrator confirmed the absence of a policy regarding RN coverage, which contributed to the failure to meet the regulatory requirement of having an RN on duty for the specified hours.

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 kitchen sanitation standards, specifically in the storage, preparation, distribution, and serving of food. During an observation, it was noted that Cook A placed food containers into a steamtable that contained contaminated water with burnt food particles. The steamtable compartments were not cleaned, and the water was tinted with various colors, indicating contamination. This was observed in multiple compartments where different food items were placed, including hamburger steaks, pinto beans, cabbage, and pork loin. Interviews revealed that Cook A was aware of the dirty steamtable compartments but proceeded to use them due to being rushed. The Dietary Manager admitted to forgetting to clean the steamtables the previous night and acknowledged that the compartments should be cleaned after each meal to prevent cross-contamination. The facility lacked a specific policy addressing kitchen sanitation, which contributed to the oversight. The Federal Food Code 2022 was referenced, highlighting the requirement for cleaning equipment and utensils to prevent food contamination.

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 right to formulate an advance directive was honored, specifically for a resident who was cognitively intact and had expressed a preference for a Do Not Resuscitate (DNR) status. Upon review, it was found that the resident's code status was not accurately documented in the facility's records, and there was no care plan addressing the resident's advance directives. The resident had not been asked about her code status upon admission, and her preference for DNR was not reflected in the physician's orders or the care plan. Interviews with facility staff, including the LVN, Social Worker, ADON, and DON, revealed a lack of communication and follow-up regarding the resident's code status. The admission nurse was responsible for obtaining and documenting the code status, while the Social Worker was expected to follow up and include it in the care plan. However, the Social Worker admitted to forgetting to care plan the resident's code status, and the ADON and DON were unaware of the oversight until it was brought to their attention. This deficiency placed the resident at risk of not having her end-of-life wishes honored.

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 update a resident's assessment using the quarterly review instrument as required by state and CMS guidelines. Specifically, the facility did not complete the Quarterly MDS Assessment for a resident within three months of their most recent comprehensive assessment. This oversight was identified during a review of the resident's records, which showed that the last MDS Assessment was submitted on 04/25/2024, and no subsequent assessment was completed by the due date of 07/25/2024. The resident in question was an elderly female with moderate cognitive impairment and several medical conditions, including diabetes, hypothyroidism, and dysphagia. Interviews with facility staff revealed a lack of awareness and oversight regarding the missed assessment. The MDS Coordinator, responsible for completing the assessments, mistakenly believed the resident had been discharged and did not realize the assessment was due. The Director of Nursing confirmed the assessment was missed but was unsure of the reason. Additionally, the facility lacked a policy addressing MDS assessments, contributing to the oversight. The MDS Coordinator relied on a consultant to alert her to overdue assessments, which did not occur 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 develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to address the resident's elected code status or advance directive. The resident, a female with intact cognition and a BIMS score of 15, was admitted with diagnoses including multiple sclerosis, anxiety disorder, and hyperkalemia. Despite these conditions, the care plan did not include her code status, and there was no active physician's order for it. The resident expressed a preference for DNR, but this was not documented or reflected in her care plan. Interviews with facility staff, including an LVN, the Social Worker, the ADON, and the DON, revealed a lack of awareness and communication regarding the resident's code status. The Social Worker admitted to forgetting to include the code status in the care plan, and the ADON and DON were not informed of the oversight until it was brought to their attention. The facility's policies on care planning and advance directives were not followed, leading to the omission of the resident's code status in her care plan, which could result in inappropriate care during an emergency.

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 final summary of a resident's status at the time of discharge was available for release to authorized persons and agencies, with the consent of the resident or resident's representative. This deficiency was identified for one resident who was reviewed for discharge summary. The resident, a male with diagnoses of bipolar disorder and Alzheimer's disease, was taken out of the facility on pass with his family and did not return. The facility did not complete a discharge summary after the resident left, and there was no documentation concerning the resident's discharge in the progress notes or assessments. Interviews with the Social Worker and the Director of Nursing (DON) revealed that the discharge was not planned, and the facility did not have a policy or a uniform discharge assessment (UDA) for discharge summaries. The Social Worker admitted to not completing the discharge summary and was unsure why it was not done. The DON assumed that a nurse would at least add a progress note related to the discharge, but this was not done. The Administrator confirmed the absence of a policy addressing discharge summaries, and there was no monitoring to ensure that discharge summaries or notes were being completed.

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 proper management of pharmaceutical services, specifically in the storage and removal of expired medications and vaccines. During an observation, expired influenza vaccines were found in the medication room refrigerator, and expired over-the-counter medications were discovered in the Central Supply medication cabinet. The Licensed Vocational Nurse (LVN) acknowledged that it was the responsibility of all nurses to check and remove expired medications, but this was not consistently done. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) also admitted to lapses in monitoring and training regarding the removal of expired medications. Interviews with the staff revealed a lack of consistent checks and training on the removal of expired medications. The Central Supply Staff, responsible for ensuring medications were not expired, missed identifying expired items during her checks. The DON and ADON were responsible for overseeing the process but could not recall specific dates of their last checks. The facility's policy required expired medications to be removed and destroyed, but this was not adhered to, placing residents at risk of receiving ineffective 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 maintain an effective infection prevention and control program, as evidenced by the actions of LVN L, who did not adhere to enhanced barrier precautions while providing care to a resident. The resident, a male with severe cognitive impairment and a gastrostomy tube, was on enhanced barrier precautions due to his medical condition. Despite the presence of a sign on the resident's door indicating the need for gown and gloves, LVN L entered the room on two separate occasions to administer a bolus feeding and medications without donning a gown, although she performed hand hygiene and wore gloves. Interviews with LVN L and the Director of Nursing (DON) revealed that LVN L was aware of the requirement to wear PPE but forgot to do so. The DON confirmed that staff were expected to wear PPE for residents on enhanced barrier precautions, which was indicated by signs on the residents' doors. A review of the facility's training records showed that LVN L did not attend the training sessions on infection control and enhanced barrier precautions. The facility's policy on enhanced barrier precautions outlined the necessity of wearing gowns and gloves during high-contact care activities, such as device care involving feeding tubes.

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 wound care treatment and follow physician orders for three residents, leading to potential risks of wound deterioration and infection. Resident #1, a cognitively intact female with a skin tear on her left elbow, did not receive wound care as per physician orders from 07/15/24 to 07/23/24. Additionally, there was no documentation of an antibiotic order for Bactrim tablets. The lack of communication and documentation among staff members, including the Treatment Nurse, Charge Nurse, and Medical Records Coordinator, contributed to the oversight in wound care management. Resident #2, a female with moderate cognitive impairment and a risk for moisture-associated skin damage, did not receive consistent wound care as ordered. The August 2024 TAR showed missing documentation for several dates, and during an observation, the resident's wound was found uncovered. The CNA assigned to Resident #2 did not notify the nurse about the missing dressing, assuming it was intentional. The Charge Nurse was unaware of the situation, indicating a breakdown in communication and adherence to wound care protocols. Resident #3, a female with moderate cognitive impairment and a diabetic foot ulcer, also experienced lapses in wound care documentation. The August 2024 TAR lacked entries for multiple dates, and during an observation, the resident's wound was uncovered. LVN E, who was new to the hall, was unaware of the resident's wounds, highlighting a lack of proper handover and training. The facility's failure to ensure consistent wound care and documentation for these residents reflects a systemic issue in following professional standards and physician orders.

Penalty

Inspection fine: $14,697

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 immediately consult with a resident's physician when there was a change in the resident's condition, specifically when the resident displayed signs and symptoms of pain in her left leg. The resident, who had a history of end-stage renal disease, arthritis, hip fracture, Alzheimer's disease, and other conditions, was non-verbal and had severe memory and decision-making impairments. On the evening of the incident, a CNA noticed the resident yelling out in pain during peri care, which was unusual for her. Despite this, the LVN on duty did not notify the physician until the following morning. The LVN assessed the resident's left leg but did not observe any visible abnormalities such as bruises or swelling. The LVN reported the resident's discomfort to the oncoming nurse but did not contact the physician, as she believed the resident was not in pain and had slept comfortably throughout the night. However, when the RN arrived the next morning, she assessed the resident and noted that the resident expressed pain through facial grimacing when her left leg was moved. The RN then contacted the physician, who ordered an x-ray that confirmed a left hip fracture. The delay in notifying the physician resulted in a delay in the resident receiving appropriate medical intervention. The facility's policy required prompt notification of the physician in the event of a change in a resident's condition, which was not adhered to in this case. This failure placed the resident at risk for delayed physician intervention and was identified as an Immediate Jeopardy situation, although it was later removed after corrective actions were initiated.

Removal Plan

• The following in-services were initiated by COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged.
• Licensed Nurses: Promptly and accurately assessing a resident when change of condition has been identified / reported.
• Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner.
• Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form.
• Non-licensed nursing staff: Reporting changes in a resident's condition to a nurse immediately.
• If the nurse does not assess timely, the DON/Designee must be notified.
• The Administrator, DON and ADON were in-serviced regarding ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement.
• An ADHOC QAPI meeting was conducted regarding this plan and monitoring.
• The Medical Director was notified of this plan and monitoring.
• The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely.
• The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change of condition.
• The QAPI committee will review the findings and make any needed changes.

Penalty

Inspection fine: $14,697

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 timely treatment and care to a resident who experienced a change in condition. The resident, a female with multiple diagnoses including dementia and cognitive communication deficit, showed signs of pain when her left leg was touched. Despite these signs, the Licensed Vocational Nurse (LVN) on duty did not notify the physician until the following morning, resulting in a delay in treatment. An x-ray later confirmed a left hip fracture, and the resident was sent to the hospital for evaluation and treatment. The resident's care plan, which included monitoring for physical and nonverbal indicators of discomfort, was not adequately followed. The LVN noted the resident's discomfort but did not perceive it as pain and failed to contact the doctor. The resident's condition was not reassessed until the next shift, when the Registered Nurse (RN) on duty identified the issue and took appropriate action by notifying the physician and ordering an x-ray. The facility's policy on changes in resident status or condition was not adhered to, as the nurse did not promptly notify the physician of the resident's change in condition. This oversight led to an Immediate Jeopardy situation, indicating a serious risk to the resident's health and safety. The facility's failure to act in accordance with professional standards of practice and the resident's care plan resulted in a significant delay in necessary medical intervention.

Removal Plan

• In-service training for nursing staff on assessing a resident when a change of condition is identified or reported.
• Education for licensed nurses on assessing a resident's change in condition using SBAR to ensure all necessary information is communicated to the physician or Nurse Practitioner.
• Training for licensed nurses on reporting changes of condition to the physician or nurse practitioner based on the Change of Condition Form.
• Education for non-licensed nursing staff on reporting changes in a resident's condition to a nurse.
• Instruction for non-licensed nursing staff to notify the DON/Designee if the nurse does not assess.
• In-service training for the Administrator, DON, and ADON to ensure all staff applicable to the in-service receive the training, using online resources and/or in-person training, and ensuring all trained staff have attested to receiving the training by a signed acknowledgment.
• Monitoring by the DON/Designee of all kiosk alerts to ensure any potential change of condition has been addressed.
• Random questioning by the DON/Designee of nurses on what they would do if a resident had a change of condition, or it was reported to them that a resident had a change of condition.
• Review by the QAPI committee of the findings and making any needed changes.