Greenville Health & Rehabilitation Center

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 deficiency involves the facility’s failure to ensure that residents who were unable to fully perform activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene, specifically related to routine bathing and showers. For Resident #1, records showed she was cognitively intact with a BIMS score of 12, had no range of motion impairment, and required supervision with bathing. Her care plan directed staff to provide shower care per schedule and as needed, with no indication of routine refusals. She was scheduled for showers on the day shift three times weekly, yet multiple dates over several weeks had no completed shower sheets, and the electronic medical record bathing task did not indicate whether she received a bed bath or shower. On observation and interview, she reported not receiving a shower that day, could not recall her shower schedule or last shower, and her hair appeared matted and greasy. Resident #2 had severe cognitive impairment with a BIMS score of 6, required moderate assistance with bathing, and had a care plan directing staff to provide showers per schedule and as needed. His care plan also included a behavioral focus for rejection of care, with a goal that he would remain clean and well-groomed. He was scheduled for showers three times weekly on the day shift. The shower assignment sheets showed only two documented showers and one refusal over the review period, with multiple scheduled days lacking any completed shower sheet. The electronic medical record bathing task again did not specify whether a bed bath or shower was provided. During interview, he stated he did not get a shower that day, believed his last shower was the previous day, and reported taking showers regularly with no specific schedule preference. Observation noted he was unshaved, had an unkempt appearance, matted hair, and an unclean odor. Resident #3 was cognitively intact with a BIMS score of 12, had no extremity impairment, and required supervision or substantial/maximal assistance with bathing according to the MDS and care plan. Her care plan required staff to provide showers per schedule and as needed, with no indication of bathing refusals. She was also scheduled for showers three times weekly on the day shift. The shower sheets showed one documented shower and two refusals, with numerous scheduled days lacking any completed shower sheet. As with the other residents, the electronic medical record bathing task did not indicate whether a bed bath or shower was actually given. In interview, she stated she did not receive or was not offered a shower that day and believed her last shower had been a couple of weeks earlier; observation showed her hair was disheveled and unclean in appearance. Staff interviews revealed systemic issues with the shower documentation and monitoring process. Multiple CNAs stated there was a shower schedule posted at the nurses’ station and that they were to complete shower sheets after each shower and turn them in to the nurse, including documenting refusals and skin concerns. Several CNAs acknowledged that sometimes they were not able to complete all scheduled showers and did not know if showers were completed on subsequent shifts, and none could explain why multiple shower sheets were missing for the three residents or confirm that showers had been provided. LVNs reported that shower sheets were important for proof of completion and for identifying skin changes, and that they were responsible for reviewing the sheets and being notified of refusals, but they also could not explain the missing documentation or confirm that showers occurred. The DON and Administrator stated their expectation that showers be completed per schedule, refusals reported to nursing, and shower sheets completed and monitored by nursing and management, but the missing shower sheets and resident reports and observations demonstrated that these expectations were not met for the three residents. The facility’s own Clinical Practice Guidelines for Activities of Daily Living Care stated that residents will receive essential services for ADLs to maintain grooming and personal and oral hygiene, and that bathing includes grooming activities such as shaving and brushing teeth and hair. Despite these guidelines and the established shower schedules and care plans, the lack of completed shower sheets on multiple scheduled days, the absence of clear documentation in the electronic medical record regarding whether showers or bed baths were provided, and the residents’ own statements and observed unkempt conditions show that the facility did not ensure that these three residents were routinely showered or bathed as planned. This combination of incomplete documentation, staff inability to verify that showers were given, and observed poor hygiene constituted the deficiency in providing necessary ADL care for bathing and grooming.

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 necessary care and services to ensure that four residents who were unable to carry out activities of daily living received the required assistance to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, the facility did not provide scheduled showers for these residents during the month of November, as evidenced by observation, interviews, and record reviews. Documentation inconsistencies and missing shower sheets were noted, and residents reported not receiving showers as scheduled or not being offered them at all. Resident interviews revealed that some residents did not receive showers on their scheduled days, with one resident stating she was not even asked or informed about her shower. Another resident reported not receiving a shower due to the absence of a shower aide, and a third resident indicated she was only given bed baths because staff did not want to use the Hoyer lift for showers, despite her preference for a shower. A fourth resident stated she received showers only about once a week and noted inconsistency in staff providing showers. In several cases, shower sheets were missing or incomplete, and staff were unable to verify whether showers or bed baths had been provided as scheduled. Staff interviews confirmed that there were challenges in completing all scheduled showers, with some nurse aides reporting insufficient time to complete showers and passing the responsibility to the next shift. There was also confusion among staff regarding the shower schedule and documentation procedures. Nursing staff and administration acknowledged the expectation for showers to be completed per schedule and for staff to notify supervisors if showers could not be completed, but records and interviews indicated this process was not consistently followed.

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's right to self-determination and choice regarding personal finances and significant life decisions. A male resident with dementia, anxiety, heart failure, hypertension, and impaired coordination, who had a moderate cognitive impairment (BIMS score of 8), was not provided access to a working debit card attached to his personal funds for daily use. The resident's care plan indicated a goal of maintaining dignity and meeting his needs in a timely manner, but the facility did not uphold these standards. The resident was unable to use his debit card for purchases, as observed when a transaction was denied at a vending machine. Additionally, the facility failed to prevent the administrator from purchasing a pre-need funeral plan for the resident, despite the resident having previously expressed to his family that he did not want such a plan. The administrator withdrew over $13,000 from the resident's account to purchase the funeral plan and start a trust fund, without the resident's informed consent. Interviews revealed that the administrator acted on the suggestion of a family member who was not the resident's POA or guardian, and that the resident had not authorized these financial decisions. There were also concerns raised by staff about other residents and staff accessing the resident's debit card without proper authorization, resulting in unexplained withdrawals from his account. The facility's inaction in addressing repeated staff concerns about unauthorized use of the resident's funds, as well as the administrator's decision to proceed with significant financial transactions against the resident's wishes, led to the identification of Immediate Jeopardy. The facility did not ensure the resident's right to make choices about aspects of his life that were significant to him, particularly regarding his finances and end-of-life arrangements.

Penalty

Inspection fine: $133,425

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 protect a resident from misappropriation of personal funds and belongings, resulting in unauthorized use of the resident's debit card by both staff and another resident. The resident, who had dementia and moderate cognitive impairment as indicated by a BIMS score of 8, was at risk for further cognitive decline. Despite the care plan interventions to maintain routine and monitor cognitive changes, the resident's debit card was used for multiple unauthorized ATM withdrawals and purchases over several dates. The resident was unaware of these transactions and did not authorize the use of his card by others, except for a single instance where he permitted another resident to use it for a small amount. Staff interviews revealed that certified nurse aides (CNAs) and another resident were involved in attempting to withdraw funds from the resident's account without proper authorization. One CNA admitted to attempting an ATM withdrawal after being given the card and PIN by another resident, only realizing the card did not belong to that resident when a fraud alert appeared. The CNA returned the card but did not immediately report the incident. Further interviews indicated a pattern of staff and residents accessing the resident's funds, with reports of other staff and family members of residents charging the resident for errands and transportation, sometimes for significant amounts. These incidents were not consistently reported to administration, and there was confusion and lack of clarity among staff and administration regarding what constituted misappropriation. The administrator was aware that the resident had given his card to another resident but was not aware of the extent of unauthorized use by staff. The administrator believed that if the resident gave his card to another resident, it did not constitute misappropriation, and was unaware of the attempted $200 withdrawal by staff. The administrator and other staff had been informed of suspicious withdrawals and concerns by the resident's family, but the issue was not promptly or thoroughly investigated. The facility's policy required protection against misappropriation, but the lack of timely action and oversight allowed unauthorized transactions to occur, resulting in financial loss and emotional distress for the resident.

Penalty

Inspection fine: $133,425

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 written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, the facility did not follow its own abuse policy for a resident with moderate cognitive impairment, who had diagnoses including dementia, anxiety, heart failure, high blood pressure, and lack of coordination. The resident was at risk for further cognitive decline and had a care plan aimed at maintaining his dignity and current level of functioning. Staff members, including CNAs, were involved in unauthorized attempts to use the resident's debit card for ATM withdrawals. One CNA admitted to attempting a transaction after being given the card and PIN by another resident, only to discover the card belonged to the affected resident. The CNA did not report the incident immediately and later revealed knowledge of multiple occasions where the resident's funds were accessed or used by other residents, staff, and even family members of other residents. The administrator was reportedly aware of these incidents but did not take appropriate action or conduct a thorough investigation into the misappropriation of the resident's funds and unauthorized transactions. Interviews and record reviews indicated that the resident was unaware of the extent of unauthorized use of his debit card and did not authorize others to use it beyond a single instance. Bank statements revealed multiple large withdrawals that the resident could not recall, causing him emotional distress. Despite staff and other residents being aware of the ongoing misuse of the resident's funds, the facility failed to protect the resident, did not follow its abuse policy, and did not initiate a timely or adequate investigation into the misappropriation of property.

Removal Plan

• The DON completed an assessment on Resident #9 to determine if resident was having any emotional distress related to this incident.
• The DON completed a Comprehensive Trauma screen on the resident, and resident will be referred to psychology services for further evaluation.
• The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a psychology evaluation related to this incident.
• The Regional Director of Operations provided 1:1 in-service with the Regional Nurse Consultant on the facility's abuse, Neglect, and Misappropriations policy.
• The Regional Nurse Consultant provided 1:1 education to the facility DON on the Abuse, Neglect, and Misappropriations policy.
• The DON started in-service education with all staff on the facility's Abuse, Neglect, Misappropriations policy, including post-test. No staff will be allowed to work until they have completed their education.
• The Administrator was suspended by the Regional Director of Operations pending investigation.
• The resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. Residents' family will be encouraged to go as well. Resident does have an active Trust fund in the facility and has access to immediate funds if he chooses.
• The Misappropriation incident was reported to HHSC by the DON.
• The Misappropriation incident was also reported to the local law enforcement agency.
• The incident was reported to HHSC by the DON regarding Resident #63 not being authorized to use Resident #9's debit card.
• Resident #63 was discharged from the facility and did not have access to resident #9's debit card.
• The facility started an investigation into the incident; the investigation was completed.
• C.N.A. E was suspended by the DON related to the incident.
• C.N.A. D was suspended and never returned to work.
• The Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately.
• The Regional Nurse Consultant will oversee this process weekly x 6 weeks.
• The facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to implement the abuse policy.
• The facility conducted an Ad Hoc QAPI meeting to discuss Misappropriation, and implementation of the abuse policy and sustaining compliance.

Penalty

Inspection fine: $133,425

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, neglect, exploitation, or mistreatment—including injuries of unknown source and misappropriation of resident property—were reported immediately, or within the required timeframes, to the administrator and appropriate authorities. Specifically, there were delays in reporting incidents involving three residents. In one case, two CNAs attempted to use a resident's debit card at an ATM after receiving it from another resident, but the incident was not reported to the administrator or state agency in a timely manner. The resident whose card was used had moderate cognitive impairment and was unaware that his card was being given to others or used for unauthorized transactions. Interviews revealed that staff and other residents were aware of ongoing issues with the resident's finances, but these concerns were not promptly reported as required. In another incident, a resident-to-resident altercation occurred in which one resident with severe cognitive impairment was struck in the head multiple times by another resident known to have aggressive behaviors. The CNA who witnessed the event reported it to two nurses, but neither nurse reported the incident to the administrator immediately. The administrator only became aware of the altercation several days later, after which the required assessments and reporting were initiated. Interviews with staff indicated confusion or lack of knowledge regarding the proper reporting procedures, with some staff assuming others had reported the incident or not understanding the steps required. Record reviews and staff interviews confirmed that the facility's policies required immediate reporting of abuse, neglect, exploitation, and misappropriation of property, but these procedures were not followed in the cited incidents. The failure to report these events in a timely manner resulted in delayed investigations and assessments, and the facility did not meet regulatory requirements for prompt notification to the administrator and state authorities.

Penalty

Inspection fine: $133,425

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 thoroughly investigate and protect a resident from misappropriation of personal funds, as evidenced by multiple staff and resident interviews and record reviews. The resident, who had moderate cognitive impairment with a BIMS score of 8 and diagnoses including dementia, anxiety, heart failure, high blood pressure, and lack of coordination, was at risk for further decline. The care plan indicated the resident required support to maintain dignity and current functioning. Despite this, there were several incidents where the resident's debit card was used or attempted to be used by others without proper authorization or oversight. On one occasion, two CNAs attempted to withdraw money from an ATM using the resident's debit card, which had been given to them by another resident. The CNAs were unaware the card belonged to the resident until a fraud alert appeared. The incident was not immediately reported to the administrator, and the CNAs were only suspended after the fact. Interviews revealed that the resident had given his card to another resident for a single use but was unaware that it was being given to staff or used for multiple unauthorized withdrawals. Bank statements showed several large withdrawals that the resident did not recognize or authorize, causing him distress when reviewed. Further interviews with staff indicated that there were ongoing concerns about the resident's funds being accessed by other residents, staff, and even family members of other residents. These concerns were reported to the administrator, who claimed to have investigated but did not take comprehensive action to protect the resident or thoroughly investigate the allegations. The facility's own policy required immediate and thorough investigation and reporting of all allegations of abuse, neglect, exploitation, and misappropriation of resident property, but these procedures were not followed in this case.

Penalty

Inspection fine: $133,425

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 two residents received therapeutic diets as prescribed by their attending physicians. For one resident, who had diagnoses including dementia, heart failure, dysphagia, and high blood pressure, the care plan required a mechanical soft diet without dairy and the provision of fortified foods and Ensure Clear at all meals. On the observed date, this resident did not receive fortified food, Ensure Clear, or water as indicated on her tray card. Staff interviews revealed that the cook did not add fortified ingredients to the mechanically soft meal and did not serve any fortified food for lunch. The CNA assisting the resident was unaware of what should have been fortified on the tray, and the dietary manager confirmed that the cook was responsible for ensuring the correct diet and supplements were provided. Another resident, with diagnoses including diabetes, anorexia, anemia, and a history of stroke, was also not provided with the required fortified foods during a lunch meal. The resident's care plan and meal ticket specified a regular diet with consistent carbohydrates, no added salt, and fortified foods at all meals, including a specific order for fortified mashed potatoes at lunch. Observation showed that the resident did not receive the fortified mashed potatoes as indicated. The cook stated she was unaware that the resident required fortified foods and did not prepare them. The dietary manager and DON both acknowledged that the resident should have received fortified foods as ordered, and the DON noted a typo on the meal ticket but confirmed the expectation for fortified foods to be provided. Facility policy required that all residents receive foods in the appropriate form and nutritive content as prescribed by the physician, with all diet orders communicated to the dietary department and validated by the dietary manager. Despite these policies, the failures in communication and execution led to residents not receiving their prescribed therapeutic diets and supplements as ordered.

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 establish and maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not follow established policies and procedures for COVID-19 isolation and use of personal protective equipment (PPE). Observations revealed that staff members entered and exited rooms of residents on isolation precautions without donning appropriate PPE or performing hand hygiene. For example, a nursing assistant was seen entering the shared room of two COVID-positive residents without gloves, gown, or N95 mask, and did not wash or sanitize her hands before or after contact. Another staff member was observed pushing a COVID-positive resident in a wheelchair in the hallway without ensuring the resident wore PPE, and did not perform hand hygiene between resident contacts. There was a lack of clear communication and awareness among staff regarding which residents were COVID-positive and required isolation. Several staff members, including nursing assistants and medication aides, reported that they were not informed about the COVID status of residents on their assigned halls, relying instead on visual cues such as PPE boxes or red floor tape, which were inconsistently used or removed. Charge nurses and the infection preventionist indicated that it was the responsibility of the charge nurses to inform staff about positive cases, but this process was not reliably followed. Documentation and lists of COVID-positive residents were incomplete or outdated, leading to confusion and improper implementation of isolation protocols. Additionally, the facility did not ensure that PPE was consistently available outside the rooms of all residents on isolation precautions. In one instance, a resident listed as COVID-positive did not have a PPE box outside her room, and both the infection preventionist and DON were unaware of this omission. The facility's own policies required that all COVID-positive residents have PPE available for staff use before entering their rooms, and that residents remain in isolation for the required period. However, these policies were not consistently implemented, as evidenced by staff interviews, observations, and record reviews.

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 treat residents with respect and dignity during dining services, as observed in two specific instances. Firstly, a CNA and an MA referred to residents needing assistance with eating as 'feeders,' which was acknowledged by both staff members as a dignity issue. The CNA admitted to using the term out of habit and recognized the need to use more respectful language, such as 'assisted dining room.' This inappropriate terminology was used in close proximity to residents, potentially impacting their dignity and self-esteem. Secondly, an LVN was observed standing while feeding a resident, which is not the correct method for assisting residents with meals. The LVN admitted to not being taught to sit at eye level with residents during feeding, which is the expected practice to ensure residents do not feel rushed or intimidated. The Director of Nursing and the Administrator both confirmed that the staff should refer to residents needing assistance as 'assisted diners' and should sit at eye level when feeding residents. These practices are part of the facility's policy to promote and maintain resident dignity.

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 protect several residents from abuse, resulting in multiple incidents of resident-to-resident aggression. Resident #3 was involved in two separate incidents where he was physically assaulted by other residents. On one occasion, Resident #9 shoved Resident #3 in the dining room, and on another occasion, Resident #4 hit Resident #3 on the back of the head. Both Resident #9 and Resident #4 had documented behavior problems, and their care plans included interventions to manage these behaviors, but these measures were not effective in preventing the incidents. Resident #6 was also a victim of abuse when Resident #5 hit her with a silverware packet during breakfast. Despite Resident #5's severely impaired cognition, her care plan did not prevent the aggressive behavior. Similarly, Resident #7 was struck on the head by Resident #8 after repeatedly reaching into Resident #8's Christmas bag. Resident #8 had a history of aggressive behaviors, and his care plan included interventions to manage agitation, but these were not sufficient to prevent the incident. The facility's failure to prevent these incidents of abuse indicates a lack of effective implementation of care plan interventions and monitoring of residents with known behavior problems. The incidents were witnessed by staff members, and immediate actions were taken to separate the residents involved, but the repeated occurrences suggest systemic issues in managing resident behaviors and ensuring a safe 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 implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, as evidenced by two incidents of resident-to-resident altercations that were not reported to the state agency within the required timeframe. The first incident involved two residents, one with supraventricular tachycardia and moderate cognitive impairment, and the other with dementia and severe cognitive impairment. The altercation occurred when one resident moved the other's wheelchair, leading to a physical confrontation. Although the incident was witnessed by staff, it was not reported to the state agency until several hours later. The second incident involved two female residents, one with heart failure and severe cognitive impairment, and the other with dementia but intact cognition. During breakfast, one resident hit the other with a silverware packet after a disagreement over seating. This incident was also witnessed by staff, but the report to the state agency was delayed. The facility's policy required immediate reporting of such incidents, but this was not adhered to in both cases. Interviews with staff, including an LVN and the Administrator, revealed that the facility's abuse prevention coordinator, who was also the Administrator, was responsible for reporting these incidents. However, the Administrator admitted to delays in reporting and acknowledged the importance of timely reporting for resident safety. The failure to report these incidents promptly was a clear violation of the facility's policies and procedures, potentially placing residents at risk for further abuse and neglect.

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 report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, within the required timeframe of 2 hours after the allegation was made. This deficiency was identified for four residents involved in two separate incidents of resident-to-resident altercations. The first incident involved two male residents, one with a diagnosis of supraventricular tachycardia and moderate cognitive impairment, and the other with dementia and severe cognitive impairment. The altercation occurred when one resident moved the other's wheelchair, leading to a physical confrontation. Although the incident was witnessed by staff, it was not reported to the State Survey Agency within the required 2-hour timeframe. The second incident involved two female residents, one with severe cognitive impairment and a history of paranoid personality disorder and depression, and the other with intact cognition but a diagnosis of dementia. The altercation occurred in the dining room when one resident hit the other with a silverware packet after a disagreement over seating. This incident was also witnessed by staff, but the report to the state agency was delayed beyond the 2-hour requirement. The facility's policy mandates immediate reporting of such incidents to ensure resident safety and compliance with state regulations. Interviews with facility staff, including an LVN and the Administrator, revealed that there were communication lapses and delays in reporting the incidents. The Administrator, who is the abuse coordinator, acknowledged the importance of timely reporting and the expectation that staff should notify her immediately of any allegations. Despite being aware of the incidents, the Administrator did not ensure that the reports were made within the required timeframe, highlighting a failure in the facility's internal processes for handling and reporting abuse allegations.

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 received treatment and care in accordance with professional standards of practice. A resident, who was at risk for developing pressure ulcers, was reported to have skin issues on her buttocks by a CNA. However, the LVN did not assess the resident's buttocks after the report was made. This lack of assessment and documentation could lead to the resident not receiving appropriate care and treatment. The resident, a female with a history of peripheral vascular disease, Type 2 diabetes mellitus, congestive heart failure, and protein calorie malnutrition, was frequently incontinent of urine and always incontinent of bowel. Her care plan included weekly skin checks and reporting any new skin conditions to the physician. Despite these measures, there was no documentation of skin issues in the resident's progress notes or treatment administration record for the month of May 2024. Interviews with staff revealed that the CNA reported the skin issues to a charge nurse, who instructed the CNA to apply cream, but no further action was taken. The ADON acknowledged that the skin breakdown should have been documented and monitored. The facility's Skin Management Policy requires that any change in skin condition be documented and communicated to the physician, wound team, and family, which was not done 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 that residents were informed about Medicaid/Medicare coverage and potential liability for services not covered. Specifically, the facility did not provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to three residents (Residents #30, #183, and #185) when they were discharged from skilled services before their covered days were exhausted. This notice is essential to inform residents that Medicare will no longer pay for skilled services and to provide them with the option to continue services at their own expense. Resident #30, a male with severe cognitive impairment, was admitted with diagnoses including gastroenteritis, anxiety, and depression. He was receiving Medicare Part A services, but no SNF ABN was completed when his coverage ended. Similarly, Resident #183, a female with moderate cognitive impairment and diagnoses including dementia, kidney failure, and atrial fibrillation, did not receive an SNF ABN when her Medicare Part A services ended. Resident #185, a female with moderate cognitive impairment and diagnoses including respiratory failure, congestive heart failure, and stroke, also did not receive an SNF ABN when her Medicare Part A services ended. Interviews with facility staff revealed a lack of awareness and training regarding the SNF ABN forms. The MDS Coordinators and the Business Office Manager (BOM) were unaware of their responsibilities related to the SNF ABN forms. The Director of Nursing (DON) and the Administrator also did not know about the SNF ABN forms or the process for completing them. This lack of knowledge and training led to the failure to provide the necessary notifications to the residents, potentially placing them at financial risk.

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 assessments accurately reflected the resident status for four residents reviewed for MDS assessment accuracy. Specifically, the facility did not accurately code the use of anticoagulant medications for these residents. This discrepancy was identified through interviews and record reviews, which revealed that the residents were not actually taking anticoagulant medications, despite being coded as such in their MDS assessments. The medications in question were aspirin and Plavix, which are antiplatelet medications and should not have been coded as anticoagulants according to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Resident #17, a female with multiple diagnoses including chronic obstructive pulmonary disease and Parkinson's, was incorrectly coded as taking an anticoagulant medication. However, her medication review report indicated she was only prescribed aspirin. Similarly, Resident #38, a male with diagnoses including deep vein thrombosis and stroke, was also incorrectly coded as taking an anticoagulant. His physician's orders indicated he was prescribed aspirin and Plavix, both of which are antiplatelet medications. Residents #49 and #53 were also affected by this coding error. Resident #49, with diagnoses including chronic respiratory failure and congestive heart failure, was coded as taking an anticoagulant, but her records only showed an order for aspirin. Resident #53, with chronic respiratory failure and type 2 diabetes, was similarly misrepresented in the MDS assessment. Interviews with the MDS Coordinators revealed that they mistakenly believed aspirin could be coded as an anticoagulant, leading to these inaccuracies. The Administrator and other staff members acknowledged the importance of accurate MDS coding for proper resident care and facility reimbursement.

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 comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident #44, a cognitively intact female with anxiety, diabetes, COPD, and stroke, had a physician's order for Lorazepam to manage anxiety. However, her care plan did not include this medication or any related interventions. Similarly, Resident #51, a cognitively intact female with PVD, COPD, high blood pressure, and bipolar disorder, was prescribed Eliquis, an anticoagulant, but her care plan lacked any mention of this medication or necessary interventions. Interviews with the MDS Coordinators and DON revealed a lack of awareness and oversight in updating care plans to reflect these critical medications, which are essential for proper resident care and staff guidance. Resident #5, a severely cognitively impaired male with anxiety, dementia, dysphagia, and a history of stroke, experienced a fall that was documented in his progress notes. Despite this incident, his care plan was not updated to include the fall or any new interventions to prevent future falls. Interviews with the MDS Coordinators, DON, and ADON highlighted a breakdown in communication and responsibility for updating care plans following incidents like falls. This oversight could lead to missed care and increased risk of further incidents. Resident #47, a severely cognitively impaired male with multiple diagnoses including pneumonia, heart failure, and diabetes, had an active order for palliative care. However, his care plan did not reflect this significant change in his care needs. The MDS Coordinators and DON acknowledged the oversight, attributing it to a lack of timely updates and coordination among staff. The failure to include palliative care in the resident's care plan could result in inadequate comfort measures and support for the resident's end-of-life care needs.

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 acceptable parameters of nutritional status for three residents, leading to potential risks of malnourishment, weight loss, and decreased quality of life. Resident #1, who had moderate cognitive impairment and was on hospice care, did not receive his prescribed magic cup with meals on multiple occasions. Despite the dietary orders, the kitchen did not provide the magic cup, and the charge nurses failed to ensure its delivery. The Assistant Director of Nursing (ADON) acknowledged the risk of weight loss due to this oversight. Resident #34, who was severely cognitively impaired and required total assistance with daily activities, did not receive his prescribed health shake with meals. The kitchen was out of stock, and the staff did not notify the physician or the administration about the shortage. The Dietary Manager (DM) admitted to not informing the Administrator about the lack of health shakes and magic cups, which were essential for maintaining the residents' weight and nutritional status. Resident #49, who had multiple chronic conditions and a recent history of significant weight loss, did not receive her Nutritious Shake for several days. The staff informed her that the shakes were out of stock, and the DM confirmed the shortage. The Nurse Practitioner (NP) and Registered Nurse (RN) were not notified about the unavailability of the nutritional supplements, which could lead to further weight loss. The facility's policy on diets, nutrition, and hydration was not followed, resulting in the residents not receiving the necessary supplements to maintain their health.

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 residents requiring respiratory care were provided such care consistent with professional standards of practice. For Resident #44, there was no oxygen order in place until after surveyor intervention, despite the resident requiring oxygen therapy for chronic obstructive pulmonary disease (COPD). The resident's oxygen was initially set at an incorrect level, and the charge nurse was unaware of the missing order until questioned by the surveyor. This oversight could have led to respiratory issues for the resident due to improper oxygen levels. Resident #51's oxygen concentrator filter was found to be dirty, and the night shift staff responsible for cleaning it had not done so. The resident's care plan indicated the need for clean filters to prevent respiratory issues, but this was not adhered to. Similarly, Resident #17's oxygen filter was also dirty, and the oxygen tubing was not stored in a bag when not in use, which could lead to contamination and respiratory complications. The staff were not following the protocol for weekly cleaning and proper storage of respiratory equipment. Resident #60's oxygen concentrator filter was observed to be dirty, indicating a failure to follow the weekly cleaning schedule. Resident #47's nebulizer mask was not stored in a bag after use, increasing the risk of cross-contamination. Lastly, Resident #53's BiPAP mask was not functioning properly, and the resident had not used it for 2-3 months due to a broken strap. The staff had not contacted respiratory therapy to address the issue, and the mask was not stored in a bag, exposing it to potential contamination. These failures in providing appropriate respiratory care could lead to significant respiratory complications for the residents involved.

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 all drugs were stored in locked compartments and labeled in accordance with professional standards. Specifically, the Treatment Cart and the 400 Hall Nurse cart were found unsecured and accessible to unauthorized personnel. Additionally, medications on the 100 Hall Nurse cart, including an insulin pen and inhalers for three residents, were not labeled with open dates. A multidose vial of Lidocaine on the 300 Hall Nurse cart also lacked an open date. These lapses were observed during various checks and interviews with staff, who acknowledged the importance of securing and properly labeling medications but failed to adhere to these protocols. The facility also failed to discard expired medications in the medication storage room. A vial of Influenza Vaccine and a vial of Tuberculin Purified Protein Derivative were found in the medication fridge, both of which had been opened for more than 30 days and should have been discarded. Staff interviews revealed a lack of awareness regarding the expiration timelines for these medications, and the Assistant Director of Nursing (ADON) admitted to not checking the medication fridge as frequently as required due to other work demands. Interviews with the Director of Nursing (DON) and other staff confirmed that the facility's policy required all medications to be stored in locked compartments and labeled with open dates. The DON and ADON acknowledged the importance of these practices for maintaining medication efficacy and resident safety. However, the facility's failure to consistently follow these protocols resulted in multiple deficiencies, including unsecured medication carts and improperly labeled or expired 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 that menus were followed for residents on a pureed food consistency diet, leading to deficiencies in the nutritional needs of these residents. Specifically, the facility served the wrong scoop size servings of macaroni and cheese during the lunch meal on 3/25/24, and failed to serve pureed bread to residents on the same day. Cook S used a #12 scoop instead of the required #6 scoop and did not provide a second scoop to compensate. Additionally, Cook S forgot to serve the pureed bread, which was prepared but not served to the residents. The Dietary Manager confirmed these errors and acknowledged that the correct scoop size and pureed bread should have been used and served, respectively. On 3/26/24, the facility again failed to follow the puree recipe for the lunch meal. Cook T did not use the recipe book while preparing the meal, instead relying on personal methods for preparing chili, collard greens, and rice. This resulted in the incorrect preparation of these items, as Cook T added ingredients and thickener without following the specified recipe. Similarly, Cook S did not use the recipe book while preparing pureed cinnamon apple slices, instead relying on her memory. Both cooks acknowledged the importance of following the recipe book to ensure residents receive the correct food, especially for those with dietary restrictions such as diabetes. Interviews with the Dietary Manager and Regional Director revealed a lack of oversight and training regarding the use of correct scoop sizes and adherence to recipe books. The Dietary Manager admitted that staff had not been trained on scoop sizes and recipe book usage in the current year and that test trays were not conducted regularly. The Regional Director was unaware of the issues with scoop sizes and had only recently taken over the facility's account. The Administrator also admitted to not inspecting the kitchen recently and was unaware of any recent in-services on scoop sizes or recipe book usage. This lack of oversight and training contributed to the deficiencies observed in the preparation and serving of pureed meals.

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 food that was palatable, attractive, and at a safe and appetizing temperature for four residents. Observations and interviews revealed that the food served was either bland, over-seasoned, or too spicy, leading to dissatisfaction among the residents. Specifically, Resident #23 found the food bland, Resident #49 found it over-seasoned, Resident #47 described it as terrible, and Resident #17 found it too spicy. Additionally, a test tray review indicated that the macaroni and cheese was cold and bland, although other items were found to be satisfactory in temperature and taste by both the Dietary Manager and State Surveyors. The Dietary Manager admitted to not tasting the food daily and acknowledged difficulties with staff finding recipes in a new program book. She also mentioned that in-services had not been conducted this year, although staff had been trained in the past. The Regional Director, who had been in the position for only a few weeks, confirmed that food complaints were handled through grievances and necessary adjustments were made. The Administrator, who had been in her role since March 2023, also confirmed that she had not conducted a test tray for March 2024 yet, although she had received both complaints and compliments about the new menu. Record reviews indicated that the menus were planned to meet the average resident's nutritional needs and were reviewed by a Registered Dietitian. However, the policy did not include information on palatability. The facility's failure to ensure the food was palatable, attractive, and at an appetizing temperature could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

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. During an observation of Refrigerator #1, it was found that a 5-pound block of sliced cheese, 5 slices of cheese in saran wrap, 8 quarts of lettuce, and 5 slices of bologna were not properly labeled with open dates, received dates, or expiration dates. Additionally, 6.5 pounds of sliced strawberries in Freezer #2 were also found without received or expiration dates. These deficiencies were confirmed by interviews with the Dishwasher, Certified Dietary Manager (CDM), and the Dietary Manager, who acknowledged the lack of proper labeling and dating of food items in the refrigerator and freezer. The CDM also admitted that there had been no recent in-services on labeling, dating, and resealing food items for the dietary staff. Furthermore, a leak in the kitchen ceiling above the food preparation area was observed, which had been reported but not yet repaired, posing a potential fall hazard and risk of contamination. During interviews, the Dietary Manager and Regional Director both confirmed the importance of labeling, dating, and disposing of expired food items according to the facility's policy. The Regional Director stated that labeling and dating were on her to-do list for the dietary staff, but she was unsure if any in-services had been conducted in the past. The Administrator, who had been employed at the facility since March 2023, also confirmed the need for proper labeling and dating of food items and acknowledged the leak in the kitchen ceiling. The Administrator stated that the leak had been reported and repaired previously but was still occurring, and she was unsure when it would be repaired again. The facility's policy on frozen and refrigerated food storage requires proper labeling of cooked foods with the date placed in the refrigerator and an expiration or use-by date. The policy also mandates that refrigerated products be labeled with an opened-on date and a use-by date, which is 7 days from when the product was opened unless there is a manufacturer's use-by, expiration, or sell-by date. The FDA Food Code for 2022 also emphasizes the importance of maintaining physical facilities in good repair. The facility's failure to adhere to these policies and standards could place residents at risk for food contamination and foodborne illness.

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 proper infection prevention and control practices, leading to multiple deficiencies. CNA X did not perform hand hygiene or change gloves while providing incontinent care to a resident, which could spread infection. The CNA admitted to not realizing the importance of hand hygiene and glove changes, despite being trained on these procedures. The Director of Nursing (DON) and the Administrator both acknowledged the expectation for proper hand hygiene and the risks associated with failing to follow these protocols. In another instance, facility staff improperly disposed of used personal protective equipment (PPE) in a resident's personal trash can instead of the biohazard bin. The charge nurse and Assistant Director of Nursing (ADON) confirmed that biohazard materials should be disposed of in designated bins to prevent contamination. The DON admitted that staff needed reeducation on proper disposal practices, and the Administrator was unaware of the improper disposal but recognized the infection control risks. Additionally, a CNA left trash and a sheet in a resident's room after providing care, and a treatment nurse failed to perform hand hygiene after glove removal and did not change gloves properly while providing wound care. Both the ADON and DON emphasized the importance of proper disposal of trash and linens and the need for hand hygiene to prevent cross-contamination and infection. The facility's policies on hand hygiene, infection control, and transmission-based precautions were not followed, leading to these deficiencies.

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 treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one resident. Specifically, a CNA entered a resident's room without knocking or identifying herself, which made the resident feel uncomfortable and unsafe. The resident, who was cognitively intact and required moderate assistance for transfers and toileting, expressed that staff regularly entered his room without knocking, which he found distressing. The CNA acknowledged that she should have knocked and introduced herself before entering the room, recognizing that the facility was the residents' home and they deserved dignity and privacy. Interviews with the ADON, DON, and Administrator confirmed that staff were expected to knock on residents' doors and introduce themselves before entering to ensure no patient care was taking place and to respect residents' rights. The facility's policy on promoting and maintaining resident dignity also required staff to explain care or procedures before initiating them and to maintain resident privacy. Despite annual and as-needed in-services on dignity, the failure to knock on the resident's door before entering was identified as a violation of the resident's rights and dignity.

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 residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain informed consent from a resident before administering Bupropion, an antidepressant medication. The resident, who was moderately cognitively impaired, did not have documentation of consent for the medication in his medical records. Interviews with the Director of Nursing (DON), Licensed Vocational Nurse (LVN), and Assistant Director of Nursing (ADON) revealed that the responsibility for obtaining and monitoring consent forms was not adequately fulfilled, leading to the resident receiving medication without informed consent. The resident's medical records indicated that he was usually understood and usually understood others, with a BIMS score of 08, indicating moderate cognitive impairment. Despite this, there was no documented consent for the use of Bupropion in his care plan. The facility's policy required that residents or their representatives be educated on the risks and benefits of psychotropic drug use and that consent be obtained before administration. However, the staff interviews revealed gaps in the process, with the DON, LVN, and ADON all acknowledging the importance of consent but unable to explain why it was not obtained 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 that a resident's right to make choices about aspects of her life in the facility was respected. Specifically, the facility did not provide showers to a resident as per her request, instead giving her bed baths. The resident, who had chronic obstructive pulmonary disease and chronic diastolic congestive heart failure, was dependent on staff for bathing and required a mechanical lift for transfers. Despite being scheduled for showers, the resident received bed baths on multiple occasions, which was against her expressed wishes. Interviews with the resident and staff confirmed that the resident had requested showers but was given bed baths due to staff being too busy and behind schedule. The Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator all acknowledged that the resident's request for showers should have been honored, emphasizing the importance of respecting residents' choices and rights. The facility's policy on resident rights also supported the resident's right to choose her bathing method. The failure to provide showers as requested was attributed to staff not reporting their inability to fulfill the resident's request and prioritizing other tasks over the resident's expressed preferences.

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 immediately notify the resident's representative(s) when there was a significant change in the resident's physical status. Specifically, the facility did not inform the emergency contact of a resident who had abnormal hemoglobin lab values and required a blood transfusion. The resident, a [AGE] year-old female with diagnoses of dementia, type 2 diabetes, hypertension, and anxiety, was cognitively intact with a BIMS score of 15. Despite this, the facility did not notify her emergency contacts about the abnormal lab values or the scheduled blood transfusion, which was confirmed by the resident's emergency contact during an interview. The RN involved admitted to not notifying the emergency contacts, assuming the resident would inform them herself. The ADON, DON, and Administrator all confirmed that the facility's policy required the nurse to notify the resident's family of any significant changes in condition, including abnormal lab results and transfers for medical procedures. The failure to notify the family placed the resident at risk of not having her family involved in critical care decisions and being unaware of her medical status while she was away from the facility.

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 residents' right to privacy during personal care for one resident. Specifically, an LVN did not provide privacy for a resident while administering g-tube medications. The resident was exposed when EMS providers entered the room, and the LVN did not pull the privacy curtain to shield the resident. The LVN acknowledged that privacy should have been provided to maintain the resident's dignity. Interviews with the ADON, DON, and Administrator confirmed that the LVN should have provided privacy and that it is the responsibility of the nursing staff to ensure residents' privacy and dignity during care. The facility's policy on resident rights also emphasized the importance of personal privacy and confidentiality. The incident was observed and documented, highlighting a failure to adhere to these standards.

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 review and revise the person-centered care plan for a resident, specifically regarding the discontinuation of her Bipap machine. The resident, who had a history of anxiety, diabetes, COPD, and stroke, was cognitively intact and required extensive assistance with daily activities. Despite the resident's Bipap being discontinued, the care plan still included interventions related to its use. This discrepancy was confirmed through record reviews and interviews with the resident, RN, DON, ADON, and the Administrator, all of whom acknowledged the oversight. The resident's comprehensive care plan, dated several months prior, indicated the need for a Bipap due to her respiratory conditions. However, the physician's orders and medication administration records did not reflect any current orders for the Bipap. Interviews revealed that the resident had not used the Bipap for a long time, and staff were unaware that it was still listed in her care plan. The facility's policy on care planning emphasized the importance of updating care plans to reflect current needs, but this was not adhered to in this case, 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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, the facility did not routinely shower or bathe Resident #23, who was dependent on staff for these activities. The resident's care plan indicated she was to receive showers per schedule and as needed, but there were multiple instances where the shower sheets were not completed, and the resident did not receive her scheduled showers or bed baths. The resident herself confirmed that she had missed several showers and attributed this to staff shortages. Interviews with staff members, including CNAs, LVNs, the ADON, and the DON, revealed inconsistencies in the monitoring and documentation of showers and bed baths. The CNAs were responsible for documenting the showers on shower sheets, which were then supposed to be reviewed by the charge nurses and ADONs. However, there were gaps in this process, and the DON acknowledged receiving complaints about missed showers. The staff cited being short-staffed as a reason for not being able to provide the scheduled showers and bed baths. The facility's policy on resident showers emphasized the importance of maintaining proper hygiene, stimulating circulation, and preventing skin issues. Despite this policy, the facility did not adhere to the shower schedule for Resident #23, leading to her missing multiple showers. The lack of proper documentation and follow-up by the nursing staff contributed to this deficiency, as evidenced by the incomplete shower sheets and the resident's own account of missed showers.

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 arrange follow-up appointments with nephrology and hematology for a resident after her discharge from the hospital. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus with hyperglycemia, thrombocytopenia, and an acquired absence of kidney, was readmitted to the facility with discharge instructions to follow up with these specialists. However, the facility did not schedule these necessary appointments, and the resident's care plan did not address these follow-ups either. Interviews with the nursing staff, ADON, and DON revealed that they were unaware of the required follow-up appointments, and the discharge orders were not properly reviewed or acted upon. The resident's discharge orders clearly indicated the need for follow-up appointments within specific time frames, but these were not entered into the electronic medical record or scheduled. The nurses and ADONs were responsible for reviewing and scheduling these appointments, but the process failed, leading to a significant oversight. The DON acknowledged the importance of these follow-ups for the resident's health and admitted that the failure to schedule them could be life-threatening. The Administrator also expected the nurses to follow discharge orders and schedule necessary appointments, but this did not occur 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 the medical record for one resident was complete and accurately documented. Specifically, the facility did not update the allergy list for a resident who was readmitted from the hospital. The resident had allergies to Zyvox and Heparin, which were not added to her list of allergies after her readmission. This oversight was identified through record reviews and interviews with staff, who confirmed that the discharge orders from the hospital included instructions to add these allergies. However, the allergies were not updated in the resident's electronic medical record, care plan, or order summary report. Interviews with the nursing staff, including an RN, ADON, and DON, revealed that the responsibility for updating the allergy list fell on the admitting nurse, with subsequent reviews by the ADONs and DON. Despite these procedures, the allergies were missed, and the staff were unaware of the new allergies. The facility's policy on recording allergies was not followed, leading to incomplete and inaccurate medical records for the resident. The administrator acknowledged the expectation for nurses to follow discharge orders and update medical records but could not address the clinical risks involved.

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 collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, the facility did not obtain the resident's physician's order for hospice services, the most recent physician order, and the most recent hospice plan of care. Additionally, the facility did not obtain the most recent hospice certification, which could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The resident in question was an elderly male with diagnoses including senile degeneration of the brain, anxiety, dementia, and protein-calorie malnutrition. His care plan indicated he was receiving hospice services, but the facility's records did not reflect an order for hospice care. The hospice binder was not up to date, with the last written certification dated several months prior and the last plan of care order dated over two months prior. The hospice administration record and the facility's physician orders did not match, indicating a lack of coordination. Interviews with facility staff and hospice representatives revealed that the hospice binder should have been updated regularly, but this was not done. The facility staff believed the hospice company was responsible for updating the binder, while the hospice company indicated that the facility staff should also monitor the binder. This lack of clarity and responsibility placed the resident at risk for medication errors and a break in continuity of care. The facility's policy on coordination of hospice services emphasized the need for cooperation and communication, 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 develop, implement, and maintain an effective training program for existing staff, specifically for the dietician who was hired on 07/17/23. The dietician did not receive the required dementia training upon hire. This deficiency was identified during a record review of personnel files on 03/27/24. The Human Resources Manager indicated that the corporate office was responsible for the training and had refused to send the necessary information, placing staff at risk for not knowing how to correctly care for residents with dementia. The Administrator confirmed that the corporate office had access to the dietician's hire records and should have sent them to the facility for filing. The facility's policy on training requirements, dated 11/29/2022, mandates that all new and existing staff, individuals providing services under a contractual arrangement, and volunteers receive training consistent with their expected roles. The policy specifies that training should be completed prior to staff independently providing services to residents and should be documented in the individual's personnel file. The failure to provide the required dementia training to the dietician upon hire placed the employee ineligible to work and raised concerns about her knowledge and ability to care for residents with dementia.

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 implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for a dietician. Specifically, the Human Resource Manager did not complete an Employee Misconduct Registry (EMR) check and Criminal History check for the dietician upon hire. This oversight was discovered during a record review of the dietician's personnel file, which indicated that these checks were not completed when the dietician was hired. Both the Human Resources Manager and the Administrator confirmed that the corporate office was responsible for these checks and that the failure to complete them placed residents and staff at risk. The facility's policy, implemented on 10/24/2022, mandates that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. This includes conducting background, reference, and credentials checks. However, the facility did not adhere to this policy in the case of the dietician, as the necessary screenings were not documented. This lapse in procedure could potentially expose residents to harm, as the facility was unaware of the dietician's criminal history or any past misconduct.