Schulenburg Regency Nursing 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 facility failed to ensure proper food handling and hygiene practices in the kitchen, as observed with one dietary assistant during meal preparation. The dietary assistant was seen touching her shirt, hair, and face, and then proceeded to handle bowls of cereal without washing or sanitizing her hands. She acknowledged during an interview that she did not wash her hands after touching potentially contaminated surfaces and understood that this could transfer germs or bacteria to the food. The dietary assistant also confirmed she had received in-service training on hand hygiene but could not recall when it occurred. Additionally, the same dietary assistant used a dish rag, which was found on top of mop heads and had visible holes and stains, to remove a hot pan of bacon from the oven. The dish rag came into direct contact with the bacon, and the assistant admitted she did not know if the rag had been used for cleaning elsewhere in the kitchen. She stated she was expected to use an oven mitt or potholder for this task and recognized that the rag was not appropriate for food handling. Another dietary staff member and the dietary manager both confirmed that the bacon and cereal were considered contaminated and should have been discarded. Interviews with the dietary manager and administrator confirmed that staff were required to wash or sanitize hands after touching their clothes, hair, or changing tasks, and that only oven mitts or potholders should be used to handle hot food. Both acknowledged that food touched by contaminated hands or items should be discarded. Record review showed that staff had been in-serviced on hand hygiene and safe food handling practices, but lapses in compliance were observed during the survey.

Penalty

Inspection fine: $13,5801 days payment denial

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 resident environment was free from accident hazards and did not provide adequate supervision to prevent accidents, specifically for a resident with a history of elopement. The resident, who had severe cognitive impairment and was at high risk for elopement, managed to exit the memory care unit and was found outside the facility on two separate occasions. The resident's care plan noted her as an elopement risk, but interventions to prevent such incidents were not effectively implemented. On the first occasion, the resident exited the memory care unit and was found outside the building after following someone through a gate. The facility's investigation revealed that the resident had been outside for approximately one hour in high temperatures, which posed a risk to her safety. Despite the resident's history of wandering and elopement, the facility did not have adequate measures in place to prevent her from leaving the secured unit. Interviews with staff indicated a lack of familiarity with the resident's behaviors and insufficient monitoring of exit doors. The facility's delayed response to the alarm and failure to conduct a timely headcount contributed to the resident's prolonged absence from the unit. Additionally, the facility's back cameras were not operational, hindering the ability to monitor the resident's movements effectively.

Removal Plan

• 1:1 Monitoring; assess staff is required to be always within arm's reach of resident.
• Door Monitoring
• Training regarding: Abuse/Neglect, 1:1 Monitoring / Guarding of exit Doors, Elopement.
• Door Signage posted as a reminder to staff not to prop the door open.
• Elopement Assessments Completed and Care plans Updated as needed.
• The facility will conduct audits to ensure that all assessments are completed.

Penalty

Inspection fine: $13,5801 days payment denial

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 that included measurable objectives and time frames to address the mental and psychosocial needs of three residents. Specifically, the care plans were not updated to reflect current clinical needs and physician orders. For one male resident with severe cognitive impairment and multiple diagnoses, including a suprapubic catheter, the care plan did not include any mention of catheter care or the updated transfer requirements, despite physician orders indicating the need for mechanical lift and two-person assistance for transfers. The care plan continued to list outdated interventions, such as assistance by one staff member for transfers, and omitted all catheter-related care instructions. Another female resident with heart failure and dysphagia had a care plan that was not updated to reflect a new physician order changing her diet consistency to regular texture. The care plan continued to reference a mechanical soft diet, even after the order and nursing notes documented the change. Similarly, a third female resident with severe cognitive impairment and significant mobility deficits had a care plan that did not reflect the current order for mechanical lift and two-person assistance for transfers, instead listing only one-person assistance. Interviews with facility staff, including LVNs, the MDS nurse, DON, and the administrator, revealed a lack of clarity regarding responsibility for updating care plans and uncertainty about who uses the care plans in daily practice. Staff acknowledged that care plans should be updated with significant changes, such as new catheters, changes in transfer needs, or diet orders, but these updates were not made. The facility's policy requires timely and appropriate assessment and care plan updates, but this was not followed, resulting in care plans that did not accurately reflect residents' current needs.

Penalty

Inspection fine: $13,5801 days payment denial

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 safety of a resident during transportation, resulting in a fall from a van. The incident involved a resident with severe cognitive impairment and multiple medical conditions, including vascular dementia, type 2 diabetes with diabetic neuropathy, and muscle weakness. The resident required assistance with transfers and was dependent on staff for most activities of daily living. On the day of the incident, the transportation aide did not follow proper procedures for unloading the resident from the van, leading to the resident falling from the van onto the lift, which was on the ground. The transportation aide, who was responsible for the resident's safety, failed to raise the lift to the van's door before attempting to unload the resident. Instead, the aide entered the van from the side door, unhooked the safety belts from the resident's wheelchair, and pushed the resident backward toward the open door without the lift being in place. This action resulted in the resident falling approximately three to four feet from the van onto the lift and ground, causing a laceration and hematoma to the back of the head. The facility's investigation confirmed that the transportation aide did not adhere to the established protocol for unloading residents from the van. The aide was terminated following the incident. The facility's protocol required the aide to stand on the lift, maneuver it to the van door, and ensure the resident's wheelchair was secured before unloading. The failure to follow these procedures directly led to the resident's fall and subsequent injuries.

Penalty

Inspection fine: $13,5801 days payment denial

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 prevent the misappropriation of a resident's medication, specifically Hydrocodone-Acetaminophen, which was prescribed for pain management. The resident, who had severe cognitive impairment and multiple diagnoses including dysphagia, cerebral infarction, rheumatoid arthritis, and pain, did not receive the prescribed medication as it was not administered at all during the review period. The discrepancy was discovered when a nurse noticed a difference in color for some of the tablets during a shift change, leading to the identification of five tablets as Isosorbide Mononitrate, a medication not prescribed to any resident in the facility. Interviews with facility staff revealed that controlled medications are supposed to be counted during shift changes, and any discrepancies should be reported immediately to the Director of Nursing (DON). However, the off-going nurse involved in the incident refused to return to the facility for a urine drug screen and was subsequently terminated. The DON confirmed that the investigation into the missing medication was considered confirmed, and the incident was reported to the relevant authorities, including the police. The facility's policy on the storage of medications requires that controlled medications be stored securely and separately from non-controlled medications. Despite this policy, the misappropriation occurred, and the resident did not receive the necessary pain medication. The facility's failure to adhere to its medication storage and administration protocols resulted in the misappropriation of the resident's medication, which could have led to significant harm if the wrong medication had been administered.

Penalty

Inspection fine: $13,5801 days payment denial

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 adequate pharmaceutical services by not removing expired medications from the medication storage room. During an observation, two expired bisacodyl suppositories and one bag of expired Gentamicin were found in the medication storage room. These medications were intended for a resident who had been admitted with multiple diagnoses, including a urinary tract infection and bacteremia. The Gentamicin was prescribed for intravenous use but was on hold due to high lab levels, leading to its expiration. Interviews with facility staff, including LVNs and the DON, revealed that there was an expectation for nurses and medication aides to regularly check for expired medications. However, the expired medications were not removed, indicating a lapse in the facility's procedures. The facility's policy required that expired drugs be returned to the pharmacy or destroyed, but this was not adhered to, resulting in the deficiency.

Penalty

Inspection fine: $13,5801 days payment denial

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 out-of-hospital do-not-resuscitate (OOH-DNR) order form was properly completed with a physician's signature, as required by state law and facility policy. Review of the resident's records showed that although there was an order for do not resuscitate and the care plan reflected the resident or family's request for DNR status, the OOH-DNR form in the chart lacked the necessary physician signature in the designated section. Multiple staff members, including LVNs, the social worker, DON, and administrator, confirmed during interviews that the OOH-DNR was not valid without a physician's signature and acknowledged that the form for this resident was incomplete. The resident involved was an elderly female with multiple diagnoses, including unspecified dementia, altered mental status, cognitive communication deficit, hypertensive heart disease with heart failure, and unspecified diastolic (congestive) heart failure. The documentation in her chart and care plan indicated her or her family's wish for DNR status, but the required legal documentation was not properly executed. Staff interviews revealed that the process for verifying and auditing OOH-DNR forms was not consistently followed, with some uncertainty about who was responsible for ensuring the forms were complete and valid. Facility policy and state health and safety codes require that an OOH-DNR order must include the attending physician's signature to be considered valid. The absence of this signature on the resident's form meant that her wishes regarding resuscitation might not be honored, as staff would have to treat her as a full code in the event of a medical emergency. The deficiency was identified through record review and staff interviews, which confirmed the lack of a valid OOH-DNR order for the resident.

Penalty

Inspection fine: $13,5801 days payment denial

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 for three residents who were on droplet precautions due to recent COVID-19 diagnoses. Observations revealed that staff members entered the rooms of these residents without donning required personal protective equipment (PPE), specifically face shields or goggles, despite posted signage indicating droplet precautions and instructions for full PPE use. For example, a CNA was observed entering a resident's room without eye protection, and other staff members entered rooms with incomplete PPE, such as wearing only masks and gowns but omitting face shields or goggles. Additionally, the facility did not ensure that PPE was adequately stocked and readily available outside the rooms of residents on droplet precautions. Multiple observations noted the absence of face shields or goggles in the PPE bins or carts stationed outside affected residents' rooms, even though other PPE items like gowns, gloves, and masks were present. Interviews with staff indicated inconsistent knowledge about PPE requirements and procedures for obtaining missing PPE, with some staff expressing uncertainty about the necessity of face shields and others relying on housekeeping or nursing staff to restock supplies. The residents involved had significant medical histories, including dementia, heart failure, metabolic encephalopathy, anxiety, depression, and hypertension, and were under strict isolation protocols due to recent positive COVID-19 tests. Care plans for these residents specified the need for strict isolation and adherence to CDC and health department guidelines, including proper donning and doffing of PPE. Despite these documented interventions, the facility's failure to ensure staff compliance with PPE protocols and to maintain adequate PPE supplies directly contributed 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 that professional staff were licensed, certified, or registered in accordance with applicable state laws, specifically concerning the Assistant Director of Nursing (ADON) who provided assessments to eight residents while her RN license was expired. The ADON's license was delinquent for several months, during which she performed various assessments and direct care activities, including perineal care, resident COVID-19 tests, and charting resident assessments and medication administrations. This lapse in licensure was not identified by the facility's HR department due to a misunderstanding of the process for checking licenses and a transition in the payroll system that disrupted automatic notifications. The residents affected by this deficiency had various medical conditions, including malignant neoplasm, anxiety disorders, osteoporosis, cognitive communication deficits, and other chronic conditions requiring regular assessments and care. The ADON conducted multiple evaluations such as Quarterly ADL Only Evaluations, Elopement Evaluations, Braden Scale for Predicting Pressure Ulcer, Fall Risk Evaluations, and others, which were supposed to be performed by licensed RNs. The comprehensive care plans for these residents required RNs to monitor and document changes in their conditions, which the ADON was not legally qualified to do during the period her license was expired. Interviews with facility staff, including CNAs, LVNs, and RNs, revealed that there was a lack of awareness and oversight regarding the licensure status of the ADON. The HR department failed to conduct regular checks on the licensure status of nursing staff, and the ADON herself was unaware of the expiration of her license due to the cessation of mail notifications by the Texas Board of Nursing. This oversight led to the ADON performing duties that required a current RN license, potentially placing residents at risk for inadequate care and services.