The Buckingham

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. Surveyors observed that necessary interventions to manage existing pressure ulcers were not consistently provided, and preventive practices such as regular repositioning, skin assessments, or use of pressure-relieving devices were not adequately documented or performed. This resulted in residents being at risk for worsening of existing ulcers and the development of new pressure injuries.

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 safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with multiple complex medical conditions. The resident, a cognitively intact female with diagnoses including cancer, coronary artery disease, heart failure, hyperlipidemia, GERD, protein calorie malnutrition, anxiety disorder, and respiratory failure, was admitted and assessed as occasionally incontinent of bladder and continent of bowel. Her assessment triggered care areas such as incontinence, pressure sore, pain, falls, ADLs, and psychotropic medications. Despite these identified needs, the care plan did not address all triggered areas, specifically omitting the anti-anxiety medication Sertraline prescribed for anxiety. Interview with the MDS Coordinator confirmed that the care plan did not include the anti-anxiety medication and acknowledged the oversight, attributing it to challenges with a new program and the need to address all care areas promptly, especially for short-stay residents. Review of facility policy indicated that a comprehensive, person-centered care plan should be developed within seven days of the required MDS assessment, involving the interdisciplinary team and the resident or their representative. The failure to include all triggered care areas in the care plan was identified through record review and staff interview.

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

A deficiency was identified when appropriate treatment and care were not provided according to physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was delivered in alignment with the established plan, which is required to meet the individual needs and wishes of the resident. This lapse resulted in the resident not receiving care as intended, based on their documented preferences and medical directives.

Penalty

Inspection fine: $21,645

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, the resident's physician, and the resident's representative after a significant change in condition following an unwitnessed fall. A male resident with a history of Alzheimer’s disease, frequent falls, abnormal gait, seizures, atrial fibrillation, and insomnia was found on the floor by nursing staff during midnight rounds. The resident was holding his head, appeared confused, and was unable to answer questions about pain or the circumstances of the fall. Despite these findings, the nurse assessed the resident, found no visible injuries, and monitored his vital signs, which were within normal limits. Instead of making an immediate phone call to the nurse practitioner (NP) on call, the nurse sent a text message reporting the fall and the resident’s confusion. The NP did not see the text until several hours later and responded that the resident should be sent to the emergency room for evaluation. The nurse did not attempt a follow-up phone call after not receiving a timely response to the text message. The resident was eventually sent to the hospital approximately six hours after the fall, where he was diagnosed with a subarachnoid hemorrhage and admitted to the intensive care unit. Interviews with staff confirmed that the nurse was trained to notify the physician by phone in the event of a significant change in condition, such as an unwitnessed fall with confusion and possible head injury. Facility policy required immediate phone notification to the physician and family in such cases. The nurse relied on her judgment that the resident was stable and did not perceive the confusion as a change in condition, resulting in delayed notification and delayed emergency services.

Removal Plan

• All facility residents were assessed for any Change in Condition.
• 1:1 education was provided to RN A by the Director of Nursing and Administrator.
• Education was provided to all licensed nursing staff and CNAs.
• Direct care staff (PRNs, new hires, from vacation) will not be allowed to render care until in-service is completed.
• Test questions were given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures.
• Education included Policy & Procedure on Notification - Physician Notification, Policy & Procedure on Quality of Care - Change in a Resident's Condition, and use of the Interact SBAR Communication Form.
• Physician and Nurse Practitioner Notification Call Tree was completed and posted in all Nurses stations.
• All direct care staff were educated on the location and use of the Call Tree during in-service.
• Audit tools/checklists were developed to monitor provider notification and change-in-condition documentation.
• Registered and licensed nurses were educated on these audit tools.
• A Notification Report audit on Change in Condition for residents was reviewed and completed.
• These tools will be reviewed for compliance.
• Staff in-services were started on Physician Notification and all clinical staff on Changes in condition; this in-servicing will continue until all clinical staff have been trained.
• Staff will not be allowed to start on the floor or give care until this training has been completed.
• All new clinical staff will receive the in-services as part of the onboarding orientation process prior to being assigned and providing care to residents.
• Post tests were conducted and completed to ensure understanding and competency.
• All current residents were assessed to determine if there is any change in status and/or condition, and the physician will be made aware of any noted changes from the resident's normal baseline.

Penalty

Inspection fine: $21,645

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

Summary

A facility failed to ensure that a resident received timely treatment and care in accordance with professional standards, the resident's care plan, and the resident's preferences following an unwitnessed fall. The resident, who had a history of Alzheimer’s disease, frequent falls, abnormal gait, seizures, atrial fibrillation, and insomnia, was found on the floor by nursing staff during midnight rounds. The resident was confused, holding his head, and unable to clearly explain what had happened. Initial assessments showed no visible injuries and stable vital signs, and the resident was assisted back to bed and monitored throughout the night. Despite the resident’s confusion and the unwitnessed nature of the fall, the RN on duty notified the nurse practitioner (NP) by text message rather than by phone, as required by facility policy. The NP did not see the text message until several hours later, as she was asleep, and instructed that the resident be sent to the emergency room (ER) for evaluation. The RN did not attempt further notification after not receiving a response, relying on her judgment that the resident was stable. This resulted in a delay of approximately six hours before the resident was transported to the hospital. Upon arrival at the hospital, the resident was found to have a subarachnoid hemorrhage and was admitted to the intensive care unit. Interviews with facility staff, including the RN, NP, DON, and administrator, confirmed that the RN did not follow the required notification procedures, which included making a phone call for urgent changes in condition and, if necessary, escalating the notification up the chain of command. Facility policies required immediate phone notification of the physician for significant changes in condition, especially after unwitnessed falls with possible head injury and confusion.

Removal Plan

• All facility residents were assessed for any Change in Condition.
• 1:1 education was provided to RN A by the Director of Nursing and Administrator.
• Education was provided to all licensed nursing staff and CNAs.
• Direct care staff (PRNs, new hires, from vacation) will not be allowed to render care until in-service is completed.
• Test questions were given and taken by all registered and licensed nurses to ensure understanding of the policies and procedures.
• Education included Policy & Procedure on Notification - Physician Notification, Policy & Procedure on Quality of Care - Change in a Resident's Condition, and use of the Interact SBAR Communication Form.
• Physician and Nurse Practitioner Notification Call Tree was completed and posted in all Nurses stations.
• All direct care staff were educated on the location and use of the Call Tree during in-service.
• Audit tools/checklists were developed to monitor provider notification and change-in-condition documentation.
• Registered and licensed nurses were educated on these audit tools.
• A Notification Report audit on Change in Condition for residents was reviewed and completed.
• These tools will be reviewed for compliance.
• The Administrator notified the Medical Director of the Immediate Jeopardy.
• A QAPI meeting was held to review policies/protocols for Change in Condition and Physician Notification.
• The Director of Nursing and the ADON were in-serviced by the Medical Director on Change in Condition and Physician Notification.
• Staff in-services for all registered nurses, licensed clinical staff, and CNAs on Physician Notification and Changes in Condition were started and will continue until all clinical staff have been trained.
• Staff will not be allowed to start on the floor or give care until this training has been completed.
• All new clinical staff will receive the in-services as part of the onboarding orientation process prior to being assigned and providing care to residents.
• Post tests were conducted and completed to ensure understanding and competency.
• All current residents were assessed to determine if there is any change in status and/or condition, and the physician will be made aware of any noted changes from the resident's normal baseline.
• After completion of the residents' audits, no other residents were found to be at risk of having a change in condition and at their normal baseline.

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

A deficiency was identified when a resident, who was dependent on staff for activities of daily living (ADLs) such as bathing, grooming, and personal hygiene, did not receive scheduled showers or baths for a two-week period following admission. The resident, who has diagnoses including hypertensive heart disease, chronic kidney disease, and chronic respiratory failure, was found to require substantial assistance for bathing and was unable to walk. Review of records revealed that no shower sheets had been completed for the resident since arrival, and the baseline care plan indicated a need to keep the resident's skin clean and dry to prevent breakdown. Interviews with the resident confirmed that she had not received a bath or shower as scheduled and had repeatedly requested assistance, which was not provided. The resident reported feeling unclean and embarrassed, and stated that her requests to the CNA were ignored. Staff interviews revealed inconsistent practices regarding resident hygiene, with some CNAs stating that residents should be awakened for showers and refusals documented, while the CNA responsible for the resident admitted to not providing showers or baths and could not specify which nurse had been informed of the missed care. Further interviews with facility leadership and other staff confirmed that the expectation was for residents to receive showers or baths on scheduled days, with refusals to be documented and communicated to nursing staff. The facility's policies emphasized the importance of maintaining resident dignity, self-esteem, and individualized grooming preferences. Despite these policies, the resident did not receive the necessary assistance with hygiene and grooming, and required services were not documented or provided as outlined in her care plan.

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 two residents, Resident #25 and Resident #86, as required by regulations. For Resident #25, the care plan did not include measurable objectives and timeframes related to his communication methods, ADL needs, and preferences. Additionally, there was no documented care plan for his use of a catheter, despite nursing notes indicating he was admitted with a Foley catheter. Observations confirmed the presence of the catheter, yet the care plan lacked any mention of it, potentially leading to unrecognized care needs and preferences. Resident #86's care plan also lacked completion in several areas, including her ADL self-care needs and communication methods. Although the care plan had prefilled sections for various levels of assistance and preferences, none of these were completed. This oversight could result in staff being unaware of the specific care requirements and preferences of Resident #86, as she was rarely or never understood, according to her MDS assessment. Interviews with facility staff, including LVNs, the ADON, the Temp MDS Nurse, the DON, and the Admin, revealed systemic issues contributing to the incomplete care plans. Staff reported a lack of training and familiarity with the facility's EHR system, which was necessary for creating and updating care plans. The MDS Nurse admitted to not knowing how to complete care plans in the EHR, and there was no staff responsible for oversight of the care plans. The facility's policy required care plans to be completed within seven days of the MDS assessment, but delays in MDS assessments led to delayed care plans, exacerbated by a high workload and insufficient training for the MDS team.

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 conduct quarterly MDS assessments for two residents, Resident #27 and Resident #35, within the required three-month timeframe. Resident #27, a woman with severe cognitive impairment and multiple health conditions, had her quarterly MDS assessment completed one month late due to the heavy caseload of the MDS Nurses. The assessment documented her severe cognitive impairment and dependency on staff for all activities of daily living (ADLs), but it was not completed within the required period. Resident #35, a man with minimal cognitive impairment and significant physical limitations, also did not have his quarterly MDS assessment completed and transmitted on time. His assessment was incomplete, with several sections not filled out, and it was not submitted to the receiving agency as required. The MDS Nurse was unaware of this oversight, attributing it to the IDT not completing their sections of the MDS and the lack of a system to flag incomplete assessments. The MDS Nurse cited a heavy workload, multiple admissions and discharges, and external factors such as an internet outage and a hurricane as contributing factors to the delay in completing and transmitting MDS assessments. The facility had previously identified a backlog of over a thousand MDS assessments that had not been transmitted timely, which was discovered in January 2024. This backlog was addressed by transmitting the assessments between May and June 2024, but the focus on clearing the backlog may have contributed to the oversight in Resident #35's assessment.

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 adhere to professional standards for food service safety in one of its walk-in freezers. During an observation, a five-gallon container of ice cream was found without a lid, with only plastic film touching the ice cream. The surface of the ice cream had black-brown areas and was covered with ice crystals. This improper storage was identified during a survey, and the ice cream was subsequently removed and disposed of by the Dietary Director (DD). Interviews with the DD and the Dietary Manager (DM) confirmed that the ice cream should have been stored with a lid to prevent contamination. The DM also stated that all items in the freezer should have two dates: the date obtained and the date for disposal. The facility's undated Standard Storage Procedure policy emphasized proper food storage, rotation, and date marking to ensure safety and quality. However, the ice cream's improper storage could have led to contamination, posing a risk of illness to residents consuming it.