Renton Health & Rehabilitation

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 notify five Medicaid recipient residents when their personal fund account balances reached $1,800, which is within $200 of the $2,000 resource limit that could impact their Medicaid coverage. This oversight placed the residents at risk for personal financial liability for their care. The facility's revised Resident Personal Funds policy requires notification when a resident's account approaches the Supplemental Security Income (SSI) resource limit, but this was not adhered to. The Business Office Manager (BOM) acknowledged the issue, citing a lack of a BOM for several months and confirming that the system was broken, leading to residents exceeding the $2,000 limit. Additionally, the facility did not ensure that funds were reimbursed to the state Office of Financial Recovery (OFR) within 30 days of a resident's discharge or death. Specifically, Resident 219, who was discharged on May 30, 2024, had a balance of $3,286.02 that was not transferred to the resident or OFR until September 13, 2024, over three months later. The BOM confirmed that Resident 219's account was not closed in a timely manner and that the personal fund was not sent with the resident upon transfer to another 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 maintain a homelike environment in several resident rooms, as observed during a survey. In nine out of eighteen sampled rooms, issues such as gouged walls, unmounted televisions, dirty fans, and unsanitary bathroom conditions were noted. Specific observations included gouges in the walls exposing drywall, televisions not mounted on walls, and fans covered in dust debris. Bathrooms in several rooms had rust, dirt, and brown stains on tiles and fixtures, with some toilets having dried smears and missing toilet paper holders. These conditions were confirmed by the Maintenance Supervisor, who acknowledged the need for repairs and cleaning. The report highlights that the facility's inaction in maintaining clean and sanitary conditions in resident rooms compromised the residents' right to a safe and comfortable environment. The Maintenance Supervisor and a Registered Nurse Manager acknowledged the deficiencies, noting that the walls needed repair, bathrooms required daily cleaning, and missing fixtures needed replacement. The presence of jagged foam on a sink and the poor condition of window blinds further contributed to the substandard living conditions observed in 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 environment was free of accident hazards, specifically in the laundry room and in the resident rooms. Observations on two consecutive days revealed that the laundry room door was unlocked due to a malfunctioning key code, allowing unrestricted access. Inside the laundry room, there were chemicals and an open exterior door leading outside, posing risks of elopement and chemical ingestion. Staff interviews confirmed that the lock had been broken for two weeks and that the issue had been reported to the Head of Maintenance, but no repairs had been made. Additionally, the facility did not adequately address fall hazards in the room of a resident with a history of falls and multiple medical conditions, including arthritis and altered mental status. The resident required maximal assistance for transfers and dressing, yet the care plan inaccurately stated they only needed supervision for dressing. Observations showed the resident's room was cluttered, with items scattered on the floor and furniture, creating a fall risk. The resident was also observed with inappropriate footwear, which was inconsistent with the facility's fall prevention policy. Interviews with staff revealed that the resident's room clutter was a known issue, and while some items were stored by the facility, the care plan lacked specific instructions on managing clutter and assisting with transfers. The resident's cognitive issues and failure to use the call light for assistance were also noted, contributing to the risk of falls. Despite these known risks, the facility's interventions were insufficient to prevent the resident from experiencing falls.

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 storage, labeling, and disposal of medications, leading to several deficiencies. Observations revealed that a narcotic medication was stored in an unlocked refrigerator within the West Hall Medication Room, contrary to the facility's policy requiring double locks for narcotics. Additionally, the Garden Wing Cart contained expired medications and eye drops without open dates, which were not removed or destroyed as required. Furthermore, a tube of medicated cream was found on Resident 60's bedside table without a self-medication assessment or physician order, violating the facility's policy on medication storage in resident rooms. The report also highlighted issues with unsecured medication carts. On the Catsablanca unit, a medication cart was left unlocked and unsupervised for 23 minutes, posing a safety risk. Similarly, on the Wild West unit, a medication cart was found unlocked with no staff present, allowing access to medications. Interviews with staff confirmed that these practices were against the facility's expectations and policies, which require medication carts to be locked when not in use to prevent unauthorized access.

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 sanitary conditions in its kitchen and unit refrigerator, which posed a risk for foodborne illness and cross-contamination. Observations revealed that the ice machine in the kitchen had brownish-black and pink mold-like debris on its surfaces, indicating inadequate cleaning. Staff Z, the Dietary Supervisor, acknowledged that the kitchen staff performed daily wipes, while maintenance was responsible for deep cleaning, which was not documented since October 2023. Additionally, wall fans in the kitchen were observed to be dirty, with debris hanging from the grills, and were running during food preparation, further compromising sanitation. Hand hygiene practices were also found to be lacking among dietary staff. Staff DD was observed handling both dirty and clean dishes without changing gloves or performing hand hygiene. Similarly, Staff EE used a thermometer probe without sanitizing it between uses and handled food with soiled gloves. Staff FF was seen touching various surfaces and then handling food without changing gloves. These actions were contrary to the facility's expectations for hand hygiene and sanitation, as confirmed by Staff Z. Furthermore, food transport and storage practices were inadequate. Uncovered cookies were observed on lunch trays being distributed by nurse's aides, exposing them to the hallway environment. The unit refrigerator was found to be unclean, with dried fluid on the shelves and crisper. Staff Z confirmed the refrigerator's condition and the expectation that food should be covered during transport. These deficiencies highlight a failure to adhere to the facility's food safety policies, as outlined in their revised policies from 2024.

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 obtain informed consent prior to administering psychotropic medications to two residents and before the use of bed rails for another resident. Resident 34, diagnosed with anxiety and depression, was administered two antidepressants and an antianxiety medication starting in May 2024, but the informed consent forms were only signed in September 2024. Staff P, an RN Manager, acknowledged that informed consent should have been obtained before administering these medications. Similarly, Resident 20, who was prescribed an antidepressant in May 2024, had a verbal consent noted but the form was not signed until September 2024, with Staff C finalizing the electronic record much later. Staff C could not demonstrate that consent was obtained prior to the electronic signature date. For Resident 60, who was admitted with paralysis on one side of the body, bed rails were ordered and installed without obtaining informed consent. The resident confirmed that staff did not discuss the risks and benefits of the bed rails with them. Staff C admitted that they had not obtained consent for the bed rails, although it was required by the facility's policy. This oversight in obtaining informed consent for both psychotropic medications and bed rails placed residents at risk for unwanted treatment.

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 the required Skilled Nursing Facility Notice of Medicare Non-coverage (SNF-NOMNC) to two residents, Resident 219 and Resident 119, whose skilled services coverage was ending. This notice is essential as it informs residents that their Medicare A benefits are ending and provides information about their right to an expedited appeals process. According to the facility's policy, the NOMNC should be given at least two days before the end of the Medicare-covered Part A stay. However, the records for both residents did not show that the NOMNC was provided, which was confirmed by the Social Services Director during an interview. Resident 219 was admitted to the facility and discharged to the community on May 15, 2024, with a physician's order for discharge dated May 14, 2024. Similarly, Resident 119 was admitted and discharged to the community on May 22, 2024, as noted in the nursing progress note. Despite these discharges, neither resident received the NOMNC, which is a violation of the facility's policy and regulatory requirements. This oversight placed the residents at risk of not being fully informed about their coverage and losing their right to appeal the decision.

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 Minimum Data Set (MDS) assessments accurately reflected the status of three residents, leading to potential risks for unmet care needs and diminished quality of life. For Resident 37, the MDS inaccurately indicated the resident had no natural teeth, despite observations showing multiple lower teeth and the resident awaiting denture repair. Staff acknowledged the error upon review. Resident 51's MDS inaccurately documented the use of a walker as the normal mobility device, while observations showed the resident in a wheelchair. This discrepancy was also confirmed as an error by the staff. For Resident 61, the MDS contained conflicting information regarding the resident's ability to be understood. Although the resident was assessed to have clear speech and intact memory, the MDS incorrectly marked the resident as rarely or never understood, leading to a staff assessment of preferences instead of a resident interview. This resulted in less specific information about the resident's preferences. Staff acknowledged the need for a resident interview, potentially using translation services, to accurately capture the resident's 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 ensure the accuracy of a Pre-Admission Screening and Resident Review (PASRR) assessment for a resident, which is crucial for identifying mental health needs and determining appropriate nursing home placement. The resident in question, who had complex medical diagnoses including dementia, anxiety, and schizophrenia, was receiving antipsychotic medication for acute psychosis. However, the Level 1 PASRR assessment inaccurately identified the resident's serious mental illness indicator as only anxiety and failed to update the assessment to reflect the resident's psychosis and schizophrenia diagnoses. Additionally, the PASRR assessment inaccurately recorded the resident's primary language as English, despite staff identifying it as Vietnamese during the admission assessment. The Social Service Director acknowledged the importance of accurate PASRR assessments for determining the need for Level 2 evaluations and ensuring residents' success in the facility. The director also confirmed that the Level 1 PASRR should have been updated to include the correct diagnoses and primary language, highlighting a lapse in the facility's adherence to its policy and regulatory requirements.

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 care plans for four residents, leading to unmet care needs and a decreased quality of life. Resident 60, who was admitted with paralysis on the left side of their body, had a physician order for bilateral bed rails, but this was not documented in their care plan. The resident was not informed about the risks and benefits of the bed rails, nor was their consent obtained. Staff C, a Registered Nurse Manager, acknowledged the oversight in care planning for the bed rails. Resident 39, who had multiple diagnoses including brain damage and pressure ulcers, had an indwelling urinary catheter that was not documented in their care plan. The resident's representative expressed a desire to have the catheter removed, but was informed by staff that it was necessary until the resident's wounds healed. Staff C admitted that the catheter should have been included in the care plan to ensure proper care. Resident 58, with a history of stroke and difficulty swallowing, was receiving nutrition via a feeding tube, but the care plan was not updated after the resident transitioned to oral intake. Staff AA, a dietician, confirmed that the care plan was outdated. Resident 1, who had conditions including stroke and aphasia, had a care plan that did not address their refusal of care. Observations noted poor hygiene and refusal of care, and staff interviews revealed a lack of documentation and communication regarding refusals, which was acknowledged by the Director of Nursing.

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 nursing care within professional standards by not adhering to physician's orders for pain medication administration for two residents. Resident 34, who experienced occasional pain affecting sleep and daily activities, was given opioid pain medication for pain levels below the prescribed threshold on multiple occasions. Similarly, Resident 20, diagnosed with chronic pain, received incorrect dosages of opioid pain medication for pain levels that did not meet the physician's specified parameters. These actions were confirmed by the Registered Nurse Manager, who acknowledged the importance of following physician-provided parameters for as-needed pain medications. Additionally, the facility did not clarify physician orders or accurately document the completion of tasks for two other residents. Resident 25 had a topical pain patch applied without proper documentation of its removal, and staff incorrectly signed the MAR indicating the patch was applied when it was not. Resident 52's orders for a pain patch were not followed as the MAR did not direct staff to remove the patch after the prescribed 12 hours. The Director of Nursing confirmed the need for clarification of pain patch orders for these residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for several residents, leading to deficiencies in care. Resident 58, who required substantial assistance due to a history of stroke and partial paralysis, was observed multiple times in bed despite orders to be up in a wheelchair daily. Staff interviews revealed that aides were expected to follow care plans, but Resident 58 remained in bed, expressing a preference to get up. Resident 52, who was dependent on staff for personal hygiene, was observed with long fingernails and facial hair, despite orders for regular nail care and shaving. The resident reported that staff did not offer to cut their fingernails as ordered and placed their electric razor out of reach, preventing self-care. Staff interviews confirmed that nail care should be offered as ordered, and refusals should be documented, but this was not consistently done. Resident 60, admitted with paralysis and no memory impairment, also experienced neglect in personal hygiene care. The resident reported not receiving nail care since admission, and staff interviews indicated a lack of documentation for refusals of nail care. Additionally, Resident 1, who required maximum assistance for various ADLs, was observed with greasy hair and long fingernails, despite scheduled bed baths. Staff interviews highlighted a failure to provide care even when residents refused, and a lack of documentation for care provided.

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 end-of-life care and services for two residents receiving hospice care, compromising their quality of life. Resident 1, who had multiple medical conditions including stroke and paralysis, was observed with greasy hair and body odor over several days, indicating a lack of personal hygiene care. Despite the care plan specifying cooperation with hospice services to meet the resident's needs, staff interviews revealed that Resident 1 frequently refused bathing, and there was a lack of communication and coordination between the facility and hospice to address these refusals. Additionally, there was a discrepancy in medication management for Resident 1. The facility's records showed that a high blood pressure medication was discontinued in June, but hospice orders in September still included the medication. This inconsistency highlighted a failure in coordinating medication orders between the facility and hospice services, as confirmed by the Director of Nursing. For Resident 7, who had complex medical diagnoses including cancer, there was a lack of documentation and physician orders for hospice services in the resident's records. Despite being admitted to hospice services in early July, there were no hospice notes or logged visits in the resident's records from late July to early September. Staff interviews confirmed the absence of hospice documentation, indicating a failure in maintaining accurate and complete records of hospice care provided to the resident.

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 a restorative program for a resident with mobility limitations, as identified by staff and reviewed for Range of Motion (ROM). The resident, who had a history of stroke with muscle weakness and functional limitations in ROM, was discharged from physical therapy with recommendations for a restorative nursing program (RNP) to maintain ROM and positioning. However, the facility did not implement the recommended RNP after the discharge from therapy, as confirmed by staff interviews and record reviews. Observations revealed that the resident was not wearing a knee brace and was not on a restorative program, despite the physical therapy discharge summary and referral form recommending specific interventions. Interviews with facility staff, including the Registered Nurse Manager and the Director of Rehabilitation, confirmed that the RNP was not established within the expected timeframe after the referral. The Director of Nursing also acknowledged that the RNP should have been implemented promptly to prevent a decline in the resident's function.

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 adequately monitor the weight of a resident, identified as Resident 58, who was transitioning from tube feeding to oral intake. According to the facility's policy, weights should be collected monthly or more frequently as needed. Resident 58, who had a history of stroke, partial paralysis, and swallowing difficulties, was receiving over half of their calories via a feeding tube. A physician's order from May 2024 directed that Resident 58 be weighed monthly. However, there was a significant gap in weight monitoring, with the resident not being weighed for over a month prior to the discontinuation of tube feeding and not for two weeks after the transition to oral intake. The dietician, Staff AA, confirmed the importance of monitoring weight during such transitions to ensure adequate nutritional intake. Despite the policy and the physician's order, Resident 58's weight was not measured since mid-August 2024. The September Medication Administration Record noted that the resident refused to be weighed, and there was no space to document a weight after the refusal, which may have contributed to the oversight. This failure to monitor weights as ordered placed the resident at risk for weight loss and other negative health outcomes.

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 prompt dental services for two residents, leading to oral discomfort and a diminished quality of life. Resident 52, who had intact mental processing abilities and was dependent on staff for denture care, experienced mouth and facial pain due to ill-fitting upper dentures. Despite a recommendation for new dentures from a dental consult in February 2024, no follow-up appointments were scheduled, and the resident was not seen by a dentist since that time. The resident expressed the need for bottom dentures and reported an incident where they waited for a dental appointment that was never fulfilled due to overbooking. Resident 37, who required substantial assistance for oral hygiene, had issues with loose-fitting upper dentures, causing difficulty in chewing and discomfort. Despite multiple dental visits and recommendations for denture realignment, no follow-up appointments were scheduled. The resident expressed a desire to wear their dentures if they fit properly, indicating the ongoing issue with loose dentures. Staff interviews revealed that the referral for denture adjustment was overlooked, and no pending appointments were scheduled since June 2024. The facility's policy required coordination of dental care and transportation as needed, but these actions were not executed for the residents in question. Staff members, including the Medical Records Supervisor and the Director of Nursing, acknowledged the oversight in scheduling necessary dental appointments, which was contrary to the facility's expectations and policies.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper infection control practices, as evidenced by several observations and interviews. Staff did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. For instance, two nurse's aides were observed repositioning a resident with an infectious immune disease without wearing gowns, despite signage indicating the need for gowns and gloves. This oversight was confirmed by the Licensed Practical Nurse responsible for infection control, who acknowledged the importance of following precaution signs to minimize disease transmission. Hand hygiene practices were also inadequate. A Certified Nursing Assistant (CNA) was observed performing incontinence care for a resident without changing gloves or performing hand hygiene between tasks, leading to potential cross-contamination. Another CNA similarly failed to change gloves during incontinence care, touching clean items with soiled gloves. These actions were contrary to the facility's expectations, as stated by the infection control nurse, who emphasized the need for hand hygiene after glove removal. Additionally, the facility did not provide catheter care in accordance with professional standards. A resident with a history of urinary tract infections and a catheter was observed with their catheter drainage bag lying on the floor, which is against infection control protocols. Staff interviews confirmed that the catheter bag should not be on the floor to prevent infection. Furthermore, the facility had uncleanable surfaces, such as worn toilet seats and damaged wheelchair armrests, which could harbor bacteria and contribute to cross-contamination, as noted by the infection control nurse.

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 an effective Antibiotic Stewardship Program, which led to inappropriate and unnecessary use of antibiotics for three residents. Resident 223 was prescribed antibiotics for a urinary tract infection (UTI) that did not meet the criteria for treatment. The facility did not follow physician orders to collect a urinalysis to confirm the UTI, and there was no documentation of a culture and sensitivity report to ensure the appropriate prescription of antibiotics. Staff interviews revealed that the necessary steps to confirm the infection and appropriate antibiotic use were not followed. Resident 224 was treated with antibiotics for pneumonia, but the facility failed to communicate the chest X-ray results to the provider in a timely manner, resulting in a delay in treatment. Similarly, Resident 38 was treated with multiple antibiotics for pneumonia, despite a chest X-ray showing no diagnosis of pneumonia. The staff did not review the antibiotic medications appropriately. These failures in communication and adherence to the facility's antibiotic stewardship policy placed residents at risk for adverse outcomes associated with inappropriate antibiotic use.

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 adequate supervision to prevent resident-to-resident altercations, specifically between two residents. Resident 1, who had a history of a right hip fracture with surgical repair, anxiety, and insomnia, reported multiple incidents involving Resident 2. These incidents included Resident 2 entering Resident 1's room, consuming their snacks, wearing their clothes, and leaving feces on their bed sheets. On one occasion, Resident 2 sat on Resident 1's leg, causing discomfort and pain, especially given Resident 1's recent hip surgery and existing knee issues. Despite Resident 1 informing the staff about these incidents, there was no documentation of staff response or intervention until Resident 2 was moved to another room. Resident 2, who had a history of dementia, psychotic disorder, and insomnia, was admitted to the facility without a proper assessment for wandering risk. The facility's policies required such assessments and care plans to address wandering behaviors, but these were not implemented for Resident 2. Staff documented Resident 2's behaviors, such as attempting to get out of bed, using fecal matter inappropriately, and wandering around the room, but there was no evidence of actions taken to manage these behaviors or ensure the safety of both residents. Interviews with staff revealed a lack of communication and documentation regarding the incidents and the necessary interventions. The Director of Nursing Services did not recall reviewing Resident 2's admission referral, and there was no care plan in place for Resident 2's wandering risk. The facility's investigation confirmed that staff were aware of the issues but did not take appropriate actions to address them, leading to a delay in moving Resident 2 to a different room and ensuring the safety and well-being of both residents.

Penalty

Inspection fine: $77,066

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 basic life support, including CPR, was initiated immediately for two residents who experienced unexpected deaths. For Resident 1, the facility's staff did not promptly initiate CPR despite the resident being designated as a Full Code. The resident's family member alerted staff to the emergency, but there was a delay in initiating CPR as staff were unsure of the resident's code status and required additional personnel to move the resident to the floor. The absence of a Code Blue Emergency Recorder form further complicated the documentation of the sequence of events. In the case of Resident 2, the facility again failed to initiate CPR in a timely manner. Although the resident was found unresponsive with weak breathing and pulse, staff did not immediately begin CPR. Instead, there was a delay as staff communicated with each other and called 911. The facility's investigation revealed that the staff member who first assessed the resident did not initiate CPR due to a back injury, and CPR was only started after another staff member returned from making the emergency call. The facility's lack of a clear and immediate response to these medical emergencies placed additional residents at risk, as there were 35 other residents with current physician orders to receive CPR. The absence of proper documentation and adherence to emergency response protocols contributed to the deficiencies observed in these incidents.

Removal Plan

• Audited the records of all residents
• Audited the Physician Order for Life Sustaining Treatment (POLST) binders
• Educated staff on the facility's Medical Emergency Response Policy and Code Blue Emergency Recorder process during CPR
• Performed CPR drills
• Implemented a plan of correction to sustain ongoing compliance

Penalty

Inspection fine: $77,066

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 in-service training program that ensured nursing assistants received the required 12 hours of annual training and education. This deficiency was identified through observation, interviews, and record reviews, which revealed that three nursing assistants did not receive the necessary training. The facility's assessment indicated that in-service training should include dementia management, communication, resident rights, cultural competency, and identification of changes in resident conditions. However, the facility could not provide documentation to confirm that the required training was completed for the nursing assistants reviewed. Additionally, the facility lacked documentation of staff training on the use of an Automated External Defibrillator (AED) and the facility's Medical Emergency Response policy. Interviews with the facility's administrator and corporate consultant revealed that there was an in-service training calendar, but it was not followed by the previous staff development coordinator. The Vice President of Operations acknowledged the absence of a system to ensure the required training was provided to each nursing aide, further contributing to the deficiency.

Penalty

Inspection fine: $77,066

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 availability and completeness of Physician Orders for Life-Sustaining Treatment (POLST) forms for two residents, which are crucial for honoring residents' medical treatment preferences during emergencies. For Resident 3, the facility did not have a POLST form accessible in the medical records, despite an order indicating the resident was a Full Code and wanted CPR. Staff interviews confirmed the absence of the POLST form, with suggestions that it might have been sent to the hospital with the resident. For Resident 4, the POLST form was initiated and signed by the resident but was incomplete as it lacked the facility provider's signature, indicating that the information was not discussed with the resident or their representative. This deficiency was noted after Resident 4 was found unresponsive and CPR was performed. Staff confirmed the form remained unsigned by the physician until after the resident's death.