Merry Wood Lodge

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 the rights of two residents, identified as RI #22 and RI #21, from verbal and physical abuse by another resident, RI #101. RI #101, who was admitted with dementia and behavioral disturbances, was involved in two separate incidents of abuse. On the first occasion, RI #101 hit RI #22 in the chest during a lunch meal in the dining area. Witnesses reported that RI #22 raised their hands in self-defense, indicating fear and distress. Despite the facility's policy to prevent abuse and provide adequate supervision, the measures in place were insufficient to prevent this occurrence. The following day, after the 15-minute monitoring checks for RI #101 had ended, another incident occurred where RI #101 verbally and physically abused RI #21. RI #101 called RI #21 derogatory names and hit them in the face while they were in the day area watching television. Witnesses described the situation as one that would make a person feel scared and unsafe. The facility's failure to provide continuous supervision and effective interventions allowed this second incident to occur shortly after the monitoring period ended. The facility's investigative files and witness statements confirmed that both incidents were deliberate acts of aggression by RI #101, who had a history of disruptive behavior. Despite this history, the facility did not implement new interventions or update RI #101's care plan to prevent further occurrences of abuse. The lack of adequate supervision and failure to intervene in a timely manner contributed to the deficiency, affecting the safety and well-being of the residents involved.

Penalty

Inspection fine: $182,96842 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 Administrator of the facility failed to implement the Abuse Policy effectively, leading to a deficiency in handling an incident involving a Certified Nursing Assistant (CNA) and a resident. On July 1, 2023, CNA #14 reported to a Licensed Practical Nurse (LPN) that she had grabbed the wrists of Resident Identifier (RI) #398 to prevent the resident from hitting her. However, this incident was not reported to the Administrator, and no protective measures were taken until July 6, 2023, when discolorations were noted on the resident's arms and wrists. The Administrator did not substantiate the allegation of physical abuse, despite the CNA's admission of grabbing the resident's wrists. The facility's investigation into the incident was inadequate, as it failed to determine the cause of the bruising on the resident's wrists. The investigation consisted of interviews and skin assessments but did not include a thorough examination of the events leading to the bruising. The Administrator did not document an interview with the resident, which contributed to the incomplete investigation. As a result, the facility allowed the CNA to return to work without taking appropriate corrective actions. The deficiency was cited as Immediate Jeopardy, indicating that the facility's noncompliance with federal regulations had the potential to cause serious harm to residents. The Administrator's failure to ensure the Abuse Policy was implemented and to conduct a thorough investigation of the abuse allegation had the potential to affect all residents in the facility. This deficiency was identified during the investigation of a Facility Reported Incident, highlighting the need for proper oversight and adherence to abuse prevention policies.

Removal Plan

• Educate the Nursing Home Administrator on implementing Abuse policies and procedures, reporting alleged violations, thoroughly investigating alleged incidents, and center's response to the results of the investigations.
• Emphasize the Administrator's responsibility of operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown source, exploitation, and misappropriation of property.
• Ensure the Administrator understands his role in operationalizing and overseeing policies within the Center, specifically the Abuse Prohibition Policy.
• Administrator will lead in the investigation process, follow up with outstanding activities needed for a thorough investigation, and ensure each reportable event is taken to the QAPI committee for review.
• Train the Administrator to notify Market Clinical Lead of each occurrence and keep them abreast of the progress of the investigation and protection of the resident.
• Review the complete investigation by the Market Clinical Lead to collaborate on the thoroughness of the investigation and ensure correct determinations are made.
• Review allegations of Abuse and Neglect to ensure policies were implemented and allegations were reported and thoroughly investigated.
• Host an AD HOC Quality Assurance Performance Improvement meeting with key personnel to review the Abuse Prohibition policy and procedure.
• Review staff on resident incidents by the Center QAPI Committee to determine if correct determination was made and if appropriate corrective action has been taken.
• Interview residents regarding rough treatment from staff and complete skin assessments for any signs of abuse.
• Re-educate staff members regarding Abuse Prohibition Policy including the ability to prevent abuse, identify signs and evidence of abuse, and report abuse.
• Educate Administrator regarding conducting thorough investigations and protecting residents during the investigation.
• Instruct Administrator to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols.
• Educate QAPI committee regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation and appropriateness of the determination.
• Review remaining incidents that were previously unverified/unsubstantiated by the Center QAPI Committee, and review corrective actions for verified incidents.

Penalty

Inspection fine: $182,96842 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 the Quality Assurance and Performance Improvement (QAPI) committee adequately reviewed and analyzed an allegation of abuse involving a resident, identified as RI #398. The committee did not identify physical abuse against the resident nor address concerns related to the identification, reporting, investigation, and protection regarding the allegation of physical abuse reported to the State Agency. This failure was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents, leading to an Immediate Jeopardy citation. The deficiency was highlighted during an interview with the Director of Nursing (DON), who explained that abuse was not consistently discussed in QAPI meetings unless an issue had occurred. The DON revealed that the Administrator (ADM) made the decision on whether to substantiate the abuse allegation without full agreement from the QAPI members. The incident involving RI #398, where a Certified Nursing Assistant (CNA) reportedly grabbed the resident's arm, was reviewed, but the ADM decided not to substantiate the allegation despite evidence suggesting abuse had occurred. Further interviews revealed that the ADM, responsible for managing daily operations and ensuring adherence to policies, did not communicate abuse allegations to the Governing Body as required. The facility's policy mandated a review of all reported abuse allegations through the QAPI process, which included assessing interventions and the effectiveness of investigations. However, this process was not followed, leading to the deficiency being cited as a result of the investigation of a Facility Reported Incident.

Removal Plan

• A QAPI meeting was held which included a review of reportables.
• The Market Clinical Advisor and Market Clinical Lead reviewed allegations of Abuse and the Quality Assurance Performance Improvement Committee meeting minutes to ensure allegations of abuse were analyzed.
• The Market President educated the Nursing Home Administrator on the Quality Assurance Performance Improvement process to include systematic identification, reporting, investigation, analysis, and prevention of abuse or allegations of abuse.
• The Market President and Market Clinical Advisor educated the Quality Assurance Performance Improvement Committee on the Abuse Prohibition policy and procedure.
• Education included emphasizing the importance of analyzing as a team the reportable events of the Center.
• Governing body to include Market President, Market Clinical Advisor, Clinical Lead, Nursing Home Administrator, and Director of Nursing reviewed the Quality Assurance Performance Improvement process.
• The Center QAPI Committee met to discuss staff on resident incidents after the incident occurring.
• Accused CNA no longer works at Merry [NAME] Lodge, her last day of work at the Center.
• 47 residents were interviewed regarding rough treatment from staff and 42 residents skin assessments were completed for any signs of abuse, none were noted.
• 110 staff members were re-educated regarding Abuse Prohibition Policy.
• Administrator was educated regarding conducting thorough investigations and protecting residents during the investigation.
• Administrator was also instructed to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols.
• QAPI committee was educated regarding thoroughly reviewing all reportable events during the QAPI process.
• The Center QAPI Committee reviewed the remaining incidents that were previously unverified/unsubstantiated.
• The review determined the appropriate corrective action had been implemented for 8 incidents, despite being initially unverified/unsubstantiated.

Penalty

Inspection fine: $182,96842 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 protect residents from abuse, as evidenced by two separate incidents involving physical abuse by Certified Nursing Assistants (CNAs). In the first incident, a resident with severe cognitive impairment and physical disabilities, including cerebral infarction and hemiplegia, reported being roughly handled by a CNA, resulting in bruising on the wrists. The resident's family members corroborated the account, noting the resident's complaints of mistreatment and visible bruises. Despite these reports, the facility's investigation concluded that the CNA's actions were not abusive, attributing the bruising to the CNA's attempt to prevent the resident from hitting her. In the second incident, another resident with Alzheimer's Disease and severe cognitive impairment was reportedly pushed back into bed by a CNA after grabbing the CNA's collar. Witnesses described the CNA's actions as rough, involving shaking the resident and causing the resident to hit the footboard of the bed. The facility's investigation did not substantiate the abuse, despite witness accounts and the CNA's admission that the situation could have been handled differently. The CNA was placed on administrative leave, but the facility did not classify the incident as abuse due to inconsistent accounts. Both incidents highlight the facility's failure to substantiate allegations of abuse and protect residents from harm. The facility's investigations were unable to confirm abuse, despite evidence and witness testimonies suggesting otherwise. The facility's policy on abuse prohibition was not effectively enforced, leading to a lack of accountability and protection for the residents involved.

Penalty

Inspection fine: $182,96842 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 implement its abuse policy following an incident of staff-to-resident physical abuse. A Certified Nursing Assistant (CNA) reported to a Licensed Practical Nurse (LPN) that she had grabbed a resident's wrists to prevent being hit. This incident was not reported to the Administrator, and no protective measures were taken until the resident's family reported the incident several days later. The resident was found to have red and purple discolorations on their arms and wrists. The facility's Administrator did not substantiate the allegation of physical abuse, despite the CNA's admission of grabbing the resident's wrists. The CNA was allowed to continue working at the facility, providing care to the same resident in the days following the incident. The facility's investigation was delayed, and the incident was not reported to the appropriate authorities in a timely manner. The facility's non-compliance with federal regulations was determined to have caused, or was likely to cause, serious harm to residents. The Immediate Jeopardy was cited in reference to the failure to develop and implement policies to prevent abuse, neglect, and exploitation. The facility's abuse policy required immediate reporting and protective measures, which were not followed in this case.

Removal Plan

• Center Social Worker notified the Administrator.
• CNA #14 was placed on administrative leave pending the results of the investigation.
• The Social Services Director and/or designee interviewed residents deemed as interviewable regarding Staff being rough with the residents. No concerns were identified.
• Licensed Nurses completed skin assessment on residents identified with severe cognitive impairment to identify suspicion of Abuse. No additional concerns were identified.
• The Nurse Practice Educator and/or designee initiated 100% re-education with employees in all disciplines on Abuse Prohibition policy and procedure, including the definition, types of Abuse, prevention and supervision, identification, reporting of abuse, and trauma.
• Education was completed with all staff present in the Center and for all staff available via telephone communication.
• The Nurse Practice Educator and/or designee will ensure employees unable to be reached after 3 attempts, those with scheduled time off, on leave of absence, vacation, or PRN will be re-educated prior to returning to duty.
• New hires will be educated on Abuse Prohibition policy during the orientation process by the Nurse Practice Educator or Director of Nursing Services.
• Market President educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure to include screening of potential hires; training of employees; prevention of occurrences; identification of possible incidents or allegations which need investigation; conducting thorough investigations of incidents and allegations; protection of residents during investigations; and reporting of incidents, investigations, and center response to the results of the investigations.
• Education included ensuring the Administrator knows and understands that abuse is identified as the individual acts deliberately, the actions of the individual were deliberate in nature and not dependent on the intent of the individual.
• Administrator has been educated regarding protecting residents by ensuring the accused individual does not have access to repeat the abuse. The accused employee is to be placed on administrative leave pending the results of the investigation.
• Education also included ensuring the administrator knows his role and responsibility in implementing the abuse policy including investigations, identification, reporting, protection and involvement of QAPI.
• Administrator knows that staff not reporting abuse is a failure to follow policy and corrective action must be taken up to and including termination of employment.

Penalty

Inspection fine: $182,96842 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 thoroughly investigate an allegation of staff-to-resident physical abuse involving a Certified Nursing Assistant (CNA) and a resident with severely impaired cognition. The incident occurred when the CNA reportedly grabbed the resident's wrists to prevent being hit, resulting in bruising. Despite the CNA's admission of grabbing the resident, the facility did not substantiate the abuse allegation, and the CNA was allowed to continue working. The investigation did not determine the cause of the bruising, and protective measures were delayed. Additionally, the facility did not adequately investigate several other incidents, including resident-on-resident abuse and injuries of unknown origin. In one case, a resident was hit by another resident in the dining area, but the facility did not document interviews or substantiate abuse due to a lack of intent to harm. In another instance, a resident was found with bruising and hip pain, but the facility failed to obtain witness statements from staff who provided care during the relevant period. The facility's investigation processes were found lacking in documentation and thoroughness, as evidenced by the absence of recorded interviews and failure to monitor residents for aggressive behavior following incidents. These deficiencies were identified during a survey, which cited the facility for non-compliance with federal regulations regarding freedom from abuse, neglect, and exploitation.

Removal Plan

• Educated the Nursing Home Administrator on the implementation of the Abuse Prohibition policy and procedure.
• Trained Administrator on steps to a thorough investigation, including identification of alleged occurrences, reporting, protecting residents, assessing for injury, performing and documenting interviews, and reviewing pertinent documentation.
• Developing appropriate conclusions and actions to prevent future occurrences.
• Center QAPI Committee met to discuss staff on resident incidents and reviewed identified events for correct determination and appropriate corrective action.
• Accused CNA no longer works at the facility.
• 47 residents were interviewed regarding rough treatment from staff and 42 residents had skin assessments completed for signs of abuse.
• 110 staff members were re-educated regarding Abuse Prohibition Policy.
• Educated Administrator regarding conducting thorough investigations and protecting residents during investigations.
• Instructed Administrator to review all reportable events with Market Clinical Lead prior to finalizing investigation protocols.
• QAPI committee educated regarding thoroughly reviewing all reportable events during the QAPI process for thoroughness of the investigation, appropriateness of the determination, and any further corrective actions.

Penalty

Inspection fine: $182,96842 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 the kitchen floor in a clean and sanitary manner, as observed during inspections conducted by a surveyor and the Dietary Manager. During the initial inspection, the kitchen floor was found to be sticky, with an unidentified black substance present in both the center and corners of the floor. A follow-up inspection confirmed that the floor remained unclean and sticky, with the black substance still visible in various sections. The Director of Operations acknowledged the issue, noting that the floors were old and required attention. He mentioned that a monthly deep clean was being considered, but was unsure of the last time such a cleaning had occurred. The Director explained that regular mopping and sweeping had been ineffective in addressing the problem areas, and a new cleaning schedule would be implemented to maintain clean, non-sticky floors.

Penalty

Inspection fine: $182,96842 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 properly dispose of garbage and refuse, as evidenced by the presence of a burn pile near the dumpster area. This burn pile contained multiple discarded cardboard boxes, which were not disposed of in accordance with the facility's policies or the 2017 U.S. Public Health Service Food Code. The code specifies that refuse should be stored in receptacles or waste handling units to prevent access by insects and rodents, and that refuse areas should be maintained free of unnecessary items and kept clean. The facility's own policies also require that trash be removed on a scheduled basis and that the surrounding area of external receptacles be free of debris. During an inspection, the Dietary Manager confirmed the presence of the burn pile and acknowledged that cardboard should not be stacked there, as it could attract pests. The Administrator also confirmed the use of the burn pile for burning old furniture and debris, but stated that cardboard should be disposed of in the dumpsters. The Administrator recognized the potential fire hazard posed by the burn pile's proximity to the dumpsters and the facility. This situation had the potential to attract rodents and pests, affecting all 98 residents living in the facility.

Penalty

Inspection fine: $182,96842 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 report accurate staffing data to the Centers for Medicare & Medicaid Services (CMS) for the second quarter of 2024, specifically regarding weekend staffing levels. The Payroll Based Journal (PBJ) Staffing Data Report indicated excessively low weekend staffing, which triggered a deficiency. Interviews with the former Staffing Manager revealed that assignment sheets did not show low staffing on weekends, contradicting the PBJ report. The former Staffing Manager was responsible for ensuring adequate staffing levels according to the census. Further investigation with the Vice President of Product Management, who was responsible for submitting PBJ data, revealed that the data was submitted based on time clock punches without distinguishing nursing staff. This method may have led to the low weekend staffing trigger, as staff working during the week were not recorded as working on weekends. The Administrator confirmed that salaried staff, who did not punch in, might have worked on weekends, leading to inaccurate reporting. The deficiency highlights the need for accurate staffing data to demonstrate adequate staffing levels on weekends.