The Health Center At Research Park

Penalty

Inspection fine: $69,0114 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 a resident from physical abuse by another resident. During lunch, one resident exhibited aggressive behavior, including verbal and physical abuse towards staff, and expressed suicidal and homicidal ideations. This resident was sent to the hospital but returned to the facility without proper supervision. Early the next morning, the resident was found in another resident's room, attempting to smother them with a pillow. The resident who committed the abuse had a history of aggressive behavior and cognitive impairment, as indicated by their medical records. Despite this, the facility did not adequately supervise the resident upon their return from the hospital. The incident was witnessed by a CNA, who intervened and separated the residents. The facility's failure to supervise the resident upon their return from the hospital led to the incident of abuse. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the lack of supervision and the subsequent incident. The facility's noncompliance with federal requirements resulted in a situation that was likely to cause serious harm to residents. The deficiency was identified as a result of a complaint investigation and was determined to be at the immediate jeopardy level.

Removal Plan

• Resident's #334 and #335 were separated by the CNA.
• Resident #334 was assessed by the Charge Nurse, with no injuries noted.
• The Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. Resident #334 was assessed by the Nurse with no negative findings.
• Resident #335 was placed on one on one by the Charge Nurse until resident transferred to the hospital by HEMSI and ultimately discharged.
• Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident with no negative findings.
• Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse with no negative findings.
• Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events by the Administrator.
• Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone with no negative findings.
• Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse with no negative findings.
• Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335.
• Clinical Record Review was initiated and completed by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of physical abuse, with no unknown new findings.
• Inservice was provided by the Assistant President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress and combative behaviors and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed.
• The Staffing Coordinator was designated as responsible for ensuring staff are educated on abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors.
• Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors and suicidal/homicidal ideation to all staff.
• Staff unavailable to receive education will not be permitted to work until the required education is completed.
• 73 out of 77 employees have been educated.
• Competency and validation questions were answered by staff currently working to ensure competency verbalized from education received.
• The Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress and combative behaviors and suicidal/homicidal ideation.
• Adhoc QAPI was conducted to include Administrator, Director of Nursing, Senior President of Operations, Assistant President of Operations, Regional Nurse Manager, Assistant President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions.
• The Medical Director was notified of the immediate jeopardy citations by the Assistant President of Operations.
• A Root cause analysis was conducted by the Administrator, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services.
• QAPI meeting was conducted to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant President of Operations, Regional Nurse Manager, Medical Director, Assistant President of Clinical Operations, Senior President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined.
• Abuse Prohibition Plan reviewed with no recommendation for changes.
• The Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideation's under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services.
• Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, combative, and Suicidal and Homicidal Ideations.
• The facility assessment plan was revised to include suicidal ideations.
• A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant President of Operations, Assistance President for Clinical, Senior President of Operations, and Regional Nurse Managers to discuss the corrective action plans to address the immediate concerns for F 600 for Resident's #334 and #335 and all current residents have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations.
• Facility implemented all corrective Actions.

Penalty

Inspection fine: $69,0114 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 necessary behavioral health care and services were provided to a resident, identified as RI #335, who exhibited physically and verbally aggressive behaviors, as well as homicidal and suicidal ideations. On one occasion, RI #335 was sent to the hospital emergency room after being physically and verbally abusive to staff and expressing homicidal and suicidal ideations. Upon returning from the hospital, the facility did not develop a plan to ensure the safety of other residents, nor were any new orders or interventions implemented. The deficiency was highlighted when a Certified Nursing Assistant (CNA) witnessed RI #335 in another resident's room, attempting to smother the resident with a pillow. This incident occurred shortly after RI #335's return from the hospital, during which time no nursing assessment was conducted, and no interventions were put in place to address the resident's aggressive behaviors. Interviews with facility staff revealed that there was an expectation that the hospital would have kept RI #335, and as a result, no immediate interventions were planned upon the resident's return. The facility's policy on Behavioral Health Services was not adhered to, as it mandates that necessary behavioral health care services be person-centered and reflect the resident's goals for care while ensuring safety. Despite RI #335's history of aggressive behavior and cognitive impairment, the facility did not implement appropriate interventions or conduct a comprehensive assessment upon the resident's return from the hospital, leading to a situation that posed a risk of serious harm to other residents.

Removal Plan

• Resident #335 was redirected from the Dining room by the Administrator after yelling, throwing things and grabbing at staff.
• Social services made referrals for Psych services related to physical and verbally abusive behaviors and suicidal ideation. Charge Nurse sent RI #335 to the ER and transported by HEMSI.
• Resident #335 returned from the hospital by HEMSI with no new orders. Labs were drawn at the ER. Per ER records resident denied any complaints, denied suicidality and homicidal ideations.
• Resident's #334 and #335 were separated by the CNA.
• Resident #334 was assessed by the Charge Nurse, with no injuries noted.
• The Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. Resident #334 was assessed by the Nurse with no negative findings.
• Resident #335 was placed on one on one by the Charge Nurse until resident transferred to the hospital by HEMSI and ultimately discharged.
• Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident with no negative findings.
• Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse with no negative findings.
• Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events by the Administrator.
• Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone with no negative findings.
• Residents with a BIMS of 12 or less, a body audit and observation for abuse and behaviors was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse with no negative findings.
• Resident interviews using a Resident Psychosocial Health Questionnaire were conducted by Social Services Director with BIMS of 13 or greater to determine resident's mood, behaviors, and thoughts such as anxiety, agitation, depression, suicidal and homicidal ideations, with no new negative findings.
• Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335.
• Clinical Record Review was initiated and completed by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of allegations of potential/actual abuse, aggressive, distress, and combative behaviors, and suicidal and homicidal ideations, with no new unknown findings.
• Inservice was provided by the Assistant President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress and combative behaviors, and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed.
• The Staffing Coordinator was designated as responsible for ensuring staff are educated on abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors.
• Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors, and suicidal/homicidal ideation to all staff. Staff unavailable to receive education will not be permitted to work until the required education is completed. 73 out of 77 employees have been educated.
• Competency and validation questions were answered by staff currently working to ensure competency verbalized from education received.
• The Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress and combative behaviors, and suicidal/homicidal ideation. This communication binder is used as a communication tool for staff to note resident behaviors, new or changes. This communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine appropriate interventions.
• Regional Nurse Manager inserviced the DON, Staffing Coordinator and Risk Manager that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations.
• The DON, Staffing Coordinator, and Risk Manager in-serviced Nursing Staff that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.
• Adhoc QAPI was conducted to include Administrator, Director of Nursing, Senior President of Operations, Assistant President of Operations, Regional Nurse Manager, Assistant President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions.
• The Medical Director was notified of the immediate jeopardy citations by the Assistant President of Operations.
• A Root cause analysis was conducted by the Administrator, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services.
• QAPI meeting was conducted to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant President of Operations, Regional Nurse Manager, Medical Director, Assistant President of Clinical Operations, Senior President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined.
• Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideations under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services.
• Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, and combative behaviors, and Suicidal and Homicidal Ideations.
• The facility assessment plan was revised to include suicidal ideations.
• A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant President of Operations, Assistance President for Clinical, Senior President of Operations, and Regional Nurse Managers to discuss the corrective action plans to address the immediate concerns for F 600, F 740, F 741 and F 867 for Resident's #334 and #335 and all current residents in the facility have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations.
• This Behavior Communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine any new or changes in behaviors, intervention implementation and appropriateness and will be revised as necessary.
• Upon return from a transfer when ER deems resident appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a Resident Return from Transfer Behavior assessment will be conducted. This will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. For any resident discharged and readmitted a readmission assessment is already part of the readmission process and is completed to include an abuse and behavior section. Nursing Staff was educated that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.

Penalty

Inspection fine: $69,0114 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 sufficient staff with the necessary competencies and skills to address the behavioral health needs of a resident, identified as RI #335, who exhibited aggressive behaviors and suicidal and homicidal ideations. On one occasion, RI #335 was physically and verbally abusive to staff and expressed suicidal and homicidal thoughts, leading to their transfer to a hospital. Upon returning from the hospital, the facility did not develop or implement interventions to ensure the safety of the resident or provide additional supervision. Staff observed that RI #335 was acting unusually, not cooperating, and not responding to redirection as they had previously. Despite these observations, no actions were taken to ensure the safety of the residents. A critical incident occurred when RI #335 was found in another resident's room, attempting to smother them with a pillow. This incident highlighted the facility's noncompliance with the requirement to have competent staff to meet the behavioral health needs of residents, as outlined in the State Operations Manual, Appendix PP, 483.40 Behavioral Health at F 741. Interviews with staff revealed that a nursing assessment was not completed when RI #335 returned from the hospital, as they had not been gone for over 24 hours. The Director of Nursing acknowledged that an assessment should have been conducted, which would have triggered necessary interventions such as one-on-one supervision. The lack of a nursing assessment and subsequent interventions contributed to the facility's failure to address the behavioral health needs of RI #335 adequately.

Removal Plan

• Resident #335 was redirected from the Dining room by the Administrator after yelling, throwing things and grabbing at staff.
• Social services made referrals for Psych services related to physical and verbally abusive behaviors and suicidal ideation. Charge Nurse sent R1#335 to the ER and transported by HEMSI.
• Resident #335 returned from the hospital by HEMSI with no new orders. Labs were drawn at the ER. Per ER records resident denied any complaints, denied suicidally and homicidally.
• Resident's #334 and #335 were separated by the CNA.
• Resident #334 was assessed by the Charge Nurse, with no injuries noted.
• The Psychiatric Nurse Practitioner assessed Resident #334 and documented in a provider note with no negative findings. Resident #334 was assessed by the Nurse with no negative findings.
• Resident #335 was placed on one on one by the Charge Nurse until resident transferred to the hospital by HEMSI and ultimately discharged.
• Resident interviews were conducted by the Social Services Director and Activity Coordinator with a BIMS of 13 or greater regarding physical or verbal abuse by another resident with no negative findings.
• Residents with a BIMS of 12 or less, a body audit was completed by the Director of Nursing and Charge Nurse with no negative findings.
• Alabama Department of Health, Adult Protective Services, and law enforcement were notified of the reported events by the Administrator.
• Resident interviews were conducted by the Social Services Director with a BIMS of 13 or greater regarding abuse by anyone with no negative findings.
• Residents with a BIMS of 12 or less, a body audit and observation for abuse and behaviors was completed by the Director of Nursing, Staffing Coordinator, and Charge Nurse with no negative findings.
• Resident interviews using a Resident Psychosocial Health Questionnaire were completed by Social Services Director with BIMS of 13 or greater to determine resident's mood, behaviors and thoughts such as anxiety, agitation, depression, suicidal and homicidal ideation, with no new negative findings.
• Charge Nurse made notifications to the practitioners and responsible parties for resident #334 and #335.
• Clinical Record Review was initiated and completed by the Director of Clinical Education and Regional Nurse Managers to include clinical notes, event notes, and daily skilled notes to identify any potential residents for instances of potential/actual abuse, aggressive, distress, and combative behaviors, and suicidal and homicidal ideation that might require Behavioral Health services, with no new unknown findings.
• Inservice was provided by the Assistant President of Operations and the Regional Nurse Manager to the Administrator, DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, updated Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behaviors and suicidal/homicidal ideation. Education was also provided regarding staff unavailable to receive education will not be permitted to work until required education is completed.
• The Staffing Coordinator was designated as responsible for ensuring staff are educated on abuse prohibition plan, behavioral health services policy, and list of interventions for behaviors.
• Inservice was provided by the DON, Staffing Coordinator, Social Services, and Receptionist/CNA on the Abuse Policy Protocol, Behavior Health Services Policy, and interventions related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation to all staff. Staff unavailable to receive education will not be permitted to work until the required education is completed. 73 out of 77 employees have been educated.
• Competency and validation questions were answered by staff currently working to ensure competency verbalized from education received.
• The Regional Nurse Manager placed signage in break rooms, nurses stations, and behavior communication binders that list interventions for behaviors including abuse, aggressive, distress, and combative behaviors, and suicidal/homicidal ideation. This communication binder is used as a communication tool for staff to note resident behaviors, new or changes. This communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine appropriate interventions.
• Regional Nurse Manager inserviced the DON, Staffing Coordinator and Risk Manager that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation's a behavioral assessment should be conducted. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation's.
• The DON, Staffing Coordinator, and Risk Manager inserviced Nursing Staff that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideation. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.
• Adhoc QAPI was conducted to include Administrator, Director of Nursing, Senior President of Operations, Assistant President of Operations, Regional Nurse Manager, Assistant President of Clinical Operations, Regional Nurse Manager to discuss resident to resident altercation event, education, root cause, and interventions.
• The Medical Director was notified of the immediate jeopardy citations by the Assistant President of Operations.
• A Root cause analysis was conducted by the Administrator, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Directors of Nursing, Assistant President of Quality, Director of Clinical Education. Root cause was identified as ineffective training and education related to behavioral health services.
• QAPI meeting was conducted to include Administrator, Director of Nursing, Staffing Coordinator, Dietary Manager, Activity Coordinator, Treatment Nurse, Receptionist, MDS Coordinator, Social Service Director, Business Office Manager, Maintenance Director, Regional Nurse Manage, Assistant President of Operations, Regional Nurse Manager, Medical Director, Assistant President of Clinical Operations, Senior President, and Director of Clinical Education regarding Immediate Jeopardy citations, Abuse and Behavior Health Services policy review, education, interventions for immediate removal plan, Medical Director notification, facility assessment updated/reviewed and root cause analysis determined.
• Abuse Prohibition Plan reviewed with no recommendation for changes.
• Behavior Health Services Policy reviewed with recommendation made to include suicidal and homicidal ideations under procedures- to include risk factors, triggering events, examples used to harm self. Definition of Suicidal Ideation added to provide clarification of terminology related to behavioral health services.
• Updated Intervention list attachment included in the updated Behavior Health Policy for behaviors to include immediate action steps to implement related to abuse, aggressive, distress, and combative behavior, and Suicidal and Homicidal Ideations.
• The facility assessment plan was revised to include suicidal ideations.
• A Governing Body meeting was held to include the Administrator, Director of Nursing, Assistant President of Operations, Assistance President for Clinical, Senior President of Operations, and Regional Nurse Managers to discuss the corrective action plans to address the immediate concerns for F600, F740, F741, and F867 for Resident's #334 and #335 and all current residents in the facility have the potential to be affected. The Medical Director agreed with the current action plan and had no new recommendations.
• This Behavior Communication binder is brought to morning QA by a member of the Behavior Committee and reviewed during QA to determine any new or changes in behaviors, intervention implementation, and appropriateness and will be revised as necessary.
• Upon return from a transfer when ER deems resident appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a Resident Return from Transfer Behavior assessment will be conducted. This will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. For any resident discharged and readmitted a readmission assessment already part of the readmission process is completed to include an abuse and behavior section. Nursing Staff educated that upon return from a transfer when ER deems residents appropriate for return for residents sent out related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations a behavioral assessment should be conducted using the Resident Return from Transfer Behavior assessment form. This form will help us determine if behaviors are present and require interventions upon return to the facility after a transfer related to abuse, aggressive, distress, and combative behavior, and suicidal/homicidal ideations. Nursing Staff unavailable to receive education will not be permitted to work until the required education is completed. 20 out of 22 Nurses have been educated.

Penalty

Inspection fine: $69,0114 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 residents received nutrition as planned per the facility's menu, as observed during lunch services on two consecutive days. On the first day, hot water was added to pureed food items to extend their volume, which diluted the nutrients and altered the consistency of the food. Additionally, the portions of chicken and noodles served for various diet textures were less than the amounts indicated on the menu. This discrepancy was observed during the lunch service, where the puree meat scoop was not filled completely, and hot water was added to the puree green beans, making them more liquid than puree. On the second day, the facility's menu indicated specific portion sizes for Chicken Fettuccini and Buttered Noodles, but these items were mixed together and served with a 4-ounce spoodle, which was insufficient according to the menu's requirements. The Kitchen Supervisor and other staff members acknowledged that the portions served were not enough, and the mixing of items led to incorrect serving sizes. Furthermore, residents on Consistent Carbohydrate (CCHO) diets were served orange slices instead of the apple slices specified in the menu, without approval from the Registered Dietitian. Interviews with the Dietary Manager and Registered Dietitian revealed that the staff was trained to follow recipes and portion sizes, but the instructions were not adhered to during meal preparation and service. The Dietary Manager confirmed that adding hot water to stretch pureed food was not acceptable, as it reduced the nutritional value. The Registered Dietitian emphasized that the menus were designed to meet residents' caloric needs, and deviations from the menu without approval could compromise the residents' nutrition.

Penalty

Inspection fine: $69,0114 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 cross-contamination in its kitchen operations, as observed on June 11, 2024. Staff members were seen moving from handling dirty dishes to clean dishes without washing their hands, which is a violation of hygienic practices. Additionally, a staff member used a cloth to dry multiple wet trays instead of allowing them to air dry, increasing the risk of contamination. The handwashing sink was blocked by a plate lowerator, causing water to splash onto stored plates when staff attempted to wash their hands. Furthermore, a staff member was observed chewing gum in the kitchen, which is against food safety regulations. The facility also failed to ensure proper sanitization of dishware due to inadequate monitoring of dish machine temperatures. On June 11, 2024, the dish machine's final rinse did not reach the required minimum temperature of 180 degrees Fahrenheit, and staff did not record actual temperatures on the dish machine temperature log. Instead, they recorded expected temperatures, which did not reflect the actual conditions. This failure to monitor and record accurate temperatures compromised the sanitization process, potentially affecting all 79 residents receiving meals from the facility's kitchen. Interviews with the Kitchen Supervisor, Dietary Manager, and Registered Dietitian revealed a lack of awareness and understanding of proper food safety practices among staff. The Kitchen Supervisor was unaware of the restrictions on chewing gum in the kitchen, and the Dietary Manager acknowledged the issues with cross-contamination and improper temperature recording. The Maintenance Supervisor confirmed that the dishwashing machine was not reaching the required temperature for the final rinse, and a new booster heater was needed. These deficiencies highlight significant lapses in the facility's adherence to food safety standards, posing a risk to resident health.

Penalty

Inspection fine: $69,0114 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 and reconcile controlled medication records, specifically oxycodone, for two residents. The issue arose when licensed staff did not add the medication to the control sheets and failed to secure the controlled medications in the narcotic drawer after receiving them from the pharmacy. This deficiency was identified during an investigation of a complaint, where it was found that 60 oxycodone/APAP tablets for one resident and 30 oxycodone tablets for another resident were unaccounted for. The medications were reportedly delivered and signed for by a nurse, but were not found in the facility. The investigation revealed that the nurse who signed for the medications did not follow the proper procedures for documenting and securing the medications. Despite multiple attempts to contact the nurse for clarification, she denied involvement in the missing medications. Interviews with other staff members confirmed that the medications were signed for but not properly documented or secured, leading to their disappearance. The facility was unable to determine what happened to the medications, although it was confirmed that neither resident missed a dose of their pain medication.

Penalty

Inspection fine: $69,0114 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 baseline care plan was developed and provided to Resident Identifier (RI) #72 within 48 hours of admission. RI #72 was admitted with diagnoses including Pleural Effusion, Pneumonia, and Chronic Respiratory Failure with Hypoxia. According to the facility's policy titled 'Baseline Careplan,' a baseline care plan should be developed upon a resident's admission to meet professional standards of quality care. However, a review of the medical records revealed that no baseline care plan was created for RI #72 within the required timeframe. Interviews conducted with the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON) confirmed the absence of a baseline care plan for RI #72. The MDSC acknowledged that the baseline care plan should have been initiated within 48 hours and identified the DON as responsible for initiating these plans. The DON, in turn, stated that the admitting nurse was responsible for initiating the baseline care plan. Despite these acknowledgments, the baseline care plan for RI #72 was not located, indicating a lapse in the facility's adherence to its policy and procedures for new admissions.

Penalty

Inspection fine: $69,0114 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 proper respiratory care for two residents, leading to deficiencies in their care. Resident Identifier (RI) #5 did not have a physician's order for oxygen therapy, and the oxygen tubing used was not labeled or dated as required by the facility's policy. Observations over several days confirmed that the oxygen was administered via nasal cannula at three liters per minute without proper documentation or labeling. Interviews with nursing staff revealed that the tubing should have been dated to inform staff of when it was last changed, but this was not done until the surveyor's inquiry prompted the input of the physician's order. Additionally, the facility did not properly store the nebulizer mask for RI #52, who was receiving Duoneb treatments three times a day. The nebulizer mask was repeatedly observed uncovered and not stored in a plastic bag when not in use, contrary to infection control protocols. Interviews with nursing staff confirmed that the mask should have been stored in a zip-locked bag to prevent infection control issues, but this practice was not followed, leading to a deficiency in the resident's respiratory care.

Penalty

Inspection fine: $69,0114 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 proper hand hygiene and storage of resident hygiene supplies, leading to potential cross-contamination. On two separate occasions, unlabeled bath basins were observed in the shared bathroom of two residents, indicating a failure to adhere to the facility's policy requiring that each resident's hygiene items be labeled and stored separately. A Certified Nursing Assistant confirmed that the basins should be labeled and stored in a clear plastic bag, which was not done in this instance. Additionally, a Treatment Nurse did not perform hand hygiene or change gloves after cleaning a resident's sacral wound and before applying a clean treatment. This was contrary to the facility's hand hygiene protocol, which mandates hand washing between resident contacts and after handling contaminated objects. The Risk Manager/Infection Preventionist confirmed that staff should wash their hands after all care and not touch clean items with contaminated gloves, highlighting a breach in infection control practices.

Penalty

Inspection fine: $69,0114 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 notify the representative of Resident Identifier (RI) #335 about an incident and subsequent hospital transfer. RI #335, who was admitted with diagnoses of Dementia with Agitation and Major Depressive Disorder, was cognitively impaired with a BIMS score of five out of 15. On 06/24/2023, RI #335 was transferred to the hospital due to increased aggressive behaviors. However, there was no documentation in the Clinical Progress Notes indicating that the representative sponsor was informed of this incident and the transfer. An interview with the representative revealed that she was not notified by the facility but learned of the situation from the hospital social worker, and only then contacted the facility. She stated that RI #335 had been in the hospital for several days before she was made aware of the incident and hospitalization.

Penalty

Inspection fine: $69,0114 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 a resident's right to be free from misappropriation of property when a registered nurse (RN) placed the resident's temazepam in her pocket and left the facility. The incident was reported to the Alabama State Survey Agency after a Drug Enforcement Agency (DEA) officer found the temazepam in the RN's possession during a K-9 search at her other job. The RN claimed that the resident had refused the medication, and she intended to return or destroy it later but forgot it was in her pocket. This incident was part of an investigation into a facility-reported incident/complaint. The resident involved was admitted to the facility in December 2022 and could not recall refusing the medication when interviewed. The facility's Regional Nurse Manager confirmed that the RN had placed the medication in her pocket, which was considered abuse by misappropriation. The RN admitted to forgetting the medication in her pocket and later placing it in her wallet, leading to her arrest for possession of a controlled substance and theft. The facility's policy on abuse prohibition clearly defines misappropriation of resident property, which the RN violated by her actions.

Penalty

Inspection fine: $69,0114 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 an allegation of physical abuse within the required two-hour timeframe to the state agency. On the specified date, facility staff reported an allegation of physical abuse involving a resident at 4:30 AM. However, the facility did not report this allegation to the Alabama Department of Public Health (ADPH) until 8:59 AM, exceeding the two-hour reporting requirement outlined in their Abuse Prohibition Plan policy. This deficiency affected one of the three sampled residents reviewed for abuse concerns. The facility's policy, effective since April 2018, mandates that all alleged violations be reported immediately, but not later than two hours after the allegation is made. An interview with the facility's Administrator, who also serves as the Abuse Coordinator, confirmed the understanding that all allegations of abuse should be reported to the ADPH within two hours of discovery. Despite this, the facility did not adhere to the policy, resulting in a delay in reporting the incident.