Winslow Campus Of Care

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 two residents from resident-to-resident physical abuse. One resident had diagnoses including unspecified dementia, a maxillary fracture, nausea with vomiting, urinary tract infection, and depression, and had a physician order to monitor for combative behavior and determine unmet needs as needed. Her care plan identified that she was fearful of men she did not know and might strike out at men in her area, with interventions to document behaviors, use female caregivers if possible, and ensure basic needs were met. Her MDS showed severe cognitive impairment with a BIMS score of 3 and disorganized thinking and inattentiveness. A progress note documented that one resident was in the hallway/TV room area when the other resident appeared to punch her on the left leg. Another note written by an LPN documented that the second resident was exit seeking, was moved to the TV room, swatted at the first resident, balled up his fist, and appeared to punch her on the left leg. The LPN documented that when asked if he meant to hurt the other resident, he nodded yes. The note also documented that the first resident became aggressive and agitated after the incident, including balling up her fist at another female resident and telling staff to "get the hell away from me." Staff interviews showed disagreement about whether contact occurred. The LPN stated she called the police and DON after the incident, and the ADON reviewed camera footage and determined there was no contact, after which the police left without investigating. The ADON stated that resident-to-resident altercations are investigated by taking witness statements, reviewing camera footage, and notifying the DON, APS, police, and state agency, but also stated the video was not saved because it only remains for 14 days. The DON stated that if contact could not be confirmed, a full investigation and reporting to the appropriate state agencies did not have to be completed. The facility policy defined physical abuse as hitting, slapping, pinching, and kicking.

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 its abuse policy after an allegation of resident-to-resident abuse involving two residents. Resident #70 had diagnoses including unspecified dementia, maxillary fracture, nausea with vomiting, urinary tract infection, and depression, and had a care plan noting she was fearful of men she did not know and might strike out at men in her area. Resident #37 had severe dementia with psychotic disturbance, a BIMS score of 0, delusions, verbal and other behavioral symptoms, and was on routine antipsychotic medication. A progress note documented that Resident #37 was exit seeking and was moved to the TV room, where Staff #84 observed him swat at Resident #70 and appear to punch her left leg. Staff #84 documented that Resident #37 nodded yes when asked if he meant to hurt Resident #70, and that Resident #70 became aggressive and agitated after the incident. Staff #84 reported contacting the DON and police, and the ADON reviewed camera footage and determined there was no contact, after which the residents were separated and assessed for injuries. Interviews showed that the facility did not complete the full abuse investigation process after concluding there was no contact. Staff #7 stated that she reviewed the footage, told police no contact was made, and the police left without investigating; she also stated that no staff or resident interviews were conducted and no other agencies were contacted, including the state agency. The DON stated that if residents hit each other it is abuse with concern for injury, but she believed that if no contact could be confirmed, a full investigation and reporting to the appropriate state agencies were not required. The facility policy stated that alleged abuse is to be investigated thoroughly and reported to State agencies as required by law.

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 follow its abuse reporting policy when a resident-to-resident altercation involving two residents was not reported to all applicable state agencies. One resident had diagnoses including unspecified dementia, a maxillary fracture, nausea with vomiting, urinary tract infection, and depression, and had a care plan noting fear of unfamiliar men and a tendency to strike out at men in her area. A quarterly MDS showed severe cognitive impairment with a BIMS score of 3, disorganized thinking, and inattentiveness. The other resident had severe dementia with psychotic disturbance, a BIMS score of 0, delusions, verbal and other behavioral symptoms, and routine antipsychotic medication use. A progress note documented that one resident was in the hallway/TV room when the other resident appeared to punch her on the left leg. Another note written by an LPN documented that the second resident was exit seeking, was moved to the TV room, swatted at the first resident, balled up his fist, and appeared to punch her left leg. The LPN documented that the second resident nodded yes when asked if he meant to hurt the first resident. The residents were separated and assessed for injuries, and the LPN contacted the DON and police to file a report. The ADON later reviewed camera footage and determined there was no contact, stating that the second resident was only moving his hand like he was shooing the first resident away. The ADON told police no contact was made and they left without investigating, and no other agencies were contacted, including the state agency. The DON stated she believed that if no contact could be confirmed, the incident did not have to be reported to the appropriate state agencies, despite the facility policy requiring immediate reporting of suspected or alleged abuse to the Administrator and other officials including the State Survey Agency and APS.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that an allegation of abuse involving two residents was fully investigated. Resident #70 had diagnoses including unspecified dementia, a maxillary fracture, nausea with vomiting, urinary tract infection, and depression, and had a care plan noting she was fearful of men she did not know and might strike out at men in her area. Resident #37 had severe dementia with psychotic disturbance, behaviors including delusions and other behavioral symptoms, and was receiving routine antipsychotic medication. A progress note documented that Resident #37 was in the TV room area when he appeared to swat at Resident #70 and then balled up his fist and appeared to punch her left leg. The note also documented that he nodded yes when asked if he meant to hurt her, and that he was aggressive and agitated after the incident. Staff separated the residents and assessed them for injuries. Another note stated that the ADON reviewed video footage and determined there was not contact. Staff interviews showed that the LPN reported the incident to the DON and police, and the ADON reviewed the camera footage but did not complete further investigation. The ADON stated that no contact was made, the police were told no contact was made and left without investigating, and no other agencies were contacted. The ADON also stated that no staff or resident interviews were conducted. The DON stated that if residents hit each other it is abuse with concern for injury, but believed a full investigation was not needed if contact could be confirmed as not having occurred. The facility abuse policy stated that investigations may include interviews with employees, visitors, and residents and that results are reported to the Administrator and appropriate State agency within five working days.

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 deficiency involves the facility’s failure to accurately record, store, and reconcile a controlled medication, Morphine Sulfate, for one resident with multiple serious diagnoses including senile degeneration of the brain, dementia, cellulitis, nutritional deficiency, psychotic disturbance, anxiety, pneumonia, and chronic pain. The resident had a physician’s order for Morphine solution 20 mg/5 mL (4 mg/mL), 0.25 mL by mouth every 4 hours as needed for pain, initiated in early March. The resident’s care plan identified end-of-life related pain and required prompt response to pain complaints, administration of pain medication as ordered, assessment of pain characteristics and effectiveness of pain medication, monitoring for side effects, and ensuring pain medication was available when needed. The individual controlled substance record for this resident’s Morphine showed a steady countdown in 0.25 mL increments until an entry on July 31, where 25.25 mL remained, followed by an undated entry showing 20 mL remaining before the next dated entry on August 5. The record then continued with a steady countdown until mid-January, when a 0.25 mL dose was documented with 10.25 mL remaining. During an observation of the narcotic count process, surveyors noted that two nurses verified narcotic counts by one reading the name and written amount from the narcotics book while the other visually checked the medication. Staff interviews revealed that the facility’s process for administering liquid narcotics included checking the eMAR, preparing the medication, signing it out in the narcotics book, rechecking the eMAR, and then administering the dose. However, an RN reported that during a narcotics check prior to a shift, the narcotic count for this resident’s Morphine was not correct, with about 7 mL missing compared to what was documented. The RN stated that the Morphine bottles supplied by hospice did not have measurement markings on the side, making it impossible to visually determine the exact amount remaining and requiring staff to estimate by “eyeballing” the bottle. She also reported that there had been incidents where nursing staff failed to document removal of Morphine in the narcotics book or failed to check it out in the eMAR, and vice versa. The DON confirmed that the facility’s medication administration process required verification of the five rights, review of orders, appropriate timing, and documentation on both the eMAR and narcotics sheet, and that this process applied to liquid Morphine as well. She explained that Morphine from the primary pharmacy arrived in bottles with clear panels and increment markings, along with a paper narcotics log, while hospice-supplied Morphine bottles had clear panels but no increment markings. The DON stated that before the incident, nurses would look at the hospice bottles without fully measuring or quantifying the remaining amount. She reported that on a date in late January, staff noticed that the amount in the Morphine bottle did not match the 10.25 mL recorded on the narcotics log for a mid-January administration. When the remaining medication was drawn into a syringe, it was confirmed that it was not 10.25 mL. The DON also noted that staff were using in-house leur-lock syringes instead of the syringe provided with the hospice medication, which could trap or leak liquid in the lower space of the syringe. The facility’s Medication Management policy required narcotics to be kept in a separate locked drawer and accounted for at each shift change, and medications to be stored in their original labeled containers, but the documented discrepancies and missing Morphine demonstrated that these requirements were not consistently met for this resident’s controlled medication. The DON further stated that the lack of measurement markings on hospice Morphine bottles made it hard to know how much medication was left and that prior to the incident, staff relied on visual estimation rather than precise measurement. She indicated that when she examined the bottle at eye level, it did not appear to contain the amount documented on the narcotics log, and that pulling the remaining medication into a syringe confirmed the discrepancy. She also acknowledged that using in-house syringes with a different tip design than the hospice-provided syringe created a risk of medication remaining in or leaking from the syringe. The DON stated that this situation could pose a risk that residents might miss medication doses, remain in pain, or not receive medication at all. Overall, the findings showed that the facility did not ensure accurate documentation, measurement, and reconciliation of a controlled substance for this resident, in contrast to its own policy and stated procedures for narcotic management.

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 deficiency involves a resident receiving prescription medications that were ordered for another resident, after those medications were left unattended in a beverage. One resident with severe cognitive impairment, who spoke and understood Navajo and had no prescription medications ordered, was care planned for confusion, forgetfulness, and inattention. This resident’s medication regimen consisted only of OTC products such as calcium carbonate, claritin, famotidine, lidocaine patch, Systane eye drops, and Tylenol. On one day, the resident was found lying on the dining room floor next to her chair, responsive but very tired, with slow speech, rapid respirations, hypotension, low oxygen saturation, and an inability to stand without assistance. Nursing documentation recorded these abnormal vital signs, and the on‑call provider ordered transfer to the ED for evaluation. In the ED, documentation reflected that EMS had been called for concern that this resident had accidentally received another patient’s trazodone and Seroquel. The ED physician note recorded a report from the nursing home that the resident had ingested 150 mg of Seroquel and 75 mg of trazodone that had been mixed into another resident’s drink at breakfast. The ED assessment described the resident as mildly somnolent but arousable to voice, oriented x0, moving all extremities at baseline, with no bony extremity injury. Poison control was contacted and advised that the resident could return once at baseline, noting it could take several hours for her to be less sleepy. The resident was observed in the ED for several hours and then discharged back to the facility in stable condition. The other resident involved also had severe cognitive impairment, with a care plan noting forgetfulness and confusion, and spoke and understood English. This resident had active orders for quetiapine totaling 150 mg in the morning and trazodone 25 mg three times daily. A progress note documented that this resident had a history of refusing medications when offered whole or crushed in pudding, and nursing staff had begun giving medications crushed in hot chocolate, which the resident accepted. On the day of the incident, the resident initially began drinking the hot chocolate with medications but then pushed the cup away and attempted to give it to another resident at the dining table. Video reviewed with the DON later showed this resident with a blue cup identified as containing medication, taking a sip, then handing the cup to the cognitively impaired resident, who appeared to drink from it; approximately 40 minutes later, the second resident slumped over and fell. An LPN reported that the morning medication pass could be difficult because some residents would only take medications while eating, and that crushed medications were usually placed in pudding, though some residents preferred them in drinks such as Boost or hot chocolate. The LPN stated that, with this particular resident, they had learned that she did not like to be watched while taking medications and usually finished the entire drink once she picked it up. On the incident day, the LPN mixed the medications in hot chocolate, saw the resident sip from the cup, and then walked away before the drink was finished, acknowledging this was a poor judgment and that the resident should not have been left until the medication was gone. Later, when called to assess the resident who fell, the LPN found her lethargic but able to talk and move, unable to walk as usual, and observed that the medicated cup from the first resident was in front of the second resident’s place, leading the LPN to assume the second resident had ingested some of the medication. The DON stated that expectations for nurses during medication administration included following the five rights (right drug, dose, resident, time, and route), attempting re‑administration if a medication was refused, and documenting and disposing of medications if still refused. The DON further stated that medications could be mixed in applesauce, pudding, or a drink with an order, but that nurses were expected to ensure residents took all of the medication delivered and that leaving medications unattended—including crushed medications in pudding or hot chocolate—was not acceptable. Facility policy on Medication Management specified that only medications ordered by a medical practitioner should be administered to a resident and that staff shall not leave medication unattended. The RN/LPN Charge Nurse job description included responsibility to ensure that prescribed medication for one resident is not administered to another.

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 residents from abuse, specifically resident-to-resident abuse, as evidenced by an incident involving two residents with severe cognitive impairment and behavioral disturbances. One resident, who had a history of aggressive and combative behavior, approached another resident in the dining room and attempted to take food from their plate. In response, the second resident physically grabbed and scratched the first resident's right breast, resulting in three scratches of varying lengths. Both residents were known to have significant cognitive deficits and behavioral symptoms, including wandering and aggression. Staff interviews and documentation revealed that staff were present in the dining room but were not directly observing the altercation when it occurred. One LPN was assisting another resident and had her back to the incident, only becoming aware of the situation after hearing the commotion. A CNA intervened to separate the residents. Video footage confirmed the sequence of events, showing the first resident approaching and the second resident reacting physically. Staff acknowledged that the second resident had a history of aggressive behavior toward others, particularly when her personal space was invaded, and that interventions such as redirection had been previously implemented. The facility's abuse prevention policy defined abuse as the willful infliction of injury or harm, regardless of the mental or physical condition of the residents involved. Staff interviews indicated some uncertainty about whether the incident constituted abuse due to the cognitive status of both residents, but ultimately, the incident was treated as an abuse allegation and reported according to policy. The deficiency was identified due to the facility's failure to prevent the resident-to-resident altercation that resulted in physical harm.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two sampled residents were protected from physical abuse by other residents. One resident with diagnoses including unspecified dementia with behavioral disturbance and insomnia had a BIMS score of 7, indicating severe cognitive impairment, and a care plan focus for pacing, wandering, and invading others’ personal space. A nursing progress note documented that this resident was walking in the hallway when another resident approached her in a wheelchair, stopped her, and kicked her in the leg. Staff separated the residents and assessed them for injuries, and no physical injuries were noted. The other involved resident had diagnoses including dementia with psychotic disturbance, anxiety disorder, and hearing loss, with a BIMS score of 9 and physical behavioral symptoms directed toward others noted on the MDS. A staff member witnessed the resident self-propel toward the other resident, stop her in the hallway, and kick her in the leg after stating she was upset that the other resident had entered her room and taken her things. The staff member separated the residents and assessed them, with no physical injuries found. The DON stated the video of the incident was no longer accessible, but she had reviewed it before deletion and saw the kick, and stated the event would be considered abuse and did not meet her expectations. A second incident involved two residents with severe cognitive impairment, one with a BIMS score of 5 and the other with a BIMS score of 6. One resident had a care plan focus indicating she may strike out at men in her area and is fearful of men she does not know. A nurse witnessed an altercation between the two residents in the television room, and both were separated with no physical injuries noted. Video review showed one resident making slapping motions toward the other, followed by the other resident slapping back and making contact. The DON stated this incident would be considered abuse and could result in psychosocial and physical harm.

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 a resident from abuse by another resident during a breakfast meal. One resident, who had severe cognitive impairment and multiple medical diagnoses including senile degeneration of the brain and diabetes, was attempting to back his wheelchair away from the dining table. In the process, his wheelchair unintentionally bumped into another resident's wheelchair. The second resident, who also had significant medical conditions such as expressive language disorder, Parkinsonism, and hemiplegia, responded by striking the first resident in the right arm with a closed fist. Multiple staff members witnessed the incident, with one CNA observing the resident being hit in the chest and another noting contact to the arm and chest area. Video footage confirmed that the two residents' wheelchairs became entangled, leading to a physical altercation where the second resident hit the first resident in the right forearm. The incident occurred because the first resident was not seated in his usual spot, which contributed to the close proximity and subsequent altercation between the two residents. The facility's policy defines resident-to-resident physical altercations as reportable events and includes actions such as hitting and punching as forms of abuse. The incident was documented in progress notes, witness statements, and a facility reportable event record. Both residents were assessed after the incident, with only slight redness noted on the first resident's wrist and no other injuries reported.

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 a resident from physical abuse by another resident, resulting in multiple incidents of verbal and physical aggression. One resident, with a history of dementia, restlessness, agitation, and severe cognitive impairment, repeatedly exhibited aggressive behaviors toward another resident who also had dementia and impaired decision-making abilities. The aggressive resident believed the other resident was her abusive ex-husband, leading to repeated verbal altercations and escalating to physical contact, including kicking and pushing the resident in his wheelchair. Staff documented several incidents where the aggressive resident confronted, yelled at, and attempted to physically harm the other resident. On multiple occasions, staff intervened to separate the residents and redirect the aggressive resident. However, despite these interventions, the aggressive behaviors continued, culminating in an incident where the aggressive resident kicked the other resident's wheelchair, pushed him into a room, and later kicked his leg. These incidents were observed by staff and confirmed through camera footage. Staff interviews revealed that there was a known pattern of behavior, and night shift staff had reported similar incidents to day shift staff over a period of one to two months. The facility's documentation and staff interviews indicated that while some incidents were reported and discussed among staff, there was a lack of timely escalation to management or comprehensive intervention to prevent further occurrences. The care plan for the aggressive resident included interventions such as offering a baby doll and documenting behaviors, but these measures did not prevent the escalation to physical abuse. The facility's abuse prevention policy required identification of residents at risk for abusive behavior and the development of intervention strategies, but the repeated incidents suggest these steps were insufficient or not effectively implemented prior to the physical abuse event.

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 evaluate and implement effective care plan interventions related to falls for a resident with severe cognitive impairment and multiple comorbidities, including dementia with behavioral disturbance, cardiomyopathy, and pulmonary fibrosis. The resident was identified as being at risk for falls due to advanced age, dementia, and a history of falls. Despite the initial care plan including interventions such as providing a clutter-free environment, night light, call light within reach, and verbal reminders, the resident experienced multiple falls after the care plan was initiated. New interventions were only added after several additional falls occurred, rather than immediately following each incident. Documentation revealed that after each fall, there was often a delay before new interventions were implemented, and in some cases, no new interventions were added at all. For example, after a series of falls, interventions such as a 'Call, Don't Fall' sign, regular changing of pull-ups, bed and wheelchair alarms, and reminders to ask for toileting assistance were added, but only after repeated incidents. Even after these interventions, the resident continued to experience both witnessed and unwitnessed falls, with some falls not resulting in any updates to the care plan. Staff interviews confirmed that while various fall prevention tools and strategies were available, their application was inconsistent, and staff sometimes struggled to respond to alarms promptly due to staffing issues. The facility's policy required that falls be reviewed daily and that care plans be updated immediately after each fall, but this was not consistently followed. The Director of Nursing acknowledged that care plans were not always updated after every fall, and decisions about adding new interventions were made on a case-by-case basis. The lack of timely and consistent updates to the care plan following each fall, as well as inconsistent implementation of available interventions, led to the resident experiencing multiple falls and injuries, including bruising and pain that required hospital evaluation.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two residents were free from physical abuse, as evidenced by an altercation between them. Resident #25, who has severe cognitive impairment and a history of physical aggression, was involved in a physical altercation with Resident #20. Resident #25 approached Resident #20 in the hallway and attempted to interact verbally, which led to Resident #20 becoming agitated and swatting at Resident #25's leg. In response, Resident #25 shoved Resident #20 on the shoulder twice. The altercation was observed on camera footage, and both residents were assessed with no injuries noted. Resident #20, who has vascular dementia and is rarely understood, also has a history of physical and verbal aggression. During the incident, Resident #20 was sitting in a wheelchair when Resident #25 approached and attempted to communicate. Resident #20, who did not want to be bothered, struck Resident #25's leg multiple times. The altercation was reported by a dementia unit aide who heard yelling and observed the physical contact. The incident was promptly reported to the nurse, and the residents were separated. The facility's policy on abuse prevention was reviewed, which defines abuse as the willful infliction of injury, including physical contact such as hitting and slapping. The policy requires that any violations or alleged violations be reported to state agencies and thoroughly investigated. The deficiency in this case was the failure to prevent the resident-to-resident altercation, which could result in further incidents and potential injury.

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 abuse, resulting in multiple resident-to-resident altercations. Eight residents were involved in incidents where physical contact was made, indicating a lack of effective monitoring and intervention by the staff. These incidents occurred despite the presence of care plans that outlined specific interventions to manage the residents' behaviors and cognitive impairments. In one incident, a resident with a history of mood disorder and cognitive impairment provoked another resident, leading to a physical altercation. The staff was present but failed to prevent the initial contact. Similarly, another incident involved a resident with dementia who was on one-on-one supervision but still managed to engage in a physical altercation with another resident. The staff's inability to effectively intervene and redirect the residents contributed to these altercations. The facility's documentation and staff interviews revealed that the staff was aware of the residents' behavioral tendencies and had care plans in place to address them. However, the execution of these plans was inadequate, as evidenced by the repeated incidents of resident-to-resident altercations. The staff's failure to consistently monitor and intervene in these situations highlights a deficiency in the facility's supervision and abuse prevention measures.

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 seven residents from abuse, resulting in multiple incidents of physical aggression and altercations. Resident #72, who has a history of traumatic brain injury and cognitive impairment, was involved in an incident where he aggressively shook another resident's wheelchair and attempted to push it into a wall. This behavior was documented in his care plan, which included interventions such as documenting behaviors and psychiatric consultations. However, the incident still occurred, indicating a failure to effectively manage and prevent such behaviors. Another incident involved residents #76 and #92, both of whom have cognitive impairments and behavioral issues. Resident #76, who has a history of aggression, was seen on camera preventing resident #92 from entering a common area and engaging in a physical altercation. Despite interventions in their care plans to de-escalate situations and remove residents from potentially harmful environments, the altercation occurred, suggesting inadequate supervision and intervention. Additional incidents involved residents #19 and #42, and residents #54 and #32, where physical aggression was observed. These residents also have cognitive impairments and behavioral issues documented in their care plans. Despite having interventions in place, such as supervision and behavioral management strategies, the facility failed to prevent these altercations, resulting in physical contact between residents. The facility's policy on abuse prevention requires immediate reporting and investigation of such incidents, but the repeated occurrences indicate a systemic issue in effectively implementing these 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 ensure that dishes and utensils were cleaned using professional standards of practice for sanitary conditions, which could result in residents becoming ill. During a kitchen inspection, it was observed that the low temperature dishwashing machine required multiple runs to reach the necessary temperature of 120 degrees Fahrenheit. The kitchen manager, Staff #201, confirmed that they use a chlorine sanitizer and conducted a test strip to determine sanitation levels, which showed a reading between 100 and 200 parts per million (ppm), approximately 150 ppm. Further review of the facility's Dish Machine Temperature Log for the months of November 2024 through January 2025 revealed that the wash temperatures were consistently logged over 120 degrees Fahrenheit, and the rinse column showed sanitizer levels over 100 ppm. However, the manufacturer's instructions for the dishwashing machine specified not to exceed 50 ppm of chlorine, indicating a discrepancy in the facility's practices. Staff #201 admitted that the ppm test results were not documented in the log sheet, as the current form did not provide an option to record them, despite performing the test strip. Interviews with the kitchen manager and the administrator revealed a lack of awareness and documentation regarding the ppm levels, with the administrator only being familiar with the use of a low temperature dish machine. The facility's policy on cleaning dishes stated that all flatware, serving dishes, and cookware should be cleaned, rinsed, and sanitized after each use, and the dish machine should be checked prior to meals to ensure proper functioning and appropriate temperatures. The absence of a ppm test results log and the use of higher than recommended chlorine levels indicate a failure to adhere to these standards.

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 monitoring and evaluation of physical restraints for a resident, leading to a deficiency in care. The resident, who was admitted with conditions including atrial fibrillation, dementia, and anxiety, experienced multiple falls, prompting the use of bed and wheelchair alarms. Despite the discontinuation of a self-releasing seat belt alarm, the resident was observed with the seat belt tied to his waist, indicating a lack of adherence to the updated care plan. Interviews with staff revealed inconsistencies in the understanding and implementation of restraint policies. A certified medication assistant and a CNA both noted the resident's instability and fall risk, justifying the use of alarms. However, the CNA mentioned that the new alarm system did not function properly, as it required a switch to be turned off by staff, which the resident was unaware of. This oversight in alarm functionality and staff's lack of awareness of non-pharmacological interventions contributed to the deficiency. The Director of Nursing acknowledged that no fall assessment was conducted before implementing the alarms, and the resident's consent for the seat belt alarm was not obtained, as it was not considered a restraint. The DON also confirmed that the seat belt alarm should not have been in use, as it was discontinued. The facility's restraint policy emphasizes a restraint-free environment unless medically necessary, highlighting the failure to comply with this standard.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a copy of the discharge notice for a resident was sent to the Office of the State Long-Term Care Ombudsman. This deficiency was identified through clinical record reviews, staff interviews, and a review of facility policy. The resident in question was admitted with diagnoses including dementia, hypertension, and dysphagia. The Minimum Data Set assessment was incomplete, as indicated by a Brief Interview of Mental Status score of 99. The resident was sent to the Emergency Department after being found unresponsive, with a do-not-resuscitate order in place. The facility's policy requires that a copy of the discharge notice be sent to the Ombudsman, but this was not done. Interviews with facility staff revealed a lack of communication and adherence to policy regarding the notification of the Ombudsman. The Social Service staff stated that the Ombudsman is notified at the start of each month, but this did not occur for the resident's discharge. The Director of Nursing confirmed that the transfer was facility-initiated and acknowledged that social services should have notified the Ombudsman. The failure to notify the Ombudsman as required by policy may result in residents not receiving necessary advocacy and support during the discharge process.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that care plans were revised as needed for three residents, leading to deficiencies in their care. Resident #45, who was admitted with dementia, muscle weakness, and adult failure to thrive, had a care plan that did not address their physical decline or include therapy interventions, despite changes in their condition noted in the Minimum Data Set (MDS) assessments. Resident #72, admitted with traumatic brain injury and cognitive impairments, exhibited aggressive behaviors towards other residents. Despite multiple incidents documented in progress notes, including attempts to physically engage with other residents, the care plan was not updated to include new interventions to address these behaviors until February 2024, leaving a gap in the management of the resident's behavior. Resident #76, with diagnoses including hemiplegia and aphasia, also displayed aggressive behaviors towards other residents. Although incidents were documented in progress notes, the care plan was not revised to reflect these events until January 2025. Interviews with staff revealed a lack of timely updates to care plans, with responsibilities for updates not clearly defined among the MDS nurse, behavioral health unit manager, and social services staff.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was safe to self-administer medication, which could result in a medication overdose. The resident, who was admitted with diagnoses of dementia, type 2 diabetes, and dysphagia, was found to have a bag of medication in their room. A CNA discovered the medication while searching for the resident's clothing and reported it to a nurse. The medications included Bisacodyl, Polyethylene glycol, Melatonin, Docusate sodium, Quetiapine, Acetaminophen, and Diclofenac sodium. The resident had a BIMS score indicating intact cognition, but there was no assessment completed for self-administration of medication. Interviews with staff revealed that the resident did not have permission to self-administer medication, and the presence of medication in the room posed a risk of self-administration or sharing with others. The LPN and CNA involved in the incident confirmed that the medication should have been locked up. The Director of Nursing stated that any medication found in a resident's room should be reported to the assigned nurse and that no residents in the facility were assessed for self-administration of medication. The facility's policy requires a self-administration assessment before residents can manage their own medications.

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 specialized rehabilitative services for a resident, identified as resident #45, who was admitted with diagnoses of dementia, muscle weakness, and adult failure to thrive. The resident's care plan, initiated on September 14, 2020, did not address the resident's physical decline or include a plan related to therapy, despite the resident's increasing dependency on staff for care. The annual Minimum Data Set (MDS) assessments indicated a decline in the resident's ability to perform activities of daily living, yet there was no documented assessment or therapeutic intervention to address this loss. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's need for therapy. A CNA noted the resident's increased dependency and the onset of contractures, while an LPN mentioned that therapy assessments might depend on insurance coverage. The Director of Therapy admitted that no baseline assessment or evaluation had been conducted for the resident, and there was no order for therapy evaluation. The Director of Nursing acknowledged the expectation for staff to notify providers of changes in condition but was unaware of any action taken beyond the MDS findings. The facility's policy on Activities of Daily Living emphasized the need for individualized assistance based on MDS assessments, which was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was offered the pneumococcal vaccine, despite having a signed consent form on file. The resident, who was initially admitted with acute respiratory failure, hypoxia, seizure, major depressive disorder, and pneumonia, had consented to receive the Pneumococcal Prevnar13 vaccine upon admission. However, there was no evidence in the records that the vaccine was administered to the resident. During an interview, the Assistant Director of Nursing/Infection Preventionist confirmed that the resident had consented to the vaccination but had not received it since admission. The facility's policy requires that each resident be presented with a Flu and Pneumonia Vaccine Authorization consent upon admission, which remains in effect until revoked. The failure to administer the vaccine as consented could increase the resident's susceptibility to respiratory infections and pneumonia.

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 two residents from abuse by another resident, leading to a deficiency in ensuring resident safety. Resident #2, who has dementia and other medical conditions, was physically assaulted by Resident #1 on two occasions. Despite staff intervention, Resident #1, who also has dementia and moderate cognitive impairment, pushed Resident #2 on the shoulder and upper back. The incidents were witnessed by staff, and although no injuries were observed, the events were substantiated as abuse by the facility's internal investigation. Resident #3, with severe cognitive impairment, was also a victim of physical abuse by Resident #1. While sitting at a CNA station, Resident #3 was struck on the arm by Resident #1, who accused Resident #3 of speaking ill of her. This incident was also witnessed by staff, and the facility's investigation confirmed it as abuse. Both residents were assessed for injuries immediately following the incidents, and appropriate notifications were made. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving Resident #1. The policy outlines the need for identifying residents at risk of abusing others and developing intervention strategies, which were not adequately executed in this case. The facility's failure to prevent these occurrences resulted in a deficiency related to resident safety and protection from abuse.

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 a resident from abuse by another resident, resulting in a physical altercation. Resident #3, who was cognitively impaired with a BIMS score of 0, approached and hit Resident #4, who was cognitively intact with a BIMS score of 14. The incident occurred in a common area near the nurses' station, where both residents were in wheelchairs and engaged in kicking each other before being separated by staff. The altercation was captured on video surveillance, which showed Resident #3 initiating the physical contact. Staff #19, a Certified Medical Assistant, witnessed the altercation and intervened by separating the residents and notifying a Registered Nurse. The Director of Nursing, who was not present during the incident, later reviewed the video footage and confirmed the sequence of events. The Director noted that the common area where the incident occurred did not have a room monitor assigned during weekends, which contributed to the delay in staff intervention. The facility's policy on abuse prevention defines physical abuse as hitting, slapping, pinching, and kicking, which occurred in this incident. The Director of Nursing acknowledged that the staff's response did not meet expectations, as more attention should have been paid to the residents in the common area. The incident highlights a deficiency in ensuring a safe environment for residents, as the lack of monitoring allowed the altercation to escalate before staff intervention.

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 basic life support, including CPR, in accordance with the advance directives for a resident who was identified as a full code. The incident involved a nurse who did not initiate CPR or call emergency medical services (EMS) when the resident was found without breath sounds and a pulse. The resident, who had a full code status, expired without receiving the necessary life-saving measures. The resident was admitted with multiple diagnoses, including adult failure to thrive, repeated falls, dysphagia, orthostatic hypotension, hyperglycemia, dementia, protein-calorie malnutrition, and chronic pain. The baseline care plan did not include the resident's advance directives of code status, although the specific treatment form indicated a full code status, meaning CPR should have been employed. On the day of the incident, the resident's oxygen saturation dropped significantly, and despite being hypotensive and requiring medication, there was no change in the code status documented. The nurse on duty, along with another LPN, assessed the resident and determined the absence of vital signs, yet failed to initiate CPR or contact EMS. Interviews with staff revealed a lack of clarity and adherence to protocol regarding the resident's code status. The facility's policy required that in the absence of a DNR order, CPR should be initiated prior to EMS arrival, which was not followed in this case.

Removal Plan

• Resident rooms had new labels posted indicating code status
• The nurse who did not initiate CPR was terminated; and, the nurse who knew about the incident but did not follow protocol was placed on probation
• Residents code status was reviewed to ensure that code status match with the physician order and paper copy
• Personnel file review/audit to ensure all staff have current CPR certification
• Facility DNR book audit to ensure all residents had current DNR forms and directives
• In-service training on protocol to follow on implementing code status of residents
• In-service training on who was responsible for making changes in the resident's code status and protocols in place should the resident move to another room

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 a care plan for a resident who required repositioning every two hours due to limited mobility and existing pressure ulcers. The resident, who was admitted with chronic pain, constipation, an open wound on the right lower leg, diabetes mellitus, and age-related physical debility, was at risk for developing further pressure ulcers. The comprehensive care plan dated July 31, 2024, included an intervention to turn the resident every two hours when in bed, starting from January 13, 2024. However, there was no evidence in the CNA plan of care tasks documentation or the clinical record that repositioning was being tracked or implemented as planned. Interviews with staff, including a CNA and the DON, revealed that the task of repositioning every two hours was not included in the plan of care tasks for the resident, and it had been missed. The facility's policy on charting and documentation required that all services provided to the resident be documented in the medical record, and the skin/wound care protocol mandated a change in position at least every two hours for bedfast or chairfast residents. The lack of documentation and implementation of the care plan intervention for repositioning could result in the resident not receiving necessary services, as outlined in their care plan.

Penalty

Inspection fine: $21,850

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 a COVID-19 screening and consistent testing program during a COVID-19 outbreak, which could result in residents becoming ill. Resident #3, who was admitted with diagnoses including COVID-19 acute respiratory disease and end-stage renal disease, was transported to the emergency room for shortness of breath and later passed away. The facility's documentation did not reveal any screening for staff, visitors, or allied healthcare professionals during the outbreak, and there were no COVID-19 testing results for all staff. Staff #9, a maintenance employee, tested positive for COVID-19 but was in contact with other staff while working in the building. Staff #14, a housekeeper, also tested positive, but the testing form did not reveal if she had symptoms. The facility's COVID-19 mapping showed thirty-six resident COVID-19 positive cases from July 7 to July 26, 2024. Interviews with staff revealed that there was no requirement for staff to screen for symptoms or check body temperature before entering the building during the outbreak. The COVID-19 Safety Coordinator and the Director of Nursing confirmed that the facility should have screened everyone before they entered the building and that staff and visitors should be screened to protect the residents. The facility's policy stated that testing should be performed for any staff or resident experiencing symptoms, during an outbreak, or as recommended by the County Health Department. However, the facility did not adhere to these procedures during the outbreak.

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 the physician of a change in condition for a resident, which could result in a lack of continuity and coordination of care. The resident, who was admitted with chronic kidney disease, chronic pain, and hypertension, experienced a decline in oxygen saturation and reported chest pain and difficulty breathing to her family. Despite these symptoms, there was no documentation that the physician was informed of the resident's condition or that the resident was taken to a community clinic by her family. Interviews with facility staff revealed that the standard procedure for notifying the Director of Nursing and the physician was not followed. The facility's policy requires that any change in a resident's condition or transfer to a hospital be documented and communicated to the appropriate parties. However, the clinical record lacked evidence of such notifications, and the documentation did not meet the facility's standards, as confirmed by the Assistant 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 protect a resident from abuse by family members during visits. The resident, who has severe cognitive impairment due to Alzheimer's disease and dementia, was involved in a verbal altercation with family members who were demanding money and threatening to sell the resident's cattle. Despite the incident being overheard by staff, there was no immediate intervention to stop the abuse or ask the family members to leave. The facility's investigation revealed that the incident occurred when the resident was taken to her room by family members, who then closed the door and began yelling and arguing with the resident. Staff members heard the altercation but did not intervene until after the family members had left, at which point the resident was found crying. The facility's policy requires immediate action to stop suspected abuse, but this was not followed during the incident. Interviews with staff indicated that they were aware of the facility's procedures for handling suspected abuse, including reporting to the DON and asking the perpetrator to leave. However, these procedures were not effectively implemented in this case, as the family members were allowed to continue their visit and were not asked to leave until a later date. The facility's failure to act promptly and decisively during the incident resulted in a deficiency in protecting the resident from abuse.

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 its policy on abuse and resident protection for a resident diagnosed with Alzheimer's disease, dementia with behavioral disturbance, agitation, psychotic disturbance, and hypertension. The incident involved the resident's family members who visited and engaged in a verbal altercation with the resident, demanding money and threatening to sell the resident's cows. Despite the altercation being audible to staff, there was no intervention or documentation of actions taken to stop the incident or prevent future occurrences. Interviews with staff, including a Registered Nurse, Certified Nursing Assistant, Receptionist, Activities Assistant, Director of Nursing, and the Administrator, revealed a lack of immediate action to protect the resident during the incident. Staff members acknowledged the importance of intervening in suspected abuse situations, yet no staff member intervened during the incident. The Director of Nursing admitted that the family was allowed to finish their visit despite the altercation, and no immediate protective measures were implemented. The facility's policies on abuse prevention and visitation were not followed, as they require immediate action to stop suspected abuse and protective measures to ensure resident safety. The policies also state that family members suspected of abuse should be restricted from visiting or allowed only supervised visits during an investigation. However, these measures were not documented or enforced, leading to a deficiency in resident protection.