Columbine West Health And Rehab Llc

Penalty

Inspection fine: $16,653

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 and promote an environment free from resident-to-resident sexual abuse, affecting four residents. Resident #2, who had a history of being verbally sexually inappropriate, was observed grabbing the breast of Resident #1 and lifting her shirt. Despite being placed on one-to-one supervision temporarily, staff interviews revealed that not all staff were aware of Resident #2's inappropriate behavior, nor were they educated on how to respond to his behavior toward female residents. Additionally, Resident #2's care plan was not updated to include his behavior of touching female residents. Resident #4, who also had a history of being sexually inappropriate, was observed rubbing the breast of Resident #3. Although the care plan was updated to seat Resident #4 next to male residents in group settings, staff interviews revealed they were not informed of the resident's inappropriate behavior toward female residents. Observations showed Resident #4 sitting within arm's reach of a female resident, indicating a lack of adherence to the care plan interventions. The facility's failure to inform and educate staff on the sexually inappropriate behaviors of Residents #2 and #4, monitor their behaviors, and implement planned interventions created a reasonable expectation of an adverse outcome. The facility's response to the incidents was inadequate, as evidenced by the lack of staff awareness and the absence of updated care plans to address and prevent recurrence of such behaviors.

Removal Plan

• Nursing home administrator assigned a one-to-one staff member to ensure that Resident #1 and other residents were protected from Resident #2. The one-to-one supervision will continue then additional staff will be added to the schedule on all shifts indefinitely for the secured unit.
• All staff that were currently working and all staff prior to the upcoming shift will be educated regarding the sexualized behaviors of Residents #2 and #4 and identified interventions as listed on the care plan.
• Education will be provided by written, verbal, and or digital means for all resident's sexual expressions of need. All working staff were to have completed this.
• Identify other residents residing in the facility that have demonstrated sexual expressions of need (behaviors) in the past and ensure that appropriate care plan interventions were in place.
• Immediate review of resident information sheets to ensure that interventions were in place for residents with inappropriate behavior. Education to be provided to clinical staff regarding newly added expressions of need and interventions.
• Implement a shift-to-shift report book with an emphasis on communicating expressions of need (behaviors) exhibited by residents on all units of the facility. Residents with active expressions of need will be identified in the shift-to-shift book. The oncoming shifts will review and sign prior to the start of shift, this includes both nurses and CNAs.
• Events will be opened when new or changed expressions of need were noted. Events were to stay open until reviewed by the behavioral management team and closed upon no expressions identified or stable with current interventions.
• Social services and/or nurse managers or their designee to ensure all residents demonstrating sexual expressions of need have a care plan and interventions in place.
• Any change in interventions or plan of care will result in an update to the resident information sheet.
• Shift-to-shift report book for all units will be monitored/reviewed by a secure unit manager, nurse manager or designee daily for one week, weekly for two weeks, monthly for two months.
• All expressions of need events will be reviewed by the interdisciplinary team or off-business hours designee daily for one week, then weekly per IDT BMT meeting. The event will be closed with demonstration of successful intervention and resolution of expressions of need.
• During the IDT BMT meeting, care plans will be audited based on the previous week events to ensure appropriate interventions were in place.
• Review and update the RIS will be a part of the IDT BMT review process documentation.

Penalty

Inspection fine: $16,653

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

Summary

The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to freedom from abuse, reporting, and investigating incidents. The QAPI committee, which included the medical director, director of nursing, and other key staff, met monthly to discuss facility issues but did not have a Performance Improvement Project (PIP) for abuse in place. Despite being cited for abuse in a previous recertification survey, the facility did not identify any concerns related to abuse, leading to a repeat deficiency. During a recertification survey, the facility was cited for failing to protect residents from resident-to-resident sexual abuse, which resulted in a serious adverse outcome and immediate jeopardy to resident health or safety. The facility's inability to prevent repeat deficiencies and initiate corrective plans of action contributed to the situation where residents were placed in harm's way, highlighting a significant gap in the facility's quality assurance efforts.

Penalty

Inspection fine: $16,653

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

Summary

The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in a deficiency in maintaining the resident's highest practicable physical, mental, and psychosocial well-being. The resident, an 81-year-old with Alzheimer's disease, stage two kidney disease, depression, and anxiety disorder, exhibited wandering behavior and was not consistently supervised as required by her care plan. Observations revealed that the resident was often left unsupervised, not engaged in activities, and not provided with comfort items like a baby doll, which were part of her care plan interventions. The facility's policy required individualized, person-centered care plans developed through an interdisciplinary team approach, including input from the resident or their representative. However, the care plan for the resident was not effectively implemented. The resident was observed wandering in common areas and other residents' rooms without staff intervention, despite being identified as a high fall risk and requiring near-constant supervision. Staff interviews confirmed that the resident's wandering behavior was known, but interventions to redirect or engage her were not consistently applied. The facility's failure to adhere to its dementia care policy and the resident's care plan resulted in the resident being left unsupervised and not engaged in meaningful activities. The staff's inaction in providing necessary interventions and supervision contributed to the resident's continued wandering and potential for altercations with other residents. The deficiency highlights a lack of effective implementation of person-centered care approaches for residents with dementia, as outlined in the facility's policies.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the inability to regulate room temperatures effectively. Observations and interviews revealed that 13 out of 15 resident rooms had temperatures exceeding 81 degrees Fahrenheit, with some rooms reaching as high as 90 degrees. The facility's policy relied on corridor air conditioning units and the practice of keeping resident room doors open to allow cool air to circulate, which proved insufficient in maintaining comfortable temperatures in individual rooms. Residents and their families reported discomfort due to the excessive heat, with some residents experiencing difficulty sleeping and feeling sticky and uncomfortable. Several residents, including those with cognitive impairments, expressed dissatisfaction with the room temperatures, and family members noted the rooms were stuffy and excessively hot. Staff members, including CNAs and LPNs, corroborated these reports, acknowledging that residents and their families had complained about the heat, and they themselves found the facility too hot at times. The maintenance supervisor admitted to taking room temperatures only once in July, which did not provide an accurate representation of the ongoing temperature issues. The nursing home administrator was unaware of the extent of the problem, as the maintenance supervisor had not communicated the high temperatures to her. Despite the facility's policy and efforts to manage room temperatures, the lack of effective air conditioning in resident rooms and inadequate monitoring of room temperatures contributed to the deficiency.

Penalty

Inspection fine: $10,238

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 at risk for developing pressure injuries received care consistent with professional standards of practice. Resident #30, who was admitted for long-term care, was identified as being at risk for pressure injuries upon admission. Despite this, preventative measures to protect the resident's heels were not implemented until after the development of a deep tissue injury (DTI) on the right heel, which was later classified as an unstageable pressure injury by the wound care physician. The resident's medical history included diabetes mellitus, end-stage kidney disease requiring hemodialysis, and dementia. The resident was severely cognitively impaired and required assistance for various activities, including rolling, transferring, and dressing. Upon admission, the resident's skin was intact, and no pressure injuries were present. However, on 10/7/23, a nurse documented the development of a DTI on the resident's right heel. The facility's treatment administration records revealed no documentation of heel protection measures until 10/16/23, after the injury had already developed. Interviews with staff indicated that the resident required assistance and wore pressure-reducing boots during dialysis, in bed, and in a wheelchair. However, the wound care registered nurse (WCRN) and the wound care physician (WCP) both noted that the resident would have benefited from preventative measures such as offloading the heels and elevating the legs upon admission. The assistant director of nursing (ADON) acknowledged that the protective booties were not implemented until after the wound developed and suggested that the injury likely occurred during dialysis sessions, which were beyond the facility's control. However, the facility did have the opportunity to implement protective measures prior to the resident's visits to dialysis.

Penalty

Inspection fine: $10,238

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 post information on how to file a complaint with the State Agency in a manner that was accessible and understandable to residents. During a group interview with eight residents who regularly attended monthly resident council meetings, all participants indicated they did not know how to file a complaint with the State Agency and were unaware that such information was posted in the facility. One resident mentioned that concerns reported to certified nurse aides were not followed up on by the facility, indicating a lack of effective communication and resolution of grievances. An observation on the following day revealed that the required posting with the State Agency information was located in the corner of the lobby, positioned above the eyeline for residents in wheelchairs, and written in a small font, making it difficult to read. Additionally, the Social Services Director (SSD) was initially unsure of the posting's location and had to ask someone for its whereabouts. The SSD acknowledged that the posting might not be visible to residents with visual impairments but believed residents felt comfortable asking staff for assistance if needed.

Penalty

Inspection fine: $10,238

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 store, prepare, distribute, and serve food in a sanitary manner in both the kitchen and a nourishment room. Specifically, the facility did not ensure that holding temperatures were maintained at appropriate levels. During an observation, tartar sauce was found on a cart next to the oven and stove without any cooling mechanism, and its temperature was recorded at 62 degrees Fahrenheit, which is above the required cold holding temperature of 41 degrees Fahrenheit. The tartar sauce was subsequently discarded after confirmation from the dietary manager and registered dietician that it needed to be kept below 41 degrees Fahrenheit to avoid potential food-borne illnesses. Additionally, the facility failed to ensure that food was labeled, dated, and disposed of in a timely manner. Observations revealed an eight-ounce plastic cup containing a chocolate milkshake labeled with a resident's name and a date from ten days earlier, an opened almond milk carton without a discard date, an opened Pedialyte carton without a date indicating when it was opened, and a Magic Cup nutritional supplement without a date indicating when it was thawed. Interviews with the registered dietician, nursing home administrator, and dietary manager confirmed that these items should have had appropriate labeling and discard dates to ensure food safety.

Penalty

Inspection fine: $10,238

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 establish a sanitary environment to help prevent the transmission of communicable diseases and infections on three of five units. Specifically, the facility did not ensure that enhanced barrier precautions (EBP) were implemented and followed for residents with wounds and/or indwelling medical devices. Observations revealed that staff did not use appropriate personal protective equipment (PPE) when providing care to residents with such conditions. For instance, a certified nursing aide (CNA) and a registered nurse (RN) did not don gloves or gowns while transferring a resident with an indwelling catheter and during a wound dressing change. Similarly, another resident with pressure ulcers did not receive care with the required PPE, as observed when an RN did not wear a gown while inspecting the resident's wounds. Interviews with the infection preventionist (IP) and corporate nurse consultant (CNC) confirmed that the facility had not yet implemented EBP for residents without multi-drug resistant organisms (MDROs) but with indwelling devices or wounds, despite having adequate PPE supplies available. Additionally, the facility failed to ensure that staff used appropriate PPE when entering the room of a COVID-19 positive resident. Observations showed that a CNA entered the room wearing a surgical mask instead of the required N95 mask, and another CNA wore a surgical mask under an N95 mask, which compromised the seal and effectiveness of the N95 mask. Interviews with the IP confirmed that the correct PPE for the COVID-19 positive room included a gown, gloves, N95 mask, and face shield, and that wearing a surgical mask under an N95 mask was not appropriate. These failures indicate a lack of adherence to established infection prevention and control protocols, potentially increasing the risk of infection transmission within the facility.

Penalty

Inspection fine: $10,238

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 potential sexual abuse by Resident #43, who had a documented history of sexually inappropriate behavior toward male residents. Despite being aware of Resident #43's behavior, the facility did not take timely steps to minimize the risks to other residents. An incident occurred where Resident #43 placed Resident #39's hand underneath her shirt, touching her breast. The facility did not report this incident to the state as potential sexual abuse and did not thoroughly assess the residents' ability to consent to sexual contact. The facility had prior knowledge of Resident #43's inappropriate sexual behavior, as documented in a social services progress note and an expression of need (EON) event. However, there was no evidence that Resident #43's care plan was revised to address the potential risk of abuse to other residents. After the incident on 4/2/24, the facility's investigation lacked sufficient documentation, and there was no plan to monitor the residents' well-being following the incident. Following the incident, Resident #43 continued to exhibit inappropriate sexual behavior, but the facility did not promptly update her care plan with effective interventions. Staff interviews revealed that not all staff were aware of the planned interventions to ensure consistent implementation. The facility's failure to address Resident #43's known inappropriate behaviors before and after the incident put other residents at risk of potential sexual abuse.

Penalty

Inspection fine: $10,238

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

Summary

The facility failed to ensure the comprehensive care plan for a resident was reviewed and revised timely to address the resident's repeated refusals of physician-ordered pain medications. The resident, aged 78, with severe cognitive impairment and multiple diagnoses including dementia, Parkinson's disease, and chronic pain syndrome, frequently refused her prescribed pain medications such as acetaminophen, Biofreeze gel, and gabapentin. Despite these refusals being documented in the medication administration records (MAR) over several months, there was no evidence in the electronic medical record (EMR) that the facility attempted to address this pattern or update the resident's care plan accordingly. Interviews with staff revealed that while it was acknowledged that residents have the right to refuse medications, there were no consistent efforts to address the underlying reasons for the refusals or to notify the provider and family as required. Licensed Practical Nurse (LPN) #1 mentioned that he tried to educate residents on the importance of taking their medications and noted that the resident in question responded better to male nurses. The Nurse Manager (NM) and Assistant Director of Nursing (ADON) both indicated that trends in medication refusals should prompt further investigation and collaboration with the provider and family, but this was not documented in the resident's case. The NM also identified a potential issue with the cold sensation of the Biofreeze gel as a reason for the refusals and suggested that a specific nurse might need additional training on how to approach the resident. However, these insights were not reflected in any updates to the resident's care plan. The ADON confirmed that trends in medication refusals should be discussed in morning meetings to develop a plan, but this process was not followed for the resident in question, leading to a deficiency in providing effective and person-centered care.

Penalty

Inspection fine: $10,238

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 with dementia received person-centered care that met her needs. Resident #43, who had severe cognitive impairment and a history of wandering, repeatedly asked for food and specific meals such as breakfast. Despite her requests, staff members did not provide her with the food she asked for or engage her in meaningful activities to distract her from her repetitive requests. Observations showed that staff either ignored her requests or provided minimal interaction, failing to address her needs effectively. During continuous observations, Resident #43 was seen asking for food multiple times, but staff either reminded her of the snacks she already had or told her that meals were coming soon without offering any immediate alternatives. The staff's interactions were limited to brief responses, and they did not attempt to engage the resident in conversation or other activities. This lack of engagement and failure to provide requested food items contributed to the resident's ongoing distress and repetitive behavior. Interviews with staff revealed that they were not fully aware of the resident's needs or the appropriate responses to her requests. The nurse manager and assistant director of nursing acknowledged that snacks should be offered to residents who ask for food, regardless of meal times, and that it is important to offer food specific to the resident's requests. However, the care plans for Resident #43 did not include interventions to address her repetitive requests for food, indicating a gap in the facility's approach to person-centered dementia care.

Penalty

Inspection fine: $10,238

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 free of unnecessary psychotropic medications. Specifically, the facility did not track and monitor behaviors for a resident who was on four different psychotropic medications. The resident, who had diagnoses of dementia with behavioral disturbance and depression, was receiving mirtazapine, olanzapine, sertraline, and trazodone. However, there was no documentation of the specific behaviors that justified the use of these medications, nor was there daily monitoring for side effects or targeted behaviors related to the medications. The care plan did not mention the resident's use of psychotropic medication for dementia and specific behaviors the resident displayed. The facility's policy required that an event be opened to document target symptoms prior to the initiation of antipsychotics and that residents be continually monitored for adverse side effects. However, the review of the resident's progress notes and monitoring events revealed no documented behaviors or active events for the documentation of targeted behaviors for psychotropic medications. Interviews with staff, including the social services director, certified nurse aide, registered nurse, and assistant director of nursing, indicated a lack of clarity and documentation regarding the resident's behaviors and the rationale for the use of multiple psychotropic medications. The social services director was uncertain about the reasons for the resident being on three different antidepressants and could not locate a physician statement documenting the rationale. The certified nurse aide and registered nurse reported that the resident did not exhibit aggressive behaviors and that his requests for help were reasonable and related to care. The assistant director of nursing confirmed that behavior tracking was usually documented under events and that assessments for side effects of psychotropic medications should be documented under progress notes. However, the resident's medication administration records did not include daily behavior tracking, leading to a failure in monitoring and justifying the use of psychotropic medications for the resident.