Westview Health Care Center

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

A deficiency occurred when a nurse aide (NA) misappropriated a resident's credit card and used it for unauthorized personal purchases over an extended period. The resident, admitted for short-term rehabilitation with diagnoses including diabetes, anxiety, and heart failure, was cognitively intact and required assistance with personal care. The NA initially used the resident's credit card to purchase snacks at the resident's request but continued to use the card for personal expenses, accumulating charges up to $20,000. The NA admitted to using the card for various personal needs and did not stop until the card was deactivated. The resident did not authorize the NA to use the card and believed it had been hacked. The facility became aware of the misappropriation after being contacted by the State Police, who reported the suspected exploitation. Facility documentation confirmed that the NA was employed during the period when the unauthorized charges occurred. The NA admitted to the actions during interviews, and the facility's policies clearly prohibit misappropriation of resident property. The incident was substantiated as abuse by the facility, and the NA was terminated following the investigation.

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 update a resident's care plan after being notified of unauthorized use of the resident's credit card by a nurse aide. The resident, admitted for short-term rehabilitation with diagnoses including diabetes, anxiety, and heart failure, was assessed as having no cognitive impairment and required assistance with personal care. Despite the facility being informed by the State Police of suspected exploitation involving significant fraudulent charges to the resident's credit card by a staff member, there was no documentation that the resident's care plan was revised to address the incident or provide interventions related to the event. Facility records, including the Reportable Event Form and interviews with the Director of Nursing Services (DNS) and Administrator, confirmed that while the resident was monitored, the care plan was not specifically updated to reflect the incident. The facility's own policies required documentation of investigation and follow-up in the clinical record for residents involved in such events, as well as the development of a comprehensive care plan addressing identified psychosocial needs. However, no evidence was found that the care plan was amended to support the resident following the financial exploitation incident.

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 medically-related social services to meet the needs of a resident after an incident of misappropriation of property by a staff member. The resident, admitted for short-term rehabilitation with diagnoses including diabetes, anxiety, and heart failure, was cognitively intact and required assistance with personal care. After the facility was notified by the State Police of suspected exploitation involving the unauthorized use of the resident's credit card by a nurse aide, the aide was suspended and later terminated. Documentation showed that the aide admitted to using the resident's credit card for personal purchases, resulting in significant unauthorized charges. Despite the incident, there was no evidence in the clinical record or facility documentation that the resident received follow-up support or medically-related social services, such as counseling or psychiatric services, related to the emotional impact of the misappropriation. Interviews with facility staff, including the social worker and APRN, confirmed that no support visits or referrals were provided or documented. The facility's policy required documentation of follow-up care in such cases, but no such documentation was found, and staff could not explain why support services were not provided.

Penalty

No penalty information released

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

Summary

The facility failed to provide a dignified dining experience for 12 residents who required assistance during mealtime. Observations revealed that two nurse aides were responsible for assisting these residents, many of whom were severely cognitively impaired and required 1:1 feeding assistance or cues and supervision. However, the aides were observed standing above the residents and moving between them to assist with feeding, rather than sitting at eye level as recommended by facility policy. Interviews with the nurse aides and the Licensed Practical Nurse confirmed that the usual practice involved two aides assisting 12 residents simultaneously, which often required them to feed multiple residents at the same time. This practice was contrary to the facility's policy, which directed staff to provide a dining experience that maintains or enhances each resident's dignity and ability to maximize their dining experience. The policy also emphasized the importance of feeding residents slowly and not rushing them through meals. The Assistant Director of Nursing acknowledged that the aides should be sitting at eye level with the residents while assisting with meals, which was not observed during the survey. The facility's failure to adhere to its own policies and provide adequate staffing for individualized feeding assistance compromised the residents' right to a dignified dining experience, as outlined in the facility's policies and resident care plans.

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 residents with PASARR Level II recommendations were provided services to meet their needs. Three residents, each with significant mental health diagnoses, were not given the necessary mental health counseling and follow-up as recommended by their PASARR Level II assessments. The facility's documentation and interviews revealed a lack of referrals and follow-up with behavioral health providers, despite clear recommendations for mental health services and medication management. Resident #35, diagnosed with generalized anxiety disorder, auditory hallucinations, delusional disorders, and vascular dementia with behavioral disturbances, was not referred for mental health counseling as recommended by the PASARR II findings. Despite ongoing symptoms such as hallucinations and anxiety, the resident's care plan did not include any follow-up with a behavioral health provider. The facility's social services and medical staff did not coordinate to ensure the resident received the necessary mental health services. Similarly, Resident #65, with diagnoses including generalized anxiety disorder, bipolar disorder, and unspecified dementia with agitation, did not receive the recommended behavioral health services. The resident's care plan and medical records lacked documentation of psychiatric or mental health care follow-up. Resident #71, diagnosed with bipolar disorder, also did not receive the necessary mental health services and medication management as recommended. The facility's social services staff did not have the appropriate qualifications to provide the required counseling, and there was no contracted behavioral health service available to the residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that nursing staff, including nurses and nurse aides (NAs), were adequately trained and competent in monitoring resident skin conditions and managing oxygen equipment. A review of the Healthcare Academy Course Status Reports revealed that a significant portion of NAs did not complete the assigned 'Skin Care Basics for Nursing Assistants' course, which is crucial for understanding skin tears, pressure injuries, and the importance of reporting skin problems to nurses. Interviews with registered nurses (RNs) indicated that preventative weekly skin assessments were not conducted by licensed nurses, and the responsibility was left to NAs, who were expected to notify nurses of any changes. However, competencies related to monitoring skin conditions and reporting concerns were not adequately documented for many NAs. Additionally, the facility did not provide sufficient training for NAs on tasks related to oxygen equipment, such as cleaning oxygen concentrator filters and changing nasal cannula tubing. RN interviews revealed a lack of awareness of policies regarding these tasks and insufficient education on delegating these responsibilities to NAs. The Oxygen Use Basics course did not cover essential training for these tasks, and there was no documentation of competencies for NAs in this area. The facility's Staff Development Corporate Compliance Policy requires NAs to complete 12 hours of continuing education annually, but the report indicates gaps in training and competency documentation.

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 adhere to its policy regarding the disposal of perishable food and beverages, leading to a deficiency in food storage practices. During an observation of the North/West medication room refrigerator, it was found that a prune juice container with an open date of four days prior and a cranberry juice container with no open date were stored improperly. An RN confirmed that the juices were used for medication passes and that the kitchen was responsible for stocking and cleaning the refrigerator. However, the RN acknowledged that the facility's policy required open food and drinks to be disposed of after three days, indicating that the juices should have been discarded. Further inspection of the nourishment rooms on the North/West Wing and Annex Wing revealed additional violations of the facility's policy. Multiple containers of milk, juice, and condiments were found without open dates or with open dates exceeding the three-day limit. The Dietary Director stated that the kitchen and unit staff were responsible for checking open dates, and that only perishable items were discarded after three days, while beverages and condiments were discarded by expiration dates. This discrepancy between the facility's policy and the actual practice contributed to the deficiency in food storage and handling.

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 timely and appropriate wound assessments for a resident with pressure injuries. The resident, who was admitted with multiple skin tears and a pressure injury, developed a new wound on the right second toe that was not assessed by a Registered Nurse (RN) until several weeks after its discovery. Initial assessments and documentation were conducted by Licensed Practical Nurses (LPNs), who did not perform comprehensive wound assessments or measurements, nor did they complete a Pressure Ulcer Packet. The facility's policy did not require an RN to perform initial wound assessments, which contributed to the delay in proper evaluation and treatment. The resident's condition worsened over time, with the wound progressing to cellulitis and eventually requiring surgical intervention. Despite the presence of a wound care certified RN at the facility, the resident's wound was not assessed by this RN, and weekly wound assessments were not documented. The lack of timely RN assessment and documentation led to a delay in appropriate wound care and management, resulting in the resident's condition deteriorating to the point of requiring amputation. Interviews with facility staff revealed a lack of clarity and adherence to wound assessment protocols. LPNs frequently conducted wound assessments without RN oversight, and there was no documentation of RN involvement in the initial stages of wound care. The facility also failed to provide a policy for RN assessment when requested, indicating a potential gap in their wound care procedures and protocols.

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 revise the resident care plan for a resident who developed a facility-acquired pressure injury and for residents who expressed suicidal ideations. Resident #16 was admitted with multiple skin issues, including a pressure injury, but the care plan was not updated when a new wound developed on the right second toe. Despite the wound's progression to a stage IV pressure injury, the care plan remained unchanged until surveyor inquiry. Resident #18, who had a history of Alzheimer's disease, bipolar disorder, depression, and suicidal ideations, was admitted to the facility. The resident exhibited aggressive behavior and expressed self-harm statements, leading to hospitalization. However, the care plan was not revised to include new interventions related to these expressions of suicidal ideations. Resident #87, diagnosed with dementia and anxiety disorder, requested a rope to hang themselves, indicating suicidal ideations. Despite this, the care plan was not updated to include further interventions, and there was no documentation of monitoring or provider visits following the incident. The facility's policy required care plan updates based on daily reviews and interviews, but this was not adhered to in these cases.

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 pressure ulcer care and prevention for a resident, leading to the development and worsening of pressure injuries. The resident, admitted with a history of pressure injuries and other medical conditions such as diabetes and muscle weakness, was not properly assessed by a registered nurse (RN) after a new wound was identified. The initial assessment of the right second toe wound was conducted by an LPN, and the first RN assessment occurred much later, after the wound had already worsened. The facility's failure to conduct timely RN assessments and complete necessary documentation, such as the Pressure Ulcer Packet, contributed to the inadequate monitoring and treatment of the resident's wounds. The facility also failed to perform weekly wound assessments and daily monitoring of the resident's wounds. Despite the presence of a pressure injury and the development of a new wound, there was a lack of detailed documentation and assessment of the wound's progress. The resident's right second toe wound was not properly monitored, leading to its deterioration and eventual recommendation for amputation. The absence of regular wound assessments and documentation hindered the facility's ability to track the wound's condition and implement appropriate interventions. Additionally, the facility did not conduct preventative weekly skin assessments for the resident, despite their medical history and risk factors. The resident's Braden Risk Assessment Scale scores were inaccurately assessed, failing to reflect the resident's true risk for developing pressure injuries. This oversight resulted in a lack of preventative interventions and monitoring, contributing to the development of additional wounds. The facility's failure to update the resident's care plan and implement new preventative measures further exacerbated the situation, leading to the worsening of the resident's condition.

Penalty

No penalty information released

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

Summary

The facility failed to obtain weekly weights for a resident, as directed by a physician's order, which was crucial due to the resident's medical conditions, including diabetes, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and anxiety disorder. The resident was admitted in September 2024, and the care plan identified a risk for nutritional deficit, with interventions including obtaining weekly weights. However, the facility did not consistently follow this order, as weights were not recorded on several occasions, specifically on 10/11/24, 12/20/24, 12/27/24, and 1/3/25. Interviews with facility staff revealed a lack of documentation and follow-up regarding the missed weights. RN #2 indicated that weights were typically obtained on shower days, but could not provide documentation or explanation for the missed weights on certain dates. The ADNS also failed to identify any attempts to reweigh the resident after refusals or missed dates and acknowledged that the physician's order for weekly weights should have been adhered to, especially given the resident's CHF diagnosis. The facility's policy required weights to be taken as per physician orders, highlighting a failure in compliance with established protocols.

Penalty

No penalty information released

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

Summary

The facility failed to provide a behavioral health assessment by a qualified clinician for a resident with suicidal ideations. Resident #87, who was admitted with diagnoses including unspecified dementia and anxiety disorder, expressed suicidal ideations on multiple occasions. Despite these expressions, the facility did not conduct a comprehensive assessment or revise the resident's care plan to address the suicidal ideations. The resident's environment was not modified to remove potential hazards, such as a corded call bell, which remained accessible. The RN Supervisor, who was notified of the resident's suicidal ideations, did not perform a thorough risk assessment or document any monitoring plan. The RN's assessment was limited to general questions about the resident's well-being and did not include targeted questions about the resident's suicidal thoughts or plans. The RN also failed to notify the resident's legal representative and did not receive specialized training in performing risk assessments for suicidal ideations. The facility's physician was informed of the resident's suicidal ideations but did not specify a monitoring frequency or duration, relying instead on the facility's protocol, which was not clearly defined. The physician was not aware of the multiple expressions of suicidal ideations and did not evaluate the resident personally. The facility lacked a specific protocol for handling suicidal ideations, and the resident was not assessed by a qualified clinician until after surveyor inquiry.

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 appropriate treatment and services to a resident who expressed suicidal ideation (SI), resulting in a finding of Immediate Jeopardy. The resident, admitted with diagnoses including unspecified dementia and anxiety disorder, expressed a desire to harm themselves on multiple occasions. Despite these expressions, the facility did not implement adequate monitoring or environmental changes to ensure the resident's safety. The resident's care plan was not updated to address the SI, and there was no documentation of a comprehensive assessment or specific monitoring orders. The facility staff, including the RN Supervisor and the Assistant Director of Nursing Services, were unaware of a protocol for handling SI. The RN Supervisor did not conduct a thorough assessment of the resident's mental state or potential for self-harm, and the resident continued to have access to a call bell with a cord, which posed a ligature risk. The Social Worker was not notified of the resident's SI, and there was no follow-up assessment or intervention from behavioral health services, which the facility lacked since 2020. The facility's policy on suicide did not include a protocol for SI, and the Administrator was not aware of the resident's expressions of SI until informed by the surveyor. The Administrator acknowledged the insufficiency of the current policy and the need for revisions. The lack of communication and coordination among staff, as well as the absence of a clear protocol for SI, contributed to the facility's failure to ensure the resident's safety and well-being.

Removal Plan

• SI policy was revised and updated to include a protocol for SI
• Resident #87 was evaluated for suicidality by both APRN #1 and MD #2 and deemed safe in the facility
• Facility staff were educated on the new SI policy related to care of residents with SI
• Residents in the facility identified to have moderate-severe depression were screened for SI

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 social services for two residents who expressed suicidal ideations. Resident #18, who had a history of Alzheimer's disease, bipolar disorder, depression, and suicidal ideations, was admitted in September 2017. Despite being severely cognitively impaired and having moderate depression, the facility did not provide social services support following an incident on December 20, 2024, where the resident expressed self-harm statements and was subsequently hospitalized. The social worker's progress note did not document any social services visits or support provided after the hospitalization. Resident #87, admitted in February 2024 with diagnoses including unspecified dementia and anxiety disorder, expressed suicidal ideations on January 20, 2025, by requesting a rope to hang themselves. The facility failed to notify the social worker or the resident's legal representative, and there was no documentation of monitoring or revisions to the resident's care plan. The social worker was unaware of the incident until informed by the surveyor and identified that the facility lacked a protocol for handling suicidal ideations and had not provided behavioral health services since 2020. The facility's policy on suicide early warnings did not include a protocol for suicidal ideations, and there was no policy provided for medically related social services or social services assessments. The lack of interdisciplinary team meetings and communication issues within the facility contributed to the failure to address the residents' needs adequately. The facility had recently contracted a new behavioral health service, but it had not yet begun providing services at the time of the survey.

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 update its facility assessment to reflect the dissolution of its contracted behavioral health services in 2020. This oversight resulted in a lack of contracted behavioral health services, which was not addressed until a new contract was set to begin in February 2025. The facility relied on the Medical Director, a geriatrician, and an APRN to manage psychotropic medications and screenings, but they did not provide psychotherapy. The Social Worker was responsible for making referrals to external mental health services, but there was no formal interdisciplinary team (IDT) meeting structure to coordinate care effectively. Interviews with staff revealed a lack of coordinated interdisciplinary communication. The facility did not hold IDT meetings to discuss resident well-being, facility needs, or unusual occurrences. Communication was primarily through written logs and reports, with nursing and rehabilitation services meeting weekly without the Administrator's involvement. This lack of structured communication contributed to the facility's inability to effectively manage and coordinate care for residents with mental and psychological concerns. The facility also demonstrated deficiencies in staff education compliance. The Director of Education Services assigned mandatory in-service courses but did not ensure completion, resulting in a significant portion of staff failing to meet the 75% completion goal for annual education. The Director of Nursing Services was aware of the issue but did not oversee the Director of Education Services, who worked autonomously. The Administrator, responsible for overseeing facility operations and ensuring compliance with regulations, failed to ensure adequate staff training and interdisciplinary communication, contributing to the identified deficiencies.

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 update its facility-wide assessment after the dissolution of its contracted behavioral health service in 2020. The assessment, completed on October 10, 2024, still identified behavioral and mental health services as part of the care offered, despite the absence of a contracted service since 2020. The Advanced Practice Registered Nurse (APRN) and the Medical Director managed psychotropic medications and related screenings, but did not provide psychotherapy. The Social Worker was responsible for determining the need for external referrals for psychotherapy, which were communicated through a daily-checked communication book or a census report. A new contract for behavioral health services was set to begin on February 1, 2025. The facility also failed to ensure compliance with required staff training and competencies. The annual facility assessment indicated that staff training and education were provided upon hire and annually, with additional training as needed. However, a review of staff education documents for 2024 revealed significant non-compliance. Many staff members failed to complete essential training in areas such as communication, resident rights, abuse prevention, infection control, and ethics. Additionally, numerous nursing assistants did not complete their required education hours or competency training, and the Administrator did not complete any mandatory in-service training for 2024. The lack of updated facility assessment and non-compliance with staff training requirements indicate deficiencies in the facility's ability to provide competent care. The absence of a contracted behavioral health service since 2020 was not reflected in the facility's assessment, and the failure to ensure staff training and competencies compromised the facility's capacity to meet the needs of its residents. These deficiencies were identified during a review of the facility's operations and staff education records.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary behavioral health services, including psychotherapy, as identified in their annual facility assessment. The assessment, completed on October 10, 2024, highlighted the need for mental health and behavior services to manage medical conditions and medication-related issues causing psychiatric symptoms and behavior. It also identified the need for interventions to support individuals dealing with anxiety, cognitive impairment, depression, trauma/PTSD, and other psychiatric diagnoses. Despite this, the facility had not contracted behavioral health services since 2020. The Advanced Practice Registered Nurse (APRN) and the Medical Director managed psychotropic medications and related screenings but did not offer psychotherapy. The Social Worker was responsible for determining the need for outside referrals for psychotherapy or unavailable services and making those referrals. Interviews with the APRN and the Medical Director revealed that the facility lacked a contracted behavioral health service for medication management or therapeutic counseling services. The Medical Director, a fellowship board-certified geriatrician, managed mental health medications and considered himself the psychiatric practitioner for the facility. However, he did not provide ongoing therapeutic counseling services. The Social Worker, identified as having a BSW and BA, was responsible for making referrals to outpatient mental health services as needed. The facility planned to begin a new contract for behavioral health services on February 1, 2025, but until then, the deficiency in providing necessary behavioral health services persisted.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the Medical Director's responsibility in coordinating behavioral health services and maintaining a complete policy for managing residents with suicidal ideations. The Annual Facility assessment identified the need for mental health and behavior services, including management of psychiatric symptoms and interventions for residents with conditions such as anxiety, depression, and PTSD. However, interviews revealed that there had been no contracted behavioral health services since 2020, and the Medical Director, a geriatrician, along with an APRN, managed psychotropic medications but did not offer psychotherapy. The Social Worker was responsible for determining the need for outside referrals for psychotherapy, which were communicated through a communication book or census report document. A new contract for behavioral health services was set to begin in February 2025. The Medical Director was notified of a resident's expressions of suicidal ideation but did not specify monitoring frequency or duration, relying on facility protocol, which lacked a specific protocol for suicidal ideation. The Medical Director acknowledged the absence of contracted behavioral health services and identified himself as the psychiatric practitioner based on his geriatrician certification, managing medications and ordering monitoring. The facility policy titled "Suicide, Early Warnings" only included definitions/examples of suicidal ideation without a protocol. These deficiencies led to the identification of immediate jeopardy and substandard care in the area of Treatment and Services Mental/Psychological Concerns, as the facility failed to utilize resources effectively to maintain the resident's well-being.

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 adhere to its infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. For three residents receiving oxygen therapy, the facility did not label and date the oxygen tubing as per policy. Observations revealed that the oxygen concentrators for these residents had unlabeled nasal cannula tubing and plastic bags, which were not dated to indicate when the tubing was last changed. Interviews with nursing staff confirmed the oversight, and the facility's policy required weekly changes and labeling of nasal cannulas. In the dining area, two nurse aides were observed assisting twelve residents with eating without performing hand hygiene between residents. This practice was contrary to the facility's hand hygiene policy, which mandates handwashing before and after resident care. Interviews with the nurse aides and the assistant director of nursing confirmed the lack of hand hygiene, and the aides acknowledged the need for improvement. The facility's training records showed incomplete hand hygiene education for the involved staff. Additionally, the facility failed to secure staff beverages in non-resident care areas, posing a risk of contamination. Observations identified unattended beverage containers in resident care areas, contrary to OSHA regulations and facility policy. Furthermore, the facility did not implement enhanced barrier precautions for a resident with a pressure injury, and signage for transmission-based precautions was unclear, potentially confusing staff and visitors. The infection preventionist acknowledged the oversight and the need for clearer communication regarding precautionary 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 maintain an effective training program for all new and existing staff members, as evidenced by a review of the Annual Facility assessment and Healthcare Academy reports. The assessment identified 19 areas of mandatory education for staff, but omitted workplace violence training, which is required by facility policy. Additionally, a significant portion of staff, including 64 out of 227 facility staff members and 53 out of 119 nursing staff members, did not complete at least 75% of their mandatory annual courses for 2024. This includes essential training such as communication courses. Furthermore, new hire Nurse Aides were required to complete an 80-hour orientation training schedule, but 6 out of 21 actively employed NAs hired in 2024 lacked documentation of completed courses. The facility's training program also failed to address several critical areas, including cultural competence, intellectual disability, person-centered care, care planning, interdisciplinary collaboration, quality of life, and care. Task Forces were initiated in 2024 to address training and competencies, but there was no evidence of education related to these Task Forces or QAPI initiatives. The Staff Development Corporate Compliance policy required annual mandatory in-services, but did not include department-specific education topics based on resident needs. This lack of comprehensive training and documentation indicates a deficiency in the facility's ability to ensure staff are adequately trained to meet the needs of residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure staff compliance with mandatory communication training, as evidenced by a review of Healthcare Academy reports. In 2024, 73 out of 227 facility staff members did not complete the required communication training. Specifically, 42.6% of Nurse Aides and 34% of Licensed Nurses did not complete the training. The Director of Education Services, responsible for assigning and monitoring course completions, identified staff with incomplete courses and notified department heads. However, the Director of Nursing Services indicated that the goal for annual education was for each staff member to complete 75% of their assigned courses, and acknowledged that some staff members had not completed any courses. The facility's organizational structure showed that the Director of Education Services reported directly to the Administrator and worked autonomously. Despite the policy requiring each staff member to complete mandatory in-services, including effective communication, by the end of the month prior to their annual evaluation, 64 out of 227 facility staff members and 53 out of 119 nursing staff members completed less than 75% of their assigned mandatory courses in 2024. This deficiency highlights a lack of oversight and accountability in ensuring staff compliance with required training, as outlined in the facility's Staff Development Corporate Compliance policy.

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 staff compliance with resident rights training, as evidenced by a review of Healthcare Academy reports which revealed that a significant portion of the staff did not complete the required training. Specifically, 44 out of 227 facility staff members did not complete resident rights training in 2024, and 28 out of 75 Nurse Aides, as well as 9 out of 44 Licensed Nurses, also failed to complete this training. Additionally, 64 out of 227 facility staff members completed less than 75% of their assigned mandatory annual courses, which included the resident rights training course. Interviews with the Director of Education Services and the Director of Nursing Services highlighted a lack of oversight and accountability in ensuring course completion. The Director of Education Services was responsible for assigning and monitoring course completion but worked autonomously and reported directly to the Administrator. The Director of Nursing Services acknowledged being informed of nursing staff with outstanding courses but indicated that the goal was for each staff member to complete 75% of their assigned courses, with no clear plan for those who had not completed any courses. This lack of oversight and enforcement contributed to the deficiency in staff training on resident rights.

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 staff compliance with mandatory training on abuse, neglect, and exploitation, as well as dementia management. According to the Healthcare Academy reports, a significant portion of the staff did not complete the required training in 2024. Specifically, 15.4% of the overall facility staff, 29.3% of Nurse Aides, and 15.9% of Licensed Nurses did not complete the abuse, neglect, and exploitation training. Similarly, 14.9% of the overall facility staff, 30.6% of Nurse Aides, and 11.3% of Licensed Nurses did not complete the dementia management training. The Director of Education Services was responsible for assigning these courses and monitoring their completion, but a substantial number of staff members did not meet the completion requirements. The Director of Nursing Services acknowledged the issue, noting that the goal was for each staff member to complete 75% of their assigned courses annually. However, 28.1% of the facility staff and 44.5% of the nursing staff completed less than 75% of their mandatory courses, which included the critical training on abuse, neglect, and dementia management. The facility's policy required these trainings to be completed by the end of the month prior to the staff's annual evaluation, but this was not achieved. The Director of Education Services reported directly to the Administrator, and there was a lack of oversight from the Director of Nursing Services, contributing to the deficiency.

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 staff compliance with the Quality Assurance and Performance Improvement (QAPI) training, as evidenced by a significant number of staff members not completing the required training. Specifically, 60 out of 227 facility staff members did not complete QAPI training in 2024, and 33 out of 75 Nurse Aides and 13 out of 44 Licensed Nurses also failed to complete the training. The Director of Education Services, responsible for assigning and monitoring course completions, identified these gaps but did not have oversight from the Director of Nursing Services (DNS), who stated that the goal was for each staff member to complete 75% of their assigned courses annually. The facility's organizational structure showed that the Director of Education Services reported directly to the Administrator, and the DNS did not oversee this role. Additionally, 64 out of 227 facility staff members and 53 out of 119 nursing staff members completed less than 75% of their mandatory annual courses, which included QAPI training. The facility's Staff Development Corporate Compliance policy required each staff member to complete mandatory in-services, including QAPI training, by the end of the month prior to their annual evaluation, but this was not achieved, leading to the deficiency.

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 staff compliance with their infection control program, which includes mandatory training on infection prevention and control, tuberculosis, COVID-19, bloodborne pathogens, personal protective equipment, transmission-based precautions, and enhanced barrier precautions. A review of the Healthcare Academy reports for 2023 and 2024 revealed significant gaps in training completion among staff members. Specifically, 23.3% of facility staff, 40% of Nurse Aides, and 25% of Licensed Nurses did not complete infection prevention and control training in 2024. Additionally, there was no documentation of tuberculosis and COVID-19 education being assigned or completed by staff in 2023 or 2024. Further examination showed that 22.4% of facility staff, 40% of Nurse Aides, and 27.2% of Licensed Nurses did not complete bloodborne pathogens training in 2024. Similarly, 25.9% of facility staff, 41.3% of Nurse Aides, and 29.5% of Licensed Nurses did not complete personal protective equipment training. The facility also lacked documentation of staff completion of transmission-based precautions education for 2024. Enhanced barrier precautions training was not completed by 29% of facility staff, 46.6% of Nurse Aides, and 34% of Licensed Nurses. Interviews with the Director of Education Services and the Director of Nursing Services revealed that the facility's goal was for each staff member to complete 75% of their assigned courses annually. However, 28.1% of facility staff and 44.5% of nursing staff completed less than 75% of their mandatory courses in 2024. The Director of Education Services was responsible for assigning courses and monitoring completion, but there was a lack of oversight and accountability, as the Director of Nursing Services did not oversee the Director of Education Services, who reported directly to the Administrator.

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 staff compliance with corporate compliance and ethics training, as evidenced by a review of Healthcare Academy reports. These reports revealed that a significant portion of the facility's staff did not complete the required training in 2024. Specifically, 52 out of 227 staff members, 29 out of 75 Nurse Aides, and 10 out of 44 Licensed Nurses did not complete the corporate compliance and ethics training. Additionally, 64 out of 227 staff members and 53 out of 119 nursing staff members completed less than 75% of their assigned mandatory annual courses, which included the corporate compliance and ethics training course. Interviews with the Director of Education Services and the Director of Nursing Services highlighted a lack of oversight and accountability in ensuring course completion. The Director of Education Services assigned the required courses and monitored completion monthly, notifying department heads of staff with incomplete courses. However, the Director of Nursing Services indicated that the goal for annual education was for each staff member to complete 75% of their assigned courses, and acknowledged that they were working on addressing those who had not completed any courses. The Director of Education Services reported directly to the Administrator, and there was no direct oversight from the Director of Nursing Services, leading to gaps in ensuring compliance with the training requirements.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Nurse Aides (NAs) completed the required 12 hours of education for the year 2024. A review of the Healthcare Academy reports for 2023 and 2024 revealed that 37 out of 75 NAs did not meet this requirement. Additionally, the facility's handwritten read and sign inservices were reviewed, and it was confirmed that the 12-hour education requirement was not met even with these additional inservices. This deficiency was identified through facility documentation, policy review, and interviews. Interviews with RN #4 and the Director of Nursing Services (DNS) revealed that RN #4 was responsible for assigning and monitoring the completion of education courses for all staff. Despite monthly monitoring and notifications to department heads, the goal for annual education was not achieved, as the DNS indicated that the target was for each staff member to complete 75% of their assigned courses. The DNS acknowledged that some staff members had not completed any of their assigned courses and stated that efforts were being made to address this issue. The Staff Development Corporate Compliance Policy requires that records of educational training be maintained, and NAs are required by state regulations to complete at least 12 hours of continuing education each year before their respective anniversary dates.

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 staff compliance with behavioral health training, as evidenced by a significant number of staff not completing required courses. Specifically, 42.2% of facility staff, 62.6% of Nurse Aides, and 45.4% of Licensed Nurses did not complete behavioral health-trauma informed care (TIC) training in 2024. Additionally, 14.9% of facility staff, 30.6% of Nurse Aides, and 11.3% of Licensed Nurses did not complete dementia management training. The facility's annual assessment identified the need for training related to various mental health conditions, yet the Healthcare Academy reports failed to show staff education for these conditions in 2024. Interviews with the Director of Education Services and the Director of Nursing Services revealed a lack of oversight and accountability in ensuring course completion. The Director of Education Services assigned courses and checked completion monthly, notifying department heads of staff with incomplete courses. However, the Director of Nursing Services indicated that the goal was for each staff member to complete 75% of their assigned courses, and acknowledged that some staff had not completed any courses. The facility's organizational chart showed that the Director of Education Services reported directly to the Administrator, and 28.1% of facility staff and 44.5% of nursing staff completed less than 75% of their mandatory courses, including behavioral health and dementia management training.