Aviata At Bryan Dairy

Penalty

Inspection fine: $24,850

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 ensure that a resident's advance directives were implemented in a timely manner and did not honor the resident's wishes regarding full code status. A resident with multiple serious diagnoses, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension, was documented as cognitively intact and had an active order for full code status. Despite this, when the resident's oxygen saturation dropped to 84% with supplemental oxygen, the LPN on duty did not notify the medical provider or document any interventions regarding this significant change in condition. Later, the resident was found pulseless and not breathing. There was confusion among staff regarding the resident's code status, as conflicting information was found between the hospital transfer form, which indicated DNR, and the facility's electronic health record, which indicated full code. Staff delayed initiating CPR for approximately 45-60 minutes while attempting to clarify the resident's code status, contacting administration, hospice, and the medical team instead of following the full code order present in the record. During this time, no resuscitative efforts were made, and the resident was ultimately pronounced dead. Interviews with staff revealed a lack of clarity and understanding regarding the process for verifying and acting on code status, as well as inconsistent documentation and communication. The facility's policy required that any changes to advance directives be properly documented and communicated, but this was not followed. The failure to promptly initiate CPR in accordance with the resident's documented wishes and physician orders resulted in the resident's wishes not being honored.

Removal Plan

• An audit of each resident's code status was completed.
• The licensed nurse was suspended, pending the facility's investigation.
• A Quality Improvement Performance Committee was conducted to review the recommendations from the root cause analysis.
• A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
• Code blue drills were initiated on multiple shifts, with ongoing drills to continue until all staff have completed and with the results reported to the QAPI committee.
• The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
• Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
• Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
• Licensed nurses received education on the identification of a change in condition including competency.
• Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
• Ongoing training is being conducted for the identification of change in condition with competency.

Penalty

Inspection fine: $24,850

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

A deficiency occurred when facility staff failed to provide timely Cardiopulmonary Resuscitation (CPR) to a resident who was found pulseless and not breathing, despite the resident having a documented full code status and no valid Do Not Resuscitate (DNR) order in the medical record. The LPN on duty observed a significant drop in the resident's oxygen saturation to 84% with supplemental oxygen but did not notify the medical provider or document any interventions regarding this change in condition. Later, when the resident was found unresponsive, there was confusion among staff regarding the resident's code status due to conflicting documentation between the hospital transfer form and the facility's records. Multiple staff members, including LPNs and CNAs, reviewed the resident's electronic health record and paper chart, confirming the absence of a DNR form and the presence of a full code order. Despite this, the LPN delayed initiating CPR, instead contacting facility administration, hospice, and the medical team, which resulted in a delay of approximately 45-60 minutes before chest compressions and ventilation were started. During this period, staff were uncertain about the appropriate course of action, and some began preparing for postmortem care before CPR was initiated. The resident had a complex medical history, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes, pneumonia, acute kidney failure, myocardial infarct, and hypertension. The resident was cognitively intact and had previously expressed a desire to remain full code, as documented in care planning and social service notes. The failure to promptly notify the physician of the change in condition and to honor the resident's advance directive for full code status resulted in the resident's wishes for resuscitation not being honored.

Removal Plan

• An audit of each resident's code status was completed.
• The licensed nurse was suspended, pending the facility's investigation.
• A Quality Improvement Performance Committee (QAPI) was conducted to review recommendations from the root cause analysis.
• A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
• Code blue drills were completed for all staff with results reported to the QAPI committee.
• The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
• Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
• Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
• Licensed nurses received education on the identification of a change in condition including competency.
• Newly hired licensed nurses will receive education to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
• Ongoing training is being conducted for the identification of change in condition with competency.

Penalty

Inspection fine: $24,850

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

A facility failed to implement timely Cardiopulmonary Resuscitation (CPR) and did not honor a resident's full code status, resulting in a deficiency. The resident, who had a documented full code order and had expressed a desire to be resuscitated, experienced a significant drop in oxygen saturation, which was not reported to a medical provider nor were interventions documented. Later, when the resident was found pulseless and not breathing, staff delayed initiating CPR due to confusion over the resident's code status, despite the absence of a Do Not Resuscitate (DNR) form and the presence of a full code order in the electronic health record. The delay was exacerbated by staff reviewing conflicting documentation and seeking guidance from supervisors and hospice rather than immediately starting resuscitation efforts. One LPN was confused by a hospital transfer form indicating DNR status, but the facility's records and care plan clearly indicated full code. During this period, staff did not promptly call a code or begin chest compressions, and instead contacted administration, hospice, and the medical team, resulting in a delay of approximately 45-60 minutes before CPR was initiated. The resident's medical history included multiple serious conditions such as metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes, pneumonia, acute kidney failure, myocardial infarct, and hypertension. The resident was cognitively intact and had actively participated in care planning, consistently expressing a wish to remain full code. The failure to promptly initiate CPR and honor the resident's wishes led to the resident's death and was determined to be an Immediate Jeopardy situation.

Removal Plan

• An audit of each resident's code status was completed.
• The licensed nurse was suspended, pending the facility's investigation.
• A Quality Improvement Performance Committee (QAPI) was conducted to review the incident, discuss corrective actions, and provide recommendations.
• A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
• Code blue drills were initiated on multiple shifts and ongoing drills will continue until all staff have completed and will continue with the results reported to the QAPI committee.
• The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR. A posttest was provided upon completion of the education.
• Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
• Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
• Licensed nurses received education on the identification of a change in condition including competency.
• Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
• Ongoing training is being conducted to reach completion for the identification of change condition with competency.

Penalty

Inspection fine: $24,850

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

Nursing staff failed to demonstrate competency in identifying a resident's code status, providing timely CPR, and responding appropriately to a change in condition for one resident. The resident, who had multiple complex diagnoses including metabolic encephalopathy, multiple sclerosis, sepsis, acute respiratory failure with hypoxia, and was cognitively intact, experienced a significant drop in oxygen saturation to 84% while on supplemental oxygen. Despite this abnormal reading, the LPN on duty did not notify the medical provider or document any interventions regarding the change in condition. Later, the resident was found pulseless and not breathing. There was confusion among the nursing staff regarding the resident's code status due to conflicting documentation between the hospital transfer form, which indicated DNR, and the facility's electronic health record and care plan, which indicated full code. The LPN and other staff delayed initiating CPR while attempting to clarify the code status, consulting with the DON and other supervisors, and paging hospice. This resulted in a delay of 45-60 minutes before chest compressions and ventilation were started, during which time the resident's wishes for CPR were not honored, and the resident died. Further review revealed that the LPN involved had incomplete orientation records, with no documentation of training on advanced directives, DNR orders, hospice care, respiratory care, vital signs, or change in condition protocols. The facility was unable to confirm whether another LPN had received the required training. Interviews with staff and review of facility policies indicated that prior to the incident, there was a lack of consistent staff training on code blue drills, advanced directives, and change in condition response, contributing to the deficiency.

Removal Plan

• An audit of each resident's code status was initiated and completed.
• The licensed nurse was suspended, pending investigation.
• An ADHOC Quality Improvement Performance Committee (QAPI) was conducted to review recommendations from the root cause analysis.
• A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
• Code blue drills were initiated on multiple shifts and will continue until all staff have completed, with results reported to the QAPI committee.
• The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
• Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
• 100% of staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
• Licensed nurses received education on the identification of a change in condition including competency.
• The Human Resource Director will ensure during new hire orientation, newly hired nurses and CNAs are educated on the facility policy related to advanced directives, CPR, and the completed road map from orientation will be signed acknowledging the education received.
• Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.

Penalty

Inspection fine: $7,488

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 labeling and dating of food items, maintain cleanliness in the walk-in freezer, and store personal belongings appropriately in the kitchen. During an initial tour of the kitchen, two bags of opened pasta and a clear container of brown liquid in the walk-in cooler were found without dates. Additionally, pieces of paper and other trash were observed on the floor of the walk-in freezer, which the Kitchen Manager acknowledged as dirty, noting that it was cleaning day. An unknown food item wrapped in plastic wrap and a container of cereal under the prep table were also found without labels or dates. Furthermore, a jacket was improperly stored, hanging from a dish rack where clean dishes were kept. The Kitchen Manager confirmed that food should be labeled and dated upon opening or placing in a container and that hangers are available for jackets.

Penalty

Inspection fine: $7,488

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 residents and/or their representatives of the bed-hold policy during transfers to the hospital, as required by state and federal law. This deficiency was identified for three residents who were reviewed for hospitalization. Resident #177 was admitted to the facility and later transferred to the hospital due to altered mental status. However, there was no documentation of a bed-hold notice being provided to the resident or their representative at the time of transfer. The facility's administrator confirmed the absence of such documentation. Similarly, Resident #280 was transferred to the hospital, and although a bed-hold notice was partially filled out, it lacked a staff signature to confirm that the notice was provided. Resident #427, who was his own responsible party, was also transferred to the hospital without evidence of receiving a bed-hold notice. The Assistant Social Services Director confirmed the absence of the necessary paperwork and stated that the expectation was for the nurse handling the transfer to initiate the bed-hold paperwork. The Regional Social Services Director also confirmed that the records for these residents did not show that the bed-hold policy was communicated as required.

Penalty

Inspection fine: $7,488

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 written notification to residents and their representatives regarding transfers or discharges, and did not notify the State Long Term Care Ombudsman's Office for three residents reviewed for hospitalization. Resident #177 was transferred to the hospital for altered mental status, but there was no documentation of a Nursing Home Transfer and Discharge Notice or notification to the Ombudsman. Similarly, Resident #280 was transferred twice to a local medical center, but the discharge notices were incomplete, lacking the resident or representative's acknowledgment and the Ombudsman notification. Resident #427 was also transferred to the hospital without a Nursing Home Transfer and Discharge Notice or documentation of Ombudsman notification. Interviews with facility staff, including the Administrator, Assistant Social Services Director, and Social Services Director, confirmed the absence of proper documentation and notification. The facility's policy requires that transfer and discharge notices be documented in the resident's medical record and communicated to the Ombudsman. However, the records for Residents #280 and #427 did not show that the residents or their representatives were notified of the transfers, and the necessary forms were incomplete or missing. The facility's failure to adhere to its policy and federal/state regulations resulted in the deficiency.

Penalty

Inspection fine: $7,488

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 returned smoking materials to staff after designated smoking times and upon returning from leave of absence (LOA). Observations revealed that multiple residents were in possession of cigarettes and lighters outside of the designated smoking area and times. Staff were observed not enforcing the policy of collecting smoking materials, allowing residents to retain these items, which led to unsupervised smoking activities. Interviews with staff and residents indicated a lack of adherence to the smoking policy. Residents admitted to keeping cigarettes and lighters on their person to prevent theft, and some were observed exchanging smoking materials among themselves. Staff members acknowledged the issue but did not consistently enforce the policy, allowing residents to smoke unsupervised and retain smoking materials, which were supposed to be stored in a lockbox. The facility's administration was aware of the ongoing issue, as evidenced by discussions in Resident Council Meetings and interactions with the Ombudsman. Despite efforts to address the problem, such as informing residents of the policy and attempting to enforce it, the deficiency persisted. Observations showed cigarette butts in non-designated areas, posing a fire hazard, especially given the dry conditions and burn ban in the county.

Penalty

Inspection fine: $7,488

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 food was prepared and served at safe and appetizing temperatures, as evidenced by two incidents involving residents being served raw chicken. A family member of one resident reported that during a visit, residents were served raw chicken, and he provided a photo showing red meat on the plate. Another resident expressed frustration over being served raw chicken on two separate occasions and also reported being served a burnt grilled cheese sandwich. Both residents had voiced grievances about the food, but these were not resolved. The Certified Dietary Manager (CDM) acknowledged receiving grievances related to the raw chicken and confirmed that the chicken was not served at the correct temperature. The CDM admitted that the chicken should have been cooked to an internal temperature of 165 degrees Fahrenheit, as per the facility's policy. Additionally, the CDM recognized that the grilled cheese sandwich served was burnt and should not have been sent out. The facility's policy on food preparation, revised in February 2023, mandates that all poultry and stuffed foods be cooked to a minimum internal temperature of 165 degrees Fahrenheit.

Penalty

Inspection fine: $7,488

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 grievance policy, resulting in unresolved grievances for multiple residents. During a Resident Council meeting, 11 out of 13 residents expressed ongoing dissatisfaction with receiving cold meals, a concern that had persisted for months. Despite being informed that tray warmers would be acquired, the issue remained unresolved. Residents reported that while grievances were accepted, the resolution process was ineffective, and they were no longer provided with copies of their grievances. The facility's grievance log revealed multiple entries related to cold food, with investigations indicating that the pellet warmer was malfunctioning and awaiting repair. Further interviews highlighted additional grievances that were not adequately addressed. One resident reported missing clothing and a broken TV upon returning from a hospital stay, with no follow-up from the facility despite the involvement of the Ombudsman. Another resident experienced a room change during which personal belongings went missing, and no grievance was filed or followed up on by the facility. The Social Services Director confirmed the lack of documentation for these grievances, indicating a breakdown in the grievance process. The facility's failure to resolve grievances and provide follow-up communication with residents demonstrates a significant deficiency in adhering to its grievance policy. The lack of effective resolution and documentation of grievances, particularly concerning dietary issues and personal belongings, highlights systemic issues within the facility's grievance handling procedures. The Administrator and Social Services Director were aware of these issues but failed to ensure proper documentation and resolution, contributing to ongoing resident dissatisfaction.

Penalty

Inspection fine: $7,488

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 accurate Level I Preadmission Screening and Resident Review (PASARR) for four residents, leading to deficiencies in the documentation of mental disorders or intellectual disabilities. Resident #20 was admitted with diagnoses including schizoaffective disorder and schizophrenia, but their PASARR did not mark these conditions. Similarly, Resident #96, admitted with schizophrenia and substance abuse, had an incomplete PASARR that failed to reflect these diagnoses. The Director of Nursing (DON) acknowledged the absence of a dedicated staff member to review PASARRs and identified a backlog of incorrect PASARRs needing correction. Resident #36 was admitted with a primary diagnosis of unspecified dementia, but their PASARR inaccurately marked 'no' for a primary diagnosis of dementia. Additionally, Resident #42, who had diagnoses including bipolar disorder and PTSD, did not have their PASARR updated to include a new diagnosis of anxiety disorder. The DON expressed an expectation for all diagnoses to be listed on the PASARR and noted that a Level II assessment should be completed for residents with a primary diagnosis of dementia.

Penalty

Inspection fine: $7,488

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

Summary

The facility failed to maintain the dignity of two residents, leading to deficiencies in their care. Resident #16 was observed wearing a hospital gown with inadequate coverage, exposing her skin, and had matted, unkempt hair. Despite being cognitively intact, she reported not having personal clothing for three weeks and expressed embarrassment about her appearance. Interviews with staff revealed that although there were donated clothes available, Resident #16's needs were not adequately addressed, and the Director of Nursing was unaware of the situation. Resident #32 was found wearing a hospital gown and multiple wristbands from a previous hospital stay, which were causing irritation. The resident, who was severely cognitively impaired, had been in the facility for three weeks without the wristbands being removed. Staff interviews indicated that the wristbands should have been removed upon admission, but this was overlooked. The Director of Nursing acknowledged the oversight and confirmed the absence of a facility policy on dignity.

Penalty

Inspection fine: $7,488

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, identified as Resident #43, had access to her personal belongings upon readmission after a hospitalization. The resident, who had moderately impaired cognition, reported not having her clothes, glasses, air mattress, and fall mats, which were essential for her care due to her medical condition. Despite her requests to the staff, these items were not provided, and she was observed wearing a hospital gown. Interviews with various staff members, including a Licensed Practical Nurse, Certified Nursing Assistant, and Therapy Assistant, revealed a lack of awareness and action regarding the resident's missing belongings. The staff acknowledged that the resident's personal items should have been retrieved from storage and returned to her room upon readmission. The facility's process for handling personal belongings during a resident's transfer was not followed, as confirmed by interviews with the Assistant Social Services Director, Regional SSD, Director of Nursing, and Nursing Home Administrator. The facility's policy required personal items to be boxed, inventoried, and stored securely during a resident's absence, with the expectation that they would be returned upon readmission. However, the staff failed to execute this process, resulting in the resident's continued lack of access to her personal effects, including her glasses, which were still missing despite efforts to locate them. The facility's failure to adhere to its policy and ensure the resident's right to personal belongings led to the deficiency identified in the report.

Penalty

Inspection fine: $7,488

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 complete the necessary Level II Preadmission Screening and Resident Review (PASARR) documentation for a resident diagnosed with Alzheimer's disease, depression, and unspecified mood affective disorder. Upon review, it was found that a Level I PASARR was not conducted at the time of the resident's admission, and it was only initiated several days later. The Level I PASARR indicated that the resident exhibited behaviors that posed a danger to themselves or others, necessitating a Level II evaluation. However, the required documentation for the Level II PASARR was not submitted in a timely manner. Interviews with facility staff revealed a lack of coordination and responsibility in handling the PASARR process. The Director of Nursing (DON) admitted to initiating the Level I PASARR late and failing to submit the necessary paperwork for the Level II evaluation. The Regional Social Services Director also acknowledged the delay in submitting the Level II documentation, attributing it to a lack of qualified personnel in the Social Services Department at the time. The facility's policy mandates that all residents with serious mental illness or intellectual disabilities receive appropriate pre-admission screenings, which was not adhered to in this case.

Penalty

Inspection fine: $7,488

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 Activities of Daily Living (ADLs) were appropriately provided for two residents. Resident #32, who was readmitted with diagnoses including anemia, dementia, and morbid obesity, was observed in a hospital gown and reported not receiving showers or being assisted out of bed. Documentation indicated she had only two showers and two bed baths since her readmission, despite being scheduled for more frequent showers. Staff interviews revealed inconsistencies in documentation, with a Registered Nurse confirming the resident had been in the same gown all day and no shower sheets were available to verify care provided. Resident #68, readmitted with conditions such as sepsis and depression, reported not receiving showers and only minimal cleaning. Her care plan required assistance for bathing, but documentation showed she had several showers and bed baths, which she disputed. Staff interviews highlighted issues with documentation and adherence to care plans, with the Director of Nursing stating that showers should be documented only if performed. The facility lacked a policy on ADLs or showers, contributing to the deficiency.

Penalty

Inspection fine: $7,488

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 assistance with activities of daily living (ADLs) for a resident who was unable to care for herself, specifically in relation to hair care. The resident, who had been admitted with matted hair following a lengthy hospitalization, expressed that she had been requesting help with her hair since her admission nearly two months prior. Despite having a cognitive status indicating intact cognition and a care plan that required staff assistance for personal hygiene, the resident's hair remained matted and tangled. The resident reported that staff were too busy to assist her, and she had not washed her hair since admission due to concerns about it not drying properly. Interviews with staff, including a CNA and the Director of Nursing (DON), confirmed the resident's need for assistance and the lack of time available to provide it. The CNA acknowledged the difficulty in managing the resident's hair among other duties, while the DON admitted to only recently becoming aware of the issue. The DON also mentioned that a concierge had been hired to help with such tasks, but the resident's hair care was not prioritized due to other higher care needs. The Nursing Home Administrator (NHA) noted the absence of a policy on ADLs and the closure of the facility's salon, which contributed to the deficiency in care.

Penalty

Inspection fine: $7,488

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 significant communication impairments received the necessary support to maintain communication abilities. The resident, who was deaf and partially blind, was observed without any communication assistive devices or personal effects that would aid in communication. The resident's care plan indicated the need for assistance with communication, including the use of American Sign Language (ASL) and a translator, but these interventions were not observed to be in place. Interviews with staff revealed a lack of awareness and training in communicating with the resident. Certified Nursing Assistants (CNAs) and a Registered Nurse (RN) admitted to guessing the resident's needs and were unaware of the resident's communication methods, such as sign language. The RN was not informed of the resident's deafness and did not know how to communicate effectively with him. There were no signs or indicators in the resident's room to inform staff or visitors of his communication preferences, and the staff did not utilize available resources to facilitate communication. The facility's policy on accommodating hearing-impaired residents was not followed, as staff did not consult with the resident or his family to determine necessary auxiliary aids. The policy outlined steps such as facing the resident when speaking and providing writing materials, but these were not implemented. The lack of effective communication aids and staff training resulted in the resident being isolated and unable to engage with others, as observed during the survey period.

Penalty

Inspection fine: $7,488

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 monitor behaviors and side effects of psychotropic medications for two residents, leading to a deficiency in medication management. Resident #36, who was admitted with diagnoses including unspecified dementia, schizoaffective disorder, and major depressive disorder, was prescribed multiple psychotropic medications such as Cymbalta, Risperdal, Seroquel, and Wellbutrin XL. However, the Medication Administration Record (MAR) for April, May, and June 2024 did not show any monitoring of behaviors and side effects for these medications, as required by the facility's policies. Similarly, Resident #77, admitted with diagnoses of unspecified psychosis and major depressive disorder, was prescribed Amitriptyline and Buspirone. The MAR for the same period also lacked documentation of behavior and side effect monitoring for these medications. The care plans for this resident included interventions to monitor for anxiety-related behaviors and side effects from medications, but these were not followed. The Director of Nursing confirmed that there should have been orders for behavior and side effect monitoring, which were not executed as per the facility's policy.

Penalty

Inspection fine: $7,488

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 accommodate the dietary preferences of a resident who expressed a need for chef salads to aid in weight loss. The resident, who had a diagnosis of atherosclerosis heart disease and diabetes, reported that the facility no longer served chef salads, which she preferred for their protein content. Despite her requests and messages to the Kitchen Manager, she continued to receive meals that did not meet her dietary preferences, such as chicken broth, which she found too salty and lacking in protein. The resident's cognitive status was intact, as indicated by a BIMS score of 15 out of 15, and she weighed 224 pounds at the time of the survey. The facility's menu did not list chef salads, and the always available menu also lacked this option. The Kitchen Manager confirmed that the menu had been changed by corporate, and chef salads were no longer offered. The Food Committee Meeting Minutes from earlier in the year showed requests for more chef salads, indicating ongoing resident dissatisfaction with the menu options. The Kitchen Manager also noted that the resident did not like several types of meat, which further complicated her dietary needs. The Administrator was unaware of why the resident could not receive a chef salad and needed to investigate further.

Penalty

Inspection fine: $7,488

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 repeated incidents of verbal abuse by another resident. Resident #34 reported being verbally assaulted by Resident #96 at the nursing station while receiving medication. Staff A, an LPN, witnessed the incident and apologized to Resident #34 but did not take further action to prevent future occurrences. Resident #34 expressed frustration over the repeated verbal attacks and the lack of effective intervention by the staff, as previous incidents had also occurred. Staff B, an LPN and Unit Manager, intervened during the altercation by instructing Resident #96 to walk away, but did not report the incident to the Administrator as required by the facility's policy. The Administrator, who also serves as the Risk Manager, was unaware of the incident until interviewed and stated that it should have been reported immediately. The facility's policy mandates that any knowledge of abuse or allegations must be reported within specific timeframes, which was not adhered to in this case.

Penalty

Inspection fine: $7,488

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 pressure ulcer care and prevent the worsening of pressure wounds for two residents. Resident #74 was observed lying in bed with bandages on both heels, propped up on a plastic pack of disposable briefs instead of using pressure-relieving boots. Staff confirmed that the boots were in the laundry, and the use of briefs for offloading was inappropriate. The resident had been admitted with diagnoses including chronic obstructive pulmonary disease and muscle weakness, and had severely impaired cognition. The resident's physician orders required offloading of the heels, but the improper method used led to the worsening of the wounds to stage 4. Resident #12, who was cognitively intact, had a care plan for pressure injuries and arterial ulcers with specific wound care orders. However, the Treatment Administration Record showed multiple missed wound treatments in May and June. The Director of Nursing initially suspected documentation errors, but Resident #12 confirmed that wound treatments were not provided over a weekend. The facility's policies required accurate and timely documentation of wound care, which was not adhered to, leading to a failure in providing necessary wound care. The facility's policies and job descriptions emphasized the importance of proper documentation and compliance with treatment guidelines. Despite these policies, the nursing staff failed to document wound treatments accurately, and inappropriate methods were used for pressure ulcer care. These deficiencies highlight a lack of adherence to established protocols, resulting in inadequate care for residents with pressure wounds.