Melbourne Terrace Rehabilitation 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

The facility failed to ensure proper food storage and labeling practices, which had the potential to negatively affect all 165 residents who consumed food by mouth. During an inspection, it was observed that several food items in the walk-in refrigerator were not labeled or dated, including containers of chicken base, beef base, mayonnaise, barbeque sauce, garlic cloves, and various cheese products. The Certified Dietary Manager (CDM) confirmed these findings and removed the items for disposal. Additionally, unlabeled and undated food items such as scrambled eggs, pureed bread, soup, diced chicken, hot dogs, pork sausages, chicken salad, egg salad, cream cheese, whipped topping, and a fish dish were found and discarded. The facility's policy required opened food items to be dated and used within a specific timeframe, which was not adhered to. In the dry storage room, several food items, including spaghetti noodles, egg noodles, elbow macaroni, oatmeal, and mashed potatoes, were found in their original but previously opened packaging without any dates indicating when they were received or opened. Furthermore, paper supplies were improperly stored on the floor. The facility's policy required food items to be dated upon receipt and stored in labeled containers, which was not followed. In the walk-in freezer, unrecognizable, unlabeled, and undated food items were discovered, including a pan of food thought to be chicken and several pans labeled only as 'Tavern.' Some of these items were exposed to air due to ripped foil coverings. Additionally, two bags of meat, one labeled as chicken and the other thought to be beef, were found with dates from over two years ago. The CDM acknowledged the importance of labeling and dating food items for resident safety, including food preferences and allergens. The facility's policy required frozen foods to be labeled, dated, and used or discarded within a specific timeframe, which was not followed. The Assistant Administrator emphasized the importance of tracking and handling food properly to prevent foodborne illness and ensure resident safety.

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 its Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. The facility's current QAPI Plan outlined a process for identifying areas of weakness and creating solutions, which were to be monitored using specific audit tools. However, during the current survey, the facility was found to have a repeat deficiency at F812 related to food safety, as numerous food items in the walk-in refrigerator, dry storage, and walk-in freezer were found unlabeled, undated, expired, and sometimes left uncovered or opened. This was observed during the initial kitchen tour with the Certified Dietary Manager (CDM). The Administrator reported that QAA/QAPI meetings were held monthly, with each department conducting audits and presenting reports to the committee. Despite this, the facility's audits and education efforts were insufficient to prevent the repeat deficiency. The Administrator acknowledged that the CDM allowed standards to slip, and the system failed, as evidenced by the numerous opened and undated food items found during the survey, despite previous audits and education sessions. The facility's plan of correction, which included audits to resolve the deficiency, was not effective in addressing the issue.

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 promote dignity in dining for a resident who was dependent on staff for activities of daily living, including eating. The resident, who had diagnoses of malnutrition, senile degeneration of the brain, and muscle weakness, was observed being assisted with his meal by a CNA who stood while feeding him, rather than sitting at eye level as required. The CNA admitted to not being seated during the feeding and acknowledged that during her orientation, she was not informed that it was inappropriate to refer to residents as 'feeders.' Further interviews revealed that other staff members, including another CNA and the East Wing Unit Manager, were aware that referring to residents as 'feeders' was against dignity and respect protocols. The Director of Nursing confirmed that residents needing assistance should be referred to as 'assisted diners' and that CNAs should sit at eye level when assisting with meals. However, it was noted that the facility lacked a specific policy and procedure for dignity or resident rights, despite having an orientation program that included education on these topics.

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 a resident was assessed for the safe self-administration of medications. Resident #84, who was cognitively impaired with a Brief Interview for Mental Status score of 6 out of 15, was observed with medications left at his bedside without a proper assessment or physician's order authorizing self-administration. The resident had a history of cerebrovascular accident, type 2 diabetes, dysphagia, lack of coordination, muscle weakness, and cognitive communication deficit. Despite these conditions, the resident was allowed to have medications left at his bedside, which he stated he would take later, and he also self-applied Benadryl cream without a physician's order. Licensed Practical Nurse (LPN) F admitted to leaving the medications unattended due to being called away for assistance elsewhere, acknowledging that this was against protocol. The facility's policy required a Self-Administration of Medication Evaluation and a physician's order for residents to self-administer medications, neither of which were present in the resident's medical record. The Director of Nursing confirmed that the expectation was for nurses to remain with residents until medications were taken and not to leave them at the bedside. The incident highlighted a lapse in following the facility's procedures for medication administration and resident safety.

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 develop a comprehensive care plan for a resident with hearing impairment, despite multiple assessments indicating moderate difficulty hearing. The resident, who was admitted and readmitted to the facility, had a history of dementia, anxiety, dysphagia, and speech and language deficits following a cerebral infarction. The Annual Minimum Data Set (MDS) assessment and subsequent Quarterly MDS assessments consistently noted the resident's moderate difficulty hearing and lack of hearing aids, yet no care plan was developed to address this issue. Interviews with staff revealed that the MDS Lead acknowledged the need for a care plan addressing the resident's hearing impairment, as it could affect communication with others. Despite this, the care plan for hearing was resolved earlier in the year based on an MDS assessment that inaccurately coded the resident as having adequate hearing. The Social Services Director and the Director of Nursing both confirmed the resident's significant hearing loss, with the audiologist's assessment indicating severe bilateral sensorineural hearing loss, rendering the resident not a candidate for hearing aids. The lack of a care plan for the resident's hearing impairment was further highlighted by the staff's reliance on care plans for guidance on resident care. The Director of Nursing admitted that the facility did not have a policy and procedure for care plans, which contributed to the oversight. The facility's assessment emphasized the importance of person-centered care, yet failed to incorporate the resident's hearing impairment into the care planning process, leaving staff without clear interventions to support the resident's communication needs.

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 proper hand hygiene and personal protective equipment (PPE) protocols, leading to deficiencies in infection control practices. In one instance, a Certified Nursing Assistant (CNA) assisted a resident with eating without performing hand hygiene before donning gloves, despite the resident being on enhanced barrier precautions. The CNA acknowledged the oversight and the requirement to wear a gown and gloves due to the resident's precautionary status. Another CNA also failed to perform hand hygiene before donning gloves when checking the resident's meal consumption. In a separate incident, a Registered Nurse (RN) did not disinfect a mobile vital signs device before and after use and failed to perform hand hygiene at multiple points during medication administration for a resident. The RN admitted to not following the hand hygiene protocol and acknowledged the importance of these practices in preventing cross-contamination. The Unit Manager and Director of Nursing confirmed the expectations for hand hygiene and equipment disinfection, emphasizing their role in infection prevention.

Penalty

Inspection fine: $15,646

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 neglect by not implementing measures to prevent elopement. A newly admitted female resident with a documented risk of elopement exited the facility unsupervised. The facility was unaware of her whereabouts for approximately 13 hours until law enforcement located her at an Assisted Living Facility 8 miles away. The resident was transported to a hospital for minor injuries and dehydration. The facility did not ensure adequate supervision to prevent the resident from leaving unsupervised. The resident was admitted with diagnoses including cerebrovascular disease, type 2 diabetes mellitus, hypertension, major depressive disorder, and dementia. Hospital records indicated she was at risk for elopement and required a surrogate for healthcare decisions. Despite this, the facility's admission assessment did not identify her as an elopement risk, and no care plans were in place for elopement or wandering. The resident's daughter, who was her legal guardian, insisted she was not an elopement risk, which influenced the facility's assessment. On the night of the incident, the receptionist assumed the resident was with visitors and did not follow protocol to verify her status. The RN on duty was not informed of the resident's elopement risk and did not review the hospital discharge paperwork. The facility's failure to communicate and implement appropriate elopement prevention measures contributed to the resident's unsupervised exit.

Removal Plan

• Resident #1 identified to have exited the facility and located at a local Assisted Living Facility, she was transported to the hospital.
• Missing Resident Process initiated by the weekend supervisor.
• The weekend supervisor and Director of Nursing verified 159 of 160 residents to be in the facility (the one resident not present was resident #1).
• 10 of 10 door guardians and 12 of 12 screamer alarms inspected by the Maintenance Assistant, with proper function verified.
• The Administrator and Director of Nursing verified staffing level appropriate: licensed nurses (1.51) and certified nursing assistants (2.42).
• Facility Administrator notified the Department of Children and Families of resident #1's elopement.
• A Federal; Immediate Report was also submitted.
• Identified receptionist provided education by the Administrator related to responsibilities/functions of a receptionist and subsequently suspended.
• With census of 160, 157 residents were assessed and deemed not at risk for elopement. Reviewed for accuracy of evaluation and care plan verified by the Director of Nursing.
• 2 of 2 residents deemed at risk for elopement reviewed for accuracy of evaluation and care plan verified by the Director of Nursing.
• 11 of 12 facility employees who function as receptionist provided education by the Administrator related to the responsibilities and functions of receptionists including but not limited to sign-in/sign-out process. One employee was currently on maternity leave, to be educated upon return.
• 210 of 333 facility employees received education provided by the Director of Nursing and the Staff Development Coordinator related to abuse, neglect, and misappropriation. Education includes but is not limited to.
• 49 of 67 current facility nurses were educated to review transfer paperwork to ensure elopement prevention intervention (electronic wander prevention bracelet) implemented if indicated to prevent neglect.
• 3 of 3 admission employees have received education provided by the facility Administrator related to accurately reflecting resident conditions including but not limited to history of wandering/elopement.
• 11 of 12 facility employees who function as a receptionist provided education by the Administrator related to responsibilities/functions of receptionist including but not limited to sign/in-sign/out process. One employee who functions as receptionist is currently on maternity leave and will have competency verified prior to return.

Penalty

Inspection fine: $15,646

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

Summary

The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a cognitively impaired resident. The resident, a female with a history of cerebrovascular disease, type 2 diabetes mellitus, hypertension, major depressive disorder, and dementia, was admitted to the facility from the hospital with a known risk for falls, wandering, and elopement. Despite this, the facility did not implement appropriate interventions or care plans to address her elopement risk. On the evening of her elopement, the resident exited the facility unsupervised through the front entrance when the receptionist, distracted by other visitors, unlocked the door. The facility's failure to recognize and address the resident's elopement risk was compounded by the lack of communication and documentation. The resident's hospital discharge records clearly indicated her risk for elopement, but this information was not adequately communicated to the staff responsible for her care. The receptionist assumed that residents at risk for elopement would have electronic wander prevention bracelets, which the resident did not have. Additionally, the nursing staff, including the RN on duty, were not informed of the resident's elopement risk, and the facility's elopement assessment inaccurately assessed her as not at risk. The incident was further exacerbated by the facility's reliance on the resident's daughter, who was also her legal guardian, for information about her mother's condition. The daughter, who had previously worked at the facility, downplayed the elopement risk, attributing the hospital's documentation to inaccurate assessments. This reliance on the daughter's perspective, combined with the facility's inadequate assessment and communication processes, contributed to the resident's unsupervised departure and subsequent elopement.

Removal Plan

• Resident #1 identified to have exited the facility and located at a local Assisted Living Facility, she was transported to the hospital.
• Missing Resident Process initiated by the weekend supervisor.
• The Weekend Supervisor and Director of Nursing verified 159 of 160 residents to be in the facility (the one resident not present was resident #1).
• 10 of 10 door guardians and 12 of 12 screamer alarms inspected by the Maintenance Assistant, with proper function verified.
• The Administrator and Director of Nursing verified staffing level appropriate: licensed nurses (1.51) and certified nursing assistants (2.42).
• Identified receptionist provided education by the Administrator related to responsibilities/functions of a receptionist and subsequently suspended.
• With census of 160, 157 residents were assessed and deemed not at risk for elopement. Reviewed for accuracy of evaluation and care plan verified by the Director of Nursing.
• 2 of 2 residents deemed at risk for elopement reviewed for accuracy of evaluation and care plan verified by the Director of Nursing.
• 11 of 12 facility employees who function as receptionist provided education by the Administrator related to the responsibilities and functions of receptionists including but not limited to sign-in/sign-out process. One employee was currently on maternity leave, to be educated upon return.
• 210 of 333 facility employees received education provided by the Director of Nursing and the Staff Development Coordinator related to sign-in/sign-out process, leave of absence/pink card process and elopement/wander process, including but not limited to review of transfer paperwork to ensure elopement prevention intervention (electronic wander prevention bracelet), implemented if indicated.