Vivo Healthcare Gandy

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to honor a resident’s clearly established Do Not Resuscitate (DNR) status during a cardiac emergency. The resident had multiple medical diagnoses, including cerebral infarction, COPD, cardiomyopathy, atherosclerotic heart disease, a nonrheumatic mitral valve disorder, cognitive communication deficit, and immunodeficiency. The medical record contained DNR orders created on two separate dates with no end dates, a DNR document signed by the resident and a nurse practitioner, and a 3008 form listing the resident’s advance directive as DNR. The resident’s MDS showed a Brief Interview for Mental Status score of 15, indicating intact cognition, and progress notes documented that the difference between DNR/no CPR and full code had been explained over 30 minutes, after which the resident chose DNR and reiterated to social services that she did not want to be resuscitated or undergo chest compressions. On the day of the incident, a CNA assigned to the resident checked on her and found her sitting in a wheelchair and unresponsive despite multiple verbal attempts to rouse her. The CNA notified the RN, who obtained a blood pressure machine, entered the room, then ran out to the nurses’ station, after which a code blue was paged over the intercom. The RN returned with a crash cart, and additional nursing staff, including RNs and LPNs, entered the room. Staff described transferring the unresponsive resident from the wheelchair to the bed and beginning chest compressions. Multiple staff members reported that when one LPN asked about the resident’s code status, no one in the room knew it at that time, and that this LPN left the room to verify the code status while CPR was already in progress. Interviews and video review confirmed that CPR was initiated and continued for approximately 12 minutes before EMS arrived, despite the resident’s existing DNR orders. Several nurses, including those who arrived after CPR had started, acknowledged that they did not check the resident’s code status before assisting with chest compressions or using a bag-valve mask. Staff later reported that the LPN who checked the record returned and announced that the resident was a DNR, yet compressions continued until EMS arrived. The physician stated that the resident was already in the system as a DNR and that staff were expected to check code status before performing CPR. The DON and regional nurse consultant confirmed, based on interviews and camera review, that staff failed to confirm the resident’s code status prior to initiating CPR and that CPR was performed against the resident’s wishes, leading surveyors to determine that this failure resulted in Immediate Jeopardy.

Removal Plan

• Implemented a revised admission/readmission process requiring an Advance Directive discussion form to be completed by the licensed nurse upon admission or with change in advance directives, with follow-up by Social Services.
• Reviewed Advance Directive discussion forms in the daily clinical meeting with the Interdisciplinary Team.
• Conducted a huddle on units after the clinical meeting to discuss any changes in advance directives/code status.
• Placed signage on each crash cart stating: "Stop check physician order prior to starting Cardiopulmonary Resuscitation."
• Implemented the "It Takes Two" process requiring two licensed nurses to verify code status/advance directives prior to initiation of CPR.
• Initiated an internal investigation including resident record review, staff interviews, and notification to the physician and resident representative.
• Suspended and terminated the assigned nurse and reported the nurse’s license to the licensing board.
• Suspended and terminated an additional nurse who responded and participated in initiation of CPR and reported the nurse’s license to the licensing board.
• Suspended two additional nurses pending investigation and returned them to work with disciplinary action, education on ANE/honoring advance directives, and participation in a code blue drill.
• Conducted a 100% audit of all current residents’ code status and care plans.
• Conducted a 100% audit of crash carts to ensure all required items were present.
• Reviewed CPR cards for identified nurses to confirm validity and inclusion of in-person skills competencies.
• Held an ad hoc QAPI meeting with Administrator, DON, Medical Director, and department heads.
• Completed an audit of residents discharged, transferred to the hospital, or expired to verify advance directives were honored.
• Provided staff education for licensed/certified staff on medical emergency response and communication of advance directives and code status, following physician orders related to advance directives, the "It Takes Two" verification process, and CNA roles during code blue.
• Provided all-staff education on Abuse, Neglect and Exploitation/Resident Rights with focus on honoring advance directives.
• Completed honoring advance directives attestation with licensed nursing staff.
• Completed physician orders education for licensed nursing staff.
• Completed medical emergency response and communication of code status education for licensed nursing staff.
• Completed ANE/Resident Rights education for all staff.
• Completed advance directives posttest for licensed staff.
• Completed ANE/Resident Rights posttest for all staff.
• Completed code blue process/"It Takes Two" education for licensed nursing staff.
• Began code blue drills every shift and required licensed nurses to attend a mock code blue quality assurance drill prior to working.
• Completed CNA roles-in-code-blue training.
• Completed quality reviews validating staff competencies for completed education.
• Completed quality reviews of newly admitted residents to verify completion of the advance directive discussion form.
• Implemented Director of Clinical Services chart review of residents who expire at the facility or are transferred to the hospital after a cardiac event to verify advance directives were followed.

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

Facility administration failed to utilize resources effectively to ensure allegations of abuse and neglect were thoroughly investigated and reported in a timely manner for multiple residents. The Nursing Home Administrator’s job description required directing day-to-day functions in accordance with federal, state, and local regulations to assure quality care, including reviewing resident complaints and grievances, maintaining written records of complaints, and reporting all allegations of resident abuse and misappropriation of property. The DON’s job description outlined responsibilities for ensuring quality and safe delivery of nursing services, accurate and timely documentation, continuous observation and monitoring of seriously ill residents, and acting as a patient advocate. Despite these defined roles and responsibilities, the facility did not ensure that an allegation of neglect involving a resident on the smoking patio was properly investigated, documented, or reported. Resident #3 was admitted with serious medical conditions including metabolic encephalopathy, major depressive disorder, antineoplastic chemotherapy, secondary malignant neoplasm of the lung, malignant neoplasm of the brain, severe calorie malnutrition, cachexia, COPD, personal history of pneumonia, and acute respiratory failure with hypoxia. A witness statement dated on a specified date described security camera footage from the smoking patio showing this resident, who was assigned to a specific CNA for care, entering the smoking patio in the afternoon and remaining there without any visits or care from the assigned CNA. The statement indicated that at 5 p.m. the resident was found unresponsive by other staff, assisted indoors, and a code blue was called, with the video showing that the resident received no care of any kind from the assigned CNA for over 4.5 hours. Review of the facility’s abuse log for the relevant period showed that this incident was not listed, indicating it was not entered into the abuse/neglect tracking system. During a complaint survey, interviews with key personnel who were employed at the time of the incident revealed they were not willing or able to participate meaningfully in the survey process regarding the investigation of abuse and neglect. The RN Unit Manager, Director of Rehabilitation, Housekeeping Manager, Assistant DON, two Social Services Directors, and therapy staff denied knowledge of the resident having been left unattended for 4.5 hours, or that the resident coded, required CPR for more than 10 minutes, and subsequently expired. Their responses included statements such as not remembering the incident, not being told anything by administration, not knowing, not feeling comfortable answering, or lacking specifics. At the time of the investigation, it was unclear whether these key staff had not participated in any investigation of this traumatic event or were not forthcoming, which impacted the survey process. Review of the facility’s Compliance and Ethics Reporting policy showed that employees were required to report suspected violations immediately and that all reports were to be investigated and tracked for QAPI, but the handling of this incident and the absence of the event from the abuse log demonstrated that these reporting and investigation processes were not effectively implemented by facility administration. Further, interviews with the RDCS and the facility’s CNO revealed that they only became aware of the witness statement about the resident being left outside for 4.5 hours shortly before the survey interview and that the allegation of neglect had only then been reported. They stated that the LPN who wrote the witness statement had focused on the caregiver rather than the resident and that the LPN had not reviewed the full 4.5 hours of video. The RDCS stated that administration was not forthcoming and that there had been an unsupervised smoking patio at the time of the incident. The CNO reported discovering that the NHA had a culture of hiding information and that the NHA had concealed matters from them. These statements, combined with the lack of timely reporting, incomplete or absent investigation, and failure to document the incident in the abuse log, demonstrate that facility administration did not administer the facility in a manner that ensured effective use of resources to investigate and report allegations of abuse and neglect as required by policy and job responsibilities.

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 consistently implement its infection prevention and control program during an influenza outbreak and in the handling of nebulizer equipment. During an initial tour, surveyors observed that all staff in resident care areas were wearing masks and staff reported this was required due to a flu outbreak that began several days earlier, with 21 residents testing positive. However, in the lobby there was no signage notifying visitors of the outbreak or recommending PPE such as masks, and the receptionist did not provide any information or instructions about the outbreak. Two family members who visited residents on multiple occasions reported they had not been notified of the flu outbreak, had not been offered masks, and only became aware of the situation by seeing staff wearing masks. The Infection Preventionist later confirmed that while resident representatives were notified of the outbreak by telephone, the facility did not encourage mask use for visitors and did not post signage to notify visitors or recommend/encourage mask use, contrary to the facility’s infection control policy requiring visitor education, use of isolation signs, and passive screening via posted signs. Surveyors also observed improper storage of nebulizer masks on two units. On the 300 unit, an uncovered nebulizer mask was seen on a resident’s dresser in front of the television, and on the 100 unit, another uncovered nebulizer mask was observed on a circular table in a resident’s room. Photographic evidence was obtained. The Infection Preventionist, upon reviewing the photos, stated that nebulizer items should be stored in a bag and that all nurses had been instructed on this practice. This practice was inconsistent with the facility’s written policy on oxygen administration, which requires delivery devices to be kept covered when not in use, and with the infection prevention and control policy that all staff follow procedures designed to prevent the development and transmission of communicable diseases and infections.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide staff with adequate training and effective processes to address language barriers that had been repeatedly reported through grievances and resident council meetings. A cognitively intact resident with a Brief Interview for Mental Status (BIMS) score of 15 reported that language remained a significant barrier and that the resident council had been discussing this issue for months without resolution. This resident stated that staff would push their phones toward residents and attempt to use translator applications for communication, which the resident refused, believing they should be able to communicate with staff directly without a translator. The resident also reported hearing staff speak Spanish while caring for other residents who only spoke English. Review of grievance records showed multiple complaints over several months related to staff not speaking or understanding English and staff speaking Spanish in front of non‑Spanish‑speaking residents, particularly on one unit. One grievance described a CNA who could not answer a resident’s question because she could not speak English and did not understand what the resident was asking, with no resolution documented. Another grievance from a resident and family member reported difficulty communicating with a specific care staff member due to a language barrier and poor response time; the only documented action was that the employee was counseled, with no follow‑up recorded. Resident council grievances repeatedly documented that CNAs on a particular station did not speak or knew very little English, that residents felt uncomfortable with staff using phones to translate, and that staff spoke Spanish to each other during mealtimes in front of English‑speaking residents. These items were repeatedly marked as “Not Resolved – Action Needed,” and residents noted that prior nursing grievances had not been resolved and that they wanted action taken. Surveyor interviews further demonstrated ongoing communication problems and lack of effective staff training. An attempted interview with a CNA could not be completed because the CNA did not understand questions asked in English, evidencing a direct language barrier between staff and surveyors. A unit manager LPN stated that communication with staff on one unit was easier for her because she could use “Spanglish,” and acknowledged that CNAs on that unit had difficulty understanding clinical questions unless speech was slow and clear; she also confirmed that resident council repeatedly raised concerns about staff speaking Spanish in the hallways and that staff used translator applications on their phones to communicate with residents and English‑speaking staff. The Social Services Director acknowledged grievances related to language barriers and stated that staff had only been given verbal reminders not to speak other languages while caring for residents, which had not been effective. The Social Worker reported a potential issue with Spanish‑speaking staff and residents, stated that staff were not allowed to use translators to communicate with residents, and that being able to communicate and read English was a requirement for staff, but also stated that resolutions to grievances were not specifically documented. The Regional Director of Operations stated that the facility needed to go beyond verbal communication to resolve a repeating issue and that more should have been done to provide staff with resources and residents with communication in a language they understand, while facility policies required culturally competent care, effective communication in a language residents can understand, and sufficient guidance and training for staff on communication, which were not effectively implemented.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to timely report and investigate multiple allegations and indications of abuse and neglect in accordance with its own Abuse, Neglect and Exploitation policy and federal reporting timeframes. The policy required all alleged violations to be reported to the Administrator, state agency, adult protective services, and other required agencies immediately but not later than 2 hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. The policy also defined an "alleged violation" as any situation or occurrence observed or reported that, if verified, could indicate noncompliance with federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property. Despite this, the facility did not treat several events as reportable allegations and did not report them within the required timeframes. For one resident with multiple serious diagnoses including metabolic encephalopathy, major depressive disorder, metastatic cancer to the lung and brain, severe calorie malnutrition, cachexia, COPD, history of pneumonia, and acute respiratory failure with hypoxia, a written witness statement described security camera footage showing the resident entering the smoking patio in the afternoon and remaining there for the entire afternoon without any visits or care from staff or the assigned CNA. The statement indicated that at 5 p.m. the resident was found unresponsive by another staff member, brought indoors, and a code blue was called, and that the resident did not receive care from the assigned CNA for over 4.5 hours. This statement was signed and dated by an LPN. The incident did not appear on the facility’s abuse logs, and the NHA, DON, and an LPN supervisor each stated they did not investigate or report the event as an allegation of neglect or a reportable event, citing reasons such as viewing it as a "regular code," believing the resident’s terminal diagnoses and poor prognosis made the death unsurprising, and stating there was no supervision of the patio at that time. The LPN who wrote the statement later said the statement about the resident remaining unattended for 4.5 hours was false and that her focus was on the CNA’s performance, but also stated that administration was aware of the statement and did not report or investigate it. For another resident with hemiplegia and hemiparesis, a psychology progress note documented that the resident, who was alert and oriented, reported that a person identified by name came to his room at dusk, patted him on the head, pinched his cheek, and made a familiarizing comment, which the resident described as violating his space and demeaning. The NHA stated that the resident had alleged that a short-haired man slapped him and that he reported this to a nurse two days prior, and that the resident had a similar prior allegation. The NHA reported that the incident was assessed with no injuries and that she did not have a name to go by, and she did not identify the named individual from the psychology note as part of the investigation. She acknowledged that she reported the incident to DCF and AHCA the day after the event and that this did not meet the facility’s policy requirement to report within two hours. For a third resident with hemiplegia and hemiparesis, the abuse log showed an incident in which the resident reported that a female staff member entered her room during the night shift, refused to give her the call light, stated she was not the resident’s assigned CNA and that the resident did not have a CNA, and then left without changing the resident despite the resident’s stated need. The NHA stated that when she reviewed the chart, she saw documentation of the resident being changed only once at 8:17 p.m. and that the assigned CNA reported being with another resident and eventually returning, but there was no exact time. The NHA said the resident had glaucoma and could not clearly identify the staff member, and that the resident later told psych it was probably a misunderstanding and denied being abused. The NHA stated she treated this as a neglect incident, not abuse, because there was no physical injury, and reported the incident to AHCA more than 24 hours after she was notified, despite acknowledging that abuse allegations should be reported within two hours and that the policy defined abuse to include deprivation of goods or services. For a fourth resident with muscle wasting and atrophy, cognitive communication deficit, and unspecified dementia, the abuse log and psychology note documented that the resident reported three people (one male and two females) in her room, with the male asleep in her bed and one female hitting her, then feeding others before all left. The NHA stated that a family member alleged the resident was beaten up by staff and that she was notified when the incident happened. She reported that she notified DCF and AHCA more than two hours after the allegation, explaining that she was with the police and unable to report sooner. The NHA acknowledged that reporting of abuse incidents should occur within two hours. The Regional Director of Clinical Services confirmed that there were no reports filed or investigations conducted for the resident who died on the patio and stated that the NHA should have filed reports within the required timeframes and that another staff member could have submitted reports if the NHA was unavailable.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to promptly and thoroughly investigate multiple allegations of abuse and neglect, and to treat certain events as reportable alleged violations in accordance with its own abuse, neglect, and exploitation policy. The policy required immediate investigation when suspicion or reports of abuse, neglect, or exploitation occurred, including identifying responsible staff, interviewing all involved persons, and providing complete documentation. Despite this, the facility did not initiate an investigation or log an allegation related to a resident who was observed on security camera footage remaining on the smoking patio for approximately 4.5 hours without care from his assigned CNA and who was later found unresponsive at 5 p.m., after which a code blue was called. The Nursing Home Administrator (NHA), Director of Nursing (DON), and an evening supervisor each stated they did not view this sudden death as an allegation of neglect or a reportable event, and no investigation or abuse log entry was made at the time. The DON acknowledged there was no hydration cart and no supervision of the patio, and the evening supervisor confirmed there was no clear view of the resident while he was outside and that the incident was not witnessed by staff. The deficiency also includes delayed and incomplete responses to other abuse and neglect allegations. One resident with hemiplegia and hemiparesis reported that a male staff member, identified in a psychology note as a person named by the resident, came to his room at dusk, patted his head, pinched his cheek, and asked, "how is my guy today," which the resident described as violating his space and demeaning. The NHA later described a similar allegation as involving a short-haired man who allegedly slapped the resident, but stated the resident could not provide a name and that prior similar incidents were not substantiated. The NHA acknowledged that the abuse allegation was not reported within the two-hour timeframe required by policy, instead being reported the next day to state agencies. Another resident with hemiplegia and hemiparesis reported that during the night shift a female staff member entered her room, refused to give her the call light, stated she was not the assigned CNA and that the resident did not have a CNA, and left without providing requested incontinence care. The NHA stated that chart review showed only one documented change at 8:17 p.m. and that the assigned CNA reported being with another resident and eventually returning, but there was no exact time established. The NHA said she treated this as neglect rather than abuse because there was no physical injury, despite the facility policy defining abuse to include deprivation of goods or services. The NHA also stated she believed she had 24 hours to report if there was no injury, and confirmed that abuse allegations should actually be reported within two hours. A further allegation involved a resident with diabetes mellitus who reported being abused by staff because a nurse would not leave medications at the bedside and the resident refused care from her CNA that night. The NHA stated she did not consider this to be abuse, even though the resident alleged abuse, and that she found it odd but did not question the CNA further after the CNA reported that nothing had happened on her shift. The resident later accepted care and medication from another nurse, and the NHA reported the matter as neglect, not abuse. The NHA also stated that the resident refused to be interviewed by her on two occasions and that she did not know what the resident meant by being abused and never found out. Across these incidents, the Regional Director of Clinical Services confirmed that no reports were filed or investigated for the resident who died after being on the patio, and that the NHA failed to file required reports within policy timeframes, despite the job description requiring the NHA to operate the facility in accordance with federal, state, and local regulations and to review resident complaints and grievances with appropriate written follow-up.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean and sanitary condition in one of the two community shower rooms located on Unit 4. Observations revealed multiple issues, including black substances on shower curtains, caked black substances on the floor around the toilet, and yellow liquid on the toilet rim. The shower stalls had yellow substances, missing tiles, and cement-like porous areas that were uncleanable. The wall vent fan was covered in dust, and the sink had rust-colored stains. Additionally, the shower bed and bedside commode were found with dried brown, black, and yellow substances. Interviews with the Housekeeping Director, RN/UM, and Maintenance Director highlighted a lack of routine checks and cleaning of the shower room and equipment. The Housekeeping Director expected daily cleaning, but the shower room was not appealing. The RN/UM admitted to not routinely checking the equipment, and the Maintenance Director was unaware of the poor condition until the survey. The facility's policy emphasized maintaining a sanitary environment, but the observed conditions did not align with these standards.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents with diagnosed or suspected mental illness were referred to the State's Mental Health authority for a Level II Preadmission Screening and Resident Review (PASRR) for four residents out of 29 sampled. Resident #47 was admitted with multiple mental health diagnoses, including paranoid schizophrenia and major depressive disorder. Despite these diagnoses, the Level I PASRR screen indicated that a Level II evaluation was not required, which was a misjudgment given the resident's mental health conditions. Resident #79, who was admitted with undifferentiated schizophrenia, bipolar disorder, and major depressive disorder, also did not receive a Level II PASRR despite exhibiting behaviors such as hallucinations and yelling. The facility's Assistant Director of Nursing (ADON) and Social Services Director (SSD) acknowledged the resident's mental health issues and behaviors but did not initially pursue a Level II assessment. The resident's care plan and psychiatric notes indicated ongoing mental health challenges that warranted further evaluation. Similarly, Resident #19 and Resident #73 were admitted with significant mental health diagnoses, including bipolar disorder, depression, and anxiety, yet their Level I PASRR screenings did not lead to Level II evaluations. Both residents had documented histories of mental health issues that caused functional impairments, but the facility's assessments failed to recognize the need for further evaluation. Interviews with facility staff revealed a lack of understanding and coordination in the PASRR process, leading to these oversights.

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 and implement care plan interventions for four residents, leading to deficiencies in their care. Resident #19, who was on a fluid restriction due to conditions such as hypo-osmolality and hyponatremia, was observed with a foam cup at her bedside, contrary to her care plan instructions. Interviews with staff revealed a lack of awareness about the resident's fluid restriction, indicating a failure to communicate and enforce the care plan effectively. Resident #24, diagnosed with COPD and chronic respiratory failure, was self-administering oxygen without a physician's order or a self-administration assessment. The care plan did not include provisions for self-administration of oxygen, and staff interviews confirmed that the resident was managing his oxygen use independently without proper authorization or documentation. Resident #32, who expressed a desire to transition to an Assisted Living Facility, did not have a discharge plan documented in his care plan, despite multiple discussions with the Social Services Director. Additionally, Resident #133, identified as a fall risk, had an incomplete baseline care plan with missing interventions to prevent falls. Observations showed the resident's call light was out of reach, and side rails were not positioned as required, further highlighting the facility's failure to implement necessary safety 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 provide wound care as prescribed for Resident #118, who was observed with an undated dressing on the right ankle. The resident, who had a left lower extremity amputation and other medical conditions such as osteomyelitis and a local skin infection, was supposed to have the dressing changed three times a week. However, the dressing was not dated, and the staff could not confirm when it was last changed, although it was documented as completed on a previous Saturday. The Treatment Administration Record (TAR) for January 2025 indicated that the dressing change was to be performed daily, involving cleansing the surgical site, applying betadine, and covering it with gauze and an elastic wrap. Despite this, the dressing was not dated, and the Director of Nursing confirmed that dressings should be dated when changed. This oversight in documentation and adherence to the prescribed wound care regimen led to the deficiency identified by the surveyors.

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 the intravenous (IV) access of a resident in accordance with professional standards. The resident, who had a peripherally inserted central catheter (PICC) in the right upper arm, was observed with a dressing that was not fully attached to the skin. The dressing was dated several days prior, and the resident reported having an infection in the spinal cord. The resident's medical records indicated a diagnosis of bacteremia and pseudomonas infection, requiring IV antibiotics. The facility's documentation revealed several deficiencies in the management of the resident's PICC line. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed inconsistencies and omissions in documenting the measurement of the external catheter length and arm circumference, as required by the facility's policy. Despite orders to measure the arm circumference and catheter length with each dressing change, the records lacked these measurements on multiple occasions. Additionally, the documentation did not consistently reflect the condition of the IV site or the completion of scheduled treatments. Interviews with staff members, including a Registered Nurse (RN), Unit Manager (UM), and Director of Nursing (DON), highlighted a lack of adherence to the facility's policy regarding PICC line management. Staff acknowledged the failure to document the catheter length and the incorrect entry of orders that did not prompt the necessary documentation. The facility's policy required weekly dressing changes and documentation of the catheter length to prevent infection and ensure proper catheter placement, but these procedures were not consistently followed.

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 effective communication with the Dialysis center providing treatment services for a resident with end-stage renal disease. The deficiency was identified through observations, interviews, and record reviews, revealing that the Dialysis nursing staff did not collaborate with the nursing facility by failing to provide and document post weights, vital signs, Dialysis vascular access site status, and details of the Dialysis treatment provided. This lack of documentation was consistent across fourteen Dialysis service visits. The resident involved was alert and able to discuss his medical care, confirming that he attended a Dialysis center three times a week. He mentioned that a yellow book was supposed to be filled out by the Dialysis center staff with his medical information, but he could not recall the last time it was completed. The facility's Licensed Practical Nurse verified that the communication sheets from the Dialysis center often returned blank, leaving the nursing facility staff without crucial information about the resident's medical and vital status during Dialysis sessions. Interviews with facility staff, including the Unit Manager and the Nursing Home Administrator, confirmed ongoing issues with the Dialysis center's refusal to fill out the necessary communication forms. Despite attempts to resolve the issue through communication with the Dialysis center, the facility did not receive the required information until the State was present in the nursing home, prompting the Dialysis staff to fax the necessary documentation. The facility's policy and the coordination agreement with the Dialysis center outlined the expectations for communication and collaboration, which were not met in this case.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to Enhanced Barrier Precautions (EBP) and proper use of Personal Protective Equipment (PPE) for a resident diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) and other infections. On the morning of January 13, 2025, a resident was observed in their room without the required signage for EBP, despite having a surgical incision and being colonized with a multidrug-resistant organism (MDRO). Later that day, two Certified Nursing Assistants (CNAs) repositioned the resident without donning protective gowns, only wearing gloves, which was against the facility's policy for residents requiring EBP. The resident's medical history included a recent admission for orthopedic aftercare following a surgical amputation, sepsis due to MRSA, and other infections. The resident's care plan, updated on January 13, 2025, indicated the need for EBP due to the risk of infection from the MDRO. However, staff members were not fully aware of the resident's need for EBP, as evidenced by their failure to use the appropriate PPE during high-contact care activities. Interviews with staff, including a CNA, a Registered Nurse (RN), the Director of Nursing (DON), and the Assistant Director of Nursing/Infection Preventionist (ADON/IP), revealed a lack of consistent understanding and implementation of EBP. The DON and ADON/IP acknowledged that the resident should have been on EBP due to their MDRO diagnosis and the presence of a surgical incision. The facility's policy, revised in September 2022, clearly outlined the need for gowns and gloves during high-contact activities for residents with MDROs, but this was not followed in practice.