Harvest Acres Nursing And Rehab

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 complete and document care conferences after admission for two residents and quarterly care conferences for two residents, and it also failed to document that care plan information was shared with the resident or resident representative. The report states that the planning of care should include assessment of the resident’s current condition, needed services, and updates communicated to the resident and/or representative, with a copy of the care plan available for review, but this was not done as documented for the residents reviewed. Resident #5 had diagnoses including hyponatremia, non-Alzheimer’s dementia, traumatic brain injury, anxiety, bipolar disorder, schizophrenia, and asthma. The resident’s MDS showed a BIMS score of 9 out of 15 with moderate cognitive impairment and delirium symptoms present. The record showed the resident had a court-appointed guardian as decision maker, and the first documented care conference occurred more than 3 months after admission. The guardian stated in interview that the facility had not held a care conference with him until November and that psychiatric medication changes were made without communication to him during the first month after admission. Resident #3’s MDS identified severe cognitive impairment with a BIMS score of 3, diagnoses of heart failure, diabetes mellitus, and non-Alzheimer’s dementia, and extensive dependence for multiple ADLs, along with delusions and behavioral symptoms directed toward others. The care conference notes showed no documentation for a 5-month period, and the notes did not include documentation of a facility self-report regarding a staff member who grabbed the resident’s arm. Resident #11’s MDS identified severe cognitive impairment with a BIMS score of 5, diagnoses of Di George’s Syndrome, diabetes mellitus, and schizophrenia, and need for assistance with several ADLs. The record showed only one care conference progress note, and two facility forms contained staff signatures but no documentation of what was discussed with the resident. The Social Worker and DON stated care conferences were held weekly and that the first care conference should have been completed within the first 30 days after admission, while the facility policy required care plan development within 7 days of the required MDS assessment and no more than 21 days after admission, with quarterly review and updates.

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 notify the resident’s guardian/power of attorney of changes in medication for a resident with moderate cognitive impairment, delirium symptoms, and a complex psychiatric history that included non-Alzheimer’s dementia, traumatic brain injury, anxiety, bipolar disorder, schizophrenia, and asthma. The resident was admitted from a psychiatric hospital with discharge orders for continued psychiatric follow-up, and the record showed multiple psychoactive medications on admission, including benztropine, divalproex, levocarnitine, levothyroxine, risperidone, trazodone, and paliperidone. Within 14 days of admission, the facility changed the psychiatric medication regimen several times, including starting haloperidol, buspirone, valproic acid, ziprasidone, and lorazepam, and decreasing then discontinuing risperidone. Staff interviews indicated the guardian had directed that psychiatric medications be managed by the resident’s psychiatrists at the psychiatric hospital, but the facility did not confer with the psychiatrist of record or notify the guardian before making the changes. The facility also failed to notify the physician in a timely manner about another resident’s continued abdominal pain and distention. That resident was cognitively impaired, dependent on staff for multiple activities of daily living, and admitted with no documented gastrointestinal issues, though the admission assessment did not complete the pain assessment. Nursing notes documented a firm, round, distended abdomen on admission, followed by nausea, vomiting, abdominal pain, bloating, and ongoing distention over the next several days. Documentation showed repeated vomiting, dark emesis, constipation, minimal bowel movement results, and continued abdominal pain, but the physician was not notified until 6 days later, when the resident had worsening symptoms and was sent to the emergency room for possible bowel blockage. The record also showed limited bowel movement documentation and inconsistent abdominal reassessments during the resident’s decline. The hospital record later documented abdominal pain, ileus versus partial small bowel obstruction, ICU transfer for shock and respiratory failure, suspected bowel perforation, and death from cardiac arrest with septic shock and bowel perforation listed as directly contributing conditions. Staff interviews and the DON’s interview reflected that the resident’s firm, distended abdomen, vomiting, constipation, and pain should have prompted ongoing assessment and physician notification, but the facility could not explain why the physician was not notified earlier.

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 implement an effective discharge planning process for a resident whose discharge needs and preferences were not addressed in a way that prepared her for a safe transition after discharge. The resident was admitted after transfer from another facility due to exit-seeking behavior and had multiple diagnoses including hypertension, renal insufficiency, diabetes, anxiety, depression, major depressive disorder, ADHD, insomnia, chronic pain, and spinal stenosis. Her assessments showed mild cognitive impairment on the BIMS, and additional cognitive testing reflected more significant impairment, with scores indicating difficulty remembering, learning new information, concentrating, and making decisions. A Level II PASRR identified serious mental illness, a history of methamphetamine use, impaired judgment, memory impairment, and the need for a supported living setting with ongoing psychiatric, behavioral health, substance use, and community support services. The resident’s nursing care plan did not address the PASRR requirements. The record also showed that the resident had a court-appointed guardian at the time of admission, and the facility could not provide documentation that the guardian had been removed before discharge. The facility’s policy required a written physician order or legal process for discharge, timely notification of the legally responsible party or representative, and a centralized coordinated discharge plan developed within 7 days of admission and updated as needed. Despite these requirements and the resident’s identified need for supported services, the resident requested discharge and was discharged with a friend without the facility documenting an effective discharge plan that incorporated the PASRR findings. After discharge, the resident was reported to have left without medications, resumed methamphetamine use immediately, lost housing within days, and became homeless after staying with acquaintances and being removed from multiple places. The guardian stated the facility did not notify them of the discharge and that the resident was not capable of caring for herself. Hospital records showed the resident was later hospitalized in critical condition in the ICU on a ventilator from a drug overdose and remained hospitalized at the time of survey exit. The facility administrator stated the resident was discharged within 2 hours of requesting discharge and that there was not time to coordinate referrals for substance abuse counseling or support groups. Pharmacy staff stated they did not receive any prescriptions for the resident around the time of discharge, despite the facility stating the provider sent prescriptions to the resident’s requested pharmacy.

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 address PASRR recommendations in the care plans for two residents with Level II PASRR evaluations and failed to include interventions identified after an incident involving one resident entering another resident’s room. Resident #5 had diagnoses including hyponatremia, non-Alzheimer’s dementia, traumatic brain injury, anxiety, bipolar disorder, schizophrenia, and asthma, with moderate cognitive impairment and symptoms of delirium noted on the MDS. The resident’s Level II PASRR identified serious mental illness, multiple prior psychiatric hospitalizations, court-ordered inpatient psychiatric treatment, a history of refusing medication and care, yelling at others, throwing and breaking things when upset, and the need for placement in a locked facility for safety. The PASRR for Resident #5 required ongoing psychiatric medication management, individual therapy, occupational therapy, physical therapy, dental services, socialization and recreation activities, family involvement in care planning, and supportive counseling from nursing facility staff. A later conditional short-term PASRR continued psychiatric medication management, socialization and recreation activities, and supportive counseling. The resident’s nursing care plan did not address the PASRR requirements until after the expiration date of the PASRR, and the facility submitted a PASRR review before expiration. The resident’s clinical record also showed multiple transfers to emergency rooms and inpatient psychiatric hospitalization for aggressive behaviors, including one hospitalization that had not ended when the record was reviewed. Resident #4 was admitted from a sister facility due to exit-seeking behavior and had diagnoses including hypertension, renal insufficiency, diabetes, arthritis, anxiety, depression, major depressive disorder, ADHD, insomnia, chronic pain, and spinal stenosis. The resident’s Level II PASRR identified schizophrenia, impaired judgment, confusion, memory impairment, and the need for a court-appointed guardian and a supportive living setting. The PASRR required psychiatric medication management, individual therapy, substance use evaluation and support, speech therapy, family involvement, supportive counseling, archived behavioral health records, and planning for supported living. The nursing care plan did not address any of the required PASRR interventions or identify that the resident had a Level II PASRR, and the resident was later discharged from the facility at her own request. The facility also failed to update care plans after an incident between two residents. Resident #7, who was cognitively intact but dependent on staff for multiple ADLs and receiving hospice services, reported that Resident #8 entered her room and caused her to feel anxious and unsafe. Progress notes and the incident report described differing versions of the event, including reports that Resident #8 came into the room, raised his arm, and in another account made a fist near Resident #7’s face without physical contact. Resident #8 was severely cognitively impaired and dependent on staff for nearly all ADLs, and observations showed him arguing with other residents and staff. The care plan was not updated after the incident occurred.

Penalty

No penalty information released

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

Summary

The facility failed to ensure staff had the basic competencies and skill sets needed to meet residents’ behavioral health needs, despite identifying in its Facility Assessment that it cared for residents with dementia, mental health conditions, trauma history, Level II PASRRs, and intellectual disabilities. The assessment stated the facility provided assistance with behavioral symptoms for 28 residents and described staffing and training expectations that included orientation, ongoing education, and competencies for all staff. However, surveyors found the facility did not provide the requested staff competency assessments, and the facility did not produce a Staff Competency Assessment policy during the survey. The facility also failed to provide the education it had identified in its own assessment as necessary for staff competency. The 2026 education calendar listed monthly topics including Dementia and Behavior Management, Caring for Residents with Mental/Psychosocial Disorders, Person Centered Care, and other resident-care subjects. When surveyors requested the 2025 Education Calendar, attendance records for the March 2026 education program, the competency policy, the outline of the March 2026 material, and the credentials of the speaker, the facility did not provide the 2025 calendar, attendance records, or the competency policy. The facility provided an outline for Resident Rights presented by the Long-Term Care Ombudsman, but did not provide documentation for the scheduled Dementia and Behavior Management education. It also provided a documentation training sign-in sheet and an undated LTC staff training handout on Schizophrenia and Bipolar Disorders, but there was no validation of when the information was presented, who provided it, or copies of completed post-education quizzes. Staff interviews reflected that education specific to managing behavioral symptoms and psychiatric conditions was limited or inconsistent. An LPN stated staff had to be reactive and flexible to keep residents safe and learned mostly from practice. Another LPN said staff were not really educated with specifics for managing resident behaviors and that the only option for aggressive and threatening behaviors was often to send the resident to the ER. An RN stated staff were not really educated to manage complex conditions and aggressive behaviors, and that there was not a plan to ensure staff had the knowledge needed. CNAs stated they were unsure whether behavior or psychiatric education was covered in staff meetings and could only recall general approaches such as trying a different staff member when a resident was difficult. Another RN stated the facility now had a more diverse population with younger, more mobile residents with psychiatric problems and that staff did the best they could with what they had.

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 incorporate PASRR-required treatment and service needs into the comprehensive care plans for two residents with serious mental illness and related behavioral health needs. One resident had diagnoses including non-Alzheimer’s dementia, traumatic brain injury, anxiety, bipolar disorder, and schizophrenia, and the Level II PASRR required ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP, individual therapy, occupational therapy, physical therapy, dental services, socialization and recreation, family involvement, and supportive counseling. Although the resident was admitted with multiple psychotropic medications and later experienced repeated psychiatric hospitalizations for aggressive behaviors, the PASRR directives were not addressed in the comprehensive care plan until months after admission. For that same resident, the facility sought psychiatric medication changes within 14 days of admission without conferring with the resident’s psychiatrist of record or the Court Appointed Guardian. The medication regimen was repeatedly changed, including haloperidol, buspirone, valproic acid, ziprasidone, lorazepam, and reductions in risperidone, while the resident continued to have escalating behavioral episodes and multiple transfers to emergency departments and inpatient psychiatric care. The record also showed the guardian did not consent to psychiatric medication management by anyone other than the resident’s psychiatrists at the VA psychiatric hospital, yet the facility’s psychiatric NP later documented that the resident would be removed from the NP’s service list. The second resident had a Level II PASRR for serious mental illness, with required services including ongoing psychiatric medication management, individual therapy, substance use evaluation and treatment access, supported community living planning, speech therapy, family involvement, supportive counseling, archived behavioral health records, and referral to recovery supports. The resident’s care plan did not include any of the PASRR-required interventions or even indicate that a Level II PASRR existed. The resident also had a lapse in tetrabenazine administration after admission, with the medication not given for several days and then discontinued after the facility reported cost and insurance issues, and the replacement medication was never administered because prior authorization was not completed. The second resident was discharged after requesting discharge, and the facility did not provide documentation that the Court Appointed Guardian had been revoked at the time of discharge. The resident left without medications, later used methamphetamine, became homeless after being removed from multiple temporary living arrangements, and was later hospitalized in critical condition in the ICU on a ventilator from a drug overdose. The facility administrator stated the resident was discharged within 2 hours of the request and there was not time to coordinate referrals for substance abuse counseling or support groups.

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

Provide and implement an infection prevention and control program was deficient when facility staff failed to change gloves after completing incontinence care involving stool and before applying Triad cream to a pressure ulcer on the coccyx of Resident #3. Resident #3 had a BIMS score of 03 and diagnoses including heart failure, diabetes mellitus, and non-Alzheimer's dementia. The MDS also identified the resident as totally dependent on staff for assistance with toileting, showers, lower body dressing, footwear, and repositioning, and as requiring substantial to maximal assistance with upper body dressing and oral hygiene. The resident's progress notes documented a buttock wound that later became a Stage 3 pressure ulcer to the coccyx requiring daily treatment. During an observation of incontinence care, staff cleansed stool from the resident's rectal crease while the resident was turned to his left side and was striking at staff, then applied Triad cream to the coccyx area without changing gloves first. Staff interviews confirmed that gloves should have been changed after cleaning stool and before applying ointment, and the DON stated that aides would be expected to change gloves before applying ointment to the resident's pressure ulcer. The facility policy for incontinence care also directed staff to remove gloves, perform hand hygiene, put on clean gloves, and then apply a moisture barrier protectant as necessary.

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 complete baseline care plans within 48 hours of admission for 4 of 5 residents reviewed. The facility policy required a baseline plan of care to meet each resident’s immediate health and safety needs within 48 hours of admission. Record review showed that the Nursing Evaluation forms for Resident #1 and Resident #7 lacked completed baseline care plan assessments in multiple areas, and the care plans were not completed within the required timeframe. Staff interviews confirmed that the admission paperwork was completed without the baseline care plans, that staff had not been trained on how to complete them, and that the facility was in the process of creating a new system for care plans. Resident #1 had a severely impaired BIMS score of 5/15 and diagnoses including type II diabetes mellitus, anxiety disorder, depression, psychotic disorder, and schizophrenia. The admission evaluation lacked baseline care plan assessments for elopement/wandering, skin integrity, ADLs, falls, nutrition, neurological status, and pain. Although later care plan focus areas were entered for skin impairment, neurological status, ADL self-care, elopement risk, and verbal behavioral symptoms, these were not completed as part of the initial baseline care plan within 48 hours of admission. Resident #7 had a severely impaired BIMS score of 3/15 and diagnoses including right femur fracture, dementia, and delirium due to a known physiological condition. The admission evaluation lacked baseline care plan assessments for skin integrity, nutrition, neurological status, and pain. Resident #18 had a severely impaired BIMS score of 4/15, diagnoses including hypertension, recent UTI, anxiety, depression, restlessness, and agitation, and required assistance with eating, hygiene, dressing, transfers, and walking; the baseline care plan document was incomplete and did not include multiple needed care areas. Resident #34 had intact cognition with a BIMS score of 15/15 and diagnoses including lumbar compression fracture, hypertension, anxiety, depression, and chronic pain; the baseline care plan document was also incomplete and lacked multiple required care areas, and the admission nursing evaluation had several care plan sections left blank.

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 comprehensive, person-centered care plans for two of five residents reviewed. For one resident with severe cognitive impairment, multiple diagnoses, and a recent admission, the care plan lacked specific, individualized information in focus areas such as hypertension, adjustment to the facility, trauma history, and behavioral problems. Interventions were generic and did not address the resident's unique triggers, behaviors, or needs, nor were they updated as required at the 14-day mark or with subsequent revisions. Observations showed the resident required frequent 1:1 staff attention, wore a wander guard, and exhibited behaviors such as wandering and difficulty with redirection, none of which were adequately addressed in the care plan. Another resident, who had intact cognition and multiple medical conditions including a lumbar fracture, hypertension, anxiety, depression, and chronic pain, also had an incomplete care plan. The plan did not include individualized interventions for psychotropic medication use or behavioral issues, and failed to address anxiety and depression altogether. Interventions for skin integrity were not resident-specific, and documentation of actual skin impairments or treatments was missing. Revisions to the care plan did not consistently reflect the resident's current status or needs. Interviews with facility leadership confirmed that care plans were expected to be complete and person-centered, but acknowledged that the plans reviewed were incomplete and lacked current, individualized information. The facility's policy required comprehensive care plans with measurable objectives and timeframes to be developed within specified timeframes, but this standard was not met for the residents reviewed.

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 notify the provider when a resident's blood glucose levels exceeded 400 mg/dl, as required by physician orders and facility policy. The resident in question had a diagnosis of Type II diabetes mellitus, was severely cognitively impaired, and was receiving insulin therapy. The care plan and physician orders specifically directed staff to call the medical provider for blood glucose readings above 400 mg/dl. Despite this, multiple blood glucose readings over 400 mg/dl were documented in the electronic medical record without corresponding documentation that the provider was notified. Staff interviews confirmed that it was standard practice to notify the provider for such readings, but one LPN stated she did not recall ever calling for this resident's high blood sugars. The DON acknowledged the lack of documentation and suggested that nurses may have called but failed to chart it. The resident's medical record showed several instances where blood glucose levels were significantly elevated, including readings as high as 584 mg/dl, without evidence of provider notification. Nursing notes indicated attempts to administer insulin were refused by the resident, and while there was some communication with a doctor regarding symptoms and monitoring, there was no documentation of provider notification for all high readings as required. The facility's policy required nurses to notify the physician of changes in the resident's condition, including specific instructions for blood glucose thresholds, but this was not consistently followed or documented.

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 medication administration error rate below 5%, as evidenced by surveyor observations, record reviews, and staff interviews. Out of 31 medications observed, 3 were not administered according to provider orders or medication guidelines, and a medicated patch intended for removal was missing and unaccounted for. The issues involved multiple residents with complex medical histories, including severe cognitive impairment, diabetes, schizophrenia, and other chronic conditions. One resident with severe cognitive impairment and hypothyroidism received Levothyroxine significantly later than the ordered administration time and not on an empty stomach as required by the medication guidelines. The nurse administering the medication acknowledged the timing was incorrect but did not notify the provider, and the facility's records did not reflect any follow-up. Another resident with severe cognitive impairment was given PRN melatonin for agitation and anxiety, although the medication was only ordered for trouble sleeping at bedtime. The medication was administered several hours before the prescribed time, and there was no documentation of provider notification or follow-up regarding the resident's behavior or the off-label use of the medication. Additional deficiencies included improper insulin administration technique for a resident with diabetes, where the LPN did not follow the manufacturer's instructions for holding the insulin pen in place, and could not articulate the correct procedure. Another resident with diabetes and severe cognitive impairment received a scopolamine patch without the nurse checking for or removing the previous patch, and the missing patch was not located or documented. The nurse did not follow up with other staff or the provider regarding the missing patch, and there was no documentation in the progress notes about its loss or removal.

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

During medication administration, a nurse was observed failing to follow sanitary procedures as required by facility policy. Specifically, the nurse was seen popping pills into her bare hand before placing them into medication cups, applying a medicated patch without washing her hands afterward, and touching multiple surfaces and personal items between medication passes without performing hand hygiene. The nurse administered medications to several residents, including controlled substances and a transdermal patch, and handled various items such as the medication cart, computer mouse, cabinet doors, and her personal water bottle, all without washing or sanitizing her hands between residents or after potential contamination. The facility's hand hygiene policy, revised in October 2023, requires handwashing immediately before and after resident contact, after touching contaminated surfaces, and after glove removal. Despite this, the nurse administered medications to 17 residents between hand washes and did not use hand sanitizer during the observed period. When questioned, the nurse acknowledged receiving infection control training but admitted to sometimes forgetting to wash her hands. The DON confirmed that nurses are expected to wash their hands between residents and are trained on these procedures before working independently.

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 the correct Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) for one resident and failed to provide Notice of Medicare Non-Coverage (NOMNC) documents for 3 of 3 residents reviewed for ABN. Record review showed that Resident #36 and Resident #22 each had Medicare Part A skilled services that ended, and NOMNC forms were signed for both residents; however, the report identified these as part of the deficiency review for ABN notification. For Resident #37, the SNF Beneficiary Protection Notification Review Form stated that Form CMS-10055 was not provided because the wrong ABN form, CMS-R-131, was used instead. During interview, the Social Worker confirmed she completed the wrong form for Resident #37 and stated she was not aware that CMS form 10123 had expired, noting she had recently received training and had been using the forms provided in that training. The Administrator stated she did not know the forms had changed and that the new forms had already been downloaded for use. The facility policy stated that the SNF ABN is issued when Part A services end and the resident remains in the facility after the Medicare stay, and that the NOMNC letter also needs to be issued.

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 protect residents from sexual abuse, specifically involving two residents. One resident, who was severely cognitively impaired, was subjected to unsolicited sexual touching by another resident. This included incidents where the resident was touched on the breast and buttock. Despite the family of the cognitively impaired resident explicitly instructing the facility staff that they did not consent to any sexual contact, the incidents occurred, indicating a failure in monitoring and intervention by the facility staff. Additionally, the facility did not adequately protect residents from physical abuse. A resident with severely impaired cognition and a history of aggressive behavior physically assaulted multiple other residents. This included hitting, scratching, and slapping other residents. The care plans for this resident included interventions to monitor and redirect behavior, but these measures were insufficient to prevent the physical altercations, suggesting a lack of effective implementation or staffing to ensure resident safety. The facility's policies and procedures regarding abuse were not effectively enforced, as evidenced by the repeated incidents of both sexual and physical abuse. Staff interviews revealed inconsistencies in understanding and applying consent and monitoring protocols, contributing to the failure to protect residents. The facility's abuse policy clearly stated the right of residents to be free from abuse, yet the incidents demonstrated a significant lapse in adherence to these standards.

Removal Plan

• Care Plan revision for Resident #12 and Resident #19.
• All staff education about abuse.
• An ad-hoc Quality Assurance Performance Improvement (QAPI) meeting completed.

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 conduct thorough investigations into allegations of abuse, including injuries of unknown origin, staff rough treatment towards residents, and resident-to-resident incidents. This deficiency affected eight out of twelve residents reviewed for abuse, resulting in Immediate Jeopardy to the health, safety, and security of the residents. The facility did not ensure the separation of alleged perpetrators after becoming aware of the allegations. One resident with moderate cognitive impairment was found with a displaced comminuted fracture of the left humeral neck and greater tuberosity, with soft tissue swelling. The facility's investigation into this injury of unknown origin lacked a root cause analysis and did not identify the potential for abuse. The resident had previously complained of rough treatment by a male CNA, but no specific dates or times were provided, and the facility did not conduct a thorough investigation into these allegations. Another incident involved two residents with a mutual friendship, where one resident allegedly groped the other's breast. The facility's self-report list lacked documentation of this incident, and there was no investigation or separation of the residents involved. Additionally, a resident with a history of physical altercations with other residents was not adequately monitored, leading to multiple incidents of aggression. The facility failed to report these incidents and did not take steps to separate the resident from others.

Removal Plan

• All residents interviewed with no further allegations of abuse or neglect identified.
• All staff interviewed with allegations reported to State Agency and initiated investigation. Any associated staff suspended pending investigation.
• Facility provided all staff education on abuse, immediate separation, and reporting of any abuse immediately to the Facility Administrator. Education completed prior to working next shift.
• An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting conducted to review policy on abuse, immediate separation, reporting of abuse, and completing thorough investigation.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely reporting of abuse allegations, including staff-to-resident rough treatment, resident-to-resident physical altercations, and inappropriate touching incidents. This failure involved ten residents and resulted in Immediate Jeopardy to their health, safety, and security. The incidents included a resident with moderate cognitive impairment who suffered a shoulder fracture of unknown origin, which was not reported as potential abuse until after the injury was discovered. Additionally, there were incidents of inappropriate touching between residents, which were not reported to the State Agency in a timely manner. Another incident involved a resident with a history of aggressive behavior who was involved in a physical altercation with another resident. Despite documentation of the incident, the facility failed to report it as an allegation of abuse. Furthermore, a resident with severely impaired cognition exhibited aggressive behaviors towards other residents on multiple occasions, but these incidents were not reported promptly to the State Agency. The facility also failed to document and report an incident where a resident grabbed another resident's arm. The facility's policy required immediate reporting of suspected abuse, but there was a lack of documentation and timely reporting of several incidents. Staff members were observed handling residents roughly, causing fear and distress, yet these allegations were not reported or investigated as required. The facility's failure to adhere to its abuse reporting and investigation policy contributed to the deficiency, as staff did not consistently report allegations to the Director of Nursing or the Administrator for further investigation.

Removal Plan

• All residents interviewed with no further allegations of abuse or neglect identified.
• All staff interviewed with allegations reported to State Agency and initiated investigations. Any associated staff suspended, pending investigation.
• Facility provided all staff education on abuse, immediate separation, and reporting of any abuse immediately to the Facility Administrator. Education completed prior to working next shift.
• An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting conducted to review policy on abuse, immediate separation, reporting of abuse, and completing thorough investigation.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate assessment and intervention for residents experiencing a change in condition, leading to significant deficiencies. Resident #25 experienced a significant change in status, including difficulty transferring and an unwitnessed fall, resulting in a laceration to the forehead. Despite the fall and subsequent decline in mobility, the facility did not adequately follow up with the physician or conduct necessary diagnostic tests for the head injury. The resident was later diagnosed with a subdural hematoma and passed away, with the death certificate citing complications from the fall as the cause of death. Additionally, the facility failed to complete neurological assessments and post-fall follow-up documentation for Resident #20 after an unwitnessed fall. The resident, who had moderate cognitive impairment and required assistance for mobility, was found on the floor without injury. However, the facility did not adhere to its policy for post-fall monitoring, which required neurological checks at specified intervals. This lack of documentation and follow-up represents a failure to ensure the resident's safety and well-being. The facility also failed to provide continued assessment for Resident #226 after an episode of excessive coughing caused by consuming the incorrect consistency of food. Despite the resident's known dysphagia and dietary restrictions, they were served regular consistency food, leading to coughing and phlegm production. The facility did not promptly assess the resident's condition or notify the physician, and the resident's vitals were not taken until much later. This oversight in dietary management and resident assessment further highlights the facility's deficiencies in care.

Removal Plan

• A comprehensive head to toe assessment conducted and completed for all residents to identify any changes that deviated from their baseline status.
• All staff members received training on how to identify changes in residents' conditions and the importance of reporting these changes to charge nurse. Staff training completed.
• All Charge Nurse staff trained on how to recognize a change in condition and the expectation to notify the attending provider via phone immediately when a change is identified. Charge Nurse training completed.
• Facility conducted an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting to review the change of condition process, assess staff education, and develop auditing mechanisms to monitor and prevent recurrence.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the proper evaluation and use of mobility devices for residents, leading to multiple incidents of falls and injuries. Resident #5, who had a history of falls and severely impaired cognition, was given a three-wheeled walker without a proper evaluation by physical or occupational therapy. This walker was provided by the maintenance department as a replacement for a faulty four-wheeled walker. The resident experienced a fall while using the new walker, resulting in a shattered humerus and hospitalization. Staff interviews revealed that the walker was inappropriate for the resident's needs, and there was a lack of communication and oversight regarding the change in equipment. Resident #22, also severely cognitively impaired, experienced multiple falls, some resulting in injuries such as skin tears and a laceration to the right orbit. The care plan for this resident included several interventions to prevent falls, but the resident continued to experience unwitnessed falls, often in common areas without adequate supervision. Staff interviews indicated that the resident was known to be at high risk for falls, yet there was insufficient monitoring and supervision to prevent these incidents. Additionally, the facility failed to provide adequate supervision for Resident #2, who had a seizure disorder and was at risk for falls. The care plan directed staff to use a gait belt during transfers and to remain with the resident during seizures, but these directives were not consistently followed. An incident occurred where a CNA assisted the resident without a gait belt, resulting in a fall and injury. The facility's failure to adhere to care plan directives and ensure proper supervision and equipment evaluation contributed to the residents' injuries and the overall deficiency in care.

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 the correct diet for two residents, leading to potential health risks. Resident #226, who has a nutritional problem and requires a pureed diet due to chewing and swallowing difficulties, was served regular consistency food by Staff A. This error occurred despite the resident's care plan and dietary orders specifying a pureed diet. After consuming several bites, the resident began coughing excessively, indicating a possible choking hazard. Staff A acknowledged the mistake and corrected it, but the resident continued to cough intermittently even after receiving the correct diet. The Director of Nursing confirmed the dietary requirements and acknowledged the risk of choking if the resident consumed regular consistency food. Resident #11, who has severe cognitive impairment and is on a mechanical soft ground meat diet, was served coleslaw instead of steamed cabbage due to a lack of available ingredients. The Certified Dietary Manager admitted to serving the incorrect food and attempted to mitigate the issue by cutting the coleslaw into smaller pieces. However, this action did not align with the resident's dietary order. The facility's policy on therapeutic diets emphasizes the importance of adhering to diet orders, which was not followed in these instances.

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 sufficient nursing staff to provide care to residents in accordance with their care plans, leading to incidents involving Resident #22, who has a history of physical altercations with other residents. Resident #22, with severely impaired cognition, exhibited physical and verbal behavioral symptoms directed towards others. Despite care plan interventions to monitor and redirect the resident, multiple incidents occurred where Resident #22 physically assaulted other residents, including hitting, scratching, and slapping. These incidents highlight the facility's inability to adequately supervise and manage Resident #22's behavior due to insufficient staffing. Additionally, the facility failed to provide timely assistance to Resident #2, who has a history of falls and seizures. On one occasion, Resident #2 activated the call light during meal time, indicating a need to lie down, possibly due to an impending seizure. However, the nurse left to get assistance, and due to a busy period, returned 10-15 minutes later, during which time the resident fell and sustained a scalp laceration. This incident underscores the facility's failure to have adequate staff available to promptly respond to residents' needs, particularly during critical times. Interviews with staff members revealed that there were often only one nurse and one CNA scheduled for the night shift, which was insufficient to meet the needs of the residents. Staff reported being unable to monitor residents like Resident #22 effectively and having to prioritize tasks, leading to delays in care. The facility's staffing policy, which was supposed to provide sufficient numbers of staff according to resident care plans and facility assessments, was not adhered to, contributing to the deficiencies observed.

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 an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies. This resulted in multiple repeat deficiencies identified during the current recertification and complaint survey. The deficiencies included issues with advanced directives, care plan revision, activities of daily living related to incontinence care, and the lack of a qualified Infection Preventionist to attend Quality Assurance meetings. These deficiencies were previously identified during surveys completed in the last twelve months. The facility reported a census of 26 residents. The Administrator explained that Quality Assurance meetings occurred monthly, with ad hoc QAPI conducted as needed to fix processes. However, the facility's QAPI plan indicated that a broad range of sources, including survey findings, should be used for monitoring and gathering data.

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 accepted standards of clinical practice by preparing medications in advance for multiple residents. During an observation, an LPN was found to have set up medications ahead of time for a resident, leaving an unlabeled medication cup containing three pills in the top drawer of the medication cart. The LPN identified the medications as Amlodipine, Carbidopa, and Citalopram, intended for a specific resident. This practice was repeated on another occasion when three unlabeled medication cups, each containing multiple medications, were found in the medication cart for three different residents who had not yet received their medications because they wanted to sleep in. The Director of Nursing confirmed that staff should not set up medications ahead of time, and the LPN admitted to the error. Another LPN stated that while she did not set up medications in advance, she would label them if necessary. The facility's policy on the storage of medications, revised in 2007, requires that all drugs be stored in a safe, secure, and orderly manner, and in the packaging in which they were received. The failure to follow this policy resulted in the deficiency noted during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to employ a required Quality Assurance (QA) committee member, specifically a qualified Infection Preventionist, to perform infection control surveillance and report to the governing body. The facility's QAPI Plan indicated that staff with the most knowledge and commitment to QAPI efforts should participate, yet review of QAPI sign-in sheets revealed no Infection Preventionist was present at meetings. The Facility Assessment reviewed by the Quality Assurance Committee included infection prevention and control as part of the services offered based on resident needs. However, the Facility Administrator reported that the Director of Nursing (DON) had acted as the Infection Preventionist but was unsure if the DON was certified, and the facility could not produce any certification for an Infection Preventionist. The facility's policy on Infection Prevention and Control Program stated that the program should be coordinated and overseen by a certified Infection Preventionist, which was not adhered to.

Penalty

No penalty information released

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

Summary

The facility failed to provide a qualified Infection Preventionist with specialized training or certification to oversee its Infection Prevention and Control Program. The facility's policy, revised in October 2018, mandates that the Infection Preventionist coordinate and oversee the program. However, during a state survey, the Facility Administrator reported that the Director of Nursing (DON) had been acting as the Infection Preventionist but was unsure if the DON had the necessary certification. The facility was unable to produce any documentation confirming the certification of the Infection Preventionist, and the DON was unavailable to provide further information during the survey. The facility, which had a census of 26 residents, could not present any data indicating that a certified Infection Preventionist was employed at the time of the survey.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the dignity and respect of residents, particularly Resident #20, who was found in unsanitary conditions on multiple occasions. Resident #20, who has moderate cognitive impairment and requires significant assistance for toilet hygiene, was observed by hospice providers to be frequently left in soiled incontinence products, emitting strong odors of urine. On one occasion, the resident was found lying flat on her back with a lunch plate on her abdomen, eating with her fingers, and with food in her hair. Despite staff claims that the resident refused care, hospice staff noted improvements in cleanliness during more recent visits. Additionally, inappropriate comments were made by a Certified Nursing Assistant (CNA) in the presence of residents in the dining room. The CNA was heard making remarks about a resident's eating habits, which were perceived as unkind. Interviews with staff members, including a CNA and the Director of Nursing from a sister facility, indicated concerns about the demeanor and compassion of the CNA involved. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in these instances.

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 safeguard residents' personal and medical information, as observed by the State Agency. On multiple occasions, the computer at the nurses' desk was left unattended with the Point Click Care (PCC) system open, displaying several residents' names. Specifically, on one occasion, the computer was left on and unattended from 08:23 a.m. to 08:26 a.m., and again from 09:22 a.m. until it timed out at 09:31 a.m. Later, at 12:54 p.m., the PCC system was open on a resident's chart with no one at the desk. Additionally, at 02:25 p.m., an LPN left a resident's chart open on the computer while stepping away to another room. The facility's Resident Rights Policy, revised in January 2019, prohibits unauthorized release, access, or disclosure of resident information, emphasizing compliance with privacy laws.

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 notify the Office of the State Long-Term Care Ombudsman of a hospital transfer for one resident. The resident, who had diagnoses including diabetes, non-Alzheimer's dementia, and a psychotic disorder, was assessed with a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. According to the facility's policy on transfer or discharge, dated October 2022, the facility was required to provide notice of therapeutic discharges to the long-term care ombudsman. However, when the resident was transferred to the emergency room for evaluation and treatment, the facility did not document the notification to the ombudsman. The resident returned to the facility two days later, but the lack of documentation of the notification was identified during the review.

Penalty

No penalty information released

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

Summary

The facility failed to revise care plans for four residents following significant changes in their medical conditions and treatments. Resident #5's care plan was not updated after the discontinuation of their antidepressant medication, Trazodone, which was stopped on 10/10/24. Despite the medication being discontinued, the care plan still indicated that the resident was receiving antidepressant medication as of 11/19/24. Resident #22's care plan was not updated to reflect the initiation of hospice services, which began on 9/19/24. The care plan still listed hospice services as pending, despite the resident having started receiving these services. Additionally, Resident #3's care plan inaccurately stated that the resident could transfer independently, while observations on 11/6/24 showed that the resident required assistance from staff for transfers. Resident #10's care plan lacked updates for new skin concerns identified in a Weekly Skin Review on 10/07/24. The review documented a stage three pressure ulcer and other skin issues, but the care plan did not reflect these findings or the interventions noted in the Hospice Admission Note dated 10/14/24. These deficiencies indicate a failure to ensure care plans were revised to accurately reflect the residents' current conditions and 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 ensure consistent documentation of code status for a resident with severely impaired cognition, leading to confusion regarding whether to perform CPR or adhere to a DNR order. The resident's care plan did not address their code status, and discrepancies were found between the IPOST form, which indicated CPR/Attempt Resuscitation, and the electronic orders, which noted a DNR status. Staff B, an LPN, acknowledged the inconsistency and noted that the resident's status changed to DNR after hospice services began, but the IPOST form in the paper chart was not updated accordingly. The Director of Nursing (DON) recognized the issue and explained that the facility was waiting for a wet signature on a verbal order for allowing natural death, which had been mailed to the family. The DON expressed concern that if an emergency occurred, the facility would be obligated to perform CPR due to the outdated IPOST form. The facility's policy stated that CPR should be initiated if a resident's DNR status is unclear, highlighting the importance of accurate and up-to-date documentation to ensure residents' wishes are respected.

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 complete a significant change assessment for a resident who began receiving hospice services. The resident, identified as having severely impaired cognition with a score of 00 out of 15 on the Brief Interview for Mental Status (BIMS) exam, started hospice care on 9/19/24. However, the quarterly Minimum Data Set (MDS) assessment dated 9/18/24 did not reflect the initiation of hospice services, and the subsequent MDS assessment was still in progress. The facility's policy requires a comprehensive assessment when there is a significant change in a resident's condition, as per OBRA regulations, but this was not conducted in a timely manner. An interview with a Director of Nursing (DON) from a sister facility confirmed that a significant change MDS should be completed immediately when such changes occur.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely assistance with incontinence care and positioning for three residents and failed to provide eating assistance for one resident. Resident #3, who has severe cognitive impairment and is always incontinent, was observed sitting in a Broda chair for over three hours without being offered toileting or incontinence care. The resident's care plan required frequent toileting, but staff did not adhere to this schedule, resulting in the resident sitting in a soiled brief for an extended period. Resident #22, also with severe cognitive impairment and requiring assistance with activities of daily living, was found naked and cold in a urine-soaked bed. Despite being informed of the situation, staff initially claimed the resident had just been changed and had the right to be naked. However, a registered nurse intervened to change the resident's clothes and bed linens. The resident's care plan indicated a need for a two-person assist for toileting, which was not provided. Resident #20, with moderate cognitive impairment and requiring assistance with eating, was left in bed with a lunch tray that remained untouched. The resident was later moved to a lobby area where staff attempted to feed them, but the resident refused. The facility's policy required supervision and assistance for residents with cognitive and mobility impairments during meals, which was not initially provided. The Director of Nursing from a sister facility confirmed the expectation for such assistance.

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 ongoing, resident-centered activities for two residents with severe cognitive impairments. Resident #3, diagnosed with non-Alzheimer's dementia, diabetes, and arthritis, expressed interest in group activities, news, and fresh air. Despite a care plan that included various activities such as playing cards, attending group activities, and outdoor events, observations revealed that the resident spent significant time in a Broda chair in the TV area without engagement in activities or conversation from staff. Documentation showed limited participation in activities, primarily watching TV or movies, with only occasional involvement in music and parties. Similarly, Resident #11, with non-Alzheimer's dementia and anxiety disorder, was observed sitting in the TV room without engagement from staff. The care plan directed staff to involve the resident in simple, structured activities, but documentation indicated the resident primarily watched TV or movies, with sporadic participation in church, current events, and music. Staff interviews revealed that residents were often bored, and the Activity Director struggled to provide adequate activities due to additional social worker duties. The facility's policy required individualized activity plans, but the implementation was insufficient to meet the residents' 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 treat a urinary tract infection (UTI) in a timely manner for a resident with severely impaired cognition, as indicated by a score of 5 out of 15 on the Brief Interview for Mental Status (BIMS) exam. The resident was frequently incontinent of urine and had a care plan in place to monitor for signs and symptoms of UTIs. Despite the resident exhibiting increased urinary incontinence and foul-smelling urine on 10/25/24, the facility delayed in obtaining a urinalysis (UA) and culture and sensitivity (C&S) test. The UA was not sent to the lab until 10/29/24, and the culture results indicating the presence of Klebsiella Pneumoniae were not received until 11/1/24. The facility's policy on antibiotic stewardship required that lab results and the current clinical situation be communicated to the prescriber as soon as available. However, the new order for antibiotic treatment with Macrobid was not issued until 11/5/24, resulting in a delay in treatment. Interviews with staff revealed that while the UA should typically be processed the next day, the C&S results took longer than usual, contributing to the delay. The Director of Nursing from a sister facility indicated that results should be sent to the clinic promptly, and if not received within an hour or two, follow-up actions should be taken. This delay in communication and action led to the deficiency in timely treatment of the resident's UTI.

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 the dimensions from the mattress to the bed rail or the bed rail gaps were less than 4 3/4 inches, posing a risk of entrapment or injury for a resident. The resident, who had a seizure disorder, anxiety disorder, and depression, was independent in certain movements but had severely impaired cognition with a BIMS score of 0 out of 15. The resident used bed rails for mobility and security due to a fear of falling out of bed. The facility's care plan acknowledged the risk of injury related to the use of bed rails. During an observation, the Maintenance Director measured the gaps in the resident's bed rail system and found them to be significantly larger than the recommended 4 3/4 inches. The Maintenance Director admitted to not conducting any audits and was unaware of the maximum gap size requirement. The Administrator acknowledged that the bed was old and believed that nursing and therapy staff should be responsible for checking side rail safety. The facility's policy, revised in December 2007, stated that gaps in the bed system should comply with FDA guidelines, which was not adhered to 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 provide necessary behavioral health care and services for a resident with a history of traumatic brain injury, depression, and alcohol abuse with alcohol-induced mood disorder. The resident exhibited physical and verbal behavioral symptoms directed toward others, as well as other behavioral symptoms not directed toward others, and rejection of care. Despite these behaviors, the resident's care plan lacked recent interventions to guide staff on managing these behaviors during care. The facility's policy on behavioral assessment and intervention did not address the provision of psychiatric services, which were inconsistent due to staffing changes. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition, and the care plan entries highlighted the resident's mood disorder and risk for inappropriate behaviors. However, the facility did not provide documentation of psychiatric services beyond a visit in April, despite ongoing behavioral issues noted in behavior notes. The Director of Nursing acknowledged the absence of Telehealth psychiatric services for a period, and the Administrator noted the need to reestablish consistent psychiatric services. The facility's failure to provide necessary psychiatric services and update the care plan with recent interventions contributed to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate below 5%, with a calculated error rate of 12%. This deficiency was identified through observations, clinical record reviews, policy reviews, and staff interviews. The errors included administering an incorrect dose of Vitamin D3 to a resident, failing to prime an insulin pen before administration, and not administering insulin in a timely manner relative to meal times. Specifically, a Licensed Practical Nurse (LPN) administered 125 micrograms of Vitamin D3 instead of the prescribed 50 micrograms. Additionally, the LPN did not prime the insulin pen before setting the dose for two types of insulin, Humalog and Humulin, and administered the insulin 34 minutes before the resident's breakfast, contrary to the prescribed timing. The facility's policy on administering medications, revised in December 2012, directed staff to follow medication orders, including any required time frames. The Humalog insulin patient information and instructions for use specify that Humalog should be injected within 15 minutes before or right after eating a meal, and the pen should be primed with 2 units before use. Similarly, the Humulin instructions direct priming the needle with 5 units before use. The Director of Nursing (DON) confirmed that residents should receive fast-acting insulin with their meals and acknowledged the error in timing. The DON of a sister facility also stated that staff should follow medication orders.

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 were free from significant medication errors, specifically in the administration of insulin. A resident with diabetes and severely impaired cognition received rapid-acting insulin without consuming food in a timely manner. The resident's blood sugar was checked, and insulin was administered at 6:26 a.m., but the resident did not receive breakfast until 6:46 a.m., despite the facility's policy that fast-acting insulin should be given with meals. The Director of Nursing confirmed that breakfast started at 7:00 a.m., and residents did not receive breakfast earlier, which led to a delay in the resident consuming food after insulin administration. Additionally, the facility failed to prime insulin pens before administration. The LPN responsible for administering the insulin did not initially prime the pens before setting the dosage, which is against the instructions for use of both Humalog and Humulin insulin pens. The facility's policy on administering medications requires adherence to orders, including any required time frames, which was not followed in this instance. The failure to prime the insulin pens and the delay in food consumption after insulin administration contributed to the significant medication error.

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 all menu items were served to residents on a pureed diet, specifically affecting two residents. Resident #1, who has a diagnosis of Cerebral Palsy and requires a pureed diet with honey thickened liquids, was not served the menu items as listed. The care plan for Resident #1 was revised on 2/20/24, and the diet order dated 10/27/2017 specified a regular, puree texture diet with honey consistency drinks. A nutritional assessment dated 11/04/24 indicated that Resident #1 remains at increased risk for altered nutrition. Similarly, Resident #226, who has nutritional problems and requires a regular diet with pureed texture, was also not served the menu items as listed. The care plan for Resident #226, dated 10/31/24, and the diet order from the same date, specified a regular, puree texture diet with thin liquids. A nutritional assessment dated 11/04/24 noted that Resident #226 is at increased risk for altered nutrition due to co-morbidities, chewing and swallowing difficulties, and modified texture. On 11/05/24, the Dietary Manager served a pureed hot dog with bun and sauerkraut instead of the smoked sausage and roll with margarine listed on the menu, failing to follow the planned menu for residents on a pureed diet.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the accuracy of medical records for two residents, one receiving hospice services and another with a change in condition. For the resident receiving hospice services, discrepancies were noted between various records. The Minimum Data Set (MDS) assessment indicated the resident had Parkinson's disease, anxiety, and depression, with moderately impaired cognition. Despite being discharged from hospice on a specific date, subsequent nursing and provider notes inaccurately documented the resident as continuing hospice care. This inconsistency was acknowledged by the facility administrator, who stated that records should be accurate. For the second resident, who had moderate cognitive impairment and a history of falls, the facility's documentation was inconsistent regarding an unwitnessed fall and subsequent injury. The resident was found with swelling and bruising on the left shoulder, leading to an emergency room visit. However, there was no clear documentation of a fall, and the cause of the shoulder fracture remained unknown. The Director of Nursing (DON) was unaware of notes indicating a fall with a fracture, and the facility's investigation summary did not clarify the incident. The facility's policy emphasized the need for complete and accurate documentation to facilitate communication among the interdisciplinary team.

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 infection control practices during a medication administration for one of the residents. During an observation, an LPN administered several medications to a resident, including Lisinopril, Olanzapine, calcium and vitamin D, iron, and Omeprazole. One of the pills was dropped by the resident into their lap, and the LPN picked it up with her bare hand and placed it back into the resident's mouth. This action was contrary to the facility's policy, which requires staff to follow infection control procedures, including using gloved hands when handling medications. The Director of Nursing from a sister facility confirmed that staff should use gloves when picking up medications.