Hickory Vlg Nrsg & Rhb

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 environment in its common areas, affecting all 69 residents. Observations included dirt-stained floors in the dining room and hallways, dried brown substances dripping on walls, a dried yellow stain at the entrance to the men's restroom, and large dried red and brown stains in the group room. These conditions were confirmed by the facility administrator, who acknowledged that the floors and common areas should be cleaned daily but was unable to identify the substances causing the stains. Additionally, a resident with a BIMS score indicating cognitive intactness reported feeling that the facility was never cleaned or repaired, expressing emotional distress about the environment. Further inspection revealed a bathroom with a toilet bowl and seat covered in a dried brown substance, identified as fecal matter, and a strong odor of feces. Staff members, including an activity aide and the activity director, confirmed the presence of these stains and odors, with uncertainty about how long the stains had been present. The facility's own housekeeping policy requires a clean, odor-free, and comfortable environment, and resident rights documents mandate that the facility be safe, clean, and homelike. Despite these policies, the observed conditions demonstrated a failure to meet 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 maintain an accurate account of a resident's personal funds, as evidenced by discrepancies in the reported balance of the resident's trust fund account. During an interview, the resident expressed uncertainty about his trust fund statement and account balance, stating that he only receives $30 a month. The Business Office Manager initially presented documentation showing a balance of $1,510.13 in the resident's trust fund account, but later corrected this to $754.00, admitting to not keeping an accurate account of the resident's funds. The facility's policy on resident personal trust funds requires the Business Office Manager to maintain a full and separate accounting of each resident's personal funds, in accordance with generally accepted accounting principles. The policy also mandates monthly audits and balancing of the personal funds bank account. However, the facility was unable to provide documentation of an accurate account for the resident's trust fund upon the exit of the survey, indicating a failure to adhere to their own policy and maintain proper financial records for the resident.

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 refer a resident with a mental health diagnosis for a PASARR level 2 screening. This deficiency was identified for one of three residents reviewed for PASARR screening and assessments. The Social Service Director acknowledged that the resident, who had a diagnosis of serious mental illness (SMI), was not referred for the necessary screening due to an oversight. The resident's face sheet indicated a diagnosis of depression, and the Minimum Data Set (MDS) section I confirmed this diagnosis.

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 effectively supervise a resident with a history of alcohol abuse, leading to a serious incident. The resident, who had a restricted community pass, was able to independently access the community and obtain two 1.0-liter bottles of alcohol-based mouthwash. Upon returning to the facility, the resident was found yelling and screaming with altered mental status, and was later hospitalized with a high alcohol level of 183, which is significantly above the normal range of 0-10. The resident subsequently passed away, with the death certificate citing cardiopulmonary arrest due to acute kidney failure and alcohol abuse as the cause of death. Interviews and record reviews revealed that the facility's staff, including the Director of Nursing (DON) and Certified Nurse Aide (CNA), were aware of the resident's behaviors and the presence of mouthwash in the resident's room. However, there was a lack of effective monitoring and intervention to prevent the resident from consuming the mouthwash. The facility's policy required staff to check residents' belongings upon their return from outside passes, but this was not adequately enforced, allowing the resident to possess and consume the mouthwash. Additionally, there was confusion among the staff regarding the resident's community pass status. The Social Services staff indicated that the resident did not have an independent pass, yet records showed that the resident had been signed out on independent passes multiple times. This inconsistency in the resident's care plan and community access privileges contributed to the failure in preventing the resident from obtaining and consuming alcohol, ultimately leading to the resident's hospitalization and death.

Removal Plan

• Ambulance was contacted for R1 nonemergent transfer to the hospital for behaviors. R1 was evaluated at the emergency room.
• Facility identified residents who are at risk for obtaining contraband. This was determined by diagnosis of history of substance abuse. Independent passes were reviewed. Current substance abuse was assessed.
• Residents were interviewed and asked if they were in possession of any contraband. All residents interviewed denied having any contraband.
• Residents consented for room search with resident present and no contraband was identified.
• Residents have been offered counseling with facility counselor.
• Facility will conduct random checks with resident present to ensure no contraband is in room. Random checks will be completed once per week.
• Staff will check residents' bags upon return from out on pass to ensure no contraband is in bags. Any items identified as contraband will be removed from bags and placed in social service office.
• Alcohol based mouthwash will be considered contraband for residents with a substance abuse diagnosis.
• DON and Administrator will educate staff including staff on leave and on vacation on facility's prohibited (contraband) items.
• Staff will complete test to gauge understanding of teachings.
• All facility staff including staff on leave and on vacation will be educated and trained on signs and symptoms of alcohol intoxication and alcohol poisoning.
• Staff will complete test to gauge understanding of teachings.
• DON will in-service all nurses including nurses on leave and on vacation on Change of Condition Policy.
• Staff will complete test to gauge understanding of teachings.
• Residents who have an independent pass and DX of substance abuse will be re-assessed for Community Pass. Completed by Social Service Director.
• Residents who go out on pass supervised or independent will be subject to a search of bags that were brought in.
• Prohibited items will be removed immediately and kept at social service office.
• Staff will inventory bags brought in from community.
• Designee will review items that were brought in the next day for compliance.
• Social service will provide list of residents who are on Community Pass Restriction to Nurses to communicate any updates to ensure residents who are on restriction do not leave for independent pass.
• Nurses will be in-serviced on process.
• It is not a new procedure to notify nurses of resident's pass privilege. Community Pass Policy Updated to reflect notification to nurses of resident's pass privilege.
• Community Pass Privilege or Restriction of Community Pass will be documented in the resident's physician orders. Community Pass Policy updated to reflect documentation in physician orders of pass status.
• Facility held resident counsel to discuss facility's prohibited and contraband items. All residents attended.
• Residents will complete test to gauge resident's understanding of teachings.
• Facility will place the list of prohibited items at the back entrance to inform family and visitors.
• Medical Director made aware of IJ.
• Administrator coordinator or designee will conduct QA studies: A QA study will be performed at random weekly to ensure residents who are at risk of obtaining contraband do not have prohibited items in room. The QA will be completed weekly for 3 months.
• A QA study will be performed random twice weekly to ensure staff knowledge of signs and symptoms of alcohol intoxication and alcohol poisoning. The QA will include 5 staff members twice weekly for 3 months.
• A QA study will be performed random twice weekly to ensure residents do not bring in prohibited items from the community. The QA will include 5 residents twice weekly for 3 months.
• A QA study will be performed random twice weekly to ensure that a physician order reflecting residents community pass privilege is up to date, reviewing community pass logs to ensure residents sign in and out from pass, and to ensure nurses are aware on who is restricted from community pass.
• QA audits will be presented and reviewed at the facility monthly QA meetings for three months to ensure maintained compliance, and on an as needed basis thereafter as deemed necessary by the QA committee.
• An emergency QAPI was conducted.

Penalty

Inspection fine: $131,7631 days payment denial

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 adequately supervise a resident identified as a high fall risk, who was dependent on staff for bed mobility and toileting. The resident was left unattended on their side on an elevated bed by a CNA, who had turned the resident to their side to provide incontinence care. The CNA raised the bed to waist level and turned the resident away from her, leaving the resident on their side while she went to retrieve linen from a dresser. During this time, the resident fell from the bed, resulting in an unwitnessed fall. The resident, who was cognitively intact and had a history of rheumatoid arthritis, depressive disorder, bilateral osteoarthritis of the knees, restless leg syndrome, and fibromyalgia, was subsequently transferred to the hospital. An X-ray confirmed an acute fracture in the left pubic bone, extending to the left superior pubic ramus. The incident was documented in the facility's accident management meeting form, which identified the root cause as the CNA stepping away from the resident during care, leading to the fall.

Penalty

Inspection fine: $131,7631 days payment denial

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

Summary

The facility failed to adhere to its notification of change guidelines by not promptly reporting a resident's fall to the physician and resident representative. The incident involved a resident who was admitted with multiple diagnoses, including rheumatoid arthritis and fibromyalgia, and was cognitively intact. On December 25, 2024, the resident experienced a witnessed fall while staff was providing care. However, the nurse responsible, identified as V5, did not notify the family, physician, or management about the fall on the day it occurred. The Director of Nursing confirmed that the facility's procedure requires immediate notification of the family, physician, and management in the event of a fall, and this should be documented in the medical record. The nurse, V5, admitted to forgetting to complete an incident report or notify the necessary parties. The facility's event report and progress notes corroborated the lack of notification. As a result of this failure to follow protocol, V5 was terminated from her position.

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 a resident, identified as R2, from abuse by another resident, R1. R2, a cognitively intact female with multiple diagnoses including Alzheimer's disease and bipolar disorder, reported an incident where R1, a male resident with a history of mental health issues, entered her room and kissed her on the cheek without her consent. This incident was witnessed by another resident, R3, who asked R1 to leave. R2 immediately reported the incident to a Certified Nursing Assistant (V5) and a Licensed Practical Nurse (V4). The facility's administrator (V1) was informed of the incident and conducted interviews with R2 and R3, both of whom provided consistent accounts of the event. The facility's abuse policy, revised in October 2022, emphasizes the residents' right to be free from abuse, including sexual harassment and non-consensual contact. Despite the policy, the facility substantiated the abuse allegation based on the corroborated testimonies of R2 and R3, highlighting a failure to protect R2 from inappropriate behavior by R1.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its abuse prevention policy by not implementing strategies to reduce the likelihood of abuse and failing to identify behaviors in residents that could lead to abuse. This deficiency was observed in four out of six residents reviewed for abuse. One resident, a male with a history of schizoaffective disorder and violent behavior, was involved in a physical altercation with his roommate. The altercation resulted in the roommate sustaining a small abrasion. The facility did not educate the roommate on potential triggers for aggression, which could have prevented the incident. Another resident, a female with a history of bipolar disorder and schizophrenia, exhibited aggressive behavior by scratching a staff member and another resident. Her care plan did not include interventions for behaviors identified in her preadmission screening, indicating a lapse in updating care plans to reflect current needs and behaviors. The facility's psychosocial services director acknowledged being behind in updating care plans, which contributed to the oversight. The facility's abuse policy emphasizes the importance of creating a resident-sensitive environment to prevent abuse. However, the failure to assess and document residents' triggers and behaviors, as well as the lack of education provided to potential roommates, demonstrates a significant gap in the facility's approach to abuse prevention. This oversight led to incidents of aggression and physical altercations among residents, highlighting the need for comprehensive care planning and staff education.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its policy and procedures for abuse reporting by not ensuring an incident of resident-to-resident abuse was reported to the administrator or the state agency. This deficiency involved two residents, a female with a history of Bipolar Type Schizoaffective Disorder, Schizophrenia, Epilepsy, and Dementia, and another female with a history of Post Traumatic Stress Disorder, Bipolar Disorder, Depression, Anxiety Disorder, Blindness in One Eye, and Seizures. The incident occurred when the first resident scratched the second resident, as well as a Certified Nursing Assistant, during an interaction. The progress notes for the second resident did not document the incident of being scratched, and the facility's abuse investigation reports for September did not include this event. The administrator was only informed of the incident several days later, and it was noted that the nurse on duty would be counseled on the importance of reporting such incidents immediately. The facility's abuse policy requires employees to report any potential abuse to a supervisor, who must then report it to the administrator or a designated individual in the administrator's absence, and any non-serious incidents must be reported to the state agency within 24 hours.

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 comprehensive care plans for two residents, R1 and R4, as required by their care planning policy. R1, a male resident with a history of mental health disorders, was admitted with a Level II PASRR that identified his interests in sports, particularly soccer, and the need for socialization and recreation activities. However, his care plan did not include these interests, focusing instead on arts and crafts, which he declined to participate in. The Activities Director, V8, was unaware of R1's interest in sports and stated that she only included information directly provided by residents. The Administrator, V1, acknowledged that past medical records should be considered in care planning, as residents may not always communicate their interests due to discomfort or communication challenges. R4, a female resident with a history of bipolar disorder, schizophrenia, epilepsy, and dementia, was admitted with a Level II PASRR that documented her mental health symptoms, including being easily upset and having rapid emotional changes. Despite these identified behaviors, her care plan did not include interventions to address them. The Psychosocial Services Rehabilitation Director, V7, admitted that the behaviors listed in R4's PASRR should have been included in her care plan but stated he was behind in updating care plans. The facility's care planning policy emphasizes the need for individualized comprehensive care plans that incorporate identified problem areas, risk factors, and residents' needs and preferences.

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 social services staff to meet the behavioral health needs of its residents, specifically impacting a resident with a complex psychiatric history. This resident, a male with diagnoses including Schizoaffective Disorder, Schizophrenia, and Major Depressive Disorder, exhibited violent and aggressive behaviors, leading to multiple hospitalizations over a few months. Despite the resident's documented need for routine mental health follow-up, the facility's social services staff interacted with him only three times between June and September 2024. The resident's care plan and PASRR Level II assessment highlighted his history of aggressive behavior and the necessity for regular mental health professional follow-up. However, the facility's records show that the resident experienced mood instability, hallucinations, and aggressive outbursts, resulting in several emergency hospitalizations. These incidents included calling 911 due to dissatisfaction with his medication and exhibiting violent behavior towards family members during visits. Interviews with facility staff revealed that the social services team, consisting of only two members, was unable to provide the necessary support and frequent check-ins for the resident. The Psychosocial Services Rehabilitation Director acknowledged the resident's need for more frequent interaction but cited staffing limitations as a barrier. The facility's policy mandates the provision of medically related social services to help residents achieve their highest practicable mental and psychosocial well-being, which was 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 its abuse policy, resulting in a deficiency where a staff member was allowed to tease and laugh at a resident, identified as R2. R2, a resident with a history of bipolar disorder, schizophrenia, and drug-induced parkinsonism, reported that staff members V5, V8, and V9 were verbally inappropriate during an overnight shift. R2 claimed that the staff called R2 names, made derogatory comments about R2's mother, and laughed at R2. This incident was corroborated by another resident, R3, who witnessed the staff's behavior and confirmed that R2 was being bullied and disrespected. The incident occurred when R2 was being monitored in the dining room due to being a potential fall risk. Despite R2's requests to be put back to bed, the staff refused, and R2 had to remain in the dining room all night. R3, who was present in the dining room, reported that the CNAs V5 and V8 were making rude comments and that the nurse, V9, did not intervene. R3 also noted that V9 made a comment suggesting that the situation was meant to teach R2 a lesson. R2 was visibly nervous and shaking, but the staff only instructed R2 to calm down without offering further assistance. The facility's investigation revealed that V5, V8, and V9 were terminated following the incident. The termination reports indicated that V5 and V8 were dismissed for mental abuse, while V9 was terminated for failing to supervise and stop the inappropriate behavior. The facility's policies on resident rights and abuse prevention emphasize the importance of treating residents with dignity and respect, and the failure to uphold these standards led 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 follow its policy and procedures to ensure food was prepared under sanitary conditions. During a kitchen tour, the surveyor observed multiple instances of unsanitary conditions, including an ice machine with residue, rust, and black buildup, improperly stored and labeled food items, and dirty kitchen equipment. The Dietary Manager admitted that the ice machine is cleaned every six months and that all kitchen staff are responsible for daily cleaning, but the observed conditions indicated a lack of adherence to these protocols. Additionally, the kitchen environment was not maintained to prevent contamination, with cracked floor tiles, rust, buildup, and residue observed in various areas, including the three-compartment sink, water temp booster, and dishwashing machine area. The Dietary Manager acknowledged that the kitchen requires more attention due to the lack of ventilation and the age of the building, which contributes to the buildup of dust and residue. Further observations revealed that the dietary staff did not perform hand hygiene when necessary, as evidenced by a Dietary Aide who dropped a water pitcher lid, picked it up, and continued to fill water pitchers without washing her hands. The Cook also used a food processor to make peach puree without allowing it to air dry completely after washing it in the dishwashing machine. The Administrator confirmed that holes should be sealed for pest control and that the food processor must be air-dried between uses to prevent cross-contamination. The facility's policies on dietary infection control, weekly cleaning assignments, and handwashing were not followed, leading to unsanitary conditions and potential risks for foodborne illnesses. The facility's Dietary Infection Control Policy and Weekly Cleaning Assignments outline the requirements for maintaining a clean and sanitary kitchen environment, including labeling and dating food, cleaning equipment thoroughly between uses, and discarding contaminated food. The Handwashing Policy mandates that food and nutrition service employees wash their hands after touching anything unsanitary. However, the observed deficiencies indicate that these policies were not adhered to, resulting in unsanitary conditions that could affect the health and safety of the 66 residents receiving food from the facility.

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 designate a qualified infection preventionist responsible for the infection prevention and control program. The Assistant Director of Nursing, who has been serving as the Infection Preventionist (IP) for approximately four years, had only completed the CDC Nursing Home Infection Preventionist Training Course on the same day the certificate was reviewed. Additionally, the facility did not provide a policy for infection preventionist qualifications when requested.

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%, resulting in a 14.81% error rate during a medication pass observation. An LPN was observed preparing and almost administering incorrect medications to two residents. For one resident, the LPN prepared and nearly administered Norco 5/325 mg instead of Lorazepam 1 mg, and also gave Cyanocobalamin 100 mcg instead of the prescribed Cyanocobalamin ER 1000 mcg. For another resident, the LPN prepared and almost omitted Atenolol 25 mg and administered Cyanocobalamin 100 mcg instead of the prescribed Cyanocobalamin 500 mcg. These errors were identified and stopped by the surveyor before the incorrect medications were fully administered. The LPN did not follow proper infection prevention practices during medication administration, as she did not wash her hands or use alcohol-based hand rub between administering medications to five residents. Additionally, the LPN improperly handled medications by using her bare hands to return a pill to its original container, which is against the facility's medication administration policy. The LPN also failed to report all medication errors to the Director of Nursing (DON) and only reported one error to the front office. The facility's policies and procedures for medication administration and infection control were not adhered to by the LPN. The Director of Nursing confirmed that medication administration should follow the five rights, infection control standards, and that any medication errors should be immediately reported to the attending physician, DON, and pharmacist. The facility's medication administration policy explicitly states that no medication may be returned to its original container once removed, and all medication errors must be documented and reported immediately.