Hillsboro Rehab & Hcc

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect multiple residents from physical abuse and resident-to-resident altercations. One resident with Klinefelter syndrome, intellectual disabilities, moderate cognitive impairment, and depression-related behavior problems reported that another cognitively intact resident with bipolar disorder and a history of aggression hit him on the right cheek and chest in the dining room. Documentation shows a new red area on his cheek, pain requiring Tylenol, and an undated statement in which he described being hit three times in the face and chest after taking back his candy. The facility’s report to the state agency notes there were no witnesses and that staff encouraged the two residents to remain in different areas of the dining room. Another incident involved two residents with dementia and bipolar or behavioral disturbances who engaged in a physical altercation in the dining room. One resident, who was moderately cognitively impaired and required partial assistance with mobility, reported that the other resident began yelling, talking badly to her, grabbed her arm, and tried to choke her before staff intervened. A CNA’s written statement and subsequent interview describe hearing yelling, then seeing one resident hitting with a fist and the other slapping, with both residents’ hands making contact. Progress notes and the facility’s report to the state agency document that both residents were yelling and slapping each other before staff could reach them. Additional altercations occurred involving residents with severe cognitive impairment and behavioral problems. In one case, a resident with vascular dementia and severe cognitive impairment struck another resident whose wheelchair had become entangled with his; staff statements and the facility’s report differ on whether the blow landed on the arm or face, but consistently describe the resident swinging his arm in agitation and making contact. In another case, a severely cognitively impaired resident with vascular dementia and potential for aggression was involved in a hallway altercation with a resident with dementia and behavioral disturbance; staff statements describe both residents yelling and hitting or slapping each other on the arms, chest, face, and hands before being separated. Across these events, residents with known behavior problems and aggression potential engaged in physical contact with one another, resulting in multiple instances of resident-to-resident physical abuse and altercations.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure sufficient nursing staff on all shifts to meet residents’ needs and to have a licensed nurse in charge on each shift. Resident council minutes documented that residents reported a need for more night staff. A daily staffing sheet for a specific date showed that only one RN (identified as V21) was working the entire midnight shift for a census of 80 residents, despite the staff scheduler stating that, based on census and level of care, there should have been two nurses on that shift. The staff coordinator/scheduler (V22) reported that when the evening nurse’s relief did not arrive, she instructed the evening nurse to stay, but the nurse refused, and despite offering bonuses, no additional nurse could be obtained. V22 stated she is a CNA and could not perform nurse duties, and there was no other nurse available to cover the shift. Multiple cognitively intact residents reported that staffing was inadequate, especially at night, and that call lights took a long time to be answered. One resident stated the facility had problems with staffing and needed to hire more staff; another stated there were no staff and it was worse on nights, and another reported staff told them they were short and that it took a long time to receive care. A CNA confirmed that V21 was the only nurse in the building for the entire night shift. V21 stated he was the only nurse for the entire building from around 11 p.m., that the evening nurse left despite his refusal to cover the hall alone, and that his attempts to contact management for assistance went unanswered. He described the night as challenging, with residents experiencing changes in condition requiring hospitalization and no additional nursing help. Another cognitively intact resident reported that staffing was bad and slow, that the facility relied heavily on agency staff who might not show up, leaving residents without care or with poor care. The DON stated the facility did not have a staffing policy, while the administrator stated the facility followed CMS regulations.

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

Surveyors identified a failure to properly secure and store controlled medications and to discard expired medications for seven residents reviewed for medication storage. During inspection of the medication room, the refrigerator was found unlocked while containing a resident’s bottle of oral lorazepam concentrated solution, despite facility policy requiring biologicals or medications requiring refrigeration to be kept in a securely fastened or locked refrigerator system. On a medication cart, an open and partially used vial of insulin glargine solution for another resident was found with a handwritten open date of 1/5/26, while the manufacturer’s expiration date on the vial was November 2025, indicating the insulin was in use past its expiration date. Further inspection of another medication cart on a different hall revealed that the lock box intended for controlled substances was unlocked and could be opened simply by lifting the lid. Inside this unlocked lock box were multiple open and unopened controlled medications in active use for several residents, including morphine sulfate oral solution, lorazepam concentrated solution, oxycodone, hydrocodone/APAP, alprazolam, and tramadol tablets. A LPN acknowledged that the lock sometimes gets stuck and does not latch, and verified that these controlled medications were in use while stored in the unlocked lock box. Another LPN later stated that all narcotics and controlled medications are supposed to be under a double-locked system, and that controlled medications in the refrigerator and on the medication cart should be secured according to this standard, as reflected in the facility’s written policies on storage of drugs and Schedule II controlled substances.

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 prevent abuse and did not document progressive interventions for three residents who were identified as vulnerable due to severe cognitive impairment and dementia. Multiple incidents occurred in which one resident, who had a history of aggressive behavior related to dementia, physically assaulted other residents. These incidents included one resident placing her hands around another resident's neck, hitting another on the head, pushing down on a resident's chest, and slapping another resident. In each case, the residents involved were unable to provide statements due to their cognitive status, and staff intervened to separate the individuals and conduct assessments. The care plans for the residents involved did not include documentation of abuse or progressive interventions following these incidents. The aggressive resident's care plan noted the potential for aggression and included general interventions such as calm redirection, removal from situations, and 1:1 observation, but did not reflect updates or specific interventions after each incident. The facility's records show that the same resident was repeatedly placed on 1:1 observation and sent to the hospital after each event, but there was no evidence of care plan updates or additional measures to address the ongoing risk. Staff interviews confirmed that the aggressive behaviors were witnessed and responded to in the moment, but there was uncertainty about the duration and implementation of 1:1 observation and a lack of clarity regarding the facility's policy on managing such behaviors. The administrator acknowledged the absence of updated progressive interventions in the care plan and ongoing challenges with the resident's power of attorney, which impacted decision-making for further placement. The facility's abuse policy prohibits mistreatment and requires staff education, but the documented failures resulted in residents experiencing physical and emotional harm.

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

A deficiency occurred when a resident, who was care planned and ordered to be transferred with the assistance of two staff members due to instability and a history of falls and fractures, was transferred by only one CNA. The CNA admitted to transferring the resident alone because the facility was short-staffed, resulting in the resident's left foot becoming caught in the wheelchair wheel and a subsequent fall back onto the bed. The resident sustained swelling, bruising, and was later diagnosed with an acute on chronic distal tibial fracture. The CNA did not immediately report the fall to nursing staff, and the injury was only discovered when therapy staff assessed the resident for therapy later that morning. The care plan was not updated promptly to reflect the new transfer status (mechanical lift) after the incident. Another deficiency was identified regarding a second resident with a history of falls and cognitive impairment. After experiencing two unwitnessed falls, the resident's care plan was not updated with progressive interventions to prevent future falls until several days later. There was also a discrepancy in the documentation dates for when new fall prevention interventions, such as a scoop mattress and low bed, were implemented. Staff were unable to clarify when these interventions were actually put in place, and there was confusion regarding the accuracy of the electronic medical record. The facility lacked a clear policy on following physician's orders for transfer status, and some staff were unaware of where to find residents' transfer requirements. This contributed to improper transfers and delayed implementation of necessary interventions to prevent further accidents. The failures resulted in injury to one resident and inadequate fall prevention measures for another.

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 a resident's emergency contact after the resident sustained an injury and was transferred to the emergency room. According to the resident's face sheet, a specific individual was listed as the emergency contact. The resident, who was alert and had a history of previous injuries and hardware in her left leg, experienced swelling and bruising on her left lower extremity after her feet gave out during a transfer. Physical therapy staff informed the RN, and a nurse practitioner assessed the resident, resulting in an order to send her to the ER for imaging. The resident was transported to the ER via EMS. Despite the facility's policy requiring notification of the resident's representative in the event of significant changes such as swelling, skin discoloration, or transfer from the facility, the emergency contact was not informed by facility staff. Instead, the resident herself called her emergency contact from the emergency room to report the injury and transfer. The emergency contact expressed upset at not being notified by the facility, stating she would have provided family support at the ER if she had been informed.

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 end-of-life and hospice skin care plan interventions for a resident who was at very high risk for skin breakdown and was dependent on staff for all mobility. The resident had multiple diagnoses, including dementia, COPD, severe malnutrition, diabetes, and was re-admitted to the facility with an existing sacral pressure ulcer. Upon re-admission, hospice services were initiated, and the hospice plan of care included specific wound care instructions and the use of an alternating pressure pad. Despite these orders, the facility did not ensure that the prescribed pressure-relieving mattress or overlays were placed on the resident's bed, and the wound care interventions were inconsistently applied. Multiple staff interviews and record reviews revealed that the hospice-provided air mattress overlay was never implemented, with conflicting explanations from staff regarding its safety and appropriateness. The Director of Nursing (DON) and other staff members acknowledged that the overlay remained unused in the resident's closet, and there was no documentation of efforts to obtain or use alternative pressure-relieving surfaces in a timely manner. Additionally, weekly wound assessments and documentation were not consistently performed, and there were lapses in monitoring and dressing the resident's wounds as required by both facility policy and the hospice care plan. The resident's family, who had medical experience, also reported concerns about the lack of appropriate wound care and the absence of a dressing on the sacral wound. As a result of these failures, the resident developed multiple new in-house acquired pressure ulcers in addition to the original wounds, as documented in the facility's records and confirmed by staff and hospice personnel. The facility's own policies required individualized interventions, regular skin assessments, and coordination with hospice providers, but these were not followed. The lack of timely and appropriate interventions directly contributed to the resident's skin breakdown and the development of additional pressure ulcers prior to the resident's death.

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 allegations of verbal abuse were reported immediately to the Administrator and in a timely manner to the State Agency for one resident. The resident, who was cognitively intact and required some assistance with activities of daily living, reported that the Social Service Director (SSD) yelled at her. Multiple Certified Nursing Assistants (CNAs) witnessed the SSD yelling at the resident, going through her drawers, slamming them, and slamming the door upon leaving. Despite witnessing the incident, none of the CNAs reported the event, expressing a belief that reporting would not result in any action by management. There was no documentation in the resident's electronic medical record regarding the alleged verbal abuse, and the incident was not reported until it was brought to the attention of the facility by a state surveyor. The facility's policy requires immediate reporting of abuse allegations to the Administrator and timely reporting to all required agencies, but this protocol was not followed in this case. The lack of timely reporting and documentation constituted a failure to comply with the facility's abuse prevention and reporting policies.

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

A deficiency occurred when a resident who required substantial to maximal assistance with bathing did not receive showers as care planned. The resident, who was cognitively intact and had a documented need for personal care assistance, was placed in isolation due to ESBL in her urine. Despite having a private room with an attached shower, staff provided only bed baths instead of showers, citing concerns about using the shower chair during isolation. The resident and her daughter expressed dissatisfaction with the quality of the bed baths and the refusal to provide showers, even though the shower chair could be cleaned according to facility procedures. Interviews with staff confirmed that the shower chair was made of cleanable PVC material and should have been used and disinfected between uses. Documentation showed that the resident received only a few showers during the month, with one instance specifically noting a bed bath was given instead of a shower. There was no documentation of the resident refusing showers, and the facility's policy required individualized care based on assessment and care plan, including bathing. The lack of proper documentation and failure to provide showers as required led to the identified 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 ensure sufficient nursing staff to meet the needs of its residents, as evidenced by multiple instances of inadequate care. The Resident Council Minutes highlighted ongoing staffing shortages, with residents reporting that call lights were not being answered and showers were not being completed due to insufficient staff. Interviews with residents confirmed these issues, with one resident stating that they had to bathe themselves without supervision due to the lack of available staff. Specific cases further illustrate the deficiency. One resident, who requires substantial assistance with bathing due to obesity and other health issues, reported not receiving scheduled showers because there was only one staff member available, making it impossible to use the necessary mechanical lift. Another resident, who is cognitively impaired and requires assistance with ADLs, had no documentation of receiving showers for over a month, and their restorative programs were not being performed as required. Staff interviews corroborated the residents' experiences, with CNAs acknowledging that showers and restorative care were not prioritized due to staffing shortages. The Director of Nursing admitted to staffing challenges and reliance on agency staff. The facility's policy on sufficient nursing staff was not being adhered to, as there were not enough team members to provide the necessary care, leading to unmet resident needs and compromised care quality.

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 scheduled showers for four residents due to staffing shortages. The Resident Council Minutes highlighted ongoing concerns about insufficient staffing, which affected the ability to provide adequate care, including showers. Residents expressed dissatisfaction with the lack of staff, which resulted in missed showers and inadequate personal hygiene care. The facility's administration acknowledged the staffing challenges and the reliance on agency workers, which contributed to the inconsistency in care. Resident 1, who is cognitively intact, reported that he manages his own showers due to the lack of staff supervision. Resident 2, who requires substantial assistance due to obesity and other health issues, stated that she often receives bed baths instead of showers because there is not enough staff to operate the mechanical lift needed for her care. Resident 3, who is cognitively impaired, had no documented showers for over a month, and Resident 5, who is also cognitively impaired and dependent on staff, had missing shower documentation for several scheduled dates. Interviews with CNAs and the Director of Nursing confirmed the staffing issues, with staff prioritizing other tasks over showers when short-staffed. The facility did not have a specific policy for showers, and the Director of Nursing was aware of the challenges but had not yet implemented a solution. The lack of adequate staffing and prioritization of tasks led to the failure to provide scheduled showers, impacting the residents' care and hygiene.

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 restorative services for a resident, identified as R3, who was admitted with a diagnosis of cerebral infarction due to embolism of the right anterior artery. R3's care plan indicated a need for assistance with activities of daily living (ADLs) due to impaired balance and required a restorative program for bed mobility and grooming. Despite these documented needs, R3's electronic record did not show any documentation of restorative programs being performed. The physical therapy discharge summary recommended a restorative nursing program for passive range of motion and transfers, but these were not documented in R3's care plan or tasks. Interviews with various CNAs and the Director of Nursing revealed that the facility was experiencing staffing issues, which led to the deprioritization of restorative programs and showers. CNAs reported that when short-staffed, they had to prioritize tasks, often leaving restorative programs incomplete. The Director of Nursing confirmed the absence of a restorative nurse or aides, with duties being divided among existing staff. Despite the facility's policy to provide restorative nursing to promote independence and safety, the lack of adequate staffing and documentation resulted in a failure to meet R3's restorative care 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 protect a resident from abuse, specifically involving an altercation between two residents, R3 and R4. R4, who was severely cognitively impaired and required assistance with mobility, was involved in an incident where R3, who was moderately cognitively impaired and independent with mobility, struck R4 on the cheek. This incident occurred despite R4's care plan identifying her as a vulnerable person with potential for aggression due to cognitive deficits, and R3's care plan noting her potential for aggression related to dementia. The altercation was witnessed by another resident, R1, who observed R3 yelling at and striking R4. No staff witnessed the incident, but staff intervened immediately after R1 called for help. The facility's policy prohibits mistreatment, neglect, or abuse of residents, yet R3 and R4 had a history of altercations, indicating a failure to adequately prevent such incidents. The Assistant Director of Nurses acknowledged that R3 and R4 had more than one altercation and that R3 would often say things to R4 when passing her room. Although R3 was moved to another hall to prevent further incidents, the altercation on the 200 hall still occurred. The facility's response included 1:1 supervision for both residents post-incident, but the repeated nature of the altercations suggests a deficiency in effectively managing and preventing resident-to-resident aggression.

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 prevent physical abuse between residents, as evidenced by two separate incidents involving resident-to-resident altercations. In the first incident, a resident with Alzheimer's disease and severe cognitive impairment, identified as R2, physically assaulted another resident, R3, who also had severe cognitive impairment and was identified as vulnerable due to intellectual disabilities. The altercation occurred in a common area, where R2 held R3's forearm and struck her on the cheek. This incident was witnessed by a CNA, who intervened by separating the residents and notifying the nurse. In a second incident, another resident, R1, who was also severely cognitively impaired, was involved in an altercation with R2. R1 reportedly hit R2 on the hand, causing a skin tear, and knocked R2 to the ground. Although the altercation was not directly witnessed, staff observed R1 standing over R2, who was on the floor, and heard R1 yelling about hitting R2. The facility's investigation could not substantiate whether the skin tear was caused by R1 or resulted from the fall. The facility's policies on abuse prevention and prohibition were not effectively implemented to prevent these incidents. The facility's abuse prohibition program includes components such as screening, training, prevention, identification, investigation, protection, and reporting/response. However, the incidents indicate a failure in monitoring and managing resident behaviors, as well as in reassessing care plan interventions to prevent abuse. The facility's inability to determine the cause of the skin tear in the second incident further highlights deficiencies in their investigation and documentation processes.

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 law enforcement of an allegation of sexual assault involving a resident, identified as R2, who was part of a sample of six residents reviewed for abuse reporting. The incident came to light when a Sexual Assault Nurse Examiner (SANE) at a regional hospital contacted local law enforcement after R2 reported being sexually assaulted in a grocery store. The facility's Admissions Coordinator, who was the weekend manager, was informed by R2 about the assault during a conversation to complete re-admission paperwork. The coordinator ensured R2's safety and attempted to notify the Director of Nurses, who was unavailable, and subsequently informed the Assistant Director of Nurses. The Assistant Director of Nurses did not contact the police, citing being occupied with the investigation and noting that the hospital had already notified law enforcement. This inaction was contrary to the facility's Abuse, Prevention and Prohibition Policy, which mandates that any employee or agent must report such incidents to law enforcement and the facility. The failure to report the incident directly to law enforcement by the facility staff constitutes a deficiency in adhering to the established policy for handling allegations of abuse.

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 physician of abnormal blood sugar levels for a resident diagnosed with Type 2 Diabetes Mellitus. The physician's order required notification if the resident's blood sugar exceeded 200. On multiple occasions, the resident's blood sugar levels were recorded above this threshold, specifically at 215, 235, and 205, but there was no documentation indicating that the physician was informed as required by the order. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nurses, confirmed the lack of documentation regarding physician notification. The facility's policy mandates notifying the resident's family and medical practitioner of significant changes, such as abnormal blood glucose results. Despite this policy, the necessary notifications were not made, leading to a deficiency in the facility's compliance with its own procedures and physician 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 perform wound care as ordered for one resident, identified as R2, who was admitted with a diagnosis of orthopedic aftercare following a right femur fracture. On a specific date, it was observed that R2 had three incisions on the right hip, with a dressing applied to only two of the lower incisions, leaving the upper incision without a dressing. R2 expressed that nurses seemed to check his hip incision but did not apply a dressing daily. The Treatment Administration Record (TAR) for December 2024 showed a physician's order to cleanse the surgical incision sites and apply a dry dressing every shift, but there was no documentation of treatment being administered on two specific shifts. The facility's Wound Prevention Policy requires documentation of all wound prevention measures and interventions in the resident's service plan and medical records.

Penalty

Inspection fine: $202,3292 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 provide adequate supervision to prevent the elopement of a resident with a known history of elopement attempts and dementia. The resident, identified as R49, was last seen in the facility at 11:30 AM and was later found 60 miles away at his past home residence. This incident occurred without the staff's knowledge, indicating a significant lapse in supervision and monitoring of residents at risk for elopement. R49 had a documented history of cognitive impairment and a desire to leave the facility, as noted in his care plan and elopement assessments. Despite these known risks, the facility's interventions, such as frequent visual monitoring and providing distracting activities, were insufficient to prevent the resident from leaving the facility unattended. The facility's elopement policy required that residents at risk for elopement be provided with safety precautions, such as door alarms or personal safety devices, but it appears these measures were not effectively implemented or monitored in R49's case. Interviews with staff revealed that there were previous incidents where R49 attempted to leave the facility, including an instance where he was found outside by a CNA. Despite these warning signs, the facility did not adequately update or enforce the resident's care plan to prevent further elopement attempts. The lack of effective supervision and failure to implement appropriate interventions contributed to the resident's successful elopement, resulting in an Immediate Jeopardy situation.

Removal Plan

• The DON and the Administrator initiated staff re-education on the elopement policy and procedure. All staff was educated, no staff worked without being educated.
• The door alarm policy including door alarms should never be shut off or disengaged for any reason.
• Care plan for the resident involved has been revised to include resident specific interventions related to the resident's risk for elopement.
• 100% Audit of the elopement risk assessment for all facility residents has been completed.
• The facility residents that trigger at a risk for elopement have had their care plans reviewed and revised to include resident specific interventions.
• The Facility has a book in place with pictures and pertinent information of residents that trigger at risk for elopement. Staff can identify where the book is located.
• Door codes to be changed and staff educated that at no time are residents to be given the door alarm code.
• Staff are to input the code for anyone needing to exit the community.
• The facility will provide ongoing education to all new employees and agency at the time of hire on the facility elopement policy and procedure and the door alarm policy. Education will be provided prior to a new employee being allowed to work in the facility as well as agency staff members.
• Concerns will be addressed immediately and discussed during the monthly QAPI Committee for resolution.
• The resident was placed on 1:1 in memory unit, then for 15-minute checks, 30-minute observations and no issues were identified upon return to facility. Staff continue to provide 1:1 supervision to resident while at Dialysis. He remains a resident on the Memory unit.
• The resident remains on the secured courtyard unit where the door alarms sound if a resident attempts to leave without entering a security code. Doors are managed by an egress exiting. The exterior courtyard is secured by a gate that is alarmed.
• The Elopement Policy and Procedure was reviewed by the Administrator, Regional Director of Operations, and RN Regional Nurse.
• The Regional Nurse, DON, and the Administrator immediately initiated education on the Elopement Policy and Procedure to all staff. All staff educated on location of Elopement books and identifiers of POC and PCC. No staff are to work without receiving education.
• The Regional Nurse, DON, and the Administrator immediately initiated education on the Door alarm policy including door alarms should never be shut off or disengaged for any reason to all staff.
• All residents have been reviewed and completed for risk of elopement. The assessments were completed by the Social Service Director, MDS, and Admission Coordinator.
• All residents identified at high risk for elopement have current care plans that have been reviewed for appropriate interventions. The high risk for elopement care plans were reviewed and updated by MDS.
• All staff will be educated at the time of hire on the Elopement Policy as part of the orientation process by the Administrator or designee.
• All staff will be educated at the time of hire on the door alarm policy as part of the orientation process by the Administrator or designee.
• Elopement drill will be completed Quarterly.
• The SSD will randomly question 5 staff per week on what to do in the event there is an elopement.

Penalty

Inspection fine: $202,3292 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 prevent verbal and physical abuse between residents, specifically involving four residents. One incident involved a resident with Alzheimer's Disease and severe cognitive impairment, who wandered into another resident's room. This resident, who also had severe cognitive impairment and a history of dementia, pulled out a fistful of the first resident's hair. The incident was immediately reported, and the residents were separated, but the care plan for the first resident did not document any risk for abuse. Another incident involved verbal threats between two residents, one of whom was cognitively intact and had a history of PTSD and behavior problems. This resident made threatening comments towards another resident, who was moderately cognitively impaired and had a history of depression and anxiety. The threats included violent language, and although staff intervened, there was no documentation of any interventions put in place to prevent future occurrences. The facility's policy on abuse prevention and prohibition states that residents have the right to be free from abuse, including resident-to-resident altercations. However, the incidents described in the report indicate a failure to adhere to this policy, as evidenced by the lack of documented interventions and care plans addressing the risk of abuse for the involved residents.

Penalty

Inspection fine: $202,3292 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 properly manage and label medications, which could potentially affect all 93 residents. During an inspection of the medication room, a Tuberculin vial was found without an open date, and a Lantus Insulin Pen was discovered without a resident name or date. The Licensed Practical Nurse (LPN) acknowledged that the Tuberculin vial is used for all staff and residents and should be discarded if found without an open date. Additionally, a bottle of Oyster Shell Calcium capsules was found with an expiration date that had passed, and a vial of Humalog Insulin was past the 30-day usage period since being opened. The facility's policies require that all medication vials be dated when opened and discarded after 30 days, and that medications be checked for expiration monthly. The Assistant Director of Nursing (ADON) confirmed that nurses are responsible for dating medication vials and discarding them after 30 days. The facility's documentation specifies that insulin vials should be discarded 28 days after opening, and multi-dose vials should be discarded 28 days after opening or according to the manufacturer's recommendation. The failure to adhere to these protocols was observed during the survey, indicating a lapse in medication management and storage practices.

Penalty

Inspection fine: $202,3292 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 update its facility-wide assessment to include all necessary components as per current standards of practice. The assessment, which was supposed to cover the period from July 11, 2022, to July 10, 2023, lacked critical elements such as identifying resources needed for resident care during both regular operations and emergencies, including nights and weekends. It also did not evaluate the overall number of staff required to meet residents' needs, nor did it include pertinent information about the resident population, such as race, ethnicity, disability, and other factors affecting access to care and health outcomes. Additionally, the assessment failed to evaluate the facility's training program for staff and volunteers, and it did not include an evaluation of applicable policies and procedures or a facility-based and community-based risk assessment using an all-hazards approach. During the survey, it was revealed that the facility did not have an updated facility assessment for 2024. The administrator, identified as V1, was unable to provide an updated assessment and was later suspended due to an abuse allegation. The regional director, V33, confirmed the absence of a 2024 facility assessment and stated that there was no policy on facility assessment. This deficiency has the potential to affect all 93 residents residing in the facility.

Penalty

Inspection fine: $202,3292 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 implement an effective infection prevention and control program during a COVID-19 outbreak, leading to multiple deficiencies. Staff members were observed not wearing appropriate personal protective equipment (PPE) such as eye protection while on the COVID-positive unit. COVID-positive residents were not isolated properly and were allowed to mingle with COVID-negative residents, increasing the risk of cross-contamination. There was also a lack of signage indicating the COVID-19 outbreak status, and visitors were seen entering the COVID-positive unit without PPE. The facility did not properly cohort COVID-positive residents, resulting in positive and negative residents sharing rooms. This improper cohorting was observed multiple times, with staff failing to encourage or enforce mask-wearing among residents. Additionally, there was no system in place to track, trend, and test residents and staff during the outbreak, and the facility had not offered or educated residents and staff about COVID vaccinations since 2022. Specific cases highlighted include a resident who was COVID-positive and placed on hospice care, later passing away. The resident's physician was unaware of the cohorting situation and expressed concerns about the practice. Staff members, including CNAs and LPNs, were observed not following proper PPE protocols, and there was a lack of communication and education regarding COVID-19 testing and vaccination among staff. The facility's infection preventionist was overwhelmed with duties, leading to a lapse in infection surveillance and control measures.

Penalty

Inspection fine: $202,3292 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 offer, provide, and track COVID-19 vaccines, boosters, and immunizations, potentially affecting all 93 residents. The Director of Nursing (DON), who is also the Infection Preventionist (IP), along with the Assistant Director of Nursing (ADON), did not maintain a list of residents who have refused, consented, or received vaccinations. The DON admitted to not having a list and mentioned the complexity of the CDC's algorithm for vaccinations. The Medical Director expressed concern that all residents should be vaccinated against COVID-19 and Influenza, emphasizing the potential for serious harm or death if residents contract COVID-19. The facility's staff, including nurses and aides, reported inconsistencies in COVID-19 testing and vaccination offers. Some staff members, such as a Registered Nurse (RN) and a Certified Nursing Assistant (CNA), stated they were not offered the COVID-19 vaccination or education at the facility. The RN mentioned that visitors often entered the 100-unit without wearing masks or other protective equipment, despite the requirement for full PPE. Additionally, a Dietary Manager and other staff members confirmed they had not been offered COVID-19 vaccinations or education, and there was confusion about PPE requirements when entering certain units. The facility's SARS-CoV-2 Infection Policy outlined the need for offering resources and counseling about the COVID-19 vaccine, as well as maintaining infection prevention control practices. However, the Infection Surveillance log had not been updated since the end of August, and the DON admitted to not having time to manage infection control duties. The facility's failure to adhere to its policy and maintain proper documentation and tracking of COVID-19 cases and vaccinations contributed to the deficiency.

Penalty

Inspection fine: $202,3292 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 ensure that Certified Nurse Assistants (CNAs) completed the required 12 hours of education per year, which has the potential to affect all 93 residents residing in the facility. The employee files documented that CNAs hired on various dates had not completed the necessary education hours. Specifically, one CNA had 1.75 hours, another had 0.5 hours, a third had no documented education hours, and a fourth had 2 hours of education for the past year. Interviews with the Director of Nursing and the Regional Director revealed uncertainty about the required education hours for CNAs. Additionally, the facility's computerized education system did not consistently provide hours for each course, and inservice logs did not specify the duration of trainings, leaving the facility without a clear method to track CNA education hours. Furthermore, the facility did not have a policy in place for CNA education.

Penalty

Inspection fine: $202,3292 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 proper food safety and hygiene practices, as observed during a survey. The Interim Dietary Manager was unable to locate the fridge/freezer temperature logs, and several food items were improperly stored, such as an open bag of bacon and a gallon of chocolate milk without an open date. Additionally, a box of cucumbers was stored on the floor, and a bag of ground meat was being thawed improperly under hot running water. Temperature logs for food were not maintained, and the last recorded temperatures were from a previous date. During lunch service, the cook, V12, did not perform proper hand hygiene or change gloves while plating food. V12 was observed using the same gloves throughout the lunch service, including when leaving the serving line to gather supplies. The cook also failed to check food temperatures before serving, and the thermometer used was not functioning properly. Furthermore, V12's mask and hairnet were not worn correctly, and V13, a dietary aide, was seen with a full beard and no hairnet while handling food. The kitchen staff did not follow proper hand hygiene protocols, and there were no towels available for drying hands after washing. The facility's food storage and hygiene policies were not followed, as evidenced by the presence of expired and improperly stored food items. Open bags of frozen curly fries and bread with mold were found in the kitchen. The facility's grievance forms documented complaints about cold meals, and investigations revealed issues with food temperature maintenance and equipment. The Interim Dietary Manager admitted to not being certified and lacking access to the facility's policies, which contributed to the deficiencies observed during the survey.

Penalty

Inspection fine: $202,3292 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 provide education, obtain consents, and administer the influenza vaccine to four residents reviewed for immunizations. Resident 61, who was admitted with multiple diagnoses including dementia and COVID-19, had not been offered or given the influenza vaccination since 2021, despite having a severe cognitive impairment and being dependent on staff for daily activities. Similarly, Resident 77, with severe cognitive impairment and requiring assistance for activities of daily living, had no documentation of receiving or being offered the influenza vaccine, nor were there any consents or refusals recorded. Resident 82, admitted with Alzheimer's disease and dementia, also had no record of being offered or receiving the influenza vaccine, with no consents or refusals documented. This resident required partial to substantial assistance from staff for daily activities. Additionally, Resident 23, who was cognitively intact but dependent on staff for daily activities, had not been offered or received the influenza vaccine, and there were no consents or refusals documented in their medical record. The Director of Nursing (DON) was unable to provide a list of residents who had refused, consented, or received vaccinations, indicating a lack of proper documentation and tracking. The facility's policy, dated 2019, stated that residents should be offered immunizations against pneumococcal and influenza diseases, but the facility failed to adhere to this policy. The Infection Preventionist was expected to manage residents' immunizations, but the lack of documentation and administration of vaccines suggests a deficiency in the facility's infection prevention and control program.

Penalty

Inspection fine: $202,3292 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 protect residents during abuse investigations, specifically involving two residents, R17 and R31. R31, who is cognitively intact, has a history of PTSD and behavior problems related to frustration and loss of independence. R17, who is moderately cognitively impaired, has multiple diagnoses including end-stage renal disease, diabetes, and schizophrenia. An incident occurred where R31 made threatening comments towards R17, escalating to verbal abuse and threats of physical harm. The facility's investigation documented that both residents' care plans were reviewed and updated, and R31 was instructed to seek staff assistance instead of responding to other residents. However, the care plans did not document specific interventions to prevent further abuse, and there was no evidence of Social Services conducting the planned visits with R17 and R31. The lack of documentation and follow-through on interventions indicated a failure to adequately address and prevent further incidents. Throughout the survey period, R17 and R31 remained in close proximity, with no changes made to their room assignments or additional interventions communicated to staff. Interviews with staff members revealed a lack of awareness regarding any specific measures in place to prevent further abuse between the two residents. The Social Service Director also confirmed the absence of documented meetings with the residents, highlighting a gap in the facility's response to the abuse incident.

Penalty

Inspection fine: $202,3292 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 provide adequate assistance with activities of daily living (ADLs) for two residents, R145 and R33. R145, who was admitted with a diagnosis of Amyotrophic Lateral Sclerosis (ALS) and is totally dependent on staff for ADLs, reported not receiving a shower or bed bath since admission. Observations confirmed that R145's lunch tray was left untouched due to a lack of feeding assistance, and R145 expressed dissatisfaction with the care provided. The Director of Nursing confirmed only one shower sheet for R145, despite the facility's shower schedule indicating showers should occur twice a week. Additionally, R145 reported not receiving assistance with basic grooming tasks such as brushing teeth. Similarly, R33, who requires assistance with personal hygiene and oral care, reported not receiving showers as scheduled. Staff interviews corroborated R33's complaints, and the facility was unable to provide documentation of showers for R33. The facility's shower schedule indicated that R33 should receive showers twice a week, but no shower sheets were available to confirm this. The Director of Nursing acknowledged the absence of a policy on ADLs, relying instead on best practice guidelines, which were not effectively implemented in these cases.

Penalty

Inspection fine: $202,3292 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 prevent the deterioration of a pressure ulcer and the development of a new pressure ulcer for a resident. The resident, identified as R85, was admitted with a pressure ulcer and had a physician's order for specific wound care to the sacrum. However, observations revealed that the wound had deteriorated, becoming deeper, and a new reddened area was noted on the right buttocks, indicating the potential development of a new pressure ulcer. The dressing was found to be missing during an assessment, and the resident's incontinence brief contained feces, suggesting inadequate wound care and monitoring. Staff interviews revealed lapses in communication and adherence to wound care protocols. A CNA admitted to removing a soiled dressing without notifying a nurse, contrary to the facility's policy that requires nurses to be informed of any new wounds or changes in skin condition. The Assistant Director of Nursing confirmed that the dressing should have been intact continuously as per the physician's orders, and staff were expected to report any issues with the dressing. These failures contributed to the resident's pressure ulcer deterioration and the emergence of a new pressure area.

Penalty

Inspection fine: $202,3292 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 provide timely toileting and incontinent care for three residents, leading to potential risks of urinary tract infections. Resident R145, diagnosed with Amyotrophic Lateral Sclerosis (ALS), was left waiting for a bedpan for an hour, resulting in an incontinent episode. When care was finally provided, the Certified Nursing Assistants (CNAs) did not dry the resident's perineal area after changing the adult brief, which is against the expected practice as stated by the facility's administration. Resident R85, who has a urinary catheter and a diagnosis of Urinary Tract Infection (UTI), was found with feces in his adult brief. The CNA providing care did not use any cleanser on the washcloths and failed to dry the resident's perineal area before applying a new brief. The Director of Nursing and Assistant Director of Nursing confirmed that staff are expected to use body wash or non-rinse peri cleanser, especially after an incontinent episode involving feces, and to pat the area dry. Resident R23, who is frequently incontinent of urine and always incontinent of stool, was found with a saturated adult diaper and linens. The CNA did not perform hand hygiene or change gloves during the care process and used hand soap instead of a no-rinse perineal cleanser. The CNAs also failed to rinse the soap from the resident's skin or dry it before changing the bed linens. The Director of Nursing stated that the facility does not have an incontinence care policy and follows best practices, which were not adhered to in this instance.

Penalty

Inspection fine: $202,3292 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 monitor and provide necessary behavioral health services for a resident who verbalized suicide threats. The resident, who has a history of PTSD, depression, and other medical conditions, expressed a suicidal threat to an LPN on July 5, 2024. The LPN acknowledged the threat but did not ensure proper documentation or notification to the resident's physician or the facility's administration. Consequently, the resident's care plan was not updated to reflect the suicide risk, and no immediate safety measures were implemented. Interviews with various staff members, including the Social Service Director, LPNs, and CNAs, revealed a lack of awareness and communication regarding the resident's suicide threat. The physician confirmed that he was not informed of the threat and stated that he would have taken immediate action had he been notified. The facility's policy on suicide threats, which requires immediate notification and assessment, was not followed, leading to a significant gap in the resident's care. The deficiency was further highlighted when the resident made another suicide threat on September 18, 2024, prompting the facility to send the resident to the hospital. The Regional Director and Administrator acknowledged the oversight, noting that the care plan was only revised after the second incident. The facility's failure to adhere to its own policy and ensure proper communication and documentation resulted in inadequate care for the resident at risk of self-harm.

Penalty

Inspection fine: $202,3292 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 monitor, track, and document microbiology organisms on the infection control log and did not properly monitor and follow up on antibiotic use for two residents. Resident R10 was admitted with multiple diagnoses, including Alzheimer's disease and a urinary tract infection (UTI). Despite receiving treatment for the UTI, there was no documentation of a urine culture in R10's medical record, nor was there a follow-up within 48 hours as required. This lack of documentation and follow-up indicates a failure in the facility's antibiotic stewardship program. Resident R61, who was admitted with several diagnoses including dementia and C. difficile infection, was also not properly monitored. Although a stool culture confirmed the presence of C. difficile, R61 was not included in the facility's infection surveillance log. The Director of Nursing (DON) admitted that the facility was not consistently checking culture and sensitivity results to ensure residents were on the correct antibiotics, and there was no follow-up action when treatments were deemed inappropriate. The facility's Infection Prevention and Control Policy outlines the need for a comprehensive infection prevention and control program, including an antibiotic stewardship program. However, interviews with the DON revealed that the facility was not adhering to these protocols, as evidenced by the lack of documentation and follow-up for residents R10 and R61. The DON acknowledged that the infection control log had not been updated since the end of August, and there was no system in place to ensure timely and appropriate antibiotic use.

Penalty

Inspection fine: $202,3292 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 document the reason for discharge in the resident's Electronic Medical Record (EMR) and did not provide written documentation of the reason for discharge or inform the resident of their rights to appeal the discharge. This deficiency was identified for one of the three residents reviewed for discharge in a sample of 57. The resident, identified as R20, had a range of diagnoses including pseudarthrosis after fusion, depression, and chronic pain, and was cognitively intact according to the Minimum Data Set (MDS). On the day of the incident, R20 exhibited confusion and agitation, and was in significant pain, requesting additional pain medication. The staff noted the resident's room was in disarray, with furniture moved and items scattered, and advised against such activities due to recent back surgery. Later that day, emergency services were called to transport R20 to an acute facility. The facility's investigation revealed that R20 was discharged due to consuming cocaine in the facility, which posed potential harm to others. However, the facility did not document this reason in the EMR or provide the resident with written notice or appeal rights. The facility's policy on discharge planning, dated November 2022, outlines the need for a comprehensive discharge plan, including resident and family education and collaboration with post-acute care providers. Despite this policy, the Social Service Director confirmed that no discharge planning was conducted for R20. The facility's failure to adhere to its discharge policy and document the necessary information led to the identified deficiency.