Anew Healthcare Oxford
Inspection history, citations, penalties and survey trends for this long-term care facility in Oxford, Kansas.
- Location
- 200 S Ohio St, Oxford, Kansas 67119
- CMS Provider Number
- 175450
- Inspections on file
- 17
- Latest survey
- August 13, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Anew Healthcare Oxford during CMS and state inspections, most recent first.
A quadriplegic resident in an LTC facility was neglected when staff failed to monitor her decreased urinary output and health decline. Despite showing signs of airway distress, the resident was left alone without oxygen support. Emergency responders found her in critical condition, and she was later diagnosed with acute respiratory failure, pneumonia, and sepsis at the hospital, where she died. Interviews revealed inadequate response and communication among staff during the incident.
A resident with a history of PTSD and other mental health issues did not receive trauma-informed care after another resident entered her room uninvited and touched her inappropriately. The facility failed to implement person-centered interventions or assess the resident's psychosocial wellbeing, leading to increased isolation and distress. Staff interviews revealed a lack of trauma-informed care training and awareness of the resident's needs.
The facility administration failed to uphold residents' rights and provide adequate care, resulting in immediate jeopardy for two residents and harm to others. A resident was denied the right to designate a representative and make care choices, while another experienced neglect leading to a critical incident and subsequent death. The facility also failed to prevent involuntary seclusion, monitor a resident post-hospitalization, and ensure staff competencies, highlighting significant deficiencies in resource management and resident care.
A resident was issued an involuntary discharge notice without meeting the necessary requirements, following a traumatic incident where another resident entered her room and touched her inappropriately. The facility failed to address the resident's psychosocial wellbeing, lacked trauma-informed care interventions, and did not provide an individualized discharge plan. The resident's mental health history, including PTSD and schizophrenia, was not adequately considered, leading to increased isolation and changes in behavior.
A resident with a history of CHF and COPD was not properly monitored after receiving blood products at a hospital. Upon returning to the facility, staff failed to assess him for adverse reactions. Later, the resident experienced respiratory distress and called EMS after waiting 10-15 minutes for a nurse. The nurse did not take vital signs and scolded the resident for calling EMS. The resident was sent back to the hospital due to low oxygen levels and COPD exacerbation.
A quadriplegic resident with multiple medical conditions experienced a severe decline in health due to inadequate hydration and monitoring following antibiotic treatment for a UTI. Despite being dependent on staff for all care, the resident was not provided sufficient fluids, leading to acute respiratory failure, pneumonia, and sepsis. The resident was found unresponsive and in severe distress, requiring emergency medical intervention, and passed away shortly after hospital admission. Interviews revealed significant lapses in care, including poor communication and failure to provide necessary interventions.
A resident with quadriplegia and multiple medical conditions was found unresponsive and in respiratory distress, but staff failed to provide oxygen or continuous monitoring. The resident was left alone while the nurse called 911, and emergency responders found her without oxygen. She was admitted to the hospital with acute respiratory failure and sepsis, and passed away shortly after. Interviews revealed inadequate emergency response and monitoring by the facility.
A resident with a history of major depressive disorder and psychotic features experienced increased tearfulness, hallucinations, and thoughts of inappropriate actions, but the facility failed to update the care plan or monitor these symptoms. Despite the resident's need for antipsychotic and antidepressant medications, there was no attempt at dose reduction or timely communication with the mental health provider. Staff interviews indicated awareness of the resident's condition, yet documentation and adherence to the facility's social services policy were lacking.
A resident with a history of major depressive disorder and psychotic features experienced increased tearfulness and hallucinations, but the facility failed to update the care plan or monitor these symptoms. Despite staff observations of the resident's deteriorating mental health, there was no documentation or notification to the resident's physician or mental health provider, leading to a deficiency in care.
The facility failed to provide evidence of a current and active Surety Bond to ensure the security of resident funds. During an investigation, it was found that the facility had a Surety Bond effective from a previous date, but there was no documentation confirming its continuation. An interview with a Social Services Designee indicated that the bond was believed to be correct, but no evidence supported this. The facility's policy required all resident funds to be covered by a surety bond, but compliance was not documented.
The facility failed to support residents' rights to voice grievances without fear of reprisal. There were no clear instructions on filing grievances, and the grievance log lacked details on issues and resolutions. A resident reported feeling unsafe after an incident with another resident, but her grievance was not documented. Staff interviews revealed confusion about the grievance process, indicating inadequate training.
The facility failed to maintain an effective QAPI program, leading to severe deficiencies in resident care and rights. A resident experienced neglect after inadequate monitoring post-UTI treatment, resulting in hospitalization and death. Other issues included failure to respect residents' rights, provide trauma-informed care, and ensure staff competencies, causing harm and immediate jeopardy to residents.
A facility failed to follow standard infection control practices for a resident with multiple diagnoses, including cerebral palsy and respiratory issues. The resident, who was completely dependent on staff, required enhanced barrier precautions due to the risk of multi-drug resistant organism colonization. However, a staff member did not use gloves while cleaning the resident's visibly dirty fingers, which were in the resident's mouth, potentially affecting all residents.
The facility failed to update care plans for several residents, resulting in deficiencies in addressing their changing needs and preferences. A resident's care plan lacked interventions for trauma and PTSD, while others had incomplete or missing instructions for medical conditions and personal preferences. Interviews revealed discrepancies and communication issues, highlighting a failure to follow the facility's policy on comprehensive care plans.
A resident with mental health diagnoses was not allowed to designate a representative to exercise her rights without fear of reprisal. After an incident where another resident entered her room and touched her inappropriately, the facility failed to assess her psychosocial wellbeing or provide trauma-informed care. The resident's guardian requested to be informed before interactions, but this was not consistently honored. The facility issued a discharge notice citing the guardian's actions, without proper communication or justification.
A resident with a history of mental health issues was denied her right to self-determination when the facility required two staff members during personal care without valid justification. This decision followed an incident where another resident entered her room and allegedly touched her inappropriately. The facility failed to assess the resident's psychosocial wellbeing or address her trauma history, leading to feelings of isolation and mistreatment.
A resident with schizophrenia and dementia was consistently placed in the same spot near the front doors, away from the dining area, without staff assessing his preferences. Despite having clear speech, staff did not engage with him or offer alternatives, leading to potential involuntary seclusion. His wheelchair was also found outside his room at night, confining him to his room. Staff interviews revealed a lack of understanding or communication regarding his preferences, and law enforcement officers confirmed his consistent placement.
A resident received an incomplete involuntary discharge notice lacking instructions for appeal, causing distress. The resident, who had been at the facility for five years, faced discharge after an incident involving another resident. Despite refusing skin assessments, the discharge was seen as unfair by the resident and her Guardian. The facility's attorney prepared the discharge letter, and corporate influenced the decision to find another facility.
Two CNAs performed a sternal rub on an unresponsive resident before notifying an LN, despite not being trained or authorized to do so. The resident showed signs of distress, including flushed appearance and wheezing, and was later sent to the ER. The facility failed to ensure only qualified staff performed medical techniques.
A quadriplegic resident with multiple medical conditions, including chronic kidney disease and a history of urinary tract infections, did not receive adequate ADL care in an LTC facility. The resident, who was always incontinent, was found disheveled and malodorous upon hospital transfer. Despite being a heavy wetter, the resident had minimal urine output on the day of the incident, and staff failed to communicate and follow up on her condition. The resident was eventually found unresponsive and died shortly after hospitalization.
A facility failed to follow care plans for two residents, resulting in falls. One resident, with cognitive impairments and mobility issues, was not transferred according to her care plan, leading to a fall in the shower area. Another resident, requiring one-on-one supervision due to severe cognitive impairments, fell out of bed and sustained a head laceration. The facility's lack of adherence to safe handling policies and inadequate supervision contributed to these incidents.
A non-verbal resident with multiple medical conditions experienced inadequate feeding tube care when a CNA accidentally dislodged the tube, requiring emergency hospital intervention. The resident's care plan lacked specific instructions for managing the feeding tube, and observations revealed poor hygiene practices. Law enforcement reported frequent issues of neglect at the facility, despite documented staff training.
A resident with a history of mental health issues experienced a traumatic event when another resident entered her room and touched her inappropriately. The facility failed to provide timely psychosocial support, did not respect the resident's preferences regarding care, and inadequately communicated with her guardian. The resident's care plan lacked person-centered interventions, and the facility imposed care protocols without consultation, leading to distress and a feeling of lost rights for the resident.
Instances of neglect and abuse were identified, leading to immediate jeopardy for residents. Resident with chronic kidney disease experienced medication errors and lack of vital sign monitoring post-hospitalization, resulting in emergency transfer for kidney failure. Another resident, under one-on-one observation, fell and sustained injuries, alleging abuse by a CNA. The facility did not promptly investigate the abuse allegation, allowing the alleged abuser to continue working with residents, thus placing the resident at risk for further harm.
A cognitively impaired resident with a history of anxiety, OCD, cognitive deficits, and major depressive disorder alleged that a CNA hit her after falling from her wheelchair. The facility did not report the abuse allegation to the Administrator, State Agency, or local law enforcement until 36 days later. The resident's care plan lacked specific interventions for falls and behavioral outbursts, and the facility's investigation into the abuse allegation was inadequately documented. This delay in reporting and insufficient care planning placed the resident and others at risk.
A cognitively impaired resident, R19, sustained injuries while under one-on-one supervision of a CNA in a closed-door room. R19 alleged that the CNA hit her, but the facility did not promptly investigate or protect the resident from potential further abuse. The CNA continued to work for 36 days post-allegation. The facility's fall investigation report lacked crucial details, including witness statements and proper injury documentation. Additionally, the CNA's handwritten note explaining the incident was unclear and inadequately documented.
The facility did not ensure staff had the necessary competencies to provide appropriate care, leading to several incidents affecting resident safety and well-being. For Resident 19, who had complex mental health needs, the staff failed to address falls, behavioral symptoms, and abuse allegations adequately, resulting in negative physical, mental, and psychosocial effects. In another case, Resident 35, diagnosed with insomnia, anxiety disorder, cerebral palsy, and dysphasia, experienced inappropriate handling by staff, including being dragged across the floor. These incidents highlight deficiencies in staff competencies related to ADLs, transfers, and safety.
A facility with 35 residents was found to have multiple deficiencies, including failures in protecting residents' privacy and dignity, promoting self-determination, and ensuring an environment free from neglect and abuse. Issues were identified in preventing misappropriation of resident property and timely reporting of alleged abuse incidents. The facility lacked effective systems for preventing medication errors, completing necessary assessments and care plans, providing appropriate care, and maintaining a safe environment to prevent accidents and infections. Additionally, there were deficiencies in staff competencies due to inadequate training programs for nurse aides. Specific incidents included failures to protect residents from abuse, neglect, and medication errors, resulting in harm such as falls, injuries, and potential untreated symptoms. The lack of timely reporting and investigation of abuse allegations, failure to provide necessary equipment and care, and inadequate monitoring for safety measures were also noted.
The facility failed to provide appropriate ADL care and meal assistance to residents, resulting in a shoulder dislocation for one resident and significant weight loss for two others. Staff did not follow care plans or provide necessary assistance during meals, leading to potential negative effects related to nutrition.
The facility did not provide an environment free from accident hazards and adequate supervision for residents, leading to multiple falls and injuries. Resident R28 experienced several falls, including one resulting in a head injury requiring staples, due to untimely fall interventions. Resident R19, with cognitive impairments, had repeated falls without identified causal factors or specific interventions in the care plan. Resident R35, with wandering tendencies, faced increased fall risks due to inadequate supervision and safety measures. Care plans lacked appropriate updates and interventions following incidents, indicating a systemic issue in ensuring resident safety.
A resident experienced a significant weight loss of 12.06% in 63 days due to the facility's failure to implement timely and pertinent nutritional interventions. The facility did not weigh the resident weekly, document nutritional intake as ordered, provide appropriate assistive devices, or ensure staff knew the nutritional monitoring system. This resulted in the resident losing 20.8 pounds, placing him at risk for continued decline in nutritional status and life-threatening symptoms.
The facility did not enter re-admission medication orders for a resident into the Electronic Medication Administration Record (eMAR) for five days post-hospitalization. This led to the administration of outdated medications, resulting in incorrect dosages and omitted newly ordered medications. The resident had a complex medical history, including heart failure, anxiety disorder, hypertension, and other conditions requiring precise medication management. The issue was identified when the resident was readmitted to the hospital, revealing discrepancies between the facility's orders and the hospital discharge orders. The admitting nurse did not process the re-admission orders, and the oversight was not detected until the resident's readmission.
The facility failed to prevent the misappropriation of controlled medications, with staff diverting narcotics and tampering with medication cards. Investigations revealed missing medications for several residents, and staff interviews highlighted inconsistencies in handling and storing discontinued narcotics.
The facility failed to ensure proper medication administration, resulting in a 6.45% error rate. A resident's G Tube placement was not checked before administering medications, and a CMA did not perform proper hand hygiene when switching between administering eye drops and oral medications.
The facility failed to remove discontinued medications from circulation, specifically for two residents. Observations revealed that the medication cart contained Ativan tablets prescribed to a resident, even though the order had ended months prior. Interviews with staff revealed inconsistencies in handling and storing discontinued narcotics, leading to the presence of these medications in the carts.
The facility failed to maintain sanitary conditions in food preparation and service. Observations included undated shredded cheese, improper use of gloves by dietary staff, and lack of regular food handling training. These actions led to the potential for foodborne bacteria.
The facility failed to maintain an effective QAPI program, leading to numerous deficiencies in resident care, including privacy violations, neglect, abuse, incomplete documentation, medication errors, and inadequate CNA training.
The facility failed to provide proof of vaccination or declination for the 2022-2023 influenza and pneumococcal vaccines for five residents. The EHRs lacked documentation of these vaccines or their declinations, and the facility did not provide a policy related to wandering/elopement when requested.
The facility failed to ensure that CNAs received the required 12 hours of in-service training, including dementia care and abuse prevention. Five CNAs reviewed lacked sufficient training hours, and administrative staff confirmed the incomplete transition to an online training system contributed to the deficiency.
The facility failed to complete or analyze the Care Area Assessments (CAAs) triggered on the residents' Minimum Data Set (MDS) for four residents. The CAAs lacked necessary analysis for further investigation and development of comprehensive care plans, leading to potential negative psychosocial effects related to safety and uncommunicated needs.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated needs for care and services. Inaccuracies included missing documentation of falls, use of oxygen, and mobility aids, as well as incomplete assessments for falls, urinary catheter use, and contractures. The facility lacked a policy for MDS completion, relying solely on the RAI manual.
The facility failed to complete comprehensive care plans for four residents, leading to uncommunicated needs and actual harm. One resident suffered a dislocated shoulder due to inadequate ADL assistance documentation, while others had missing care plans for respiratory care, medication needs, and safety measures. The facility's policy on comprehensive care plans was not followed, and the CAAs lacked necessary analysis.
The facility failed to have a clear system in place to document and communicate residents' code status, affecting seven residents. Discrepancies were found in the documentation of code status in care plans and physician orders, with significant delays between admission and documentation. Staff relied on walkie-talkies and face sheets to communicate code status, which was insufficient for prompt awareness.
The facility failed to ensure an effective pharmacy system for controlled medications, leading to discrepancies in accounting, reconciliation, and destruction of narcotics. This affected multiple residents, with missing medications and tampered medication cards observed. Staff interviews revealed inconsistencies in handling discontinued narcotics, and proper documentation was often lacking.
The facility failed to maintain an effective infection control program, with issues including improper cleaning of respiratory equipment, inadequate hand hygiene during medication administration, and improper cleaning of glucometers. Staff did not follow proper hand hygiene protocols, and nebulizer equipment was not properly cleaned and stored.
The facility failed to protect the privacy and dignity of two residents. One resident was repeatedly disturbed in her room by another resident with wandering behaviors, while another resident was left in the dining area wearing only a shirt and an incontinence brief, expressing discomfort with the situation. The facility lacked specific interventions and policies to address these issues.
The facility failed to promote and facilitate resident self-determination when a resident with diabetes and intact cognition was not given a choice about his meals and was not promptly attended to when he expressed hunger. Despite care plan instructions, the resident was not adequately monitored, and his request for more food was delayed, highlighting a deficiency in supporting resident choice.
The facility failed to provide written notification to two residents or their representatives about their hospitalization and the reasons for the transfer. Staff confirmed that while verbal notifications were made, written notifications were not provided, and no policy on written notification was available.
The facility failed to provide a copy of the bed hold policy to two residents or their representatives at the time of their transfer to the hospital. Both residents' electronic medical records lacked a signed bed hold for hospitalization, and staff provided conflicting information about who was responsible for bed hold notifications.
The facility failed to revise the care plan for a resident after multiple falls. Despite the resident's high risk for falls and requiring maximal assistance with ADLs, the care plan lacked specific interventions following incidents where the resident was found on the floor or had to be lowered to the floor due to combative behavior. Inconsistent fall risk assessments and inadequate documentation and assessment processes contributed to this deficiency.
Neglect of Quadriplegic Resident Leads to Fatal Outcome
Penalty
Summary
The facility failed to prevent the neglect of a quadriplegic resident, who was dependent on staff for care, when nursing staff did not adequately monitor or follow up on the resident's decreased urinary output and decline in health status. The resident, who had a history of multiple medical conditions including quadriplegia, chronic kidney disease, and a recent urinary tract infection, was found unresponsive and in critical condition by staff. Despite showing signs of airway distress, the staff did not apply oxygen or ensure continuous monitoring during the incident. On the night of the incident, the resident was found with no urinary output, cyanotic, and with wet lung sounds. The licensed nurse on duty left the resident alone to call the physician and emergency services, failing to provide immediate oxygen support. When emergency responders arrived, they found the resident alone and without oxygen, despite the obvious need for respiratory support. The resident was transported to the hospital where she was diagnosed with acute respiratory failure, pneumonia, and sepsis, and subsequently died. Interviews with staff and law enforcement revealed a lack of proper response and monitoring during the critical incident. The nurse failed to administer oxygen and left the resident unattended, while the CNAs did not report the resident's condition changes effectively. The facility's communication and response protocols were inadequate, contributing to the resident's deterioration and eventual death.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care to a resident, R1, who had a history of paranoid schizophrenia, major depressive disorder, PTSD, and suicidal ideations. The deficiency arose when another resident, R3, entered R1's room uninvited, attempted to get into her bed, and touched her private parts. Despite the incident being reported, the facility did not implement person-centered interventions to address R1's trauma or assess her psychosocial wellbeing. The care plan lacked specific interventions related to her PTSD diagnosis and potential triggers for re-traumatization. Following the incident, R1 exhibited changes in behavior, including increased isolation and feelings of embarrassment due to repeated requests for skin checks. The facility's response was inadequate, as they failed to recognize the impact of the incident on R1's mental health and did not provide appropriate support or interventions. The facility's actions, such as offering to send R1 to the emergency room and conducting skin assessments, did not address her psychosocial needs or trauma-related concerns. Interviews with staff and R1's guardian revealed a lack of trauma-informed care training and awareness of R1's trauma-related needs. The facility's failure to address R1's psychosocial wellbeing and implement trauma-informed care interventions resulted in a deficiency, as they did not account for her experiences and preferences, nor did they mitigate triggers that could cause re-traumatization.
Facility Administration Failures Lead to Resident Harm and Immediate Jeopardy
Penalty
Summary
The facility administration failed to ensure the rights and well-being of several residents, leading to significant deficiencies. Resident 1 was denied the right to designate a representative and make choices about her care, including the number of staff present during her care. The facility also failed to provide a safe and homelike environment, as evidenced by dirty floors and meals served on Styrofoam plates. Additionally, Resident 1 was issued an involuntary discharge notice without meeting the necessary requirements, following an incident where another resident entered her room and touched her inappropriately, impacting her psychosocial well-being. Resident 4, who was quadriplegic and dependent, experienced neglect when the facility staff failed to monitor her decreased urinary output and overall decline after completing antibiotic treatment for a UTI. This neglect led to a critical incident where Resident 4 was found unresponsive and in respiratory distress, requiring emergency medical intervention. The staff failed to provide necessary care, such as applying oxygen or staying with the resident during the emergency, resulting in her admission to the hospital with severe conditions, including acute respiratory failure and sepsis, ultimately leading to her death. The facility also failed to prevent the involuntary seclusion of Resident 5, who was repeatedly placed in the same spot away from other residents without being offered alternatives. Furthermore, the facility did not ensure proper monitoring and care for Resident 2 after receiving blood products at the hospital, leading to a situation where the resident had to call EMS due to respiratory distress. The administration's failures extended to inadequate staff training and competencies, as seen in the improper handling of Resident 16's transfer, resulting in a fall, and the lack of trauma-informed care for Resident 1 after a traumatic event. These deficiencies highlight the facility's inability to use its resources effectively and efficiently to maintain the highest practicable well-being of its residents.
Inadequate Discharge Process and Trauma Response
Penalty
Summary
The facility failed to provide evidence that a resident met discharge requirements as outlined in the State Operations Manual, Appendix PP. The deficiency arose when the facility issued an involuntary discharge notice to a resident without adequately recognizing the impact of a traumatic incident involving another resident. The incident involved another resident entering the resident's room uninvited, attempting to get into her bed, and touching her private parts. Following this incident, the resident exhibited changes in behavior, such as increased isolation and altered day-to-day activities, which the facility did not adequately address in terms of her psychosocial wellbeing. The resident had a history of mental health diagnoses, including paranoid schizophrenia, major depressive disorder, PTSD, and suicidal ideation. Despite these conditions, the facility's care plan lacked interventions that recognized the impact of trauma or addressed the resident's PTSD diagnosis. The care plan also failed to provide an individualized discharge plan that identified interventions to meet the resident's discharge goals or address her psychosocial needs following the incident. The facility's response to the incident was inadequate, as it did not assess the resident's psychosocial wellbeing or implement appropriate interventions. The facility's actions, such as frequent requests for skin checks and the requirement for two staff members to be present during care, were perceived by the resident as punitive and embarrassing. The facility also failed to effectively communicate with the resident's guardian and did not provide sufficient documentation or rationale for the involuntary discharge notice.
Failure to Monitor Resident After Blood Transfusion
Penalty
Summary
The facility failed to properly identify and monitor a resident, referred to as R2, after he received blood products at a hospital. Upon his return to the facility, the staff did not monitor him for signs of adverse reactions, such as respiratory distress or bronchospasm. Later that night, the resident used his emergency call light to report difficulty breathing, but after waiting 10 to 15 minutes without a response from the nurse, he called EMS himself. His roommate assisted in reporting the concerns to EMS. When the nurse finally entered the room, she did not take the resident's vital signs, despite his report of respiratory distress and fear. The resident had a history of congestive heart failure and chronic obstructive pulmonary disease (COPD), with a recent exacerbation. His care plan included monitoring for respiratory distress and maintaining oxygen saturation levels, but it lacked instructions related to his low hemoglobin and recent blood transfusion. The nurse scolded the resident for calling EMS without waiting for the nursing staff and documented his actions as rude. The resident was subsequently sent back to the hospital due to low oxygen levels and exacerbation of COPD. The facility's records showed that the resident's vital signs were not assessed after his return from the hospital until he called 911. Interviews with staff revealed that the resident's condition was not adequately monitored, and there was a delay in the nurse's response to his emergency call. The facility's failure to monitor the resident's condition after receiving blood products and the inadequate response to his respiratory distress led to the deficiency.
Failure to Ensure Adequate Hydration for Quadriplegic Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a quadriplegic, dependent resident who experienced a significant decline in health following the completion of antibiotic treatment for a urinary tract infection (UTI). The resident, who had a history of multiple medical conditions including dysphagia, anemia, chronic pain, hypertension, and chronic kidney disease, was found unresponsive with decreased urinary output, cyanotic, and with wet lung sounds. Despite being dependent on staff for all activities of daily living, including hydration, the resident was not adequately monitored or provided with sufficient fluids, leading to a critical health emergency. On the day of the incident, the resident was noted to have consumed minimal food and fluids, and staff reported that she was not feeling well. Despite these observations, there was a lack of effective communication and follow-up among the staff regarding her condition. The resident's vital signs were not adequately monitored, and there was a failure to recognize and respond to her deteriorating condition in a timely manner. The resident's condition worsened overnight, and she was eventually found unresponsive with severe respiratory distress and no urinary output, necessitating emergency medical intervention. The emergency department documented the resident's poor health condition upon arrival, noting severe distress, cyanotic nail beds, and a lack of grooming. The resident was diagnosed with acute respiratory failure, pneumonia, and sepsis, and she passed away shortly after being admitted to the hospital. Interviews with staff and law enforcement revealed significant lapses in care, including inadequate monitoring, poor communication, and a failure to provide necessary interventions such as oxygen therapy. The facility did not provide a policy regarding UTI and hydration, highlighting a systemic issue in ensuring adequate care for residents with complex medical needs.
Failure to Provide Respiratory Care to Resident in Distress
Penalty
Summary
The facility failed to provide necessary respiratory care to a quadriplegic resident, who was found unresponsive and displaying signs of respiratory distress. The resident, who had a history of multiple medical conditions including quadriplegia, dysphagia, and chronic kidney disease, was not administered oxygen despite showing symptoms such as cyanosis and wet lung sounds. The licensed nurse on duty, after being informed of the resident's condition, left the room to call the physician and 911, but did not apply oxygen or ensure continuous monitoring of the resident during this critical period. When emergency responders arrived, they found the resident alone in her room without oxygen, despite her obvious respiratory distress. The resident's oxygen saturation was critically low at 77%, and she required immediate medical intervention, including supplemental oxygen and transport to the hospital. The hospital records indicated that the resident was admitted with acute respiratory failure, pneumonia, and sepsis, and she passed away a few hours later. Interviews with staff and law enforcement revealed a lack of appropriate response and monitoring during the incident. The nurse admitted to not applying oxygen and leaving the resident unattended to use the restroom. Law enforcement officers noted the absence of staff in the resident's room upon their arrival and expressed concern over the facility's handling of the situation. The deficiency highlights a significant lapse in the facility's emergency response and monitoring protocols for residents in distress.
Inadequate Behavioral Health Support for Resident
Penalty
Summary
The facility failed to ensure sufficient staff with the appropriate competencies and skills to meet the behavioral health needs of a resident diagnosed with a mental disorder. The resident, who had a history of major depressive disorder with psychotic features, experienced increased tearfulness, auditory and visual hallucinations, and expressed thoughts of doing something inappropriate to other residents. Despite these symptoms, the resident's care plan was not updated to reflect these changes, and there was a lack of monitoring for these specific behaviors. The resident's electronic health record indicated a need for antipsychotic and antidepressant medications, but there was no attempt at a gradual dose reduction of the antipsychotic medication. The care plan included interventions such as encouraging participation in group activities and discussing behaviors with the resident, but it did not address the recent increase in symptoms. Additionally, the facility staff failed to document or closely monitor the resident's tearfulness, hallucinations, or thoughts of inappropriate actions, as evidenced by the lack of documentation in the nurse's notes over several weeks. Interviews with facility staff revealed that the resident had been more tearful and showed signs of depression for a month or two, yet there was no evidence of timely communication with the resident's mental health provider or updates to the care plan. The facility's policy on providing medically related social services was not adhered to, as the resident did not receive the necessary support to maintain their highest practicable mental and psychosocial well-being.
Failure to Monitor and Update Care Plan for Resident with Mental Disorder
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with a mental disorder, resulting in a deficiency. The resident, who had a history of major depressive disorder with psychotic features, became increasingly tearful over several weeks and reported auditory and visual hallucinations. Despite these changes in behavior, the resident's care plan was not updated to reflect the increased symptoms, and there was no documentation of staff monitoring for these symptoms. The resident's care plan included instructions for staff to administer medications, monitor for side effects, and encourage participation in non-pharmacological interventions. However, the care plan lacked updates to address the resident's increased tearfulness and hallucinations. Additionally, there was no evidence that the resident's physician or mental health provider was notified of these changes, and the facility did not attempt a gradual dose reduction of the resident's antipsychotic medication. Interviews with staff revealed that the resident was more tearful and showed signs of depression, but these observations were not documented in the resident's records. The facility's policy required staff to provide medically related social services to assist residents in attaining their highest practicable mental and psychosocial well-being, but this was not adequately implemented for the resident in question.
Lack of Evidence for Active Surety Bond for Resident Funds
Penalty
Summary
The facility failed to provide evidence of a current and active Surety Bond to ensure the security of resident funds, as required by regulations. During an onsite complaint investigation, it was found that the facility had a Surety Bond for the amount of $20,000.00, effective from 03/01/2022, which was supposed to terminate one year from that date unless continued by certificate or cancelled by the Surety. However, none of the documentation provided by the facility confirmed that the bond was still ongoing and active. An interview with the Social Services Designee revealed that the current copy of the Surety Bond was believed to be correct, but there was no evidence to support this claim. The facility's policy on Transactions Involving Resident Funds stated that all resident funds entrusted to the facility would be covered by a surety bond, but the facility did not provide documentation to prove compliance with this policy. This deficiency had the potential to affect all residents with personal funds accounts.
Failure to Support Resident Grievance Rights
Penalty
Summary
The facility failed to uphold residents' rights to voice grievances without fear of discrimination or reprisal. During an inspection, it was observed that there were no visible signs indicating where grievance forms could be found or submitted, nor was there information on how to file grievances anonymously. The grievance forms were located in a manila folder outside the Social Services Designee's office, but this was not clearly communicated to residents or visitors. Additionally, the grievance log lacked a section to record the nature of grievances, and several grievances were documented without specifying the issues or resolutions. A specific incident involved a resident who reported feeling unsafe and embarrassed after another resident entered her room and allegedly touched her inappropriately. The resident expressed that staff were dismissive of her concerns and felt retaliated against after reporting the incident. She also mentioned that her rights were restricted following the incident, as she was required to have multiple staff present during personal care, which she found distressing. Despite these serious concerns, there was no record of her grievance in the facility's grievance log. Interviews with staff revealed a lack of clarity and consistency in handling grievances. Some staff members were unsure of the grievance process or where forms were located, indicating insufficient training or communication. The Social Services Designee stated that grievance forms were accessible and that staff were trained on the process, but this was not evident in practice. The facility's failure to document and address grievances properly had the potential to affect all residents, as it undermined their ability to voice concerns safely and effectively.
Severe Deficiencies in Resident Care and Rights
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program, which resulted in numerous deficiencies affecting the quality of care and life for residents. The QAPI program did not develop, implement, or maintain a comprehensive, data-driven approach to monitor and improve care outcomes. This was evidenced by multiple severe deficiencies cited during the survey, including the failure to respect residents' rights, provide a safe and clean environment, and prevent neglect. One significant deficiency involved the neglect of a quadriplegic resident, who experienced a critical decline in health following inadequate monitoring after antibiotic treatment for a UTI. The resident was found unresponsive, cyanotic, and without urinary output, requiring emergency medical intervention. The staff failed to apply oxygen or stay with the resident during the incident, leading to the resident's hospitalization and subsequent death from acute respiratory failure, pneumonia, and sepsis. Additional deficiencies included the failure to respect residents' rights to designate representatives, provide trauma-informed care, and prevent involuntary seclusion. The facility also failed to ensure adequate staff competencies and training, resulting in improper care techniques and supervision, which led to falls and inadequate response to medical emergencies. These failures placed residents in immediate jeopardy and caused harm to several individuals.
Infection Control Lapse in Resident Care
Penalty
Summary
The facility failed to ensure staff provided care to Resident 3 according to standard infection control practices. Resident 3, who had multiple diagnoses including cerebral palsy, Down's syndrome, autism, and respiratory issues, was completely dependent on staff for personal care. The care plan for Resident 3 included enhanced barrier precautions due to the risk of multi-drug resistant organism colonization, requiring staff to use personal protective equipment (PPE) during high-contact activities. However, during an observation, staff failed to adhere to these precautions when a licensed nurse did not don gloves while cleaning the resident's visibly dirty fingers, which were in the resident's mouth. The incident was observed by a surveyor who noted that the resident's feet were also dirty, and the staff member initially looked for gloves but proceeded to clean the resident's fingers without them. This lapse in infection control practices had the potential to affect all 31 residents in the facility, as it demonstrated a failure to follow established protocols for preventing the spread of infections. The administrative nurse confirmed that the resident had been under one-on-one supervision since a previous incident, yet the infection control practices were not adequately followed.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to ensure that care plans for several residents were revised to reflect their changing needs, goals, and preferences. Specifically, Resident 1's care plan did not include interventions related to trauma experienced from an incident involving another resident, nor did it address her post-traumatic stress disorder diagnosis. Additionally, the care plan lacked updates regarding her need for two staff members during interactions for safety concerns and did not include a personalized discharge plan. Resident 2's care plan was missing instructions related to low hemoglobin and risk of internal bleeding, while Resident 3's care plan did not focus on his G-tube care, lacking instructions for preventing dislodgment and actions to take if it occurred. Resident 4's care plan was incomplete and lacked interventions for her mobility issues, oral health problems, and cognitive impairments. It also failed to address her bowel incontinence. Resident 5's care plan did not reflect his preferences for seating and dining locations, nor did it account for his wheelchair placement at night. Resident 11's care plan was not updated to address his increased tearfulness, depression, and hallucinations, nor did it include instructions for staff to assist him with his desire to go outside and ambulate more. Interviews with staff and residents revealed discrepancies in the care plans and a lack of communication with residents and their representatives. Resident 1 expressed concerns about her rights being taken away and inaccuracies in her care plan, while a law enforcement officer noted differences in care provided during day and night shifts. Staff members indicated they relied on care plans and resident charts to provide care, but the facility's policy on comprehensive care plans was not adequately followed, leading to deficiencies in individualized care for the residents.
Failure to Honor Resident's Rights and Ensure Psychosocial Wellbeing
Penalty
Summary
The facility failed to ensure that a resident, who had diagnoses including paranoid schizophrenia, major depressive disorder, PTSD, and suicidal ideations, had the right to designate a representative of her choice to exercise her rights without fear of reprisal. The resident's care plan lacked evidence of her appointing a representative or guardian and her wishes regarding the presence of the representative during interactions with staff. The resident reported an incident where another resident entered her room and touched her inappropriately, but the facility did not adequately assess her psychosocial wellbeing or implement interventions related to the incident. The facility's documentation showed a lack of follow-up on the resident's psychosocial wellbeing after the incident, and there was no evidence of trauma-informed care being provided. The resident's guardian requested to be informed before any interaction with the resident, but the facility failed to honor this request consistently. The facility issued a discharge notice to the resident, citing the guardian's actions and inactions as reasons, but there was no evidence that the facility communicated with the resident about her wishes regarding her guardian's involvement. Interviews with staff and the resident revealed that the facility did not address the resident's psychosocial impact from the incident with the other resident. The resident expressed feeling isolated and fearful of retribution, and her guardian reported that the facility did not assess the resident for past trauma. The facility's actions and inactions led to the resident feeling that her rights were taken away, and she was issued a discharge notice without proper justification or communication regarding her care plan.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing a valid rationale for requiring two staff members during personal care interactions, despite the resident's request for only one staff member. The resident, who had intact cognition and a history of mental health issues including paranoid schizophrenia and PTSD, expressed a preference for privacy during care. The facility's care plan lacked documentation or justification for the two-staff requirement, and the resident's wishes were not adequately considered or respected. The situation was exacerbated by an incident involving another resident, R3, who entered the resident's room uninvited and allegedly touched her inappropriately. The facility's response to this incident was inadequate, as they failed to assess the resident's psychosocial wellbeing or implement appropriate interventions. The resident reported feeling isolated and mistreated by staff following the incident, and her concerns about privacy and safety were not addressed. The facility's actions, including frequent and unwarranted skin checks, further contributed to the resident's distress and sense of being treated as if she were at fault. Interviews with staff and the resident's guardian revealed a lack of communication and understanding of the resident's needs and rights. The facility did not adequately address the resident's trauma history or the impact of the incident with R3 on her mental health. The guardian's requests for involvement in the resident's care decisions were not consistently honored, and the facility's actions were perceived as punitive rather than supportive. The overall handling of the situation demonstrated a failure to prioritize the resident's rights and wellbeing.
Failure to Assess and Accommodate Resident Preferences Leads to Involuntary Seclusion
Penalty
Summary
The facility failed to ensure that Resident 5 was not involuntarily secluded, as staff did not assess or accommodate his preferences for location within the facility. Resident 5, who has a complex medical history including schizophrenia, dementia, and movement disorders, was consistently placed in the same spot near the front doors, away from the dining area and other residents. Despite having clear speech and being usually understood, staff did not engage with him or offer alternatives to his seating arrangement, leading to potential involuntary seclusion. Observations revealed that Resident 5 spent most of his time in a high-back wheelchair by the front doors, with a bedside table in front of him, and was not included in the dining room activities. Staff interviews indicated a lack of understanding or communication regarding Resident 5's preferences, with some staff assuming that his placement was due to his own choice or to prevent overstimulation. However, there was no documentation in his care plan addressing his seating preference or the rationale for his consistent placement by the front doors. Additionally, the facility failed to ensure Resident 5's mobility needs were met at night, as his wheelchair was found outside his room with the door closed, effectively confining him to his room. Interviews with law enforcement officers who frequently visited the facility corroborated that Resident 5 was always seen in the same location, suggesting a pattern of neglect in addressing his needs and preferences. The facility's lack of assessment and documentation regarding Resident 5's preferences and mobility contributed to the deficiency of involuntary seclusion.
Incomplete Involuntary Discharge Notice
Penalty
Summary
The facility failed to provide a complete involuntary discharge notice to a resident, identified as R1, which lacked essential elements such as specific instructions on how to obtain and complete an appeal form. The discharge notice was issued on two occasions, yet it did not include the necessary information for the resident to understand their rights and the process for appealing the decision. This oversight was identified during a review of the discharge letter and was corroborated by the facility's Transfer and Discharge policy, which mandates the inclusion of such information. The deficiency was further highlighted during an observation and interview with R1, who expressed distress over the involuntary discharge and the circumstances leading to it. R1 had been a resident at the facility for five years and was reluctant to move, especially after an incident involving another resident entering her room uninvited and touching her inappropriately. Despite the resident's refusal to undergo skin assessments following the incident, the facility's actions to discharge her were perceived as unfair by both R1 and her Guardian. Interviews with facility staff revealed that the discharge letter was prepared by the facility attorney, and the decision to assist R1 in finding another facility was influenced by corporate, following the resident's dissatisfaction and intent to file charges against the other resident.
Unqualified Staff Performed Medical Technique on Unresponsive Resident
Penalty
Summary
The facility failed to ensure that only qualified staff performed medical techniques to assess a resident's level of consciousness. This deficiency was identified when two Certified Nurse Aides (CNAs) performed a sternal rub on an unresponsive resident, Resident 4, before notifying a Licensed Nurse (LN). The incident occurred during the early hours when CNAs N and P were conducting rounds. Upon entering Resident 4's room, they observed signs of distress, including flushed appearance, pale lips, wheezing, and minimal urine output. Despite these observations, CNA P attempted a sternal rub, a medical technique not included in the facility's Nurse Aide Competency Review, and found the resident unresponsive. CNA P then informed the LN of the resident's condition. The LN documented the resident's condition, noting lethargy, inability to arouse, and crackles in the lungs, and subsequently contacted the physician, who ordered the resident to be sent to the emergency room. The LN also notified administrative staff and arranged for emergency medical services to transport the resident to the hospital. Interviews with the CNAs and administrative staff revealed that not all CNAs were trained or authorized to perform sternal rubs, highlighting a lapse in ensuring that only qualified personnel conducted such assessments. This incident underscores the facility's failure to adhere to protocols requiring qualified staff to perform specific medical techniques.
Failure to Provide Adequate ADL Care to Quadriplegic Resident
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to a dependent resident, identified as R4, who was quadriplegic and required total assistance for self-care and mobility. R4 had a history of multiple medical conditions, including dysphagia, chronic kidney disease, and a history of urinary tract infections. The resident was always incontinent of bladder and occasionally incontinent of bowel, necessitating regular checks and changes by the staff. Despite these needs, the facility did not ensure that R4 received the necessary care, as evidenced by the resident being found disheveled and malodorous upon transfer to the hospital. On the day of the incident, R4 was noted to have minimal urine output and was not feeling well, as reported by the Certified Nurse Aides (CNAs) on duty. The CNAs documented that R4 was dry or only lightly wet during their shifts, which was unusual given her typical condition as a heavy wetter. Despite these observations, there was a lack of communication and follow-up by the staff to address the resident's condition. The resident was eventually found unresponsive and was transferred to the emergency department, where she was described as appearing in poor health, disheveled, and malodorous. Interviews with staff and law enforcement officers revealed that there were significant lapses in care and communication within the facility. The CNAs and administrative staff acknowledged that R4 was not receiving the necessary attention and care, particularly during the night shift. The facility's failure to provide adequate ADL care and monitor the resident's condition contributed to the deterioration of R4's health, ultimately leading to her hospitalization and subsequent death.
Inadequate Supervision and Transfer Procedures Lead to Resident Falls
Penalty
Summary
The facility failed to transfer Resident 16 according to her care plan, resulting in a fall. Resident 16 had diagnoses of muscle weakness, abnormalities of gait and mobility, and a history of falling. Her care plan required the assistance of two staff members for shower transfers, but this was not followed, leading to a fall in the shower area. The resident's cognitive impairments and physical limitations necessitated careful adherence to her care plan, which was not observed, resulting in the incident. Additionally, the facility did not provide adequate supervision for Resident 3, who required one-on-one supervision due to his severe cognitive impairments and risk of wandering. Despite the care plan's directive for continuous supervision, Resident 3 fell out of bed and sustained a laceration to the back of his head. The care plan lacked specific instructions for staff regarding the resident's waking hours, which contributed to the inadequate supervision and subsequent fall. The report also highlights ongoing issues at the facility, as noted by law enforcement officers who have been called to the facility multiple times for staff-to-resident battery issues and neglect. The facility's failure to adhere to its own policies on safe handling and transfers, as well as the lack of clear guidelines for staff supervision, resulted in these deficiencies, compromising the safety and well-being of the residents involved.
Inadequate Feeding Tube Care and Hygiene for Non-Verbal Resident
Penalty
Summary
The facility failed to provide feeding tube care in accordance with professional standards of practice, resulting in a significant incident involving a resident, R3. R3, a non-verbal resident with cerebral palsy, Down's syndrome, autism, and other medical conditions, was dependent on a feeding tube for nutrition. On June 16, 2024, a Certified Nurse Aide (CNA) accidentally pulled out R3's feeding tube while changing his shirt, necessitating emergency medical transportation to a local hospital for surgical replacement. The care plan for R3 lacked specific instructions for preventing and responding to G-tube dislodgment, and there was no documentation of previous incidents or interventions related to the feeding tube. Following the incident, R3 was placed on one-on-one observation, but the care plan still did not include adequate instructions for staff regarding the management of the feeding tube. Observations during the survey revealed that R3 was often seen with dirty fingers and feet, indicating a lack of proper hygiene care. Interviews with staff and law enforcement officers highlighted ongoing concerns about the facility's ability to provide adequate care, particularly for residents who are non-verbal or unable to advocate for themselves. The report also noted that law enforcement had been frequently called to the facility due to issues of staff-to-resident battery and neglect, with over 300 calls in two years. Despite training records indicating that staff had been trained in necessary areas, there was skepticism about the effectiveness of this training. The facility's documentation and response to changes in R3's condition were inadequate, as evidenced by the lack of monitoring and documentation related to the replacement of the feeding tube after the incident.
Failure to Provide Adequate Social Services and Support
Penalty
Summary
The facility failed to provide medically related social services to a resident, identified as R1, who had a history of paranoid schizophrenia, major depressive disorder, PTSD, and suicidal ideations. The deficiency was noted when the facility did not adequately address R1's needs after a traumatic event involving another resident, R3, who entered R1's room and touched her private areas. Despite R1's report of the incident, the facility did not provide timely or sufficient psychosocial support, as evidenced by the lack of person-centered interventions in R1's care plan and the delayed scheduling of a mental health consultation. The facility's inaction extended to the handling of R1's rights and preferences. R1's care plan did not reflect her wishes regarding the presence of her guardian during interactions with staff, nor did it include an individualized discharge plan when the facility initiated an involuntary transfer. Additionally, the facility imposed a requirement for two staff members to be present during R1's care without consulting her or her guardian, which was not documented in her care plan. This change in care protocol was distressing to R1, who expressed feeling that her rights were taken away and that she was being treated unfairly by the staff. Furthermore, the facility's communication with R1's guardian was inadequate, as evidenced by the lack of follow-up on the guardian's requests and the failure to document grievances properly. The facility issued a discharge notice to R1, citing the guardian's actions as a reason, but did not provide social services to assist R1 through the transition. Interviews with R1, her guardian, and staff revealed a lack of support for R1's psychosocial well-being and a failure to address the impact of the incident with R3 on her mental health.
Deficiencies in Resident Care and Abuse Investigation
Penalty
Summary
The report highlights multiple instances of neglect and abuse within the long-term care facility, leading to immediate jeopardy for the residents involved. In the case of Resident (R)89, a resident with chronic kidney disease and electrolyte imbalances, the facility failed to provide appropriate nursing care and monitoring following the resident's return from a hospitalization for sepsis. This failure resulted in medication errors, lack of monitoring of vital signs, and ultimately led to the resident's emergency transfer to the hospital for kidney failure. The facility's deficiencies in medication administration, monitoring, and follow-up placed R89 in immediate jeopardy. Additionally, the report details an incident involving Resident 19, who was allegedly abused while under one-on-one observation. The resident fell out of her wheelchair, sustaining injuries, and accused a Certified Nurse Aide (CNA) of hitting her. Despite the allegation, the facility failed to investigate the incident promptly, leading to a prolonged period where the alleged abuser continued to work with residents. This failure to address and report the abuse allegation to the appropriate authorities placed R19 at risk for further harm and demonstrated a lack of protection for residents from abuse within the facility.
Delayed Reporting of Alleged Abuse and Inadequate Care Plan for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure the timely reporting of alleged abuse to the State Agency (SA) or local law enforcement, as required by regulations. On 03/19/24, a cognitively impaired resident (R19) allegedly fell out of her wheelchair, sustaining injuries, and repeatedly stated that a Certified Nurse Aide (CNA C) hit her. Despite the incident being reported to the Director of Nursing, the facility did not report the allegation of abuse to the Administrator, SA, or local law enforcement until 36 days later, during an onsite survey. This failure to promptly report placed R19 in immediate jeopardy and put all residents at risk for abuse. R19's medical history revealed diagnoses of generalized anxiety disorder, obsessive-compulsive disorder, cognitive communication deficit, and major depressive disorder with psychotic symptoms. The resident had documented memory problems, hallucinations, and required substantial assistance for daily activities. R19 had a history of falls, including a fall with a fracture of nasal bones, and exhibited behaviors such as paranoia, anxiety, and restlessness. Despite these documented conditions and incidents, the facility's care plan lacked specific interventions related to R19's falls on 03/19/24 and 03/29/24, as well as behavioral outbursts. The facility's investigation into the alleged abuse lacked thorough documentation and immediate interventions to prevent further incidents. The facility's failure to follow established protocols for reporting abuse, conducting investigations, and implementing appropriate care interventions led to a deficiency in ensuring the safety and well-being of residents, particularly R19. The lack of timely reporting and action in response to the abuse allegation highlighted significant gaps in the facility's compliance with regulatory requirements for protecting residents from abuse and neglect.
Investigation and Documentation Deficiencies in Alleged Abuse Case
Penalty
Summary
The facility failed to thoroughly investigate incidents of alleged abuse and protect residents from further abuse, as evidenced by the case of resident R19. On 03/19/24, R19, a cognitively impaired resident, sustained a knot on her forehead and a bruised eye while under the one-on-one supervision of Certified Nurse Aide (CNA) C in a closed-door room with no other witnesses. R19 had been exhibiting behaviors of yelling and screaming since early morning, and upon assessment, repeatedly stated that CNA C had hit her in the face. Despite these serious allegations, the facility did not promptly investigate the incident or take steps to protect R19 from potential further abuse. CNA C continued to work in the facility for 36 days after the allegation, placing R19 in immediate jeopardy and exposing all residents to the risk of abuse. The facility's failure to address the allegation of abuse in a timely and appropriate manner was further highlighted by the lack of proper documentation and investigation procedures. The Electronic Health Record (EHR) of R19 indicated that she was placed on one-on-one observation due to her behaviors, including paranoia and yelling, since early morning on 03/19/24. The facility's fall investigation report documented the incident but lacked crucial details such as witness statements and proper documentation of injuries. Additionally, the handwritten note provided by CNA C, which attempted to explain the incident, lacked proper documentation and clarity, further raising concerns about the facility's handling of the situation.
Staff Competency Deficiencies Impact Resident Safety and Well-being
Penalty
Summary
The facility failed to ensure that staff possessed the appropriate competencies to provide nursing and related services to assure resident safety and well-being. Several incidents were documented that highlighted this deficiency. For example, in the case of Resident (R)19, who had complex mental health needs including anxiety disorders, OCD, cognitive deficits, and major depressive disorder with psychotic symptoms, the staff did not adequately address falls, behavioral symptoms, and abuse allegations. The facility's lack of appropriate interventions and failure to investigate abuse allegations led to negative physical, mental, and psychosocial effects on the resident. Similarly, in the case of R35, who had diagnoses of insomnia, anxiety disorder, cerebral palsy, and dysphasia, the staff demonstrated inappropriate handling by dragging the resident across the floor. This incident showcased a lack of understanding and competency in providing care for residents with specific needs. The deficiency in addressing ADLs, transfers, and safety for R35 further emphasized the facility's failure to ensure staff possessed the necessary competencies to meet residents' needs effectively.
Deficiencies in Resident Care and Safety Protocols
Penalty
Summary
The facility, with a census of 35 residents, was found to have multiple deficiencies during a recent survey. These deficiencies included failures in protecting residents' privacy and dignity, promoting resident self-determination, ensuring an environment free from neglect and abuse, preventing misappropriation of resident property, and timely reporting of alleged abuse incidents. The facility also lacked effective systems for preventing medication errors, completing necessary assessments and care plans, providing appropriate care for residents, and maintaining a safe environment to prevent accidents and infections. Additionally, the facility did not have proper training programs in place for nurse aides, leading to deficiencies in staff competencies. Specific incidents highlighted in the report included a failure to protect residents from abuse, neglect, and medication errors, resulting in harm to residents such as falls, injuries, and potential untreated symptoms. The facility's lack of timely reporting and investigation of abuse allegations, failure to provide necessary equipment and care, and inadequate monitoring for safety measures put residents at risk for physical, mental, and psychosocial harm. The deficiencies in documentation, care planning, medication administration, and staff training further compounded the risks faced by residents in the facility.
Failure to Provide Appropriate ADL and Meal Assistance
Penalty
Summary
The facility failed to provide appropriate ADL care to a resident, resulting in actual harm. On 04/18/24, a CNA pulled on the resident's sore arm while assisting her in bed, leading to a right shoulder dislocation and suspicion of a Hill Sachs Fracture. The resident was transported to the local Emergency Department for evaluation and treatment. The care plan for this resident lacked specific instructions for ADL assistance, including transfers and bed mobility, which contributed to the incident. The resident had previously reported pain, but the care plan did not address pain management or ADLs until after the injury occurred. Another resident, who had severe cognitive impairment and required supervision or touch assistance with ADLs, did not receive the necessary assistance during meals. Despite being on a regular diet with specific instructions for staff to offer help and encourage eating, the resident was observed struggling to eat without staff intervention. The resident experienced significant weight loss, and staff failed to provide the recommended divided plate, built-up silverware, and covered mug. Multiple observations confirmed that staff did not assist the resident during meals, leading to potential negative effects related to nutrition. A third resident, who required extensive to total assistance with ADLs, was also not provided with the necessary help during meals. The resident was observed in the dining room with eyes closed and minimal food intake, relying on another resident to wake her up. Staff did not consistently offer assistance, and the resident consumed very little food and drink. The care plan for this resident included instructions for set-up assistance and cueing during meals, but these were not followed, leading to potential negative effects related to nutrition and weight loss.
Deficiency in Accident Hazard Prevention and Supervision
Penalty
Summary
The facility failed to provide an environment free from accident hazards and adequate supervision to prevent accidents for several residents, including R28, R19, and R35. Specifically, the facility did not effectively implement timely fall interventions for R28, who had multiple falls, leading to an incident where R28 fell from his wheelchair, resulting in a head injury requiring staples. The facility also failed to identify causal factors for falls experienced by R19, a resident with repeated falls and cognitive impairments. Additionally, inadequate supervision and safety measures were noted for R35, a resident with wandering tendencies, as staff allowed R35's wheelchair to be propelled in a manner that caused a backward motion of the legs, potentially increasing the risk of falls or accidents. The deficiencies observed in the care provided to these residents were further highlighted by the lack of appropriate interventions in their care plans following incidents of falls or accidents. For example, the care plan for R19 did not include specific interventions related to the falls that occurred on 03/19/24 and 03/29/24, as well as behavioral outbursts. Similarly, the care plan for R35 lacked instructions related to activities of daily living, transfers, and safety measures to address the resident's wandering behavior and potential elopement risks. These gaps in care planning indicate a failure to address the individual needs and risks of the residents, contributing to the overall deficiency in providing a safe environment free from accident hazards. The facility's policies and procedures related to accidents and safety were not effectively implemented, as evidenced by the lack of timely and appropriate responses to incidents of falls and accidents involving the residents. The failure to promptly identify and address potential hazards, implement necessary interventions, and update care plans accordingly demonstrates a systemic issue in ensuring the safety and well-being of residents within the facility. These deficiencies have the potential to impact the overall health and quality of life of the residents and highlight the need for improved oversight and adherence to regulatory standards in providing a safe care environment.
Failure to Implement Nutritional Interventions Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure pertinent and timely interventions were implemented as ordered to prevent a resident's significant weight loss of 12.06% in 63 days. The facility did not weigh the resident weekly, did not document nutritional intake as ordered, did not provide appropriate assistive devices to help the resident feed himself, and did not ensure staff knew of the nutritional monitoring system regarding who provided nutritional shakes to the resident. This failure resulted in the resident losing 20.8 pounds in 63 days, placing the resident at risk for continued decline in nutritional status and the development of life-threatening symptoms, which could negatively affect the mental, physical, and psychosocial well-being of the resident. The resident's Electronic Health Record (EHR) documented pertinent medical diagnoses including dementia, dyspepsia, dysphagia, and schizophrenia. The resident had a Body Mass Index (BMI) of 21.6, indicating he was underweight for his age. The resident's care plan noted a recent significant weight loss of 5% in one month following a recent hospital stay. The care plan included interventions such as offering alternative meals if the resident did not like the meal served, providing snacks and health shakes, and using assistive devices like a divided plate and built-up silverware. However, these interventions were not consistently implemented. Observations and interviews revealed that the resident often sat in his wheelchair with food in front of him but without the necessary assistive devices or staff assistance. The facility's documentation showed multiple instances where the resident's nutritional intake was not recorded, and weekly weights were not taken as ordered. Staff interviews confirmed that there was confusion about who was responsible for documenting tasks and providing nutritional shakes. The facility's policy on weight monitoring was not followed, leading to the resident's significant weight loss and the associated risks to his health.
Medication Administration Errors Due to Delayed eMAR Entry
Penalty
Summary
The facility failed to prevent significant medication errors for Resident (R)89 due to staff not entering R89's re-admission medication orders into the Electronic Medication Administration Record (eMAR) for five days after returning from the hospital. This failure resulted in staff administering medications from a prior order, leading to incorrect dosages and omitted medications that were newly ordered for R89's treatment post-hospitalization. The report highlighted that R89 had a complex medical history, including diagnoses such as heart failure, anxiety disorder, hypertension, edema, alcohol abuse, atrial fibrillation, acute kidney failure, and other conditions, requiring a range of medications for management. The deficiency was further exacerbated by the lack of proper documentation and communication among staff members. Administrative Nurse B admitted during interviews that the admitting nurse did not process R89's admission orders upon return from the hospital, leading to the resident receiving the same medications from the prior admission. This oversight was not discovered until R89 was readmitted to the hospital, and the discrepancy in medications was identified when comparing the facility's orders against the hospital discharge orders. Physician U, the facility's medical director, expressed concerns about the errors in medication administration, particularly regarding cardiac and hypertensive medications, emphasizing the importance of following physician orders accurately.
Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure an effective system to prevent the misappropriation of resident property, specifically controlled medications. During the onsite health resurvey and complaint investigations, it was revealed that staff diverted controlled medications and could not account for numerous missing narcotic medications affecting five residents. The facility's investigation into these incidents showed that narcotic cards had been tampered with, and medications were replaced with non-narcotic drugs, such as Hydralazine. The facility was unable to determine when these medications were taken or who was responsible for the diversion, although one nurse was terminated for erratic behavior and suspected involvement. The facility reported two Facility Reported Incidents (FRIs) regarding drug diversions. The first FRI involved the discovery of tampered narcotic cards for two residents, with Oxycodone being replaced by Hydralazine. The second FRI revealed missing narcotic medications for five residents, discovered during a monthly pharmacy narcotic destruction. The facility's records showed discrepancies in the narcotic count sheets and missing medication cards. The surveyor's investigation confirmed that several residents had unaccounted-for narcotic medications, including Norco, Oxycodone, and Ativan, some of which had been discontinued months prior. Interviews with facility staff revealed inconsistencies in the handling and storage of discontinued narcotic medications. Staff members were unsure about the proper procedures for storing and destroying these medications, and there were lapses in the narcotic count process. The facility's policy required discontinued medications to be destroyed or returned to the dispensing pharmacy, but this was not consistently followed. The facility's failure to maintain an effective system for managing controlled medications placed residents at risk for untreated symptoms and potential harm.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that medications were administered correctly, resulting in a medication error rate of 6.45%, which is above the acceptable threshold of 5%. Specifically, a resident with congenital stenosis and stricture of the esophagus, cerebral palsy, and aphasia did not have their G Tube placement checked before the administration of water and medications. This oversight was confirmed by the Licensed Nurse during an interview. Additionally, a Certified Medication Aide did not perform proper hand hygiene when switching between administering eye drops and oral medications for another resident, which was also confirmed during an interview. The facility's policy on medication errors mandates that residents receive care in an environment free of medication errors and that the medication error rate must be below 5%. However, the facility did not adhere to this policy, as evidenced by the failure to check G Tube placement and the lack of hand hygiene during medication administration. These deficiencies were acknowledged by the administrative nurse, who confirmed the correct procedures that should have been followed.
Failure to Remove Discontinued Medications from Circulation
Penalty
Summary
The facility failed to remove discontinued medications from circulation, specifically for two residents. During an onsite survey, it was observed that the medication cart contained Ativan tablets prescribed to a resident, even though the order for Ativan had ended several months prior. Additionally, the narcotic sheet for another resident did not contain a prescription number, making it difficult to verify the medication. Interviews with staff revealed that discontinued narcotics were supposed to be removed and stored in a locked compartment, but this process was not consistently followed. The facility's policy required that discontinued medications be destroyed or returned to the pharmacy, but this was not adhered to in these cases. The surveyor noted that the facility had one medication room and two medication carts, and the failure to remove discontinued medications was observed in both carts. Interviews with various staff members, including a CMA and two administrative nurses, revealed inconsistencies in the handling and storage of discontinued narcotics. The administrative nurses admitted that discontinued narcotics stayed in the medication carts until both of them were available to collect and store them securely. This practice led to the presence of discontinued medications in the carts, posing a risk to residents. The facility's policies on controlled substances and discontinued medications were not followed, contributing to the deficiency.
Failure to Maintain Sanitary Conditions in Food Preparation and Service
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as evidenced by several observations and interviews. During an initial kitchen tour, a large bag of shredded cheese was found opened and undated in the refrigerator, which was subsequently disposed of by the Certified Dietary Manager (CDM). Dietary Staff Z was unable to locate test strips for the dishwasher, and the CDM confirmed that the wrong strips had been ordered, necessitating the use of a three-compartment sink for dishwashing until the correct strips arrived. A follow-up kitchen tour revealed that the dishwasher machine was tested at 100 parts per million (ppm) by the CDM. Additionally, Dietary Staff Z was observed handling multiple food items and kitchen equipment with the same pair of gloves, failing to change gloves and wash hands between tasks, which is a breach of sanitary food handling practices. Further observations included Dietary Staff Y handling chicken with the same pair of gloves, using tongs and a knife, and placing the chicken in various pans and a food processor without changing gloves or washing hands. An interview with the CDM revealed that dietary aides did not receive regular training on food handling. The facility's policy on date marking for food safety was not adhered to, as evidenced by the undated shredded cheese. These actions and inactions led to the potential for foodborne bacteria, compromising the sanitary conditions required for food preparation and service in the facility.
Multiple Deficiencies in Resident Care and QAPI Program
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, leading to numerous deficiencies in resident care. The survey identified multiple instances where the facility did not protect the privacy and dignity of residents, such as a resident being disturbed in her room by another resident with wandering behaviors and another resident being seated in the dining area inappropriately dressed. Additionally, the facility did not support resident self-determination, as one resident was not given a choice about the meals he ate, potentially affecting his psychosocial well-being. The facility also failed to ensure an environment free from neglect and alleged abuse. One incident involved a cognitively impaired resident who fell and sustained injuries while under one-on-one supervision. The resident repeatedly stated that the CNA hit her, but the facility did not report the allegation to the appropriate authorities until 36 days later. Furthermore, the facility did not investigate the allegation or protect the resident from potential further abuse, allowing the CNA to continue working with residents. Other deficiencies included the failure to provide a copy of the bed hold policy to residents or their representatives, incomplete and inaccurate Minimum Data Set (MDS) documentation, and failure to revise care plans for residents. The facility also did not provide appropriate ADL care, leading to actual harm in one case where a resident's shoulder was dislocated. Additionally, the facility failed to maintain an effective pharmacy system, resulting in medication errors and the potential for untreated symptoms. The facility's in-service training program for CNAs was also found to be inadequate, lacking the required hours of training to ensure continuing competence in providing appropriate care and services to residents.
Failure to Document Vaccinations
Penalty
Summary
The facility failed to provide proof of vaccination or declination of vaccines for the 2022-2023 influenza or pneumococcal vaccines for five residents reviewed. Specifically, the Electronic Health Records (EHR) for Residents 89, 18, 10, 33, and 25 lacked documentation of the 2022-2023 influenza vaccine or declination of the vaccine. Additionally, there was no documentation of any pneumococcal vaccine or declination of the vaccine(s) for these residents. On April 25, 2024, at 1:37 PM, Consultant Nurse E was informed that influenza and pneumococcal vaccination records for the five residents were needed, including education for residents/responsible parties, signed consent, or signed declination by residents/responsible parties. The facility also failed to provide a policy related to wandering/elopement as requested on the same date.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to maintain an in-service training program for nurse aides that was appropriate and effective to ensure the continuing competence of nurse aides. The facility identified eleven Certified Nurse Aides (CNAs) who had been employed for over one year. Of the eleven, five were reviewed, and all five CNAs lacked the required 12 hours of in-service training, including dementia care and abuse prevention training. This deficiency was confirmed through a review of training logs and interviews with administrative staff, who acknowledged the lack of required training and the incomplete transition from a paper-based to an online training system. Specifically, the training logs for the five reviewed CNAs showed insufficient training hours and a lack of training in abuse, neglect, and exploitation (ANE) as well as dementia care. For example, CNA II, CNA JJ, and CNA KK each had only 75 minutes of training in the last 12 months, while CNA AA had 120 minutes, and CNA LL had no training at all. Administrative Staff N and A confirmed the deficiency, stating that the facility was in the process of transitioning to an online training system, which contributed to the incomplete training records. The facility also failed to provide a policy regarding the required training and in-service of staff when requested.
Failure to Complete and Analyze Care Area Assessments
Penalty
Summary
The facility failed to complete or analyze the Care Area Assessments (CAAs) triggered on the residents' Minimum Data Set (MDS) for four residents. This deficiency was identified through interviews and record reviews. The residents involved had various medical conditions and cognitive impairments, and the CAAs lacked the necessary analysis for further investigation and development of comprehensive care plans. The CAAs were merely restatements of the codes themselves rather than an analysis of underlying issues, which is required to develop a care plan for the individual resident's root cause of triggered areas. This failure was acknowledged by the administrative and consultant nurses during the survey. Resident 18 had multiple diagnoses, including sepsis, impulse disorder, depression, anxiety disorder, anoxic brain damage, and nontraumatic intracerebral hemorrhage. The resident's Admission MDS indicated moderate cognitive impairment and dependence on staff for mobility and care. The CAA dated 03/15/24 lacked analysis for further investigation. Similarly, Resident 21, who had diagnoses including type 1 diabetes mellitus, gastroparesis, ulcerative pancolitis, and enterocolitis due to clostridium difficile, had an Admission MDS indicating intact cognition but required staff assistance with daily cares. The CAA dated 02/16/24 also lacked analysis for further investigation and development of a comprehensive care plan. Resident 22, diagnosed with diabetes mellitus, congestive heart failure, hypertension, and chronic kidney disease, had an Admission MDS indicating normal cognition and independence with daily cares. The CAA dated 08/18/23 lacked analysis for further investigation. Resident 25, with diagnoses including diabetes mellitus type two, generalized muscle weakness, and delusional disorder, had an Admission MDS indicating intact cognition but required maximal to total assist with ADLs. The Functional Abilities and Falls CAAs lacked analysis of findings, and the care plan did not adequately address the resident's fall risk. The facility's failure to complete accurate comprehensive assessments and analyze findings on the MDS and CAAs had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs.
Inaccurate MDS Documentation and Assessment
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated needs for care and services. For Resident 28, the MDS lacked documentation of a fall that occurred on 12/10/23, despite the resident's history of falls and unsteady gait. The facility's fall notes confirmed the incident, but the MDS did not reflect this, indicating a failure in accurate record-keeping and assessment. Additionally, the MDS coding was based on incomplete information, as assessments were not completed on time, and the facility lacked a policy for MDS completion, relying solely on the Resident Assessment Instrument (RAI) manual as a reference. Resident 24's MDS also contained inaccuracies, particularly regarding the use of oxygen and mobility aids. The Annual MDS did not document the resident's use of oxygen, despite physician orders and observations confirming its use. Similarly, the Quarterly MDS failed to document the resident's use of a wheelchair or walker for mobility. These discrepancies highlight a significant gap in the facility's assessment and documentation processes, potentially leading to unmet care needs for the resident. For Resident 25, the MDS and Care Area Assessments (CAAs) were incomplete and inaccurate, particularly concerning falls, urinary catheter use, and a contracture in the left hand. The MDS did not trigger a falls assessment, despite multiple documented falls and a high-risk evaluation. The CAAs lacked analysis of findings, merely restating codes without addressing underlying issues. The care plan did not identify the resident's left-hand contracture, and there were no specific orders for safety or falls prevention. This lack of comprehensive assessment and accurate documentation could lead to negative psychosocial effects and uncommunicated needs for the resident.
Failure to Complete Comprehensive Care Plans
Penalty
Summary
The facility failed to accurately complete comprehensive care plans for four residents, leading to uncommunicated needs for care and services. Resident 32 had multiple diagnoses, including acute respiratory failure and COPD, but the care plan lacked documentation related to respiratory care, oxygen delivery, or nebulized medication use. The Care Area Assessment (CAA) for this resident lacked causal factors for further investigation, and the facility's policy did not specify the timeline for creating comprehensive care plans. This deficiency had the potential to negatively impact the resident's physical and psychosocial well-being. Resident 3 had diagnoses of abnormalities of gait and mobility and morbid obesity. The care plan did not address the resident's ADL assistance needs, which resulted in actual harm when a CNA pulled on the resident's sore arm, leading to a dislocated shoulder and a suspected Hill Sachs fracture. The facility's policy on comprehensive care plans was not followed, and the CAA lacked analysis of findings, merely restating codes rather than identifying underlying issues. Resident 22 had multiple diagnoses, including diabetes mellitus with neuropathy, congestive heart failure, and chronic kidney disease. The care plan lacked documentation related to the resident's medication needs. Similarly, Resident 35 had diagnoses of insomnia, generalized anxiety disorder, cerebral palsy, and trisomy 21. The care plan did not include instructions for ADLs, transfers, or safety measures related to the resident's behavior of sitting on the floor. The facility's policy on comprehensive care plans was not adhered to, and the CAAs lacked analysis of findings. This deficiency had the potential to lead to negative psychosocial effects and unmet care needs for the residents involved.
Failure to Document and Communicate Residents' Code Status
Penalty
Summary
The facility failed to have a clear system in place to document residents' choices regarding code status, which indicates the type of resuscitation procedures for a resident if their heart stops beating. This deficiency was identified during an onsite survey and affected seven residents. For example, Resident 11's care plan indicated a Do Not Resuscitate (DNR) status, but there was a lack of evidence of an order regarding the resident's code status for approximately three and a half months. Similarly, Resident 13 had a full code status documented two months after admission, and Resident 26 had a full code status documented four months after admission. Other residents, including Residents 29, 32, 16, and 18, also had discrepancies in their code status documentation, with significant delays between admission and the documentation of their code status in their care plans and physician orders. The survey revealed that the facility did not have a system to indicate a resident's code status on their doors or within their rooms. Interviews with staff members, including housekeeping staff and licensed nurses, confirmed that there was no consistent method to communicate code status. Staff relied on walkie-talkies to notify each other in the event of an emergency, and code status information was located on physician orders and face sheets. However, this approach was not sufficient to ensure that all staff members were aware of each resident's code status promptly. The facility's policy on Residents' Rights Regarding Treatment and Advance Directives stated that the facility would support and facilitate a resident's right to request, refuse, and/or discontinue medical treatments and to formulate an advanced directive upon admission. The policy also required periodic reassessment of the resident's desired changes related to any advanced directives, which should be documented in the resident's electronic health record (EHR). The facility's failure to implement a clear system for documenting and communicating residents' code status had the potential to negatively affect the mental, physical, and psychosocial well-being of the affected residents and placed all residents at risk for potential negative outcomes during an emergency.
Deficiency in Pharmacy System for Controlled Medications
Penalty
Summary
The facility failed to ensure an effective pharmacy system was in place to accurately account for, reconcile, and destroy controlled/narcotic medications. This deficiency affected multiple residents, including those who had been discharged or had passed away, and placed any resident receiving controlled medications at risk for staff diversion and potential untreated symptoms. The survey revealed discrepancies in the handling and documentation of narcotic medications, including missing medications and tampered medication cards. For instance, a narcotic card for a resident's Oxycodone was found to have been tampered with and replaced with a different medication, Hydralazine. Additionally, several narcotic medications were unaccounted for, including 96 tabs of Norco for one resident and 97 tabs of Oxycodone for another resident who had passed away months prior. During the onsite survey, it was observed that the narcotic sheets for some residents did not contain proper documentation, such as dates for when medications were signed out or wasted. For example, a PRN Oxycodone was removed for one resident without a date entry, and another resident's Ativan tablets were wasted without proper documentation. Interviews with staff revealed inconsistencies in the procedures for handling discontinued narcotic medications, with some staff unsure of the correct process and others not performing required narcotic counts when handing over keys. The facility's policy on medication errors and discontinued medications was not effectively implemented, leading to significant lapses in the management of controlled substances. The facility's failure to ensure proper procedures for the accounting, reconciliation, and destruction of narcotic medications resulted in potential risks to residents' health and safety. The survey findings highlighted the need for improved oversight and adherence to established protocols to prevent medication errors and ensure the well-being of residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper cleaning of respiratory equipment, inadequate hand hygiene during medication administration, and improper cleaning of glucometers. Certified Medication Aide (CMA) CC was observed on multiple occasions failing to perform hand hygiene before and after glove use, and improperly cleaning the glucometer with ungloved hands. CMA CC admitted that hand hygiene should be performed after removing gloves and that the glucometer should be cleaned with gloves if blood is visible. Additionally, CMA CC did not wash hands before administering medications, including eye drops, which should have been prepared and given last. Administrative staff confirmed that hand hygiene should be performed before and after glove use and after administering care. The facility also failed to properly clean and store nebulizer equipment. Resident 32's nebulizer was observed with an unknown clear liquid in the medication chamber, and the cannula lacked a date to indicate when it was last changed. Staff interviews revealed that the nebulizer mask and medication chamber should be disassembled, rinsed with tap water, and left to air dry after each use, but this was not being done. The facility's policies on infection prevention and control, glucometer disinfection, and oxygen administration were found to be lacking or undated, contributing to the deficiencies observed.
Failure to Protect Resident Privacy and Dignity
Penalty
Summary
The facility failed to protect the privacy and dignity of two residents, R24 and R25. R24, who had intact cognition and required assistance with personal care, was repeatedly disturbed in her room by another resident with wandering behaviors. Despite R24's ability to sometimes redirect the wandering resident, she often had to wait for staff assistance, which was not always promptly available. The facility lacked specific interventions in R24's care plan to protect her privacy and dignity, and staff confirmed the wandering behaviors of the other resident but did not provide a policy related to resident privacy and dignity when requested. R25, who also had intact cognition and required maximal assistance with activities of daily living, was observed in the dining area wearing only a shirt and an incontinence brief, with his lap partially covered by a blanket. R25 expressed discomfort with this situation and also noted that he had not been shaved, which he preferred. The care plan for R25 lacked interventions related to maintaining his privacy and dignity, and staff were unaware of his preferences regarding clothing and grooming. The facility failed to provide a policy related to privacy and dignity when requested. The deficient practices in the facility led to R24 being disturbed in her room on multiple occasions and R25 being left without proper clothing and grooming, which had the potential to lead to negative psychosocial effects related to dignity. The facility's failure to protect the privacy and dignity of these residents was confirmed through interviews, observations, and record reviews.
Failure to Promote Resident Self-Determination in Meal Choices
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice when Resident 25 was not given a choice about the meals he ate. Resident 25, who had a diagnosis of diabetes mellitus type two and intact cognition as indicated by a BIMS score of 15, required maximal to total assistance with activities of daily living. Despite the care plan instructions for staff to provide set-up assistance for meals and monitor the resident's nutritional intake, Resident 25 was not given a choice about his meal and was not adequately attended to during mealtime. On one occasion, after finishing his supper, Resident 25 expressed that he was still hungry and requested more food. However, he was not promptly attended to and was eventually offered a peanut butter and jelly sandwich, which he declined as he did not like it. It was only after a significant delay that Resident 25 was offered food from the anytime menu, which he accepted. The facility's failure to provide a policy related to resident choices and the lack of timely and appropriate response to Resident 25's request for more food highlight the deficiency in promoting and facilitating resident self-determination. The observations revealed that other residents were offered additional food and checked on by dietary staff, while Resident 25 was not acknowledged for nearly an hour. This deficient practice had the potential to negatively affect Resident 25's psychosocial well-being, as he was not given a choice about his meals and was not promptly attended to when he expressed hunger.
Failure to Provide Written Notification of Hospitalization
Penalty
Summary
The facility failed to notify Resident 18 and Resident 21, or their representatives, in writing about their transfer to the hospital and the reasons for the transfer. Resident 18, who had multiple diagnoses including sepsis, depression, and anoxic brain damage, was transferred to the hospital due to gross hematuria and surgical wound dehiscence. The facility's records lacked documentation of written notification to the resident's representative about the transfer and its reasons. Interviews with staff confirmed that while verbal notifications were made, written notifications were not provided, and no policy on written notification was available upon request. Similarly, Resident 21, who had diagnoses including type 1 diabetes mellitus and ulcerative pancolitis, was hospitalized after vomiting, which was a symptom of diabetic ketoacidosis. The facility's records also lacked documentation of written notification to the resident's representative about the hospitalization and its reasons. Staff interviews revealed that the practice was to call the representative but not to send a written statement, and no policy on written notification was provided when requested. The deficiency was identified during a survey where the facility reported a census of 35 residents, with 20 included in the sample. The failure to provide written notifications affected two of the three residents reviewed for hospitalization. The facility did not have a policy in place for written notification of hospitalization, as confirmed by staff interviews and the absence of such a policy when requested by the surveyors.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a copy of the bed hold policy to two residents, R18 and R21, or their representatives at the time of their transfer to the hospital. R18, who had multiple diagnoses including sepsis, depression, and anoxic brain damage, was transferred to the hospital due to gross hematuria and surgical wound dehiscence. The facility's electronic medical record for R18 lacked a signed bed hold for hospitalization, and there was confusion among staff about who was responsible for providing the bed hold notice. Administrative Nurse F, Social Service Staff L, Consultant Nurse E, and Administrator A all provided conflicting information regarding the responsibility for bed hold notifications, despite recent training on the issue. Similarly, R21, who had diagnoses including type 1 diabetes mellitus and ulcerative pancolitis, was transferred to the hospital due to vomiting and symptoms of diabetic ketoacidosis. The electronic medical record for R21 also lacked a signed bed hold for hospitalization. Staff interviews revealed the same confusion about the responsibility for bed hold notifications, with Administrative Nurse F, Social Service Staff L, Consultant Nurse E, and Administrator A all providing inconsistent information. The facility's undated bed hold policy stated that residents should be informed upon admission and prior to a transfer for hospitalization or therapeutic leave about the bed hold policy, including any charges and the time limit established by the State Medicaid Plan. However, the facility failed to notify both R18 and R21 or their representatives with a written notice specifying the duration and cost of the bed hold policy at the time of their transfer to the hospital.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to revise the care plan for Resident 25 after multiple falls occurred. Resident 25, who has a diagnosis of diabetes mellitus type two, generalized muscle weakness, absence of the left leg below the knee, abnormalities of gait and mobility, and delusional disorder, was found to have an intact cognition with a BIMS score of 15. Despite requiring maximal to total assistance with ADLs and having impairments in both upper and lower extremities, falls were not assessed in the Admission MDS. The care plan dated 04/22/24 identified Resident 25 as high risk for falls but lacked specific interventions for staff guidance following incidents on 12/28/23, 01/03/24, and 01/11/24, where the resident was found on the floor or had to be lowered to the floor due to combative behavior. The care plan did not include measures to prevent further falls after these incidents. The facility's documentation and assessment processes were found to be inadequate. The Functional Abilities CAA dated 01/26/24 lacked analysis of findings, and the Falls CAA did not trigger on the MDS as falls were not assessed. Staff completed fall risk evaluations on 01/03/24 and 01/11/24, revealing inconsistent fall risk assessments. The EHR Physician Orders lacked specific orders for safety or falls prevention. Interviews with administrative and consultant nurses revealed that MDS coding, CAA development, and care plans were completed off-site and often lacked detailed analysis, relying instead on restatements of codes. The facility did not have a specific policy for MDS, relying on the RAI manual as a reference. This lack of proper care plan revision and assessment had the potential to lead to negative psychosocial effects and further falls for Resident 25.
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Surveyors found that the facility failed to maintain sanitary food storage, handling, and dishwashing practices in the kitchen. Clean dishes were stored upright instead of inverted, and numerous food items in coolers, freezer, pantry, and spice racks were undated, missing the year, had unreadable dates, or showed visible mold, while some bags and containers were left open or unsealed. A dietary staff member handled ready-to-eat foods such as bread and butter with bare hands and repeatedly washed hands with water only, without soap or sanitizer, while preparing pureed meals for a resident. The low-heat dish machine repeatedly operated below the facility’s stated minimum wash temperature, as documented on the temperature log. These practices were inconsistent with the facility’s own food storage policy and staff’s stated expectations for glove use, labeling, sealing of food, dish storage, and dishwashing temperatures.
The facility did not employ a full-time Certified Dietary Manager (CDM) as required by its own Nutritional Services Policy, despite serving meals to 31 residents. A dietary staff member without CDM credentials was observed overseeing meal preparation, and both this staff member and an administrative nurse confirmed that the staff member was not certified, although enrolled in CDM classes. The policy specified that a CDM must oversee key functions such as menu planning, diet and diet manual with nutritional evaluations, office procedures for notifying the RD of new elders, food production, and food service, but no certified individual was fulfilling these responsibilities.
Surveyors found that the facility failed to follow professional standards for food storage and temperature monitoring. A freezer had significant ice buildup, and a refrigerator contained unlabeled, undated sliced cheese. Temperature logs for multiple freezers and refrigerators were incomplete over several days, despite policy requiring routine monitoring and documentation. The ice machine area contained extraneous items, including a plastic lid, a metal object on the floor, and a cup on the drain. In dry storage, several open food items, including pasta, noodles, gelatin, and pancake mix, were undated, unlabeled, or unsealed. Dietary staff confirmed these conditions, and the Dietary Manager later described expectations that all food be labeled, dated, and properly sealed per facility policy.
Surveyors found that staff did not consistently follow EBP, hand hygiene, and clean laundry handling practices. During tracheostomy care for a resident, a nurse wore gloves and a mask but did not don a gown or change gloves before placing clean gauze and the trach cannula. In a separate case, after completing wound care for another resident, the same nurse manipulated a suprapubic catheter tubing while still holding wound supplies and then left the room without performing hand hygiene. Additionally, a housekeeping/laundry staff member removed residents’ personal items from a covered cart and carried them over the shoulder between halls without keeping the items covered. These actions did not follow facility policies requiring targeted gown and glove use for high-contact care, proper hand hygiene around invasive devices and dressings, and keeping laundry carts covered between rooms.
A resident with hemiparesis, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy experienced a fall in his room, was found on the floor near a heater with pain and bruising, and was later confirmed by mobile X-ray to have a nondisplaced fracture of the left superior pubic ramus. Despite this, the subsequent quarterly MDS documented no falls since the prior assessment and did not code the event as a fall with major injury, even though the care plan and progress notes described the fall and resulting fracture. An administrative nurse later acknowledged that the falls section of the MDS had been coded in error, contrary to facility policy and RAI manual requirements for accurate resident assessment.
A resident with severe morbid obesity, vascular dementia, anxiety, and a history of falls, but intact cognition per BIMS, was repeatedly assisted in a wheelchair by staff without foot pedals in place. On multiple observed occasions, staff pushed and turned the resident in the wheelchair while the resident held his feet off the floor and a sock was seen dragging on the floor. Interviews showed staff uncertainty and inconsistency regarding the requirement for foot pedals when assisting the resident, despite the resident’s documented fall risk and a facility falls policy requiring interventions to reduce fall risk.
A resident with Alzheimer’s disease, CKD, BPH, obstructive uropathy, and urinary retention had a suprapubic catheter that staff repeatedly secured incorrectly. During catheter care, two nurses cleaned the abdominal insertion site but attached the Stat-lock to the resident’s thigh, anchoring the tubing to the leg instead of the abdomen. Nursing leadership stated they expected leg anchoring and noted the catheter policy did not specify Stat-lock placement, even though the facility’s suprapubic catheter competency checklist explicitly directed that the tubing be secured to the abdomen.
A resident with dementia, severe cognitive impairment, and depression experienced unplanned weight loss after the RD documented a slow weight-loss trend and recommended house supplement shakes TID with added calories to meals. The facility entered and carried out the supplement order only once daily, and staff confirmed the resident received a shake only on second shift. Weight documentation showed a large, unverified increase followed by a re-weigh that demonstrated a 3.16% loss over a short period, and nursing staff did not promptly recognize or recheck the significant weight discrepancy. The RD was not informed that her TID recommendation had been effectively reduced to once daily, and the facility’s own weight-loss prevention processes were not followed.
A resident with chronic respiratory failure, a tracheostomy, and oxygen therapy orders did not have an Ambu bag or emergency tracheostomy kit readily available at the bedside, despite care plan directives for respiratory care, suctioning, and emergency response if the tracheostomy tube came out. Surveyors observed on multiple occasions that only oxygen and suction were present in the room, while the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, requiring movement of equipment before use. Staff, including CNAs, an LN, and an administrative nurse, confirmed that emergency tracheostomy supplies were kept in the hallway or medication room and not at the bedside, and that they were instructed to call 911 rather than attempt reinsertion of the tracheostomy tube, even though the facility’s respiratory care policy required services in accordance with professional standards and the resident’s care plan.
A resident with diabetes, heart failure, muscle weakness, severe cognitive impairment, incontinence, and limited mobility was identified as at risk for pressure ulcers, with care plans calling for turning/repositioning, use of a pressure-reducing device, and extensive staff assistance for ADLs. Despite these documented risks and interventions, the resident, who preferred to remain in a recliner or wheelchair and became less mobile after a foot fracture requiring a walking boot, developed a facility-acquired Stage 2 pressure ulcer on the buttocks. Wound assessments showed the ulcer’s presence and progression over time, indicating that timely and effective preventive measures were not implemented in accordance with the facility’s wound assessment and prevention policy.
Unsanitary Food Storage, Handling, and Dishwashing Practices in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain sanitary conditions for food storage and preparation in the kitchen. During an initial kitchen tour, they observed multiple clean containers and plates on the drying rack not inverted, leaving eating surfaces exposed. Numerous food items in the kitchen cooler, walk-in cooler, freezer, pantry, and spice rack were either undated, missing the year, had unreadable dates, or were past labeled use-by dates. Examples included cheese and ham slices with only month and day, multiple large containers of sauces, dressings, olives, cherries with visible black mold on the rim and lid, parmesan cheese, syrups, soy sauce, wing sauce, and green beans all lacking complete or legible dating. Additional findings included rusted and peeling cooler racks, open and unsealed bags of frozen foods and pantry items, and a rice bin with a handwritten prep date missing the year. Further observations showed improper food handling and hand hygiene practices by dietary staff. One dietary staff member handled ready-to-eat foods, including butter and bread for toast, with bare hands and then placed the toast on a tray for a resident. On another occasion, a partially wrapped package of cheese slices in the cooler was found without any date. The same dietary staff member was observed washing hands under running water without using soap or sanitizer on three separate occasions while pureeing food for lunch. The facility did not provide a hand hygiene policy specific to dietary staff when requested. Surveyors also reviewed the operation of the low-heat Ecolab dishwasher and its temperature logs. At the time of observation, the wash temperature was 102°F, and the April temperature log showed multiple days with wash temperatures below the documented minimum of 120°F at which the supervisor should be notified. Administrative and dietary staff later confirmed that gloves should be worn when handling ready-to-eat foods, all stored food should be sealed and labeled with month, day, and year, dishes should be inverted, and the dishwasher wash cycle should be at least 120°F. The facility’s existing Food Storage policy required staff to label all food items with the name and date opened or use-by date and to discard food past expiration, but survey findings showed these practices were not consistently followed in the kitchen.
Lack of Certified Dietary Manager Overseeing Food and Nutrition Services
Penalty
Summary
The facility failed to employ a full-time certified dietary manager (CDM) to oversee food and nutrition services for 31 residents receiving meals from the facility kitchen. On one observed noon meal, the menu consisted of shrimp, cornbread, cooked sliced squash, rice, and yellow cake with chocolate frosting, and dietary staff member BB was observed overseeing preparation of this meal in the kitchen. During an interview, dietary staff BB confirmed she was not a CDM, stating she had enrolled in but not completed the certification classes. Administrative Nurse D also verified that dietary staff BB did not have dietary manager certification, although she had started the dietary certification classes. The facility’s Nutritional Services Policy, revised 01/21/26, documented that a certified dietary manager would oversee all kitchen procedures, including menu planning, diets and the diet manual with nutritional evaluations, office procedures related to notifying the Registered Dietitian of new elders, food production, and food service, but no such certified individual was in place at the time of the survey.
Failure to Properly Label, Store, and Monitor Food and Equipment Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage, distribution, and service practices based on observations, record review, and staff interviews. In the kitchen, a white upright freezer had approximately one-quarter inch of ice buildup along the inside and shelves, and the kitchen refrigerator contained a plastic bag of sliced yellow cheese that was unlabeled and undated. Review of March temperature logs showed missing morning and evening temperature documentation for multiple units, including a chest freezer in dry storage on numerous dates, a white stand-up freezer on several dates, a double-door refrigerator on several dates, and a single-door refrigerator on multiple dates. April logs also lacked documentation of readings for a double-door freezer on specified dates. The facility’s policies required that frozen foods be stored at 0 to -10°F, produce at 38-44°F, dairy at 35-40°F, and that temperature logs be completed and monitored by the Certified Dietary Manager or designee. Additional observations showed sanitation and labeling issues in and around the kitchen and dry storage areas. The ice machine between the kitchen and storage room had a plastic lid and a metal object on the floor behind it, and a plastic green drinking cup sitting on top of the drain underneath it. Eight 15.5-lb plastic jugs of used cooking grease were observed with numerous grayish-black substances on their tops. In dry storage, surveyors found an approximately one-quarter full 5-lb package of undated pasta Labello egg noodles, an approximately one-quarter full 4.5-lb package of unlabeled, undated, unsealed noodles, approximately three-quarters of a full package of undated strawberry gelatin, and an approximately three-quarters full bag of unsealed buttermilk pancake mix. A dietary staff member verified these findings during the survey, and the Dietary Manager later stated that staff were expected to label and date all food placed in dry storage, refrigerators, or freezers when received and when opened, and ensure items were sealed, labeled, and dated with the open date, as outlined in the facility’s written policies.
Failure to Follow Enhanced Barrier Precautions, Hand Hygiene, and Laundry Handling Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP), hand hygiene, and handling of clean laundry. During tracheostomy care for Resident 2, a licensed nurse performed hand hygiene, donned gloves, and wore a mask but did not don a gown as required under EBP and did not change gloves before placing clean gauze or the tracheostomy cannula. In a separate wound care observation for Resident 6, the same nurse performed hand hygiene and applied a gown and gloves before care, but after completing the wound care and while holding gauze and wound cleanser, the nurse inspected and manipulated the resident’s suprapubic catheter tubing and then left the room without performing hand hygiene. Additional deficiencies were observed in the handling of clean laundry. A housekeeping/laundry staff member placed a covered cart with residents’ personal items in one hall, then removed items from the cart and carried them over the shoulder to another hall without using the cart and without keeping the items covered between rooms. Interviews with nursing and administrative staff confirmed that wound care supplies should be kept in residents’ rooms or bagged and taken to the wound nurse, that hand sanitizing should be performed before and after wound care and after contact with catheters or tubing, and that staff are expected to wear gown, gloves, and mask at minimum for EBP. The housekeeping supervisor also stated that laundry staff are expected to keep the cart covered between rooms. These practices did not align with the facility’s written policies on EBP and hand hygiene, which require targeted gown and glove use during high-contact care and hand cleansing before and after resident contact, after contact with blood or body fluids, after removing PPE, and before procedures involving invasive devices or dressing care.
Inaccurate MDS Coding of Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete the Minimum Data Set (MDS) assessment for Resident 13, resulting in an incorrect coding of the resident’s fall history and injury status. Resident 13’s electronic medical record documented multiple diagnoses, including hemiparesis/hemiplegia, chronic osteomyelitis, and intervertebral disc disorder with radiculopathy. The quarterly MDS dated 03/24/26 recorded a Brief Interview for Mental Status (BIMS) score of 15, indicated the resident required supervision for walking 10 feet and partial assistance for walking 50 feet, and documented that the resident had no falls since the previous MDS assessment. However, this conflicted with clinical documentation and the resident’s care plan and progress notes. On 01/16/26, progress notes showed that staff responded to the resident’s call light and found him on the floor next to his heater, lying on boxes, papers, and his bedside table. The resident complained of back and left hip pain, had swelling behind his left ear from hitting the heater, redness on his left cheek, and reported tenderness with weight-bearing on his leg. A mobile X-ray later confirmed a nondisplaced fracture of the left superior pubic ramus, and the provider assessed the resident the same day. The care plan documented that the resident continued to act independently despite education to use the call light, and the resident later reported to therapy staff that he had falls and was working to get stronger after his last fall. During interviews, an administrative nurse acknowledged that the resident had a fall resulting in a hip fracture that should have been coded on the MDS as a fall with major injury, and that the falls section of the MDS had been coded in error, contrary to the facility’s policy to complete the MDS according to federal regulations and the RAI manual.
Failure to Use Wheelchair Foot Pedals When Assisting a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an environment free of accident hazards by not ensuring the use of wheelchair foot pedals when staff assisted a resident in a wheelchair. The resident had diagnoses including severe morbid obesity, vascular dementia, anxiety, and noncompliance, and had a BIMS score of 15 on multiple MDS assessments, indicating intact cognition. The resident’s assessments and Falls Care Area Assessment documented a history of falls within the previous months and identified the resident as being at risk for falls. The care plan documented that the resident was at risk for falls, had experienced a fall, and that his back locked up at times requiring the use of a wheelchair. On one observed occasion, a CNA pushed the resident in a wheelchair without foot pedals attached as he was brought from outside smoking back to his room, during which the resident crossed and held his feet off the floor. On another observed occasion, a nurse turned the resident in his wheelchair and assisted him to the dining room without foot pedals, during which the resident’s sock was half off and dragged on the floor, and the resident again held his foot off the floor. During interviews, one nurse expressed uncertainty about whether the resident should be assisted in the wheelchair without foot pedals, while a CMA stated the resident used foot pedals when being assisted but not when self-propelling. Administrative nursing staff confirmed that staff should not assist the resident in the wheelchair without foot pedals. The facility’s falls policy stated that residents would be assessed for fall risks and interventions implemented to reduce those risks.
Improper Securing of Suprapubic Catheter Tubing
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for a resident with a suprapubic catheter by not securing the catheter tubing according to current standards of practice and the facility’s own competency checklist. The resident had multiple urologic and cognitive conditions, including Alzheimer’s disease with severely impaired cognition (BIMS score of four), chronic kidney disease stage three, benign prostatic hyperplasia, obstructive uropathy, and urinary retention, and was documented as having an indwelling catheter. The care plan included an order from the resident’s urologist directing staff not to remove the catheter and directed staff to apply Skin-prep prior to attaching a Stat-lock for the suprapubic catheter. On two separate observations, licensed nurses assessed and cleaned the suprapubic catheter site on the resident’s abdomen but attached the Stat-lock to the resident’s left upper thigh, securing the tubing from the abdomen to the leg. One nurse confirmed the Stat-lock was attached to the thigh and stated they were unaware that a Stat-lock could be adhered to the abdomen. The administrative nurse stated she expected the Stat-lock to be anchored to the leg and acknowledged that the facility catheter policy did not specify Stat-lock placement for a suprapubic catheter. However, she also stated that the facility’s suprapubic catheter replacement competency checklist, which she had previously reviewed, directed that the catheter tubing should be anchored to the abdomen. The competency checklist documented that the catheter tubing should be secured to the abdomen, but this was not followed in practice.
Failure to Implement Dietitian’s TID Supplement Order and Validate Significant Weight Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate nutritional maintenance for Resident 27 by not implementing the registered dietitian’s recommendation for house supplement shakes three times daily and by not appropriately monitoring and validating significant weight changes. Resident 27 had dementia with severe cognitive impairment, chronic pain, unspecified intellectual disabilities, and major depressive disorder, used a wheelchair, and required set-up or clean-up assistance for eating. The MDS documented a weight of 123 lbs with no weight loss or gain at that time, and the care plan included nutrition-focused interventions such as providing diet as ordered, snacks between meals, monitoring for loss of appetite while on Remeron, and providing supplements as ordered. On 03/03/26, the dietitian documented that the resident had slow, unplanned weight loss related to a decline in energy and recommended offering a house supplement three times a day and adding extra sugar, cream, and butter to foods and fluids to increase energy intake and promote weight stability. Despite this recommendation, the electronic task list from 03/16/26 to 04/13/26 showed the resident was only offered and received a supplement drink once daily in the afternoon. Staff interviews confirmed that the resident received a supplement only on second shift around 2:00 PM, and an administrative nurse acknowledged she had missed the dietitian’s TID recommendation and entered the order for only once daily. Weight records showed a documented weight of 123.4 lbs on 04/01/26 and an implausible weight of 168.0 lbs on 04/10/26, which was not recognized or rechecked at the time by nursing staff. A subsequent re-weigh on 04/15/26, using the wheelchair tare method, yielded a resident weight of 119.5 lbs, reflecting a 3.9 lb (3.16%) loss from 04/01/26. Administrative staff later stated that the 168 lb weight should have been immediately reported and rechecked, and that whoever weighed the resident should have reviewed the previous weight and performed a re-weight if there was a significant change. The facility’s weight loss prevention policy required nutritional interventions and RD consultation for residents with poor or declining intake or weight loss, but the RD was not informed that her TID supplement recommendation had been effectively reduced to once daily.
Emergency Tracheostomy Equipment Not Readily Available at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to ensure that emergency respiratory equipment, specifically an Ambu bag, was readily available at the bedside for a resident with a tracheostomy in the event of accidental extubation or respiratory distress. The resident had diagnoses including sleep apnea, chronic respiratory failure with hypoxia, obesity, dysphagia, malignant neoplasm of the nasopharynx, and required oxygen therapy and tracheostomy care. The resident was cognitively intact, used a wheelchair, and required varying levels of assistance with ADLs. The care plan documented that the resident received breathing treatments, required staff reminders to notify them when treatments were finished, and that staff were to provide oxygen via tracheostomy mask and suction as indicated. The care plan and physician orders also directed staff to call 911 and send the resident to the ER if the entire tracheostomy tube came out, and to follow the facility’s Emergency Protocol Health policy. Surveyor observations on multiple occasions showed that while oxygen and suction were available at the bedside, there was no Ambu bag in the resident’s room. Instead, the Ambu bag and emergency supplies were stored on a covered cart in the hallway under a Hoyer lift, with a battery charger on top, requiring staff to move equipment and wheel the cart into the room before use. Staff interviews confirmed that the emergency tracheostomy supplies and Ambu bag were not kept at the bedside and were instead located in the hallway or medication room. Nursing staff stated that all nurses were CPR-qualified and that hospice residents with tracheostomies had bedside emergency kits because hospice provided them. An administrative nurse reported that tracheostomy care competencies were done annually and explained that there was no emergency kit or Ambu bag at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out, but to call 911 immediately. The facility’s Respiratory Care policy stated that necessary respiratory care and services would be provided in accordance with professional standards of practice, the resident’s care plan, and resident choice.
Failure to Implement Timely Interventions to Prevent Facility-Acquired Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to initiate timely and adequate interventions to prevent the development and progression of a pressure ulcer for Resident 27, who was identified as at risk for pressure ulcer development. The resident had multiple diagnoses including diabetes mellitus, osteoarthritis, heart failure, and muscle weakness, and had a BIMS score of five indicating severely impaired cognition. Assessments documented that the resident required extensive assistance of one to two staff for bed mobility, personal hygiene, dressing, repositioning, and transfers, and that she had a urinary catheter for constant urinary retention and incontinence. The MDS and care plans identified the resident as at risk for skin impairment, with a history of refusing to lie down to relieve pressure from the buttocks, and indicated she was on a turning/repositioning program with nutritional or hydration interventions and a pressure-reducing device in her chair. A Braden Scale score of 16 further indicated risk for pressure ulcer development. Despite these identified risks and care plan directives, the resident developed a facility-acquired Stage 2 pressure ulcer on the left buttocks. Weekly wound assessments documented the presence and progression of an open area on the left buttocks, with measurements changing over time, including a lateral opening measuring 2.0 cm by 1.0 cm and later a left inner buttocks wound measuring 3.0 cm by 2.0 cm by 0.5 cm depth, and then 2.0 cm by 3.5 cm by 0.8 cm depth. The record noted that the resident became less mobile after sustaining a left 5th metatarsal fracture requiring a walking boot, and that she was incontinent and preferred to sit in a recliner and wheelchair rather than sleep in bed. The facility’s own Wound Assessment, Prevention and Treatment policy required timely skin assessments, Braden evaluations, and immediate implementation of plans to reduce pressure ulcer risk, but the development of a facility-acquired pressure ulcer under these known risk conditions demonstrated that timely preventive interventions were not effectively implemented.
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