Medicalodges Coffeyville On Midland

Penalty

Inspection fine: $54,084

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

Summary

The facility failed to complete annual performance reviews at least once every 12 months for two CNAs, which is required to ensure adequate and appropriate care and services for residents. On 04/08/26 at 3:52 PM, review of employee files showed there were no performance evaluations or skills check-off documents for CNA OO, hired on 11/10/23, and CNA PP, hired on 07/29/24. Later that day, Administrative Staff A and Administrative Nurse D confirmed that the evaluation documents provided to the survey team did not include performance evaluations for these two CNAs, and Administrative Staff A stated she expected performance evaluations to be performed annually. The facility was unable to provide a policy related to annual performance evaluations when requested on 04/09/26, further demonstrating that there was no documented process in place to ensure that CNAs received regular performance reviews and skills assessments as expected.

Penalty

Inspection fine: $54,084

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

Summary

Surveyors identified a deficiency in the facility’s failure to store and prepare food under sanitary conditions in both the South and North kitchens. During an initial tour of the South kitchen, surveyors observed grime build-up on a handwashing sink and backsplash, grime along the baseboards in a kitchen alcove, and a freezer without an internal thermometer, despite a temperature log entry having been taken from another freezer. In dry storage, bread was found unsealed and unlabeled, and in the refrigerator there were unsealed and unlabeled ham spread sandwiches, unlabeled salad dressing bottles, an unlabeled container of pancake batter with congealed batter on the outside, and an unsealed, unlabeled bread/bun bag with buns missing. Additional issues included two unlabeled bags of potato chips, an open and undated bag of Cheetos, plate covers stored upright rather than inverted, and the absence of sanitizing strips in the South kitchen. Equipment and surfaces were also unclean: fryer baskets were dirty, fryer oil contained old food pieces across the surface and on the sides, the dipping spatula was greasy and dirty, the floor had dirt, grease, and food debris, and the spike can opener and mounting bracket had rust and debris. The ice machine had hard water and calcium build-up and holes on its outer surface, and a cart labeled as clean, used for an ice chest for resident ice service, had dirty lower shelves with food debris, dirty napkins, and unsheathed straws. In the North kitchen, surveyors observed a dietary staff member with a beard and no hair restraint entering the food preparation area and later standing over the steam table to check food temperatures without a beard guard, contrary to facility policy requiring hair restraints in food preparation and serving areas. Environmental and equipment sanitation issues were also noted, including grease build-up on the outside panel of a deep fat fryer, crumbs at the bottom of a food steamer door, food debris around and on the counter next to a sink near the puree area, and a dirty, stained, wet wooden board behind the sink faucet with a rusty garbage disposal tool lying on the sink. The counter around the large electric food steamer had food debris underneath, in front, to the sides, and behind the unit. Dietary staff interviewed acknowledged that food should be sealed, labeled, and dated; that each refrigerator and freezer should have an internal thermometer with temperatures checked and logged daily; that staff with facial hair should wear beard guards; and that the observed practices did not follow facility policies on food storage and hair restraints. These observations formed the basis of the deficiency for failure to procure, store, prepare, and serve food in accordance with professional standards and facility policy.

Penalty

Inspection fine: $54,084

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

Summary

The deficiency involves the facility’s failure to provide appropriate activities of daily living (ADL) care, including shaving, nail care, face cleansing, and clothing hygiene, for multiple residents who were cognitively impaired and dependent on staff. One resident with dementia, documented as requiring substantial to maximal assistance with personal hygiene on the MDS, CAA, care plan, and EMR, was repeatedly observed on multiple days with long facial whiskers. CNAs and a licensed nurse stated that residents were supposed to be shaved on shower days, but acknowledged that this did not always occur. Administrative nursing staff also stated residents were to be shaved on shower days and as needed, consistent with the facility’s policy that residents have the right to be treated with dignity and respect. Another resident with severe cognitive impairment and dependent on staff for personal hygiene had a care plan directing staff to trim her fingernails weekly. She was observed on consecutive days sitting in a recliner with jagged, dirty fingernails. CNAs, a licensed nurse, and an administrative nurse all stated that residents’ fingernails were to be kept clean, smooth, and trimmed at least weekly, confirming that the observed condition did not meet facility expectations. The same facility policy on resident rights and dignity applied to this resident’s care. Additional residents with dementia or Alzheimer’s disease, all with MDS and care plan documentation showing moderate to severe cognitive impairment and dependence on staff for ADLs and personal hygiene, were observed with unshaven faces, dirty clothing, jagged and dirty fingernails, and dried food on the face. One resident was seen twice in the same day with an unshaven face and dried-on food debris on the front of his t-shirt, and another was observed on two days unshaven with jagged, dirty fingernails and dried food on his face around his mouth. Staff interviews confirmed that residents were supposed to be shaved on shower days, have their clothes changed when dirty, have their fingernails trimmed and filed weekly, and have their faces cleaned after meals as needed, but staff acknowledged these tasks did not always get done. These observations and statements show the facility did not follow its own care expectations and resident rights policy regarding dignity and respect.

Penalty

Inspection fine: $54,084

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

Summary

The deficiency involves the facility’s failure to provide resident-specific activity programs for multiple residents with dementia or severe cognitive impairment on the memory unit. For several residents, including those with diagnoses of dementia and Alzheimer’s disease, the Minimum Data Set (MDS) assessments documented severe cognitive impairment, with Brief Interview for Mental Status (BIMS) scores of 99 or staff assessments indicating severe impairment. These assessments also documented that it was very important to the residents to listen to preferred music, participate in favorite activities and religious services, and go outside for fresh air when the weather was good. Despite these documented preferences, the Activity Care Area Assessments (CAAs) did not trigger for these residents, and their care plans lacked staff instructions regarding their preferred activities. For each of the identified residents, the facility’s records showed minimal or no documented participation in activities over a one-month review period. Electronic Medical Record (EMR) review for the residents showed that each participated in only one documented activity, a music program on a single date, with no other activities recorded from early March through early April. Activity Assessments completed for these residents identified specific interests such as church services, parties, visiting with others, watching westerns or baseball on TV, listening to country music or other music, going for walks, being around animals, and going outside in good weather. However, these preferences were not reflected in individualized care plan instructions, and there was no documentation that these preferred activities were being provided on an ongoing basis. Surveyor observations and staff interviews further demonstrated that scheduled activities on the memory unit were not carried out as planned. The posted Activity Calendar listed an "Afternoon Hand and Nail Spa" at a specified time, but at that time residents were observed resting in bed, sitting in recliners with eyes closed, sitting at the dining room table, or wandering the unit, with no hand and nail spa activity occurring. A CNA confirmed that the fingernail activity did not take place and that staff instead handed out snacks, and stated she did not know why the scheduled activity was not provided. Activity staff reported that unit staff were responsible for conducting activities on the memory unit, while CNAs and a nurse indicated that there were not many activities on the unit and that staff mainly ensured the TV was on or passed out snacks, which they considered “somewhat of an activity.” An administrative nurse stated that the activity staff planned the activities and that nurses on the memory unit were responsible for executing and documenting them, but the facility’s own policy required the Activity Department to provide an activity program that supports positive self-esteem, well-being, and satisfaction with the facility’s active lifestyle, which was not reflected in practice for these residents. Title: Failure to Provide Resident-Specific Activities on Memory Unit ShortSummary: Multiple residents with dementia and severe cognitive impairment did not receive individualized activity programming despite documented preferences for music, religious services, social events, outdoor time, and specific leisure interests. MDS assessments and activity assessments identified what was very important to these residents, but CAAs did not trigger, care plans lacked instructions for preferred activities, and EMR review showed only a single documented group music activity over a month. A scheduled hand and nail spa activity on the memory unit did not occur as posted; instead, residents were observed resting, sitting, or wandering without the planned activity, while staff reported that there were few activities on the unit and that turning on the TV or passing out snacks was treated as activity. This practice conflicted with the facility’s policy that the Activity Department provide a program supporting residents’ self-esteem, well-being, and satisfaction with an active lifestyle.

Penalty

Inspection fine: $54,084

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

Summary

The facility failed to maintain privacy for a resident with dementia and severe cognitive impairment who was dependent on staff for all ADLs while she was in bed in her room. The resident’s EMR and MDS assessments documented severe cognitive impairment and total dependence for ADLs, and her care plan reflected this dependence. During observation, the resident was resting in bed covered with blankets, with her room door open to the hallway, when another resident wandered into the room and began moving the blankets covering her. A licensed nurse removed the wandering resident from the room after being informed of the incident. Staff interviews revealed that on the memory care unit residents were allowed to wander wherever they wanted, with no boundaries for wandering, including going into and out of other residents’ rooms, despite a facility policy stating that resident dignity and privacy are to be respected. This failure to provide privacy occurred in the context of a memory care unit practice that permitted unrestricted wandering into other residents’ rooms, including the room of a cognitively impaired, fully dependent resident who was in bed at the time.

Penalty

Inspection fine: $54,084

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

Summary

The deficiency involves the facility’s failure to provide required written notifications of transfer, discharge, and bed-hold rights to two residents and/or their representatives, and to send copies of such notifications to the ombudsman. One resident with dementia and anxiety had an unplanned discharge to the hospital for a right hip fracture, with progress notes documenting the hospital transfer and subsequent cancellation of a care plan meeting due to the hospitalization. However, the electronic record under the miscellaneous tab lacked evidence that written bed-hold documentation was provided to the resident or representative at the time of transfer. Staff interviews revealed confusion and inconsistency regarding responsibility for issuing bed-hold notices: nursing staff reported that social services handled bed-hold notices, social services and administrative staff identified a specific administrative staff member as responsible, and that staff member stated she completed bed-hold forms after being notified via the EHR dashboard and typically obtained signatures upon the resident’s return or by mailing the form days later. This practice conflicted with the facility’s own written bed-hold policy, which required written notice at admission and again at the time of transfer, with the charge nurse sending a blank notice with the resident at discharge and administration documenting attempts to contact the resident or representative within 24 hours. The deficiency also includes the facility’s failure to provide written notification of the reason for hospital transfers to another resident with dementia, Stage 2 skin breakdown, and CHF, who experienced multiple acute episodes requiring transfer to the hospital for pneumonia and other symptoms such as shortness of breath, chest pain, pallor, weakness, diaphoresis, brief unresponsiveness, drooling, and hypotension. Nursing notes documented the clinical events and physician orders to send the resident to the hospital, as well as the hospital admissions, but the electronic medical record lacked documentation of any written notification to the resident or representative explaining the reasons for these transfers. In interviews, social services staff stated that the business office manager obtained bed-hold signatures and acknowledged being unaware of the regulatory requirement to notify residents in writing of the reason for transfer, although they reported notifying the ombudsman of transfers. Administrative staff further stated that bed-hold forms should be completed and signed when a person was transferred out, but also stated that the facility did not notify residents’ representatives in writing of a discharge or transfer, and the administrative nurse reported that the facility did not have a discharge policy.

Penalty

Inspection fine: $54,084

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

Summary

The deficiency involves the facility’s failure to provide catheter care in accordance with standards of practice and the resident’s care plan for a resident with an indwelling urinary catheter. The resident had Alzheimer’s disease, CKD stage 3, BPH, obstructive uropathy, neurogenic bladder, weakness, and minimally impaired cognition, and required staff assistance with ADLs due to physical limitations and decreased safety awareness. The care plan directed use of a 16Fr urinary catheter for acute urinary retention with obstruction, use of a Stat-lock device to secure the catheter and reduce tugging, and monitoring of catheter output every shift. The urinary incontinence CAA documented the need for a catheter to address obstructive uropathy and to help prevent skin breakdown and UTI. Despite these directives, the resident was observed self-propelling in a wheelchair with a steady stream of apparent urine on the floor along the hallway, which staff immediately recognized as belonging to this resident. Further observations and interviews showed that catheter care practices were inconsistent with the care plan and standards of practice. During catheter care, the CNAs emptied the catheter bag and assessed the insertion site but the resident did not have a Stat-lock on the thigh to anchor the catheter tubing. A CNA stated they were supposed to empty catheter bags at the end of their shift and that a Stat-lock was not used because the resident “just takes them off.” On another occasion, the resident was observed sitting in the dining room with a full, round catheter bag hanging under the wheelchair, and nursing staff were notified. A nurse stated that CNAs typically empty catheter bags at the end of their shift, while also acknowledging that all catheterized residents should have a Stat-lock and that multiple cases were in stock. The administrative nurse stated her expectation was that the Stat-lock be used unless not tolerated, with such intolerance documented in the care plan, and also reported that the facility had no written catheter care policy and instead followed standards of practice.

Penalty

Inspection fine: $54,084

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

Summary

The deficiency involves the facility’s failure to provide non-pharmacologic pain management interventions for a resident with acute pain related to a wedge compression fracture of the second lumbar vertebra. The resident’s MDS assessments documented moderately to severely impaired cognition, receipt of PRN pain medications, and use of non-medication pain interventions during one assessment period, but no scheduled or PRN pain medications and no non-medication pain interventions during a subsequent look-back period. The resident reported occasional pain with the worst pain rated as eight out of ten in the prior five days and received opioid medication during the seven-day look-back period. The care plan, revised 03/31/26, directed staff to use alternative pain management methods such as massage, aromatherapy, warm packs, and distraction, and the physician’s orders included PRN ibuprofen and hydrocodone-acetaminophen for pain. Despite these orders and care plan directions, observations showed the resident tearful, with clenched fists and facial grimacing while seated in the dining room, and again with facial grimacing and audible indicators of pain during a transfer from wheelchair to recliner requiring extensive assistance. The MAR documented pain scores ranging from one to seven, with staff administering ordered pain medications and documenting effective results, but there was no evidence that non-pharmacologic interventions were offered or implemented. CNAs interviewed stated the resident often complained of pain after a fall and had a lot of hip pain, and that nurses would give pain medication, but they were not aware of any non-pharmacologic pain interventions being used for this resident. An administrative nurse stated that, in addition to scheduled and PRN pain medications, staff were expected to attempt non-pharmacologic pain interventions and acknowledged the facility did not have an actual pain management policy, relying instead on a standard of care.

Penalty

Inspection fine: $54,084

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

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and the sanitary handling and storage of respiratory treatment devices. Surveyors observed one resident’s oxygen tubing wound around a portable oxygen tank, and the nebulizer mouthpiece attached to a medication bowl that still contained a small amount of fluid and remained attached to the nebulizer machine. Another resident’s nebulizer machine was observed with the face mask and medication bowl still attached and containing fluid, lying on a chair beside the bed with the tubing wound up with a blanket and a back brace placed on top of the nebulizer. A licensed nurse reported that after completing breathing treatments, she rinsed the medication cup and mask, dried the mask with a paper towel, allowed the equipment to air dry, and then placed it in a plastic bag, and an administrative nurse confirmed that staff were expected to clean the mouthpiece and medication cup, allow them to dry, and place them in a bag for infection control. The deficiency also includes failure to follow EBP during catheter care for a resident with an indwelling catheter. During an observed toileting and catheter care episode, two CNAs entered the resident’s room, donned gloves, and assisted the resident with toileting and clothing changes after a bowel movement. The catheter bag was emptied into a plastic urinal and placed on the back of the toilet, then the urine was poured into the toilet. Afterward, both CNAs removed their gloves; only one washed her hands before leaving the room, and the other exited the room and escorted the resident to the dining room without hand hygiene. In interviews, both CNAs acknowledged they forgot to don the EBP gowns posted on the resident’s door, and one CNA stated that handwashing was supposed to be done before and after handling a patient or a catheter. The facility’s infection control surveillance policy documented that all staff are to be educated on infection control prevention practices as they relate to their job.

Penalty

Inspection fine: $54,084

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

Summary

Failure to properly maintain and dispose of garbage and refuse occurred in the facility’s dumpster area, as identified during an initial kitchen tour when surveyors, accompanied by a dietary staff member, observed multiple items of trash and discarded furniture around the dumpster. Specifically, two used gloves were lying on the ground beside the base of the dumpster, along with one broken metal and upholstered armchair, four cloth recliners with large black stains or substances on the fabric (including one red recliner with the back pulled or broken off), and a broken chest of drawers with broken shelving and top. The dietary staff member confirmed these observations, stated she had not been aware of the trash and garbage accumulation around the dumpster, and reported she did not know what arrangements were in place for trash and garbage pickup, indicating that maintenance was responsible for disposal. Further interview with a maintenance staff member revealed that maintenance staff were responsible for maintaining and cleaning the dumpster area and that he had placed the chairs by the dumpster for disposal several months earlier. He reported that the person who previously picked up and disposed of the garbage and trash around the dumpster had stopped performing this duty and that he had not found a replacement, resulting in the continued accumulation of debris. The maintenance staff member acknowledged that the condition of the dumpster area, with debris, trash, and used gloves, posed potential for rodent infestation and cross-contamination and spread of infection to residents and staff. The facility’s undated policy on Housekeeping, Laundry and Maintenance – Basic Services Provided stated that storage areas must be kept neat and free of extraneous material such as refuse and discarded furniture, which was not followed in this situation.

Penalty

Inspection fine: $84,124

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

Summary

The facility failed to prevent the neglect of a cognitively impaired resident, identified as R2, who exhibited a recent increase in behaviors. On the evening of August 26, a licensed nurse completed a skin assessment on R2 and documented her skin as clean, dry, intact, and without new skin conditions. However, the following morning, staff observed blood on a tissue after wiping R2 but failed to notify the licensed nurse in charge of her care. Later that day, when R2 was taken to a senior behavioral unit, hospital staff discovered multiple areas of bruising, bleeding, and genital trauma, which were possible indicators of sexual assault. R2 had a medical history that included dementia, cognitive communication deficit, muscle weakness, major depressive disorder, and anxiety. She was assessed with severe cognitive impairment and required assistance with activities of daily living. Despite her increased behaviors and the need for psychotropic medications, the facility's documentation and observations failed to identify any skin issues or signs of trauma until hospital staff conducted a thorough assessment. The facility's neglect was evident as the hospital staff's findings of bruising, bleeding, and genital trauma were made less than 17 hours after the facility's nurse documented no skin issues. The presence of these injuries prompted the completion of a sexual assault kit by the hospital staff, highlighting the facility's failure to protect R2 from neglect and potential abuse.

Removal Plan

• The facility contacted R2's physician.
• The facility began interviewing staff and residents for any indications of abuse and neglect.
• Staff in-service on abuse, neglect and exploitation and education completed.
• The facility held a quality assurance performance improvement (QAPI) meeting.
• The facility educated staff to provide care in pairs for all residents until further notice and initiated immediately.
• A skin sweep of all residents in the building initiated with care plans revised and physician and responsible party notified with any findings from assessments.
• The facility held a resident council meeting to review abuse, neglect, and exploitation.

Penalty

Inspection fine: $48,130

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

Summary

The facility failed to prevent the verbal and physical abuse of a cognitively impaired resident, identified as R2, on two separate occasions. On the first incident, a Certified Nurse Aide (CNA) was observed by a non-certified staff member grabbing R2's arms and pushing them to her chest while verbally threatening her. The staff member did not report the incident immediately, allowing the CNA to continue working. On the second occasion, another CNA heard yelling and witnessed the same CNA grabbing R2's arms and forcefully pushing them against her chest, again accompanied by verbal threats. This incident was also not reported immediately, as the observing CNA chose to write a note and slide it under an administrative nurse's door, which was not discovered until days later. R2, who has Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder, was assessed with severe cognitive impairment and required assistance with activities of daily living. Despite her cognitive deficits, R2 did not reject care but exhibited behavioral symptoms. The care plan for R2 included staff assistance and specific instructions to explain activities to her before beginning. However, the incidents of abuse were not prevented, and the staff involved failed to follow the facility's policy on immediate reporting of abuse allegations. The facility's policy required immediate reporting of any alleged abuse, neglect, or mistreatment, but this was not adhered to by the staff who witnessed the incidents. The failure to report allowed the abusive CNA to continue working in the memory care unit, placing R2 and other residents at risk. The incidents caused a negative psychosocial impact on R2's safety and well-being, highlighting a significant deficiency in the facility's ability to protect residents from abuse.

Removal Plan

• The facility suspended CNA O.
• The facility conducted a skin assessment of R2.
• The facility notified the responsible party and left a voicemail.
• The facility provided additional education to CNA M and Non-Certified Staff N.
• The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director.
• The facility began education with all staff and completed.
• The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks.

Penalty

Inspection fine: $48,130

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

Summary

The facility failed to immediately report incidents of verbal and physical abuse involving a cognitively impaired resident, identified as R2, on two separate occasions. On the first occasion, a non-certified staff member observed a certified nurse aide (CNA) grab R2's arms and push them to her chest while verbally threatening her. The staff member did not report this incident immediately, allowing the CNA to continue working her scheduled shifts. On the second occasion, another CNA heard yelling and witnessed the same CNA grab R2's arms forcefully and verbally threaten her again. This CNA also failed to report the incident immediately, instead leaving a note for the administrative nurse, which was not discovered until several days later. R2, the resident involved, had a medical history of Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder. She was assessed with severe cognitive impairment and required assistance with activities of daily living. Despite her cognitive deficits, R2 did not reject care but exhibited behavioral symptoms. The incidents of abuse occurred in the memory care unit, where R2 resided, and were not reported in a timely manner, placing her and other residents at risk. The facility's policy required immediate reporting of any alleged abuse, neglect, or mistreatment, but this protocol was not followed. The failure to report these incidents allowed the abusive CNA to continue working with vulnerable residents, creating an environment where further abuse could occur. The lack of immediate action by the staff members who witnessed the abuse contributed to the deficiency, highlighting a significant lapse in the facility's duty to protect its residents.

Removal Plan

• The facility suspended CNA O.
• The facility conducted a skin assessment of R2.
• The facility notified the responsible party and left a voicemail.
• The facility provided additional education to CNA M and Non-Certified Staff N.
• The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director.
• The facility began education with all staff and completed.
• The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks.

Penalty

Inspection fine: $48,130

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

Summary

The facility failed to protect residents from abuse when staff did not immediately report incidents of verbal and physical abuse involving a cognitively impaired resident, R2. On two separate occasions, a Certified Nurse Aide (CNA O) was observed physically restraining R2 by grabbing her arms and pushing them against her chest while verbally threatening her with explicit language. These incidents occurred on 07/13/24 and 07/19/24, yet were not reported immediately by the witnessing staff members, Non-Certified Staff N and CNA M, allowing CNA O to continue working with residents. R2, who has a medical history of Alzheimer's disease, dementia with behavioral disturbance, and major depressive disorder, was assessed with severe cognitive impairment and required assistance with activities of daily living. Despite her cognitive deficits, R2 did not reject care but exhibited behavioral symptoms. During the incidents, R2 attempted to hit CNA O, who responded with physical restraint and verbal threats, causing a negative psychosocial impact on R2's safety and well-being. The failure to report these incidents immediately placed R2 and other residents in the memory care unit at risk for abuse. The facility's policy requires all alleged violations involving abuse to be reported immediately, yet this protocol was not followed. The delay in reporting allowed CNA O to continue working her scheduled shifts, further endangering the residents under her care.

Removal Plan

• The facility suspended CNA O.
• The facility conducted a skin assessment of R2.
• The facility notified the responsible party and left a voicemail.
• The facility provided additional education to CNA M and Non-Certified Staff N.
• The facility held a Quality Assurance and Performance Improvement meeting with the Medical Director.
• The facility began education with all staff and completed.
• The facility notified local law enforcement, interviewed three residents with intact cognition, and updated R2's care plan to include follow up with the social service designed post event weekly for four weeks.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to implement timely and pertinent interventions to prevent significant weight loss in Resident 13, who experienced a 25.11% weight loss over 141 days. The resident, diagnosed with diabetes mellitus type 2 and other conditions, was not weighed monthly as required, and the facility did not identify or assess the resident when meal intake consistently declined. This oversight resulted in a total weight loss of 40.6 lbs, or 29.64%, over 182 days, placing the resident at risk for further nutritional decline and life-threatening symptoms. Resident 13's care plan included interventions such as a low concentrated sweet diet with fortified foods, double proteins, and supplements. However, the facility did not consistently monitor the resident's weight or meal intake, as evidenced by missing weight records for several months. Despite recommendations from the dietary consultant to continue the current plan of care, the resident's weight continued to decline, indicating a lack of effective monitoring and intervention. Interviews with facility staff revealed inconsistencies in obtaining resident weights and offering alternative food selections when meals were refused. The facility did not provide a policy related to weight loss and monitoring, further highlighting the deficiency in care. The failure to monitor and address the resident's weight loss as ordered by the physician contributed to the resident's significant weight loss and potential negative impact on their well-being.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to maintain sanitary conditions in the kitchen and during food service, as observed during a survey. During an initial tour of the kitchen, several issues were noted, including an uncovered trashcan at the hand-washing sink, unlabeled food items such as dressing cups, gelatin parfaits, and baked potatoes, and improperly covered peach slices. Additionally, the refrigerator had racks with dried-on food substances and rust, and the outside dumpster was not closed. Containers of flour and dried milk were found with grime on their lids. The facility also lacked a policy for kitchen sanitation, which contributed to these deficiencies. During meal service in the memory care unit, a dietary staff member was observed with hair not fully covered by a hairnet, and she used the same pair of gloves throughout the service, touching the eating surfaces of plates and the food with her thumb. The staff member acknowledged her improper handling of plates and hair covering, attributing it to an old habit. The facility's policy on proper hand washing and glove use, dated 2020, was not adhered to, as gloves were not changed frequently, and proper hand washing procedures were not followed. These actions led to the failure to serve food in a sanitary manner.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to ensure proper hand hygiene practices among staff during meal times and dressing changes, contributing to potential infection risks. Observations revealed that a Certified Nurse Aide (CNA) assisted residents with their meals without performing hand hygiene after handling various items and residents. Additionally, a Licensed Nurse (LN) did not perform hand hygiene between glove changes during a dressing change for a resident with a pressure ulcer, contrary to the facility's policy. The facility also did not maintain sanitary conditions for oxygen concentrators and glucometers. Observations showed unlabeled oxygen concentrators with tubing and cannulas stored improperly, with one cannula resting on the floor. Furthermore, glucometers used by multiple residents were not sanitized according to the manufacturer's instructions, with staff using alcohol wipes instead of the recommended Sani-wipes, and not adhering to the correct wet time for disinfection. Enhanced barrier precautions were not consistently implemented for residents with urinary catheters. A CNA was observed emptying a urine collection bag without knowledge of the necessary personal protective equipment, while another CNA did not follow proper procedures for rinsing and storing urinals. Interviews with staff indicated a lack of understanding and implementation of enhanced barrier precautions, despite recent efforts to introduce these measures based on CDC recommendations.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to uphold the residents' rights to organize and participate in resident groups, specifically the Resident Council, and to address grievances and recommendations from these groups. A resident reported issues with the quality and availability of food, noting that concerns raised in Resident Council meetings were not addressed with an action plan. The facility did not provide feedback or solutions to the residents' grievances, which included complaints about food temperature, variety, and availability. During a Resident Council meeting, multiple residents expressed dissatisfaction with the meals, citing issues such as cold food and lack of ethnic variety. Despite these concerns being voiced, the facility did not document a plan of action or follow-up to resolve these issues. The facility's records showed a lack of evidence of monthly Resident Council meetings and follow-up on grievances for several months, indicating a systemic failure to address residents' concerns. Interviews with facility staff confirmed the absence of documented Resident Council meetings and follow-up actions. The facility's grievance policy required prompt resolution of grievances, but it did not specifically address those reported to the Resident Council. This lack of response and documentation demonstrates the facility's failure to consider and act upon the views and grievances of resident groups, impacting the quality of care and life in the facility.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to provide quarterly statements for 31 residents with active trust accounts, as required by their policy. The trust transaction history review revealed that no copies of the quarterly statements were available for review. Administrative Staff O, who had been in her position for just over a week, was unable to locate any copies of the quarterly statements for the residents with trust funds managed by the facility. She mentioned that it was the facility's policy to offer trust statements quarterly and typically sent two copies to the resident's representative, requesting one signed copy to be returned to the facility. However, no such copies were found. Additionally, Administrative Staff A confirmed that quarterly statements should be sent to residents or their responsible parties, and a copy should be maintained in the resident's file. The facility's updated policy on Resident Funds Trust Account stated that the trust account should be maintained at a local bank in an interest-bearing checking account, and a signed copy of the quarterly transactions should be kept on file for five years post-discharge. The facility failed to establish and maintain a system that ensured a full and complete separate accounting of each resident's personal funds, according to generally accepted accounting principles.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to ensure that residents had the right to voice grievances regarding their care and treatment, as well as other concerns related to their long-term care stay. A resident reported dissatisfaction with the food quality, noting that it was often cold and that the facility sometimes ran out of food. Despite voicing these concerns to the Social Service Designee and during Resident Council meetings, no changes were made, and no action plans were communicated back to the residents. During a Resident Council meeting, multiple residents unanimously complained about the food temperature, variety, and lack of ethnic choices, yet these grievances were not addressed or resolved by the facility. The facility's grievance logs from February 2023 to May 2024 showed a lack of tracking and action plans for recurring grievances noted in Resident Council meetings. The logs did not document any action plans or reviews with residents regarding their concerns, particularly those related to food dissatisfaction. Administrative staff confirmed the absence of evidence for action plans and follow-up with residents, indicating that the facility did not provide a forum for residents to voice grievances or make prompt efforts to resolve them. The facility's grievance policy, dated March 2024, required follow-up within seven days but failed to address grievances reported to the Resident Council.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to provide appropriate and timely assistance with activities of daily living (ADLs) for several residents, specifically regarding personal grooming such as facial shaving and nail trimming. Resident 13, who has type II diabetes mellitus and moderate cognitive impairment, was observed with long facial hair over several days despite being dependent on staff for personal hygiene. The resident expressed discomfort with the facial hair and stated that staff did not shave her, although it was expected to be done on shower days or as needed. Resident 8, diagnosed with Parkinson's disease and severe cognitive impairment, also did not receive timely grooming care. The resident was dependent on staff for all ADLs, including shaving on shower days. However, records indicated missed showers on multiple occasions, and the resident was observed with long, unshaven facial hair. Staff interviews confirmed that residents should be groomed appropriately daily, but the facility lacked a policy for ADLs. Resident 46, with a diagnosis of weakness and severe cognitive impairment, required extensive assistance for personal hygiene. Despite receiving a shower, the resident was observed with long facial hair and expressed a desire for staff to shave her chin hairs. Similarly, Resident 49, who has dementia and intact cognition, required assistance with personal hygiene and was observed with long facial hair and fingernails. The resident preferred to have her facial hair shaved and fingernails kept short, but staff did not meet these preferences. The facility's lack of a policy for ADLs contributed to the failure to provide timely and appropriate care.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to complete a comprehensive care plan for a resident with Parkinson's disease, who was prescribed oxygen therapy. The resident's electronic medical record indicated a severe cognitive impairment with a BIMS score of zero and did not initially utilize oxygen. Despite a physician's order for oxygen therapy to maintain saturation above 90%, the care plan lacked specific staff instructions for managing the oxygen tank and supplies. Observations revealed that the resident's oxygen tubing was left uncovered, contrary to the facility's expectation to store it in a bag when not in use. Additionally, the facility did not have a policy in place for care plans, contributing to the deficiency.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to provide a resident, identified as R13, with an accurate accounting of her personal funds, resulting in an overcharge of $51.00. The trust transaction fund review documented a closing balance of $11.01 for R13, which was disputed by R13's family member who believed there should have been more money in the account. Administrative Staff O, who had been employed at the facility for just over a week, was unsure of the previous business officer manager's actions and stated that the facility became the payee for R13 in May 2023. The facility received verbal permission from the responsible party to withhold extra funds, but a document showed a $51.00 overcharge dated May 2024. The facility's policy was to offer trust statements quarterly, and there were discrepancies in the handling of resident funds. Certified Medication Aide Q reported that if a resident requested money during off-hours, it would be taken from a bag in the medication cart, but there was no list of residents with trust accounts. Administrative Staff A mentioned a petty cash box in the medication cart with a list of available funds, but this was a new addition, and the staff was unsure when it was implemented. The facility's policy required a signed invoice or receipt for purchases, but the facility failed to maintain the correct trust balance for R13.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to ensure the timely conveyance of personal funds for two residents, leading to a deficiency. The facility had a census of 81 residents, with 31 having active personal funds accounts. Upon review, it was found that two residents, who were no longer on the current resident census list, still had active personal funds accounts. One resident had expired, and the other had been discharged, both over 30 days prior. Despite the federal requirement to disperse personal funds within 30 days of discharge or death, the facility had not returned the funds. Administrative staff acknowledged awareness of this requirement, yet the policy for Resident Funds Trust Account lacked documentation for returning funds within the stipulated timeframe. Consequently, the facility did not convey personal funds within 30 days for the deceased resident and the discharged resident.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to maintain a clean and sanitary storage method for oxygen tubing for a resident identified as R8. The resident, who has a diagnosis of Parkinson's disease and severe cognitive impairment, was observed with oxygen tubing hanging uncovered over an oxygen concentrator. Despite a physician's order for oxygen administration to maintain blood oxygen saturation above 90%, the facility did not have a policy in place for storing oxygen tubing when not in use. The resident's care plan also lacked specific instructions for the care of the oxygen tank or supplies. An administrative nurse confirmed that the expectation was for staff to place the oxygen tubing in a bag when not in use, but this was not adhered to, leading to the deficiency.

Penalty

Inspection fine: $31,327

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

Summary

The facility failed to ensure that the daily resident census was recorded on the Daily Staff Postings as required. During a review of the Daily Staff Posting for February, March, and April 2024, it was found that there was a lack of documentation of the resident census for each day. An interview with Administrative Staff HH on May 13, 2024, revealed that she did not document the daily resident census on the Daily Staff Postings. Another interview with Administrative Staff A confirmed the absence of the resident census on the Daily Staff Postings and highlighted that the facility lacked a policy for the documentation required on the form.