Signature Healthcare At Summerfield Rehab & Wellne

Penalty

Inspection fine: $170,450

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

Summary

The facility failed to provide adequate notice before transferring or discharging residents, violating the 30-day notification requirement. Four residents were affected, with transfers initiated under the pretense of the facility's inability to meet their needs. However, it was later revealed that the transfers were to make room for a new rehabilitation unit. The residents were selected based on their perceived lack of community connection, and the transfers were executed without the necessary approval from the residents' State Guardian. The transfers caused significant distress to the residents and their families. One resident, who was cognitively intact, expressed confusion and distress about the transfer, which moved her 80 miles away from her family, making visits challenging. Another resident, with moderate cognitive impairment, was transferred without the State Guardian's approval, despite the guardian's request to delay the transfer until proper procedures were followed. The facility's actions disregarded the guardian's process for approving transfers, leading to a lack of proper oversight and communication. Additionally, a resident with severe cognitive impairment and behavioral issues was transferred to an emergency psychiatric service without proper notification or approval. The facility refused to readmit the resident after a hospital visit, leaving her in a hospital setting until a new placement was found. This action was taken without a written discharge notice or proper communication with the State Guardian, further highlighting the facility's failure to adhere to regulatory requirements for resident transfers and discharges.

Removal Plan

• Social Service spoke with Resident #3's appointed State Guardian and discussed the transfer of Resident #3 to a sister facility. Social Services talked to the Ombudsman and informed them of the transfer. The facility transferred Resident #3 to the sister facility. Resident #3 is no longer a resident of the facility.
• Social Service spoke with Resident #4's appointed State Guardian and discussed the transfer of Resident #4 to a sister facility. Social Services talked to the Ombudsman and informed them of the transfer. The facility transferred Resident #4 to the sister facility. Resident #4 is no longer a resident of the facility.
• Social Services spoke with R13's appointed State Guardian and discussed the transfer of R13 to a sister facility. Social Services talked to the Ombudsman and informed them of the transfer. The facility transferred R13 to a sister facility. R13 is no longer a resident of the facility.
• The facility Administrator reviewed 98 residents currently in-house for facility-initiated transfer/discharge. No facility-initiated transfer/discharge notices were in effect on the 98 residents.
• The Corporate Independent Risk Manager spoke with the State Guardian for the current residents. The Guardian educated the Corporate Independent Risk Manager on the process the State Guardian office must complete before approving a Facility-Initiated Transfer/Discharge of a resident.
• The Corporate Independent Risk Manager educated in a small group setting the President of Clinical Operations, Signature Care Consultant, Regional Social Services, the Administrator, Interim Director of Nursing, Business Office Manager, and Social Services on the process the State Guardian office must complete for a Facility-Initiated Transfer/Discharge of a resident.
• The Corporate Independent Risk Manager created two resource binders to be kept in each Social Service Office. The resource binders would include the steps needed for the state Guardian Office concerning transferring or discharging a resident with an appointed state guardian. If a new Social Service, Business Office Manager, Director of Nursing, or Administrator is hired, they will be trained in orientation by Signature Care Consultant or Corporate Independent Risk Manager on the process the State Guardian office must complete for a Facility Initiated Transfer/Discharge of a resident.
• The Senior President of Quality requested the local Ombudsman to be a member of the newly created Facility-Initiated Transfer or Discharge Subcommittee. The local ombudsman agreed to be a team member on the Facility-Initiated Transfer or Discharge Subcommittee.
• The facility implemented a new procedure concerning Facility initiated transfers or discharges, utilizing a subcommittee of members (Vice President of Operations, President of Clinical Operations, Independent Risk Manager, Signature Care Consultant, Social Services, a nurse or C.N.A. familiar with the resident, the Medical Director, and the Ombudsman. There has not been a meeting scheduled for the subcommittee as there has not been an identified need for a Facility-Initiated Transfer or Discharge in the facility.
• An Ad Hoc Quality Assurance meeting was held with the Medical Director, the Facility Administrator, the Interim Director of Nursing, and the Care Consultant. The Facility Administrator presented the plan and information at the QAPI meeting. The Medical director attended via phone and was notified of the implementation of the facility's improvement plan. The Medical Director reviewed the entirety of the plan and made no further suggestions.
• The Medical Director stated the plan was appropriate. The Facility Administrator will hold a Quality Assurance meeting daily until immediacy is removed. Then, it will decrease to monthly for recommendations and further follow-up regarding the above-stated plan. Moving forward, the Facility Administrator will continue to be the person who presents the information and audits at the QAPI Meetings, and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Plant Ops Director, Social Services Director, Activity Director, Therapy Director, and MDS Coordinator. The QAPI Committee will determine at what frequency any ongoing audits must continue. The Administrator is responsible for implementing this plan.

Penalty

Inspection fine: $170,450

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 a safe environment and adequate supervision for a resident, leading to a fall and injury. The resident, who was quadriplegic and dependent on staff for transfers, was supposed to be transferred using a mechanical lift as per her care plan. However, an unknown staff member attempted to transfer her without the lift, resulting in the resident falling and sustaining a fracture of the distal right femur. The resident's care plan clearly indicated the need for a mechanical lift for transfers, but it did not specify the number of staff required to assist. Despite this, the staff member proceeded with the transfer without the lift, ignoring the resident's repeated statements that she could not stand and needed the lift. After the fall, the resident experienced pain and swelling in her knee, but her complaints were not adequately addressed by the facility staff, leading to a delay in receiving appropriate medical care. Interviews with staff revealed a lack of awareness and adherence to the mechanical lift policy, with some staff members admitting to transferring residents without the lift if they felt capable. The facility also lacked a specific policy for mechanical lift use, relying instead on the manufacturer's guidelines, which were not well-known among the staff. This lack of clear policy and training contributed to the incident and the subsequent injury to the resident.

Penalty

Inspection fine: $170,450

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 labeling and storage of drugs and biologicals, as observed in one of the medication refrigerators and a medication cart. An opened and undated vial of purified protein derivative (PPD) was found in the medication refrigerator, not stored in its original packaging. The facility's policy required medications to be dated when opened and stored according to the manufacturer's instructions, but this was not adhered to, as confirmed by interviews with staff members. Additionally, multiple instances of non-compliance were noted on the 700 Hall medication cart. Several insulin vials, insulin pens, and eye drops belonging to six residents were found opened and undated. One insulin pen lacked the original pharmacy label, and an antibiotic ointment was improperly stored with other medications. Interviews with nursing staff revealed a lack of routine audits and checks for expired or undated medications, contrary to the facility's policy. Interviews with various staff members, including the LPN, Unit Manager, Infection Preventionist, Assistant Director of Nursing, Interim Director of Nursing, Care Consultant, and the Administrator, highlighted a systemic issue with medication management. Staff members acknowledged the importance of following the facility's policies for medication storage and administration but admitted to lapses in practice, such as not conducting formal audits and failing to ensure medications were dated and labeled correctly.

Penalty

Inspection fine: $170,450

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 store food in the residents' refrigerator in a safe and sanitary manner, affecting 25 of 96 current residents. Observations revealed that the resident food freezer on the [NAME] Unit lacked a thermometer, contained an unfrozen ice gel pack, and had multiple frozen food boxes stored inside grocery bags that were unlabeled and undated. The boxes of food were not frozen solid, and the freezer compartment floor was dirty with melted liquid, packaging debris, dirt, food particles, and hair. The freezer temperature logs showed inconsistent recordings, with temperatures ranging from two to six degrees Fahrenheit, which is above the recommended zero degrees Fahrenheit for proper food storage. Interviews with various staff members, including the Interim Director of Nursing (IDON), Licensed Practical Nurses (LPNs), Registered Nurse (RN), Dining Services Director (DSD), and Registered Dietitian (RD), revealed a lack of clarity and consistency in responsibilities for monitoring and maintaining the nourishment refrigerator and freezer. The IDON and LPNs stated that everyone was responsible for ensuring cleanliness and proper food storage, but there was no set cleaning schedule. The DSD and RD emphasized the importance of maintaining proper temperatures and labeling food, but there were discrepancies in the expected freezer temperature, with some staff incorrectly stating it should be 32 degrees Fahrenheit. The facility was unable to provide requested documentation for the nourishment refrigerator/freezer temperature logs and a Resident Food/Nourishment Storage policy. The lack of proper documentation and adherence to food safety guidelines, as well as the absence of a clear cleaning and monitoring schedule, contributed to the deficiency in maintaining a safe and sanitary environment for food storage. The failure to follow established policies and procedures was noted by the Chief Executive Officer (CEO) and Medical Director, who both emphasized the importance of adhering to facility guidelines for the safety and well-being of residents.

Penalty

Inspection fine: $170,450

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 establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to infection control protocols. On several occasions, doors to droplet precaution isolation rooms were left open, contrary to CDC guidelines, which require such doors to remain closed to prevent the spread of infectious droplets. Additionally, personal protective equipment (PPE) was not properly managed, with overflowing trash cans of contaminated PPE and improper storage of gloves and hand sanitizer observed. Staff members, including CNAs, LPNs, and RNs, were observed not following proper PPE protocols. For instance, an LPN failed to don appropriate PPE when entering an enhanced-barrier precaution room and did not clean shared medical equipment between uses. Similarly, a CNA and a Unit Manager did not wear all necessary PPE while providing direct care to a resident under enhanced-barrier precautions and mishandled contaminated linen. Furthermore, a registered nurse did not perform hand hygiene after removing gloves and before donning a new pair, violating hand hygiene guidelines. Interviews with staff revealed a lack of adherence to infection control training and policies, despite receiving training upon hire. Staff members acknowledged the importance of following infection control procedures but failed to consistently apply them in practice. The Infection Prevention/Staff Development Coordinator emphasized the importance of following infection prevention and control procedures, yet the facility did not have a formal auditing process to ensure compliance, relying instead on spot education when breaches were observed.

Penalty

Inspection fine: $12,038

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 recommended interventions for the cleaning and disinfecting of a shared glucometer according to the manufacturer's instructions. This deficiency was observed when an LPN performed blood glucose fingersticks on two residents without cleaning and disinfecting the glucometer between uses and without performing hand hygiene. Additionally, another LPN was observed improperly cleaning and storing the glucometer after use on a resident. These actions were in direct violation of the facility's policies and the manufacturer's guidelines for cleaning and disinfecting the glucometer, which required the use of bleach wipes and specific storage procedures to prevent cross-contamination and the spread of infections. Further observations revealed that the facility's infection prevention and control policies were not followed regarding the handling of linens and the disinfection of shared equipment. Dirty linens were found on the floor and in hallways, and staff were observed carrying clean linens against their uniforms, which could lead to cross-contamination. Additionally, a shared lift was found visibly soiled and not cleaned after use, further indicating lapses in the facility's infection control practices. Interviews with staff, including the DON and other nursing personnel, confirmed that there were gaps in training and adherence to infection control protocols. Staff members admitted to not following proper procedures for cleaning glucometers and handling linens. The facility's leadership acknowledged these deficiencies and the potential risk they posed to residents, particularly those with bloodborne pathogens. The facility's failure to ensure compliance with infection control policies and procedures was identified as an immediate jeopardy to resident health and safety.

Penalty

Inspection fine: $12,038

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans for nine residents, leading to various deficiencies in care. For Resident #59, the care plan included interventions for incontinence care, but staff failed to provide timely assistance, causing emotional distress. Similarly, Resident #41 and Resident #381 were identified as fall risks, but the facility did not implement the necessary interventions, such as keeping the bed in a low position and using Dycem in the wheelchair, respectively. This lack of implementation was observed during multiple instances, and staff interviews revealed a lack of knowledge about the care plans and interventions required for these residents. Residents #39 and #48 had care plans that did not adequately address their hydration needs, increasing the risk of dehydration. The facility failed to monitor and document their fluid intake as outlined in their care plans. Resident #325's care plan included pain management interventions, but the facility did not administer the prescribed pain medications promptly, nor did they document the effectiveness of the pain management strategies. This led to the resident experiencing severe pain without adequate relief. Resident #1's care plan included the provision of a communication device, but the facility did not ensure the device was functional, leaving the resident unable to communicate effectively. Resident #11's care plan did not include management for supplemental oxygen therapy, despite the resident using an oxygen concentrator. Lastly, Resident #4's care plan did not specify the resident's preferences for getting out of bed in the morning, leading to the resident's repeated dissatisfaction with the care provided. Staff interviews indicated a lack of awareness and training regarding the care plans and the specific needs of the residents, contributing to the deficiencies observed.

Penalty

Inspection fine: $12,038

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

Summary

The facility failed to provide necessary services to a resident who was incapable of carrying out activities of daily living, specifically in maintaining personal hygiene. Resident #59, who was dependent on staff for toileting hygiene, was left in a bed soaked with urine for an extended period. The resident's call light was on, and despite informing the Registered Nurse (RN) of the need for incontinence care, the RN did not provide immediate assistance, stating that the Certified Nursing Assistant (CNA) was busy. The resident expressed emotional distress and frustration over the delay in care, which was observed to be a recurring issue. The resident, who was cognitively intact and had diagnoses including unspecified dementia and overactive bladder, reported that aides typically changed his/her brief only twice a day, leading to frequent instances of lying in wet sheets. On the day of observation, the resident had last been changed at 5:00 AM and was still waiting for incontinence care by 10:32 AM. When CNA #4 finally provided care, the resident's brief, absorbent pad, draw sheet, and fitted sheet were all saturated with urine. The resident was visibly upset and cried during the care, expressing feelings of neglect and frustration. Interviews with staff revealed that CNAs were often assigned to too many residents, making it difficult to provide timely care. CNA #1, who was responsible for 22 residents, acknowledged that residents had to wait longer than they should for incontinence care. RN #1 admitted to prioritizing other nursing responsibilities over providing immediate incontinence care. The Director of Nursing (DON) and the Administrator both stated that it was their expectation for staff to provide incontinence care every two hours and immediately upon a resident's report of an incontinence episode, which was not adhered to in this case.

Penalty

Inspection fine: $12,038

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 store and prepare food under sanitary conditions. During an initial kitchen tour, it was observed that ingredient containers were not dated, and scoops, stainless steel bowls, and a strainer were stored improperly. During the supper meal service, staff did not wash their hands between glove changes, and a dietary aide touched the surface of a plate with bare hands that had long painted nails. These actions were in violation of the facility's policies on food labeling, hand hygiene, and dishware storage. Interviews with various staff members, including cooks, dietary aides, the Dietary Manager, the Director of Nursing, and the Administrator, confirmed that the facility's policies were not being followed. Staff acknowledged that food should be labeled with use-by dates, hands should be washed between glove changes, and dishware should be stored properly to prevent cross-contamination. The Dietary Manager and Director of Nursing both emphasized the importance of these practices to ensure food safety and prevent contamination.

Penalty

Inspection fine: $12,038

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 its Facility Assessment was clear on evaluating its resident population, identifying the necessary resources, and determining the level of staffing required for each unit to provide adequate care and services. The assessment document titled 'Facility Assessment, [NAME] 2023 Facility Assessment, Resident Population Profile 08/05/2022-08/04/2023' included columns for Admissions/Stays, % of Admissions/Stays, and Frequency Relative to Benchmark. However, the last column lacked quantitative data, and the assessment did not determine the amount of staff needed based on resident acuity. The Barthel Index was used to measure the degree of assistance required by residents, but the assessment did not translate these scores into specific staffing needs. Additionally, sections on staffing, training, and services were marked as sufficient without providing quantitative data, and the section on Acuity-Diseases, Conditions, and Treatments indicated either sufficient or not applicable for staffing requirements. Interviews with facility staff revealed a lack of involvement and understanding of the Facility Assessment process. The Social Services Director was familiar with the assessment but not involved in its composition. The Director of Nursing stated she had no role in the Facility Assessment, as it was handled by the Administrator. The Administrator, responsible for completing the assessment, admitted difficulty in explaining the document and could not provide specific values for the data presented. She acknowledged that the Facility Assessment did not clearly indicate the discipline and amount of staff needed to provide quality care based on residents' acuity levels.

Penalty

Inspection fine: $12,038

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 residents who needed respiratory care were provided such care consistent with professional standards of practice. Resident #11 received oxygen without a physician's order, and the facility did not include supplemental oxygen therapy management in the resident's care plan. Additionally, the oxygen tubing for Residents #1, #8, #11, and #381 was not labeled or dated, and Resident #324's nebulizer machine was not stored in a plastic bag when not in use. Resident #11 was observed wearing a nasal cannula attached to an oxygen concentrator set to deliver two liters of oxygen per minute without a corresponding physician's order. The facility's staff, including the RN and DON, acknowledged the absence of the order and the failure to follow the facility's policy. Similarly, Resident #1 had an open-ended order for oxygen therapy, but the oxygen tubing was not labeled or dated as required by the facility's policy. Resident #381's oxygen tubing was also not dated, and the facility's staff could not confirm the presence of an order for tubing changes. Resident #8's oxygen tubing was observed to be dated incorrectly, and the staff failed to change it weekly as required. Resident #324's nebulizer machine was found sitting on top of the resident's bedside commode without a protective plastic bag, and the oxygen tubing was not dated. The DON and other staff members acknowledged these deficiencies and the failure to adhere to the facility's policies and procedures.

Penalty

Inspection fine: $12,038

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 medications were stored at proper temperatures and under appropriate environmental controls to preserve their integrity. Observations revealed that the medication refrigerators on both the Blue and Green Units were not maintaining the required temperature range of 36 to 46 degrees Fahrenheit. Specifically, the Blue Unit refrigerator was observed at temperatures as low as 28 degrees Fahrenheit, and the Green Unit refrigerator was observed at temperatures ranging from 33 to 52 degrees Fahrenheit. Despite these deviations, there was no documentation that maintenance was notified, and the temperature logs for the last three months were not provided upon request. Interviews with staff, including the Director of Nursing (DON) and a Licensed Practical Nurse (LPN), confirmed that medications might not be effective if not stored at the correct temperature, potentially causing adverse reactions and medical complications for residents. The DON stated that all refrigerated medications would be wasted due to improper storage conditions. The facility also failed to ensure that opened and in-use vials of tuberculin skin test (TST) solution, eye drops, and inhalers were not expired. Observations of three out of five medication carts revealed multiple instances of opened medications that were not dated, including eye drops, an albuterol inhaler, and TST solution. Interviews with various staff members, including a Certified Nursing Assistant/Kentucky Medical Assistant (CNA/KMA), a Registered Nurse (RN), and Licensed Practical Nurses (LPNs), indicated that they were aware of the facility's policy requiring medications to be dated upon opening and disposed of after 28 days. However, they could not verify when the medications were opened, and acknowledged that using outdated medications could potentially harm residents. The Director of Nursing (DON) and the Administrator both stated that they expected staff to follow the facility's policies on medication storage and dating. However, the DON admitted that she did not know why there were undated medications on the carts, and the Administrator was not aware of any issues with medication storage. The failure to adhere to these policies was confirmed through multiple observations and interviews, indicating a systemic issue in the facility's medication management practices.

Penalty

Inspection fine: $12,038

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 safe, clean, comfortable, and homelike environment for five of seventy-one sampled residents. Observations during the survey revealed a continuous odor of urine on the 100 Unit. Residents reported the odor was offensive and caused them to avoid the hallway. Housekeeping staff admitted to inadequate cleaning practices, and the District Manager for Housekeeping confirmed that the expected cleaning protocols were not being followed consistently. Resident #60's room was found to be in a particularly poor state, with excessive dead skin, stained linens, and overflowing trash. The resident had open wounds and was observed using tissue to blot blood, which was then discarded onto the floor. Despite the resident's difficult behavior, staff acknowledged the room's uncleanliness and admitted to not following proper procedures for cleaning when a resident refused services. Residents #65 and #88 also had visibly soiled and stained bed linens, and neither could recall the last time their linens had been changed. Interviews with staff, including the Director of Nursing and the Administrator, revealed that there were no specific policies for changing linens, and the cleaning was based on need. The Administrator confirmed that the facility should be free from odors and that all rooms should be cleaned daily, but these expectations were not being met.

Penalty

Inspection fine: $12,038

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

Summary

The facility failed to treat three residents with dignity and care in a manner that promotes their quality of life. Resident #324, who was cognitively intact and continent, was coerced by staff to wear briefs and was left to sit in his own feces and urine until assisted. This resident expressed feeling embarrassed and undignified due to the staff's actions. Despite having a bedside commode and bedpan available, the resident was not adequately assisted by staff, leading to episodes of incontinence primarily due to delayed assistance during laxative use. Resident #1, who had a severe hearing impairment, had a caption phone in his room that had not been functional for an unknown amount of time. Despite notifying the facility staff multiple times, the issue was not resolved, leaving the resident without an effective means of communication. The facility's staff, including the Plant Director and the DON, were either unaware of the issue or did not take appropriate actions to ensure the resident's communication needs were met. Resident #11 was left naked in bed by CNA #11 while the CNA left the room to obtain additional supplies during a bed bath. The curtain was initially open, exposing the resident to his roommate. Even after the curtain was closed, the resident remained uncovered for several minutes. This action was acknowledged by the CNA as a lapse in maintaining the resident's dignity and privacy, which was also confirmed by the DON and the Administrator as not meeting the facility's expectations for resident care.

Penalty

Inspection fine: $12,038

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 honor a resident's right to self-determination by not getting the resident out of bed in the morning according to their preferences. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed a preference to be up by 9:30 AM. However, the facility did not document this preference in the care plan or CNA care guide. The resident was observed multiple times still in bed, wearing a hospital gown, and with unbrushed hair well past their preferred time to get up. The resident expressed frustration and dissatisfaction with the care provided, stating that staff did not honor their request to be up by 9:30 AM and that there was usually only one aide assigned to the hall, causing delays in care. Interviews with staff revealed that the CNA assigned to the resident's hall was aware of the resident's preference but was unable to meet it due to a high workload and prioritizing residents who were unable to voice their needs. The Director of Nursing and the Administrator both stated that it was their expectation for staff to update care plans and CNA care guides with residents' preferences and to honor those preferences. However, this was not done for the resident in question, leading to the deficiency in care.

Penalty

Inspection fine: $12,038

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 residents' environment remained as free of accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents for two residents. Resident #381 sustained a fall on 01/18/2024, but the facility did not implement new interventions to address the resident's safety and prevention of further falls. Although the Comprehensive Care Plan was revised to include Dycem for the resident's wheelchair, this intervention was not consistently implemented by the staff. The resident experienced another fall on 01/27/2024, indicating a lack of adequate supervision and failure to follow the care plan interventions. Resident #41 fell out of bed on 01/14/2024, and during the State Agency Survey, it was observed that the resident's bed was in an elevated position, contrary to the care plan intervention that required the bed to be kept in a low position. The facility staff, including CNAs and LPNs, were not aware of the specific care plan interventions for Resident #41, and the bed remained elevated during multiple observations. Interviews with staff revealed a lack of communication and training regarding the care plans and fall prevention measures. The facility's policies and procedures for fall prevention were not adequately followed. The care plans were not reviewed and updated appropriately after falls, and the staff did not consistently implement the prescribed interventions. The lack of proper documentation, communication, and training contributed to the failure to provide a safe environment and adequate supervision for the residents, leading to repeated falls and potential harm.

Penalty

Inspection fine: $12,038

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

Summary

The facility failed to provide the necessary hydration needs for two residents, Resident #48 and Resident #39. Resident #48 was assessed to require 1950 ml to 2030 ml of fluid intake daily, but the facility's records showed that these needs were not met on multiple days across several months. Observations revealed that Resident #48 often did not have water available at the bedside and was unable to reach or consume food and fluids independently. The resident's medical history included kidney disease, respiratory failure, epilepsy, and type 2 diabetes, and the resident was moderately cognitively impaired. Despite these needs, the facility did not document any refusals or reasons for the lack of fluid intake, and the resident was eventually hospitalized for acute hypoxic respiratory failure, UTI, and toxic metabolic encephalopathy. Resident #39 required a daily fluid intake of 1420 to 1660 ml, but the facility's records indicated that these needs were not met for numerous days over two months. Observations showed that Resident #39 frequently did not have drinking water available at the bedside and had difficulty accessing fluids independently. The resident's medical history included cerebral infarction, malnutrition, and psychosis, and the resident was severely cognitively impaired. The facility's care plan for Resident #39 did not initially include hydration needs, and when it was added, it lacked specific limits for fluid intake. The facility failed to document fluid intake adequately and did not address the hydration needs in a timely manner. Interviews with staff, including CNAs, RNs, the DON, and the Administrator, revealed that there were systemic issues in monitoring and documenting fluid intake. Staff members acknowledged the importance of hydration but were unable to explain why the deficiencies were not identified and addressed during daily clinical meetings. The DON and Administrator admitted that the lack of documentation meant that the necessary care was not provided, leading to potential health risks for the residents.

Penalty

Inspection fine: $12,038

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 effective pain management for a resident who required such services. The resident, admitted with left ankle pain due to tenosynovitis and other conditions, had a care plan that included administering pain medications as ordered and monitoring their effectiveness. However, on a specific date, the resident experienced severe pain and requested pain medication through the call light system. Despite multiple attempts to get assistance, the resident's call light was ignored for nearly three hours. When a nurse finally responded, the resident was given acetaminophen instead of the requested oxycodone-acetaminophen, which did not alleviate the pain. The resident subsequently called 911 for help, leading to police involvement. The facility's policies on pain management and medication administration were not followed. The resident's care plan required staff to observe and record complaints of pain, administer medications as ordered, and monitor their effectiveness. However, there were no nursing progress notes documenting the resident's pain or the administration of pain medication on the date in question. The resident's request for stronger pain medication was not honored, and the staff did not assess the resident's pain or check the affected area before administering the medication. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's expectations were for medications to be administered timely and as per physician orders, and for care plans to be resident-specific and implemented by staff. The failure to follow these protocols resulted in the resident experiencing prolonged and severe pain, ultimately leading to the resident calling 911 for assistance.

Penalty

Inspection fine: $12,038

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 pharmaceutical services to meet the needs of two residents. For Resident #11, who was admitted with diagnoses including congestive heart failure, acute respiratory failure, and COPD, the facility did not have magnesium oxide 400 mg available as prescribed. During a medication pass observation, RN #1 marked the medication as unavailable and proceeded with the administration of other medications. RN #1 stated that her process for handling unavailable medications was to notify the pharmacy after completing the medication pass to get the medication delivered the next day. For Resident #17, who was admitted with diagnoses including diverticulitis, muscle weakness, and type 2 diabetes, the facility failed to have lidocaine 5% patches and polyethylene glycol (Miralax) available as prescribed. The eMAR showed that the lidocaine patches were marked as unavailable on multiple dates, and the Miralax was marked as unavailable on one occasion. LPN #9 reordered the lidocaine patch but found it was still not delivered. The DON stated that the process for ensuring timely medication availability was for staff to reorder medications when they were low, but she had not been notified of any issues with medication delivery.

Penalty

Inspection fine: $12,038

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 obtain and respect the dietary needs, preferences, and religious restrictions of a resident. The resident, who was admitted with diagnoses including type 2 diabetes, morbid obesity, and gastroesophageal reflux disease, was assessed to be cognitively intact. Despite having a physician's order for a controlled carbohydrate diet with no pork due to religious reasons, the resident was repeatedly served pork products. The resident had informed the staff multiple times about the dietary restriction and had requested to speak with the Registered Dietician, but no action was taken. The resident also spoke to the Director of Nursing about the issue, but no changes were made to address the concern. The facility's policies on Resident Rights and Dining and Food Preferences were not followed, as the resident's food preferences were not identified or respected. The resident's care plan and progress notes did not reflect the religious dietary restriction, and there was no documentation of any grievance filed by or on behalf of the resident. Interviews with the Director of Nursing and the Administrator revealed that it was their expectation that dietary restrictions and resident choices be honored, but this was not the case for the resident in question.

Penalty

Inspection fine: $12,038

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 palatable hot and cold food for four residents. Observations revealed that the hot food was served at temperatures lower than required, and cold beverages were warmer than necessary. Specifically, scrambled eggs were served at 105 degrees F, orange juice at 58 degrees F, and milk at 50 degrees F. Additionally, the oatmeal had a watery consistency. The Dietary Manager admitted that the plates could cool down between meal services and that the food temperatures were consistently in the same range during weekly tests. This issue was observed during a test tray on the 400 Hall, where the food was not hot to the touch and tasted warm or room temperature. Resident #12, who had moderate cognitive impairment, was observed to be dissatisfied with the dinner served, specifically the fried fish filet, which appeared soggy and discolored. Resident #88, also with moderate cognitive impairment, was observed to have an unappealing lunch tray consisting of a small piece of turkey breast on dry white bread, diced cucumbers with onions, and plain potato chips. Both residents expressed dissatisfaction with the taste and appearance of their meals. These observations and interviews indicate a failure to provide palatable and appropriately temperature-controlled food to the residents.

Penalty

Inspection fine: $12,038

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

Summary

The facility failed to notify the Power of Attorney (POA) of a fall and transfer to the hospital for a resident with moderate cognitive impairment. The resident, who had a history of falling and was admitted with an indwelling catheter, experienced a fall and was found on the floor with left hip pain and a laceration on the back of the head. Despite the facility's policy to notify family members of such incidents, the resident's son, who is the POA, was not informed about the fall and subsequent hospital transfer. The son only learned about the incident from his stepsister after she visited the facility and found the resident was not there. The son confirmed that he had not received any calls or messages from the facility regarding the incident, despite being available 24/7. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's policy required nurses to document changes in condition and notify family members and the DON in case of a fall with injury. However, the documentation did not provide details of when and how the resident's son was notified, and the son stated he was not contacted. The DON confirmed that she was notified about the fall and transfer, but the staff failed to properly document the notification to the family. The facility's failure to notify the POA of the resident's fall and hospital transfer constitutes a deficiency in following proper notification procedures.