St Patrick's Manor

Penalty

No penalty information released

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

Summary

The facility failed to administer a physician-ordered antihypotensive medication, Midodrine, as needed (PRN) for a resident when their systolic blood pressure (SBP) was documented below 100 mmHg. This deficiency was identified for one resident out of a sample of 36. The facility's policy on medication administration requires reviewing and confirming medication orders and checking vital signs before administering medications. However, the facility did not adhere to this policy, as evidenced by the resident's medication administration records (MARs) for December 2024, January 2025, and February 2025, which showed multiple instances of SBP readings below 100 mmHg without the administration of the prescribed Midodrine. The resident involved was admitted to the facility with multiple diagnoses, including hemiplegia, end-stage renal disease, heart failure, and type 2 diabetes. The resident was cognitively intact, with a perfect score on the Brief Interview for Mental Status. Despite the physician's order for Midodrine to be administered when the resident's SBP was below 100 mmHg, the MARs indicated that the medication was not given on several occasions when the SBP was below the threshold. During an interview, the Director of Nursing acknowledged the oversight and confirmed that the medication should have been administered as ordered.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Advance Directives were accurately executed for a resident, leading to a deficiency. Upon admission, the resident's MOLST form was illegible, and a handwritten card indicating DNR/DNI status was undated and unsigned. Despite these documents, the resident's care plan inaccurately indicated a full code status, and there was no physician's order for the resident's advance directives. The facility's policy required that advance directives be identified and reviewed upon admission, but this was not done for the resident. Interviews with facility staff revealed that the resident was presumed to be a full code due to the unreadable MOLST form. The Unit Manager acknowledged that the MOLST form should have been reviewed and updated upon admission, and a physician's order should have been obtained. However, these actions were not completed, resulting in a discrepancy between the resident's documented wishes and the care plan, which could lead to inappropriate medical interventions in the event of a change in the resident's condition.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was free from physical restraints, as required by their policy. The resident, who had severe cognitive deficits and required maximum assistance for transfers and ambulation, was observed sitting in a stationary chair positioned in a way that limited their ability to move freely around the room. The stationary chairs were placed in the corner of the room, with one chair on each side of the resident, effectively preventing them from exiting the room. This setup was intended as a safety intervention to prevent falls but was not assessed as a potential restraint, contrary to the facility's policy. The resident's care plans indicated a history of behaviors associated with cognitive decline and a tendency to sit on the floor. Despite these considerations, the facility did not assess the stationary chairs as a restraint when the intervention was initiated. The Director of Nursing acknowledged that the chairs limited the resident's movement and that the interdisciplinary team only assessed the chairs as a restraint after the surveyor's observation. The failure to assess the stationary chairs as a potential restraint led to the deficiency identified by the surveyor.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary grooming assistance for two residents who were dependent on staff for activities of daily living (ADLs). Resident #164, who was admitted with diagnoses including Hemiplegia, Hemiparesis, and Cognitive Communication Deficit, was observed multiple times with approximately one inch of facial hair on the chin, despite being dependent on staff for personal hygiene and grooming. The resident had not refused care, and a CNA confirmed that the resident had never refused ADL care or facial hair removal. The Director of Nursing stated that it was expected for CNAs to offer and provide facial hair removal with daily care. Resident #556, admitted with diagnoses such as Adult Failure to Thrive, Chronic Kidney Disease Stage 3, and Depression, was observed with long, untrimmed fingernails with debris under and around the nails. The resident required supervision or touching assistance with personal hygiene and had not refused care. The care plan indicated the need to keep fingernails short to prevent skin integrity issues. Despite this, the resident reported that staff had attempted to cut the nails once but were unsuccessful due to inadequate tools, and no further attempts were made. Observations confirmed that the resident's nails remained untrimmed over two days. Interviews with staff, including CNAs and a nurse, revealed that the resident required assistance with all ADLs, and nail care should be part of the routine care provided. However, the CNA responsible had not recently checked the resident's nails, and the nurse acknowledged the need for nail trimming and cleaning. The Director of Nursing also confirmed the expectation for CNAs to perform nail care during morning routines.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that assistive devices to maintain hearing and enhance communication were utilized for a resident who required staff assistance for insertion and manipulation of hearing aids. The resident, admitted with diagnoses including bilateral glaucoma and auditory hallucinations, had an audiology consult indicating the need for daily assistance with hearing aids. Despite physician orders and treatment administration records indicating that hearing aids should be applied daily during the day shift, observations revealed that the resident frequently did not have the hearing aids inserted during breakfast and other times, impacting their ability to hear and communicate. Multiple observations by the surveyor noted the resident without hearing aids during breakfast and while interacting with staff, despite expressing a desire to hear better. Interviews with nursing staff confirmed that hearing aids should be applied once the resident wakes up and before breakfast, yet the resident was observed without them on several occasions. The medical record did not indicate any refusals by the resident to wear the hearing aids, highlighting a failure in staff adherence to the facility's policy and physician's orders regarding hearing aid placement.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary care and services related to enteral feeding for a resident, identified as Resident #111, who was admitted with diagnoses including vascular dementia, dysphagia, and moderate protein-calorie malnutrition. The resident was severely cognitively impaired and received nutrition and hydration via a feeding tube. The deficiency was identified when surveyors observed that the enteral feeds and fluids being administered to the resident were not labeled or dated as required by the facility's policy. This policy mandates that all enteral nutrition formula administration containers should be labeled with specific information to avoid misinterpretation and ensure proper care. During observations on two consecutive days, surveyors noted that the bags containing the enteral feed and water flushes were not labeled or dated. Nurse #6, who was responsible for the resident during the 7:00 A.M. to 3:00 P.M. shift, confirmed that the bags should have been labeled and dated by the nursing staff who hung them. The nurse identified the contents of the bags as Jevity product and water for flushes but acknowledged the lack of labeling, which was a deviation from the facility's established procedures for enteral feeding management.

Penalty

No penalty information released

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

Summary

The facility failed to provide proper respiratory care for Resident #246, who was diagnosed with Alzheimer's and Asthma. The deficiency was identified when the nebulizer setup equipment for the resident was found to be unlabeled, undated, and not stored in a storage bag, contrary to the facility's policy. The policy required the night nursing shift to date and label the nebulizer tubing and bag, and store them in a labeled and dated plastic bag after drying. The equipment was also supposed to be changed weekly. However, observations on two separate occasions revealed that the nebulizer tubing and handheld piece were left exposed on a chair cushion and a shelf in the resident's room, without proper labeling or storage. Interviews with Nurse #1 and the Director of Nursing confirmed the importance of bagging the nebulizer equipment to prevent infection control issues and the necessity of labeling and dating the equipment to track when it was last changed. Despite the facility's policy and the physician's orders, the nebulizer equipment for Resident #246 was not managed according to the required standards, leading to a failure in maintaining proper respiratory care and potentially exposing the resident to infection risks.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medications were stored securely in the Sacred Heart Unit's medication storage room. The Central Supply Manager (CSM) was observed inside the medication storage room with a cart of supplies propping the door open, and no other staff were present in the immediate area. The CSM accessed the room using a key provided by Nurse #2, who was not supervising the CSM at the time. The facility's policy requires that only authorized personnel, specifically Licensed Nurses, have access to the medication storage room, and that the room remains closed and locked at all times. The medication storage room contained prescription medication cards, emergency medication kits with Narcan, anaphylaxis medications, and a refrigerator with insulin. During interviews, both the CSM and Nurse #2 acknowledged that the CSM regularly accessed the medication storage rooms unsupervised to stock over-the-counter medications. The Administrator confirmed that the CSM should not have been given the nursing keys and should not have been in the medication storage room unsupervised, as access is restricted to Licensed Nurses and the Licensed Nurse management team.

Penalty

No penalty information released

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

Summary

The facility failed to provide a written notification of transfer or discharge for a resident who was transferred to the hospital. The resident, who had been admitted to the facility with diagnoses including End Stage Renal Disease, Diabetes Mellitus Type 2, and Chronic Kidney Disease Stage 4, was sent to the hospital due to worsening renal function. Despite obtaining a physician's order for the transfer and documenting the transfer in a nurse's note, there was no evidence that a written notice of transfer or discharge was provided to the resident or their representative. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman about the resident's transfer to the hospital. During an interview, a social worker confirmed the absence of documentation for the written notice and the notification to the Ombudsman. The social worker acknowledged that the written notice should have been completed at the time of the transfer and included in the notification list sent to the Ombudsman every two weeks.

Penalty

No penalty information released

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

Summary

The facility failed to provide a Bed Hold Policy Notice to a resident or their representative upon the resident's transfer to a hospital. This deficiency was identified during a review of the facility's records and an interview with a social worker. The facility's policy, effective since December 2018 and reviewed in March 2020, mandates that residents and their representatives be notified of the Bed Hold and Return to Facility Policy upon admission and transfer. This policy ensures that residents are informed about the state's bed hold duration, payment, and their right to return to the facility after hospitalization or therapeutic leave. In the case of the resident involved, who was admitted in June 2022 with diagnoses including End Stage Renal Disease, Diabetes Mellitus Type 2, and Chronic Kidney Disease Stage 4, there was no documentation of the Bed Hold Policy Notice being provided. The resident was transferred to an acute care hospital for evaluation of worsening renal status, as per a physician's order. However, during an interview, the social worker was unable to provide evidence that the required written notice had been given to the resident or their representative at the time of transfer.

Penalty

No penalty information released

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

Summary

The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in the recorded discharge locations. Resident #253, who was admitted with diagnoses including an unspecified fall and Adult Failure to Thrive, was inaccurately documented as being discharged to a Short-Term General Hospital. However, the nursing progress notes and discharge summary indicated that the resident actually returned home on the same day. This error was confirmed during an interview with MDS Nurse #1, who acknowledged that the MDS assessment should have reflected the discharge to home. Similarly, Resident #254, admitted with Alzheimer's Disease and age-related osteoporosis, was incorrectly recorded as being discharged to their home in the community. In contrast, the SBAR communication form and nursing progress notes revealed that the resident was transferred to a hospital for further evaluation. MDS Nurse #1 confirmed the inaccuracy during an interview, stating that the MDS assessment should have been modified to reflect the hospital discharge. These inaccuracies in the MDS assessments highlight a failure in ensuring accurate documentation of discharge locations for residents.

Penalty

Inspection fine: $9,318

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 staff consistently implemented and followed interventions identified in a resident's care plan. A resident, who required extensive assistance from two staff members during transfers for safety, was transferred by a CNA using a Sit/Stand Lift device without the assistance of another staff member. During the transfer, the resident became weak, started to slide out of the lift seat, and was lowered to the floor by the CNA. The resident complained of pain and was later diagnosed with a right femur fracture, requiring hospital admission for treatment. The resident had a history of hemiplegia and hemiparesis following a stroke, difficulty walking, lack of coordination, unsteadiness on feet, and anemia in the setting of chronic kidney disease. The resident was assessed as being at high risk for falls and required maximum assistance from staff with transfers and mobility. The care plan and CNA Care Kardex indicated that the resident required extensive assistance from two staff members for all transfers, which was not followed by the CNA involved in the incident. The CNA admitted to not reviewing the resident's CNA Care Kardex on the day of the incident and had previously transferred the resident without assistance, believing the resident was strong enough to participate. However, this was contrary to the care plan requirements. The CNA also claimed the resident had socks and shoes on during the transfer, which conflicted with the nurse's observation that the resident did not have socks or shoes on when found on the floor.

Removal Plan

• Resident #1 fell, was assessed by Nursing for any injuries, and was transferred to the Hospital Emergency Department for evaluation.
• Resident #1's Care Plan was reviewed and updated to include the fall and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers.
• Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary which indicated no fractures found, but continued pain led to an X-ray revealing a right femur fracture.
• Resident #1's Care Plan was updated to include the fracture and that he/she required extensive assistance from two staff members using a Hoyer Lift.
• The Interdisciplinary Team reviewed Resident #1's fall, X-ray results, and need for hospital transfer, and continues to update the Plan of Care.
• The Facility Nursing Staff completed an Audit to ensure all residents using mechanical devices had appropriate Care Plans and CNA Care Kardex instructions.
• Mandatory education for all Licensed Nurses and CNAs was initiated, including competencies on Sit/Stand Lift device and review of residents' care plans.
• All Sit/Stand Lift devices were inspected by the Maintenance Department to ensure safety.
• Physical Therapy Department Staff completed Audits to ensure transfer status and staff assistance needs were up to date on residents' Plan of Care and CNA Care Kardex.
• Random Audits were completed by administrative staff on Resident transfers with the Sit/Stand Lift to ensure procedures are followed.
• Audit results were presented at Quality Assurance Performance Improvement meetings, with ongoing review until 100% staff compliance is met.
• The facility's QAPI meeting minutes indicated a plan to continue reviewing concern areas for potential deficient practice, including falls.
• The Director of Nurses and/or designee are responsible for overall compliance.

Penalty

Inspection fine: $9,318

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

Summary

The facility failed to provide adequate supervision and assistance to a resident who was at high risk of falls, resulting in a serious injury. The resident, who had a history of hemiplegia and hemiparesis following a stroke, required the assistance of two staff members for transfers. However, on the day of the incident, a CNA attempted to transfer the resident using a Sit/Stand Lift device without the required assistance of another staff member. During the transfer, the resident began to slide out of the lift seat, and the CNA attempted to lower the resident to the floor, resulting in the resident complaining of hip pain. The resident was initially assessed at the hospital emergency department, where no fractures were found. However, the resident continued to experience pain, and an X-ray conducted at the facility several days later revealed a distal right femur fracture. The fracture was attributed to the forceful movement during the fall, which occurred when the resident was being transferred without the necessary assistance. Interviews with the CNA and other staff members revealed inconsistencies in the account of the incident. The CNA admitted to not using a gait belt or having another staff member assist during the transfer, contradicting earlier statements made to the Physician Assistant, Director of Nursing, and Administrator. The facility's policy required two staff members for such transfers, and the failure to adhere to this policy directly contributed to the resident's injury.

Removal Plan

• Resident #1 fell, was immediately assessed by Nursing for any injuries, Resident #1 had reported he/she had pain to right hip, and was transferred to the Hospital Emergency Department (ED) for evaluation.
• Resident #1's Care Plan was reviewed and updated to include the fall, and to ensure transfer status indicated he/she required physical assistance of two staff for all transfers.
• Resident #1 returned to the facility, nursing reviewed the Hospital ED Discharge Summary (Final Report) which indicated Resident #1 was assessed and treated at the ED with no fractures found. However, he/she continued to experience pain and an X-ray completed at the facility a few days later indicated he/she had a right femur fracture.
• Resident #1's Care Plan was updated to include that Resident #1 was in pain, Facility X-ray indicated Resident #1's right femur was fracture status post fall, which was not previously diagnosed, that he/she had been transferred back to the ED and was admitted to the Hospital.
• The Facility's Morning Meeting and the Weekly Risk Meeting Fall Review minutes indicated the Interdisciplinary Team (IDT) reviewed Resident #1's fall, his/her X-ray results, and need for him/her to be transferred back to the Hospital ED for evaluation. The minutes indicated the IDT continues to discuss (and update as needed) Resident #1's Plan of Care including orthopedic appointments, weight bearing status, nutritional status, and overall health status.
• The Facility Nursing Staff completed an Audit to ensure all residents who used any type of mechanical device, that their individual Care Plan and the CNA Care Kardex indicated the appropriate type of device to be used and how many staff were needed for assistance with the transfer.
• The Staff Development Coordinator (SDC) and the DON initiated mandatory education for all Licensed Nurses and CNA's, which included completion of competencies on Sit/Stand Lift device, and staff were required to complete return demonstration of appropriate use of the transfer device. Education also included nursing staff requirement to review and follow residents plan of care, knowledge of how to access and review the CNA Care Kardex, prior to providing care.
• Resident #1's Care Plan was updated to include, right distal femur fracture related to a fall, and that he/she required extensive assistance from two staff members using a Hoyer Lift (mechanical lift used to safely transfer patients).
• All Sit/Stand Lift devices were Inspected by the Maintenance Department, to ensure all parts were functioning properly and transfer device was safe to use.
• Physical Therapy Department Staff also initiated and completed Audits related to the incident to ensure all residents including new admissions, that their transfer status degree and number of staff needed for assistance during the provision of all care need areas identified were up to date on residents Plan of Care and CNA Care Kardex.
• Random Audits were completed by administrative staff, on Resident transfers with the Sit/Stand Lift to ensure that transfer procedures from Sit/Stand Lift Competencies are being followed by staff. Random Audits will be completed by the DON three times weekly for 3 months.
• The DON presented the Audit results at monthly Quality Assurance Performance Improvement (QAPI) meeting, where the QAPI Committee discussed the results. The DON will present the Audit results for three months, then quarterly until the Committee determines 100% staff compliance is met, and the concern area thereafter will be present for yearly review.
• Review of the facility's most recent QAPI meeting minutes indicated leadership's plan is to continue to review the concern areas for potential deficient practice, including falls, to ensure that residents were provided with appropriate level of assistance as determined by assessments and identified in the residents Plan of Care and CNA Care Kardex.
• The Director of Nurses (DON) and/or designee are responsible for overall compliance.

Penalty

Inspection fine: $9,318

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 report details an incident at a long-term care facility where a resident, identified as Resident #2, who primarily spoke a language other than English, was subjected to verbal abuse by Nurse #1. On April 8, 2024, during the evening shift, Nurse #1 yelled at Resident #2 in a humiliating and verbally aggressive manner, telling Resident #2 that he/she needed to learn English as they were now in America. This incident was witnessed by other residents, causing Resident #2 to become upset and cry. Resident #2 had a medical history that included diagnoses of Parkinson's disease, type 2 diabetes mellitus, major depressive disorder, sleep terrors, spinal stenosis, and hypertension. The facility's investigation revealed that Nurse #1 not only verbally abused Resident #2 but also made inappropriate comments about the resident in the presence of other staff members. Nurse #1's behavior was reported by Resident #1, who heard the verbal abuse, and by Nurse #2, who witnessed Nurse #1's actions and reported them to the Nurse Supervisor. Additionally, Certified Nurse Aide (CNA) #3 and Resident #3 corroborated the incident, stating that Nurse #1 had aggressively yelled at Resident #2 in a humiliating manner, causing Resident #2 to appear scared and upset. The Administrator of the facility took immediate action upon receiving reports of the incident, including suspending and ultimately terminating Nurse #1, who was a contracted staff member from an agency. Despite attempts to interview Nurse #1 for the investigation, she did not respond to requests. The facility's policies on abuse prevention and resident rights were cited in the report, emphasizing the importance of providing a safe and respectful environment for all residents, regardless of their language or background.

Penalty

Inspection fine: $9,318

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 staff implemented and followed their Abuse Policy when an allegation of verbal abuse was reported. On the evening shift, a nurse reported that another nurse had been verbally abusive towards a resident. The Nurse Supervisor did not immediately notify the Administrator and Director of Nursing (DON) of the alleged abuse and did not suspend the accused nurse. As a result, the accused nurse continued to work the overnight shift, providing care to the resident and other residents, placing them at risk for potential further abuse. The Facility's Internal Investigation revealed that the management team did not become aware of the incident until three days later when the Administrator received an email from a family member. The investigation included statements from witnesses and confirmed that the accused nurse had been verbally abusive. Despite the Facility's Abuse Policy requiring immediate action, the Nurse Supervisor failed to follow the protocol, resulting in the accused nurse continuing to work and interact with residents during the investigation period.