Bronson Commons

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure an area free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to elopement risk and safe mechanical lift transfers. One resident with a history of falls, multiple rib fractures, and recent head trauma was admitted from a hospital with documented confusion, agitation, paranoia, and impulsive behaviors. On admission, the RN completing the elopement assessment marked the resident as not at risk for elopement, despite her own verbal report that the resident was terrified, disoriented, repeatedly stated she wanted to leave, believed people were trying to harm her, and was frequently up and wandering in the room. Progress notes and the admission history and physical documented that the resident was quite confused, agitated, impulsive, and exhibiting abnormal behaviors, including asking staff to help her commit a mass murder, making accusations that hospital staff and paramedics had stolen from her, and expressing delusional beliefs about being harmed. The care plan addressed potential changes in mental status and mood but did not identify or address elopement risk. Nursing and CNA staff interviews showed that staff relied primarily on the presence of a wander guard to identify elopement risk and did not reference other assessments or tools to determine risk. Staff reported that when a resident was identified as an elopement risk, a wander guard was applied and this was communicated in shift report; if a resident was not assessed as a risk, no wander guard was used and no reevaluation occurred unless triggered by preset intervals or events. The admitting RN initially stated she believed she had documented the resident as an elopement risk, but later clarified she had not, explaining she did not think the resident was physically capable of reaching the door and was hopeful the resident would adjust. Subsequent nursing staff on the night shift were informed only that the resident was new, had fallen at home, had a knot on her head, and was "fine," and they were unaware she was an elopement risk. During that night, the CNA and LPN observed the resident as confused, wanting to call her son, not knowing how she arrived at the facility, asking for her husband and son, and stating she wanted to leave. The resident was kept at the nurse’s station for a time, then assisted back to bed around 3:30 AM. Later, camera footage showed the resident self-propelling in a wheelchair to the main entrance, using the handicap button to open the door, and exiting the building without staff awareness. She walked away from the facility and was not discovered missing until the LPN went to administer medications and found her room empty, prompting a search that ended with the resident being located outside near a neighboring house. A second deficiency involved the facility’s failure to ensure safe use of a mechanical lift and appropriate sling selection for another resident with moderate cognitive impairment and generalized weakness, who was dependent on staff for all bed mobility and transfers. During a transfer from bed to recliner using a Hoyer lift, two CNAs used a hygiene sling that was present in the resident’s room and that they reported had been used for months. As the lift was pulled away from the bed, the resident was unable to maintain the upper body and arm support required for that type of sling, slid out of the sling, and fell onto the legs of the lift, sustaining a head laceration that required four staples in the emergency department. Therapy staff, including the supervisor of rehabilitation, PT, and OT, later stated that the hygiene sling is a specialized sling intended for toileting, requires sufficient shoulder engagement and core strength, and is not appropriate for routine bed-to-chair transfers without prior assessment. They confirmed that therapy had not assessed this resident for hygiene sling use and had expected a standard full-body Hoyer sling to be used. The RN unit coordinator acknowledged that the hygiene sling had been used, described it as the resident’s preference, but could not provide documentation of such a preference or any assessment supporting its safety for this resident. Interviews with nursing and therapy staff further revealed that CNAs typically used whatever sling was in the resident’s room and that the resident’s care plan did not specify the type of sling to be used for transfers. There was no documented assessment by therapy or nursing indicating that the resident had the necessary upper body strength and core stability to safely use a hygiene sling for non-toileting transfers. As a result, the resident, who had dementia and Alzheimer’s disease and was dependent for transfers, was transferred with a sling that did not provide adequate support for her condition, directly leading to her fall and head injury during the Hoyer lift transfer.

Removal Plan

• Review elopement and missing person policies and procedures.
• Modify the elopement assessment tool scoring to enhance identification of safety risks.
• Reassess all residents for elopement risk.
• Initiate wander guards for residents identified as elopement risks based on the updated elopement assessment tool.
• Check all wander guards and alarms for functionality.
• Provide comprehensive education on elopement prevention, including ongoing assessments, definitions, exit-seeking behaviors, and role expectations, to all licensed nursing staff and certified nursing assistants.
• Provide education to remaining employees prior to the start of their next working shift.
• Review education material and completion quarterly at the QAPI meeting.
• Perform weekly audits of new admissions for 4 weeks to ensure elopement assessments are completed on admission, kept up to date, and that a care plan addresses any identified risk.
• Create a workstation at the main entrance and schedule staff to monitor traffic in and out of the building.
• Install a Red Box Audible Alarm at the main entrance.
• Maintain the alarm by the entrance attendant.
• Activate the alarm any time the door is opened.

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 Registered Nurse (RN) served full time in the role of Director of Nursing (DON), as required, because the DON simultaneously held the position of Executive Director/Nursing Home Administrator (NHA). When surveyors entered the facility, they were informed that the NHA and DON were the same person, and the DON confirmed she had been functioning in both roles since the previous NHA left. The facility assessment listed the same individual as both Interim Executive Director and DON, and the employee report did not list any separate Executive Director. The DON described her DON responsibilities as including auditing and education, new processes, policy updates, employee issues, payroll and budget tasks, staff meetings, skills fairs, infection prevention meetings, clinical oversight, and IDT meetings, while also assuming responsibility for rehabilitation, activities, dietary, and social work departments as NHA. Due to the dual roles, the DON reported she was one person doing 40 hours of work in two positions, was not always performing quality work, and could not attend certain meetings or complete some DON functions. She stated that her DON responsibilities were delegated to unit coordinators, and staff interviews confirmed multiple delegations from the DON and that access to the DON had become limited. Staff reported the DON was less available to discuss issues and less hands-on with clinical staff than before. The DON also reported she could no longer serve on the safety committee or run the nurse aide training program, which were reassigned to a unit coordinator and staff development RN, respectively. A unit coordinator reported being placed into the safety committee role shortly after starting and learning the role “on the fly,” further illustrating that DON duties were shifted to other staff because the DON was covering both DON and NHA positions instead of serving full time as DON.

Penalty

21 days payment denial

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

Summary

The facility failed to ensure that appropriate transfer techniques were implemented for two residents, resulting in injuries. One resident, a female admitted for physical and occupational therapy following a previous femur fracture, was assessed as requiring limited assistance for transfers, with therapy recommendations including the use of a front-wheeled walker, wheelchair, gait belt, and verbal cues. During an assisted transfer from the bathroom to the bed, the CNA did not use a gait belt as required by the resident's care plan. While the CNA was pulling down the bedding, the resident let go of her walker to point at the bed control and fell backward, sustaining a hand laceration and a new acute fracture to her distal femur. The CNA admitted to not checking the care plan and not realizing a gait belt was required for the transfer. Another resident, a female with gastroparesis and dependent for care, was to be transferred with a hoyer lift to the toilet and a slide board only for bed-to-wheelchair transfers. Over a weekend, staff used a slide board transfer to the toilet instead of the required hoyer lift, and when the process took too long, staff reportedly picked the resident up and placed her on the toilet, resulting in bruising on her inner upper arms. Multiple interviews confirmed that the resident's care plan specified a hoyer lift for toilet transfers, and staff were either unaware of or did not follow these instructions. The resident and several staff members reported the improper transfer and resulting bruising. In both cases, the deficiencies were due to staff not following the residents' care plans and not using the required assistive devices or transfer techniques. Staff either did not check the care plans or made assumptions about the residents' transfer status, leading to improper handling and injury. The incidents were witnessed, reported, and confirmed through interviews, observations, and record reviews.

Plan Of Correction

1. One of the residents had discharged at the time of the survey. The care plans of the other affected resident were reviewed and updated by the Interdisciplinary Team (IDT). Updated level of assistance and transfer status were shared with clinical teams by leadership to ensure understanding and compliance. 2. All residents have the potential to be affected. 3. Clinical Oversight Committee will audit care plans to ensure clear direction and appropriate levels of assistance. Refreshed education was provided to clinical staff on where to locate care plan information on EMR devices, and they were reminded to always carry these devices to be ready to verify care plans and assistance levels. Policies were reviewed, and no necessary updates were identified. 4. Routine audits of five care plans are conducted weekly at Clinical Oversight meetings for clarity of assistance levels. Additionally, five weekly audits are performed on transfers to ensure the transfer aligns with care plans. There are also five weekly audits of staff demonstrating where to locate care plan information on devices, and audits to ensure devices are on staff members at all times to guarantee they are always ready to access the care plan. 5. The Executive Director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

The facility failed to inform and educate residents about the grievance process and did not effectively implement procedures for documenting, tracking, and resolving grievances. During a confidential group meeting, all six residents present reported that they repeatedly discussed the same concerns in resident council meetings without resolution. These residents were unaware that they could have their private concerns documented on a form, that staff could assist them in completing the form, or that they could submit concerns anonymously. They also did not know that concern forms were available or how to access them, but indicated they would use the forms if they were accessible. Observations revealed that blank concern forms were stored in a binder on a shelf located 4-5 feet up on the wall in a sitting area near the main lobby, making them not easily accessible to residents. Interviews with staff, including an LPN and two Activity Associates, showed a lack of awareness about the location and use of concern forms. The LPN stated she did not know where to find the forms or assist residents with them, and one Activity Associate was unfamiliar with the forms altogether. The other Activity Associate, who conducted resident council meetings, reported that she emailed concerns to relevant departments but did not follow up to ensure concerns were addressed, only discussing responses from previous meetings if available. Further interviews with facility leadership, including the Nursing Home Administrator and DON, confirmed that concern forms were not placed in areas frequented by residents and were posted high on the wall, making them difficult to access. The DON also noted that staff, rather than residents, typically initiated the concern forms. As a result, the facility did not ensure that residents were properly informed about their right to file grievances, did not make the process accessible, and failed to document, track, and record the resolution of grievances as required.

Plan Of Correction

1. The facility moved concern/grievance forms to a tabletop location that is prominent and easily accessible in the lobby. A prominent notice was placed to guide residents to the location. 2. All residents who have concerns about their care have potential to be affected. 3. The facility created a log of concerns and grievances to monitor follow-up and ensure each concern is resolved. The log also enables the facility to track and trend concerns to identify opportunities for continuous quality improvement. The facility will report the number and nature of concerns, resolution status, and trends at monthly Quality Assurance Performance Improvement (QAPI) meetings, where the QAPI Committee will use the information to direct performance improvement projects as warranted. The facility will also provide written information to all residents on the right to air concerns or grievances, and the location of self-reporting forms. This information will be provided to the Resident Council at the July meeting. Going forward, this information will also be included in the admission packet. Education will be provided to all employees about the right to air concerns and grievances, and how residents can submit concerns or grievances using forms that are available in the lobby or with confidential help from an employee. Education will include how these are tracked for continuous quality improvement. 4. During routine daily leadership rounds, each leader will interview at least one resident for awareness how to report a concern or grievance for at least the next 12 weeks. During monthly QAPI meetings the committee will review the number, nature and status of concerns and will determine if opportunities are present for performance improvement. 5. The executive director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

The facility failed to ensure that residents were properly assessed for the appropriateness of self-administering medications, as required by policy and regulation. Three residents were observed or reported to have self-administered medications or had medications left at their bedside without a completed assessment or physician order authorizing self-administration. In each case, staff confirmed that no assessment had been completed and no orders were present to allow self-administration, despite the facility's policy requiring both an assessment and a provider order before permitting this practice. One resident, with a history of gastroparesis and dependence for care, was observed independently instilling eye drops at her bedside. Staff confirmed there was no physician order for the eye drops, no assessment for self-administration, and that the resident had a history of having unauthorized items removed from her bedside. Another resident, diagnosed with end stage kidney disease and on dialysis, reported that nurses inconsistently left her chewable tablet (Fosrenal) at her bedside to take after meals, as prescribed. Staff acknowledged that this resident had not been assessed for self-administration, and that the facility did not have a process in place for such assessments, even though the medication was being left for her to take on her own. A third resident, with diagnoses including cancer, heart failure, anxiety, and depression, reported that nurses sometimes left her medications, such as supplements and vitamins, for her to take independently. She recounted an incident where she nearly attempted to pick up a dropped pill herself, despite a history of falls. Staff confirmed that no residents on her unit had been assessed for self-administration of medications. Review of facility policy indicated that an assessment and provider order are required before allowing residents to self-administer medications or have medications left with them, but these procedures were not followed for the residents involved.

Plan Of Correction

1. One of the three residents was found to have medications in their possession. This was retrieved and locked up. Education was provided to residents and assigned nurses regarding self-administration of medication and expectations related to protocol. One affected resident has discharged from the facility. The other two will be assessed for their ability to self-administer medications safely per policy. 2. Any resident has potential to be affected. 3. Education will be provided to admission staff related to self-administration of medication policy, to include asking if the resident has any kind of over-the-counter or prescribed medication in their possession, and explaining expectations related to this policy. Specified scripting will be provided. Education will be refreshed with nursing employees related to the existing self-administration policy. It will be added to new hire orientation checklist for new employee education. An additional step will be added to the new admission checklist to include a discussion with the nurse and resident regarding the self-administration policy. Nurses will be instructed to include a comment in Admission Navigator Section of the EMR to reflect that the conversation was completed. The Self-Administration of Medication policy was updated to include an explanation to residents upon admission related to the policy and its expectations. Five weekly audits will be completed of admission documents and nursing assessments to ensure the policy is discussed as expected for the next 12 weeks. Five verbal weekly audits will also be completed with nurses to seek their understanding of the policy for the next 12 weeks. The Executive Director is responsible for compliance with this policy.

Penalty

21 days payment denial

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

Summary

A deficiency was identified when a cognitively intact resident, who was dependent on staff for toileting and transfers, was not consistently provided with assistance according to her preferences. The resident preferred to use a bedside commode for toileting, as documented in her care guide, but staff frequently offered a bedpan instead, particularly during nighttime and mealtimes. Staff interviews confirmed that the use of the commode was limited by staffing levels and time constraints, with staff indicating that using the mechanical lift for commode transfers was too time-consuming. The resident expressed dissatisfaction with being offered the bedpan, which she found uncomfortable, and reported that her requests to use the commode were sometimes denied unless there were enough staff available. Review of the resident's care plan indicated a goal for her to be clean, dry, and odor-free, with interventions to encourage her to verbalize toileting needs and keep her call light within reach. However, the care plan did not specifically document her preference for the commode. Progress notes and occupational therapy documentation further supported that the resident was encouraged to use the commode and was not appropriate for bedpan use. Despite this, staff practice did not consistently align with the resident's preferences, resulting in care that did not fully support her right to self-determination and choice in daily living activities.

Plan Of Correction

1. A care conference will be scheduled with the Interdisciplinary Team (IDT) and resident to identify preferences and discuss how the facility can best meet resident's needs. Care plan will then be updated to reflect the discussion. 2. All residents have the potential to be affected. 3. Existing "Interdisciplinary Long-Term Care Resident Review Protocol" was updated to include: Resident and/or resident representative interview should include a discussion about care preferences and will be completed by a member of the IDT. Standard care preference questions should include the following: toileting, sleep and wake preferences, meals, and other care preferences the resident would like to share. With this information, care plans will be updated at least quarterly with resident and/or representative input and subsequently implemented into how their care is provided. 4. Bi-weekly long-term care resident review meetings will include an audit of all residents due for quarterly review to ensure that interviews were completed and identified preferences were implemented into the care plan for at least the next 12 weeks. 5. The Executive Director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

Surveyors identified that the facility failed to comply with federal requirements regarding the use of PRN (as needed) psychotropic medications for two residents. Specifically, the facility did not limit the duration of PRN psychotropic medication orders to 14 days, nor did it ensure that the prescribing physician documented a clinical rationale for extending these orders beyond the 14-day limit, as required by regulation. For one resident with Alzheimer's disease and major depressive disorder, a PRN order for lorazepam was in place for a period exceeding 14 days. The resident was severely cognitively impaired and had no documented behaviors during the assessment period. The medication order for lorazepam was renewed multiple times without evidence of a physician's documented rationale for the extended duration. Facility staff confirmed the ongoing order and acknowledged the lack of compliance with the required documentation. Another resident with generalized anxiety disorder also had a PRN lorazepam order written for 30 days. Although the resident reported some anxiety and staff noted the medication was beneficial, there was no documentation from the physician providing a rationale for extending the PRN order beyond 14 days. The pharmacy's monthly review did not identify any irregularities or make new recommendations regarding this medication order.

Plan Of Correction

1. Medical records will be reviewed by providers and the Interdisciplinary Team (IDT) to determine the necessity of medication and frequency. Medications will be discontinued or frequency modified accordingly. All residents have the potential to be affected. 2. EMR Reports will be utilized to identify those with orders for PRN psychotropic medications. Behavior Management Program Policy was updated to include: "When pharmacological interventions are utilized, the duration of order must meet regulatory requirements. PRN psychotropic medications should not exceed more than 14 days unless clinical documentation by a provider is present to provide rationale. Orders will be reviewed during the Behavioral Health Committee meeting to ensure pharmacological interventions meet criteria for use and regulatory requirements." 3. Antipsychotic Medication Management policy was updated to include: "When pharmacological interventions are utilized, the duration of order must meet regulatory requirements. PRN Psychotropic medications should not exceed more than 14 days unless clinical documentation by a provider is present to provide rationale." Education will be provided to nurses, providers, and social services teams regarding policy updates and expectations. External partners providing pharmacy and behavioral health services will receive this refreshed education as well. Weekly Clinical Oversight meetings will monitor these medications utilizing EMR report on a weekly basis. 4. Behavioral Health Committee will review a report of all PRN psychotropic medications during monthly routine meetings to determine the necessity of medication and appropriate frequency. Medications will be discontinued or frequency modified accordingly. Weekly Clinical Oversight meetings will monitor these medications utilizing EMR report on a weekly basis. Five weekly audits to ensure compliance will be completed by Social Services or designee utilizing EMR report for the next 12 weeks. The executive director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

A deficiency occurred when a resident's Minimum Data Set (MDS) discharge assessment was inaccurately coded and submitted. The resident, who was admitted with diagnoses including weakness and a need for personal assistance, was documented on the MDS as having been discharged to a short-term general hospital. However, review of the resident's medical record revealed no documentation of a hospital transfer, and it was later confirmed by the MDS Coordinator that the resident had actually been discharged to home, not to a hospital. The MDS Coordinator acknowledged during an interview that she had incorrectly coded the discharge status and that the error was present at the time of submission. The Nursing Home Administrator confirmed the inaccuracy of the submitted MDS and stated that the MDS Registered Nurse was ultimately responsible for ensuring the accuracy of the data submitted. The MDS Registered Nurse admitted to only performing spot checks rather than a full review of the assessment before submission, resulting in the inaccurate discharge information being reported.

Plan Of Correction

1. The MDS Nurse appropriately modified and resubmitted the MDS assessment with corrected discharge destination. 2. All residents have the potential to be affected. 3. Bronson Commons MDS RN will double check discharge destination on all assessments prior to signing and submitting to provide a second check of MDS LPN assessments. Policies were reviewed and no necessary updates were identified. 4. The Director of Nursing will complete five weekly audits of discharge location on MDS assessments to ensure accuracy for the next 12 weeks. 5. The Executive Director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

A deficiency occurred when nursing staff failed to follow professional standards of nursing practice for medication administration for one resident. The resident, who was prescribed Apresoline for hypertension with specific physician orders to hold the medication if systolic blood pressure (SBP) was less than 130, reported that a registered nurse did not listen to her concerns about low blood pressure and administered the medication despite her warning. Documentation review showed that the resident's blood pressure was 112/56 earlier that day, and there was no record of a blood pressure reading prior to the evening dose when the medication was given. The medication administration record indicated the medication was given in the evening, and there was no documentation of a blood pressure reading or assessment for dizziness at that time. Interviews with staff confirmed that the resident was knowledgeable about her medications and often reminded nurses when her blood pressure was too low for antihypertensive administration. Staff also reported that the medication was frequently held due to low SBP, and dizziness was a known side effect for this resident when her blood pressure was low. The Director of Nursing stated that nurses were expected to verify and document blood pressure readings in accordance with physician orders before administering such medications, but this was not done in this instance. The failure to obtain and document the required assessment prior to medication administration led to the deficiency.

Plan Of Correction

The nurse of the affected resident was provided one-to-one education about the parameters. Nurses will continue to be educated on expectations related to parameters and medication administration. All residents have potential to be affected. Education will be provided to all nurses regarding medication administration expectations for orders with specified parameters. Medication administration expectations related to parameters will be included in new hire orientation. Medication administration policies were reviewed and no necessary updates were identified. The Clinical Oversight Committee will complete five weekly audits of medications with ordered parameters to ensure compliance for the next 12 weeks. The Executive Director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

The facility failed to provide meaningful activities tailored to the interests and needs of a resident with a diagnosis of depression, as required by their care plan and comprehensive assessment. The resident, who was cognitively intact and expressed a strong preference for choosing her own bedtime, being around pets, and participating in favorite activities, reported that the facility did not support her involvement in activities of interest. Observations showed the resident often remained in her room, and interviews revealed she felt the activities program did not meet her needs, particularly due to the lack of evening activities, pet therapy, and opportunities to serve others or participate in community outings. Review of activity calendars and participation records confirmed that group activities were only offered during daytime hours, with no evening activities, pet therapy, or community outings available. The activity program did not include activities that allowed residents to serve others or gain a sense of purpose, and the last such activity was a one-time event several months prior. The resident described the available group activities as unfulfilling and childish, and expressed feelings of boredom, lack of purpose, and disconnection from the community. Interviews with facility leadership revealed that resident activity needs were assessed primarily through MDS assessments, and there had been no recent assessment of the need for evening activities. The facility had not provided community outings in years and relied on family or friends for residents' participation in community-based leisure. The activity director was unaware of the need for evening activities and did not routinely review activity assessments, resulting in a lack of individualized programming to meet the diverse needs and preferences of residents.

Plan Of Correction

1. Activities staff visited with the resident to update the resident's needs and preferences, and encouraged the resident to express wishes for activities. The resident provided ideas and suggestions that will be implemented. 2. All residents who would like help to plan or participate in activities have the potential to be impacted. 3. The facility reviewed the Patient Activities Assessment policy, assessment tools, and documentation tools, and determined they are appropriate to capture individual resident preferences and participation. The facility reviewed the policy Patient Activities Program and added a quality assurance process to ensure the program meets the needs of the resident population. Beginning July 2025, the activities calendar will include evening activities and opportunities to serve others. Seasonal outings will begin in August. The activities department will audit resident participation monthly to ensure group activities are well attended. At least monthly, the activities department will ask residents to evaluate a group activity for opportunities to improve or replace it. Education will be provided to all employees about the right to participate in activities that meet the interests and needs of each resident and how the facility supports these activity pursuits through group and individual programs. The resident council will also receive this education in the July meeting. 4. The activities department will interview five residents monthly to ensure each individual resident is offered activities that are meaningful to them personally, for at least the next 12 weeks. 5. The Executive Director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

A deficiency was identified when a resident with Alzheimer's disease and renal insufficiency, who was severely cognitively impaired, did not have water available at the bedside as required. Multiple observations over two days showed that the resident's water cup was consistently placed on the sink counter, approximately eight feet away from the bed, and not within the resident's reach. The resident was observed lying in bed with dry lips and reported feeling thirsty. No other beverages were present in the room during these observations. Interviews with staff confirmed that the expectation was for water to be kept within reach of residents and replenished at least every shift. Staff also acknowledged that the resident had difficulty holding the standard maroon cup and should have been provided with a more suitable cup. The facility's policy required fresh water to be available to residents at all times, but this was not followed for the resident in question, as evidenced by the repeated lack of accessible water and low recorded fluid intake.

Plan Of Correction

Corrective action took place immediately upon identification of the issue by moving the water within the resident's reach. All residents have the potential to be affected. Education to all staff related to ensuring water is within patient reach at all times in the resident's room. Policies were updated to reflect that water must be within the resident's reach in their room: Water Pass policy, TEMP Purposeful Rounding policy. Five weekly audits of water location within resident's reach in their room will be completed for the next 12 weeks. The Executive Director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

A deficiency was identified when staff failed to maintain enhanced barrier precautions (EBP) during the administration of tube feeding for a resident with a percutaneous gastrostomy tube. The resident, who had a history of stroke and was admitted with a feeding tube, was under EBP as indicated by signage outside her room and documented in her care plan. Despite these precautions, an LPN administered a bolus feeding without wearing a gown, contrary to facility policy and posted instructions. The LPN stated that EBP was only necessary for CNAs and not for nurses, as she believed she did not come into direct contact with the feeding tube. Further interviews revealed inconsistent understanding and application of EBP among staff. One RN reported that EBP was not used during tube feeding administration, while another LPN stated that both gown and gloves were required for such procedures. A CNA indicated that EBP did not apply to her as she did not administer tube feedings. The facility's policy specified that EBP, including gown and gloves, should be used during high-contact care involving indwelling medical devices such as feeding tubes. The failure to follow these precautions during tube feeding administration resulted in a deficiency related to infection prevention and control.

Plan Of Correction

1. The Infection Prevention Nurse provided one-to-one education on enhanced barrier precautions (EBP) with the resident's nurse. 2. All residents have the potential to be affected if they meet criteria for EBP. 3. Education will be provided to clinical employees related to EBP standard work. The following policies were updated to include verbiage related to using the appropriate personal protective equipment (PPE) as ordered, including EBP: Enteral Feeding, Indwelling Catheter, Peripherally Inserted Central Catheter Change, Irrigating Foley Catheter, Peripheral Intravenous Therapy Procedure, Male Straight Catheter, Female Straight Catheter, Care-Cleaning Urinary Drainage Bags, Pressure Injuries and Wound Care, Wound Culture. 4. Five weekly audits will be completed by the Infection Prevention Nurse or designee to ensure compliance with using EBP when appropriate, for the next 12 weeks. 5. The Executive Director is responsible for compliance.

Penalty

21 days payment denial

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

Summary

The facility failed to ensure that the results of the most recent federal surveys and corresponding plans of correction were readily accessible to all residents. During a confidential group meeting, all six residents present reported that they were unaware they could read the survey reports and did not know who to ask or where to find them. An observation revealed that the binder containing survey reports was placed on a shelf approximately 4-5 feet up on the wall in a sitting area next to the main lobby, making it difficult for residents to access. Interviews with staff further confirmed the deficiency. An LPN stated she did not know where the survey reports were located or how residents could access them. The Nursing Home Administrator acknowledged that the reports were kept in an area not frequently visited by residents and were not easily accessible. Additionally, an Activity Associate who conducts monthly resident council meetings was not aware of how residents could obtain access to the survey reports. These findings demonstrate that the facility did not make survey results and plans of correction readily accessible to residents as required.

Plan Of Correction

The facility moved the binders containing survey results to a prominent location in the lobby on a table that residents, family members, and legal representatives can reach either standing or sitting in a wheelchair. The public binders include survey results for the current year and the previous 3 years along with plans of correction. The facility also placed a prominent notice at the table stating that survey and advocacy information is available here. All residents who want this information have the potential to be affected. The facility created the policy: Facility Required Postings. The facility created the flier "Where to Find Survey Reports" and will distribute it to all patients and residents. The flier will also be added to the facility admission packet. Education will be provided to all employees about where survey information can be found. The resident council will also be given this information at the July meeting. During daily routine leadership rounds, each leader will interview at least one resident for awareness where to locate survey results, for at least the next 12 weeks. The executive director is responsible for compliance.

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 notice of transfer for a resident reviewed for hospitalizations, resulting in the potential for residents and/or their representatives to be uninformed of the reason for transfer and their rights. Resident #65, who had a moderately impaired cognition with a BIMS score of 12, was admitted on 1/17/2024 and had several discharges to the emergency room and a hospital admission. During an interview, the resident could not recall receiving a written transfer notice each time she went to the hospital. A review of the resident's chart revealed no evidence of written transfer notices being provided, which should have included specific information such as the reason for transfer, effective date, location, appeal rights, and contact information for relevant advocacy agencies. During interviews with facility staff, it was discovered that the paperwork sent with residents when they leave the facility did not include a transfer/discharge notice. A registered nurse was unaware of what the transfer/discharge notice was, and the Executive Director confirmed that they had not been sending out such notices with residents. This oversight indicates a failure to comply with regulatory requirements for notifying residents and their representatives about transfers or discharges, including their rights to appeal.

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 oxygen services per professional standards of practice by improperly storing CPAP masks for three residents, leading to potential respiratory infection risks. Resident #8, diagnosed with obstructive sleep apnea, was observed multiple times with his CPAP mask laying uncovered on top of the CPAP machine on his nightstand. Despite being cognitively intact and able to remove the mask himself, Resident #8 reported that staff assisted with storing the mask, which was not done according to infection control practices. Resident #13, with diagnoses including dysphagia and hypoxemia, also had her CPAP mask improperly stored. Observations revealed the mask laying uncovered on top of the CPAP machine or on a plastic bag inside the nightstand drawer. Although Resident #13 could remove the mask herself, she relied on staff for proper storage, which was not consistently done. She confirmed that staff had been in to take care of the mask, yet it was still found uncovered. Resident #59, diagnosed with Parkinson's disease and dementia, had similar issues with CPAP mask storage. His mask was found uncovered in the nightstand drawer or on top of the CPAP machine. Despite being able to remove the mask, Resident #59 required staff assistance to put it on. Interviews with staff, including an LPN, CNA, Unit Coordinator, Respiratory Therapist, and the DON, confirmed that CPAP masks should be stored in bags when not in use, which was not adhered to during the survey period.

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 proper communication and coordination with the dialysis provider for a resident requiring dialysis services. Specifically, there was no pre and post dialysis treatment assessment and monitoring communication between the facility and the dialysis provider. Additionally, the facility did not have an established agreement with the dialysis provider. This deficiency was identified for a resident with renal failure who was dependent on dialysis three times a week. The resident's medical record lacked documented communications from the facility to the dialysis center before dialysis and from the dialysis center to the facility after dialysis treatments. Interviews with facility staff, including the Executive Director, Licensed Practical Nurse, Unit Coordinator, Unit Clerk, and Director of Nursing, revealed that there was no regular communication with the dialysis center unless there was an abnormality. The facility staff also confirmed that there was no contract or agreement with any dialysis provider, and the post dialysis treatment information uploaded to an electronic record program was not consistently reviewed by the facility staff. This lack of communication and formal agreement resulted in the potential for unrecognized adverse reactions and disruptions in the continuity of care for the resident receiving dialysis treatments.