The Laurels Of Sandy Creek

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 maintain the roof and interior ceilings in a safe, functional, and sanitary condition, resulting in widespread leaks and water damage throughout resident care areas. Observations on multiple halls revealed discolored, brown, and black ceiling tiles, sagging tiles, bubbling and chipping wall surfaces, rusted light fixtures, and makeshift systems such as plastic tarps funneling water into buckets at the nurses’ station. The East wing medication room and spa areas showed signs of heavy moisture damage, and numerous ceiling tiles in various halls were dried out and stained, indicating ongoing and repeated water intrusion. One cognitively intact resident had lived in a room with a large orange ceiling stain near a light fixture, measuring approximately 17 by 22 inches, with raised areas suggesting buildup or deterioration. This resident reported that the ceiling had been leaking for over a year, causing the light fixture to stop working and requiring him to move his bed and eventually be transferred to another room. Facility records confirmed that he was moved from that room due to roof leaks, and resident council minutes documented resident concerns about leaks in rooms. Another resident, with chronic pain, depression, and moderate cognitive impairment, experienced a fall in his room after slipping on water that had leaked from the roof onto the floor. An incident report and staff interviews described the resident being found on the floor near his bed with water present on the floor, and the resident himself reported that the roof had been leaking into his room for quite some time. Multiple staff members, including CNAs and the former DON, reported that the roof had been leaking for months to over a year, that residents and their belongings were getting wet, that residents were frequently moved from leaking rooms, and that leaks extended into shower rooms where residents were being dripped on during showers.

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 protect residents from verbal and physical abuse by nursing staff. One cognitively intact resident with a BIMS score of 13 reported that a night-shift RN told him he did not need oxygen, said “f*** you, I hate you,” and gave him the middle finger during a late-night interaction. The resident stated this was the first time the RN had used that specific profanity toward him, but that the RN had previously told him he did not like him. The resident’s roommate, who also had a BIMS score of 13, corroborated hearing the RN and the resident arguing and hearing the RN use a curse word and say “I hate you.” Facility documentation, including the facility-reported incident and complaint forms, identified this as an allegation of verbal abuse by the RN, and the facility concluded that verbal abuse had occurred based on the resident’s report and the roommate’s confirmation. A second deficiency involved physical and verbal abuse of another resident by an LPN. This resident had chronic pain, anxiety, dementia, and a BIMS score of 9, indicating moderate cognitive impairment, and was care planned for impaired communication and potential verbal aggression related to dementia, depression, and poor impulse control. On the evening in question, the resident was pacing the hallway as was her usual pattern. According to the LPN involved, she approached the resident at another nurse’s medication cart, asked the resident to give the other nurse space, and then, after the resident turned and began swinging at her, she got behind the resident and guided her to her room with her hands around the resident’s arms. The LPN stated the resident went into her room, continued pacing, and voiced intent to leave, and that she did not yell but had a loud voice. Multiple staff witnesses provided a different account of the same event, describing escalating verbal and physical actions by the LPN toward the resident. A former CNA reported that the LPN had been rude to the resident earlier, then told the resident she was bothering the other nurse and needed to go to her room. When the resident refused, the LPN escalated, grabbed both of the resident’s wrists, forced her arms together behind her back, and held them up in a way that appeared painful while walking her down the hall. The CNA stated the resident repeatedly yelled “ouch, that hurts” and “get off of me,” and that the LPN “bashed” the resident into a utility closet door and then into the entrance area of the resident’s room before entering the room and slamming the door. The CNA reported hearing further “bashing” noises and the resident screaming “Stop, I can’t breathe,” and later observed the resident visibly shaken, crying, with disheveled hair, and reporting that the LPN had choked her and thrown her to the ground. Another LPN witness stated that the resident had been calmly standing and chatting at her med cart, which helped the resident’s anxiety, and that the resident was not being disruptive when the involved LPN approached and told the resident the nurse did not want her bothering her. According to this witness, the resident laughed, which appeared to escalate the LPN, who then loudly insisted the resident go to her room. When the resident refused and attempted to strike the LPN, the LPN grabbed the resident’s arms, “whipped” them behind her back, and walked her toward her room while the resident yelled that she was being hurt and tried to break free. This witness also described the LPN picking up the resident and slamming her into the utility closet door, then taking her toward her room, after which loud bashing noises and the resident’s yelling were heard from the room. Both this LPN and the CNA reported seeing the LPN slam the resident’s door on her twice as the resident tried to exit, while yelling at her to stay in her room, and hearing the LPN say she would “fight” the resident. Additional corroboration came from the receptionist, who encountered the resident shortly after the incident. The receptionist described the resident speed walking, crying, and saying she had just gotten into a fight. When the receptionist attempted to escort the resident back toward her room, the resident became more distressed and said she did not want to go down that hallway because she did not want another fight. The receptionist observed the resident’s hair was messed up and that she appeared very shaken, and reported that the resident said the LPN had grabbed her by the shirt and thrown her down. The administrator later confirmed that, based on witness interviews, she substantiated that the LPN had verbally and physically abused the resident. Together, these events demonstrate that the facility failed to ensure residents were free from verbal and physical abuse by staff, as required by its abuse policy and resident rights. The facility’s own investigation documents characterized the LPN’s conduct as verbal and physical abuse and noted that the LPN did not use de-escalation skills and that her frustration intensified the situation. The resident involved had known behavioral and communication needs, including dementia and a history of pacing and anxiety, and the care plan called for specific communication and de-escalation strategies such as not rushing, using simple cues, and providing verbal and physical cues to alleviate anxiety. Despite these identified needs and interventions, the LPN’s actions, as described by multiple witnesses and the resident, involved forceful physical handling, painful arm positioning, slamming into doors, door slamming to confine the resident, and threatening statements, all of which constituted abuse and a failure to follow the resident’s care plan and the facility’s abuse policy. In both cases, the residents and witnesses were considered by the administrator and social worker to be reliable historians without a known history of making false allegations. The facility’s own documentation and interviews with leadership acknowledged that verbal abuse occurred in the first case and that verbal and physical abuse occurred in the second case. These findings establish that the facility did not protect residents from all types of abuse by staff, including verbal and physical abuse, as required by regulation and by the facility’s own abuse policy, resulting in residents being subjected to abusive language and physically abusive handling by nursing staff.

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 follow policies and state law requiring timely reporting of staff-to-resident abuse to the appropriate state licensing authority. Resident #104, who had chronic pain, anxiety, and dementia, was involved in an incident where an LPN (LPN CC) engaged in conduct that the facility later substantiated as verbal and physical abuse. According to the facility-reported incident investigation, the resident was agitated and pacing when LPN CC instructed the resident to go to her room and stay there. The resident refused, approached the LPN, and attempted to strike her. LPN CC then placed the resident’s arms behind her back, physically assisted the resident to her room, and closed the door, during which the resident stated, “stop that hurts.” The facility’s in-depth analysis documented that the LPN did not use de-escalation skills and that her frustration intensified the situation, resulting in verbal and physical abuse. The investigation summary did not document that the facility reported LPN CC to the State Bureau of Professional Licensing, despite the substantiated abuse and the disciplinary action taken against the nurse. During interviews, the Nursing Home Administrator confirmed that she had substantiated the verbal and physical abuse and that the LPN’s employment had been terminated. When asked whether the termination and abuse had been reported to the State Bureau of Professional Licensing, the administrator initially could not recall and later confirmed that no report had been made. She stated that she had completed the reporting form but forgot to fax it, and the report was missed. This failure to report occurred despite state law (Michigan Public Health Code MCL 333.20175) requiring health facilities to report specified disciplinary actions and employment changes related to licensed health professionals within 30 days.

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 implement care plan interventions and physician-ordered wound care for a resident with significant skin integrity issues. The resident had chronic pain, a history of cerebral infarction with expressive aphasia, left hemiplegia, obesity, bowel incontinence, diarrhea, and moderate protein-calorie malnutrition, and was identified as having actual impairment to skin integrity. The care plan and orders included daily wound care to the right elbow, right plantar foot, and heel, as well as continuous use of a soft pillow boot on the right elbow and pressure-reducing boots to both lower extremities, along with turning and repositioning every two hours and as needed. Despite these orders and care plan interventions, surveyor observations on the same day showed the resident lying on her back in bed without the ordered pressure-reducing boots, which were instead found in a chair, and her feet resting directly on the bed without any offloading devices. Further observation during wound care revealed that when the RN removed the soft pillow from the resident’s right arm, the right elbow wound was open to air with no dressing in place, and no dislodged dressing could be found in the bed or on the floor. Interviews with staff confirmed that the resident was supposed to wear the pressure-reducing devices on the right arm and both feet at all times and that the resident tolerated these devices well. The wound care NP stated that the resident was at high risk for worsening skin breakdown and that adherence to pressure-reducing interventions was crucial. An LPN reported that CNAs were not consistently communicating when dressings became soiled or dislodged and were removed, resulting in nurses not being notified to reapply dressings. These observations and interviews demonstrate that the facility did not consistently implement the resident’s care plan interventions and wound care orders as written.

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 provide adequate care and monitoring for a resident receiving enteral nutrition. The resident had a history of dysphagia following a cerebral infarction and moderate protein-calorie malnutrition, and was dependent on tube feeding and water flushes. Physician orders and the care plan required Jevity 1.5 at 80 mL/hr at bedtime and elevation of the head of bed to at least 30 degrees during feeding. On multiple observations, the resident was found lying flat or with the head of bed not elevated to 30 degrees while the tube feeding was running. During one observation, the assigned LPN acknowledged that the resident was “way too flat” and raised the head of bed to 45 degrees but did not further assess the resident. The facility also failed to ensure proper handling and labeling of enteral feeding formula. Surveyors observed two opened bottles of Jevity on the resident’s tray table, one dated from the previous day and one not dated, both partially full. The running formula bag was not labeled or dated to indicate when the formula was opened or when the feeding was started, and this lack of labeling persisted across several observations on consecutive days. The LPN caring for the resident stated that the open Jevity containers should have been discarded and that nurses were supposed to date enteral feeding formulas with the date and time when opened to ensure the formula was safe and not spoiled. These practices were inconsistent with the facility’s enteral feeding policy, which required residents to be in semi-Fowler’s position (30–45 degrees) during administration and for 30 minutes to one hour after to prevent aspiration.

Penalty

Inspection fine: $14,020

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, identified as being at risk for elopement due to a history of attempts to leave the facility unattended, impaired safety awareness, severe depression with psychotic symptoms, and anxiety, was able to exit the facility without staff knowledge. The resident had a Wanderguard device in place and was care planned for elopement risk, including interventions such as placement and function checks of the Wanderguard, redirection, and 1:1 observation as of the date of the incident. Despite these interventions, the resident was able to leave the facility in a wheelchair and was found approximately 50 yards away on a sidewalk near a road by an off-duty staff member. Staff interviews and record reviews revealed that on the morning of the incident, multiple staff members heard the exit door alarm sounding several times but did not respond appropriately. One CNA deactivated the alarm without fully investigating the cause or ensuring all residents were accounted for, and did not call a code search when the resident's whereabouts were unknown. The DON also deactivated the alarm and returned to her office without first checking outside the building for a missing resident. The alarm system was observed to function properly, sounding when a Wanderguard was near the door, regardless of whether the door code was entered. However, staff failed to follow protocol for responding to exit alarms and did not ensure the safety of residents at risk for elopement. Documentation also showed that the resident's elopement risk assessments were not accurately completed prior to the incident, as they did not reflect the resident's ongoing verbalizations and behaviors indicating a desire to leave. Staff interviews confirmed that the resident had been expressing anger and a desire to leave the facility, but these were not properly documented in the risk assessments. The combination of inaccurate assessments, failure to respond appropriately to exit alarms, and lack of immediate action to locate the resident resulted in the resident eloping from the facility without staff knowledge.

Removal Plan

• DON and nurse assessed Resident #101 in the parking lot and returned him to the facility.
• Resident #101's responsible party was notified.
• Resident #101 was placed in dining room under supervision for breakfast and then on 15-minute checks, escalating to 1:1 supervision after further elopement attempt, until transfer to psychiatric facility.
• Resident #101's elopement risk assessment was updated, and his care plan and orders were reviewed.
• Resident #101's Wanderguard was tested for function and placement upon return to building.
• Elopement books were updated and placed at the front desk and each nurse's station.
• Housekeeping Supervisor and Maintenance Director inspected all emergency exits and completed a Wanderguard test on doors.
• Secure Care was notified to validate door function; maintenance reviewed main door for proper alarm function.
• Secure Care validated and cleared system functions.
• All residents were assessed for risk of elopement; residents determined at risk had care plans reviewed for completeness.
• Maintenance Director or Housekeeping Supervisor/designee checks and logs all exit doors for proper function; Administrator reviews logs.
• DON/designee provided education to staff regarding Elopement policy, including immediate response to door alarms, exiting building for full view, use of light source, and calling code search if no one is observed.
• Staff were educated; remainder received 1:1 education or were educated upon arrival to work before assignment.
• Ongoing staff education on Elopement Policy and procedure, including residents at risk for exit seeking and Wanderguard use.
• Missing Guest Book/Residents with Wanderguards is updated minimally weekly and with any changes by the Interdisciplinary team.
• DON/Designee reviewed all residents at risk for exit seeking and Wanderguards for elopement risk; ongoing assessment upon admission, quarterly, and with change of condition.
• Administrator reviewed the investigation performed by DON and interviewed all staff from relevant shifts.
• Administrator and QAPI committee reviewed the missing guest policy and deemed it appropriate.
• Administrator audited the elopement books for accuracy and currency.
• New employee orientation includes Elopement policy and procedure education.
• Maintenance Director/Designee checks alarmed doors as part of Preventative Maintenance; findings submitted to QAPI committee; Administrator reviews logs.
• Code search drills were held on all shifts; ongoing process of code search drills.
• Medical Director was made aware of the elopement.
• Incident reviewed in ad hoc and monthly QAPI meetings; root cause analysis performed; decision to add light source to reception desk for search.
• Continued education on elopement policy and response to alarms, complete visualization, and calling code search; drills to ensure proper response and reduce alarm fatigue.
• All staff completed education prior to next shift worked.

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 maintain professional standards for food service safety, as evidenced by multiple observations of unclean kitchen equipment and improper food handling. During a kitchen tour, clean utensil bins were found to contain utensils with dried food debris, and clean pots and pans had stuck-on food and faded date stickers that should have been removed during washing. Large sheet pans stored under a preparation table were observed with encrusted grease, and the Dietary Manager acknowledged that staff often rely solely on the dish machine rather than scrubbing by hand. Additionally, the seal gasket on a refrigeration unit was not properly attached, compromising its ability to maintain a good seal. Improper storage and handling of ice and ice scoops were also noted. An ice chest used for water pass was found full of ice with no drainage for melted water, and ice scoops in two pantries were stored right side up in their holders, contrary to best practices for air drying and contamination prevention. The facility did not regularly log cooling for food saved from service, and sausage patties from breakfast were left in a tightly covered container on a preparation table before being moved to a cooler, where their temperature was found to be 88°F, indicating improper cooling procedures. Further deficiencies included a kitchen chemical closet with a four-way splitter on the faucet, causing constant back pressure on the internal vacuum breaker, and two spray bottles of quaternary ammonium sanitizer in the dish machine area with concentrations around 500 ppm. These findings demonstrate a lack of adherence to FDA Food Code requirements for equipment cleanliness, food cooling, utensil storage, plumbing maintenance, and chemical sanitizer use.

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

Nursing staff failed to administer medication in accordance with physician orders for a resident with hypertension. The resident had a physician order for Lotrel, an antihypertensive medication, to be held if the systolic blood pressure (SBP) was less than 110 or heart rate was less than 60. Despite this, review of the Medication Administration Record showed that Lotrel was administered on multiple occasions when the resident's SBP was below the ordered threshold. Documentation indicated that an LPN was responsible for administering the medication on most of these occasions. A pharmacy consultation report identified the issue and recommended that staff be reminded of the importance of adhering to medication administration parameters. However, the DON, who signed the pharmacy recommendation, reported not recalling the recommendation and confirmed that no follow-up education or action was taken to ensure staff compliance with the ordered parameters. The facility's own policy requires medications to be administered according to physician orders, but this was not followed in this case.

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 consistently honor residents' food and drink preferences, allergies, and intolerances as documented on their meal tickets and care plans. Multiple residents were observed being served food items they had specifically indicated as dislikes, such as sausage, eggs, black pepper, carrots, zucchini, and lima beans, despite these preferences being clearly listed. Residents expressed frustration, sadness, and anger over receiving unwanted food and drink items, and some reported that this was a common occurrence. In several cases, residents left the unwanted food uneaten, and one resident noted that she did not receive the correct number of coffee creamers as requested. In addition to disregarding preferences, the facility also failed to prevent exposure to known food allergens. One resident with documented allergies to cucumbers and pickles was served potato salad containing pickles, which resulted in him experiencing mouth itching and requiring antihistamine and anti-nausea medication. The resident expressed ongoing fear and vigilance regarding his meals due to this incident. Review of his records showed that his allergies were documented in multiple places, including his meal ticket and medical record, but this information was not effectively communicated to or recognized by all staff involved in meal delivery. Interviews with dietary staff and CNAs revealed a lack of awareness and adherence to residents' documented food preferences and allergies. The dietary manager confirmed that food items were available to meet residents' preferences but were not provided as required. Staff also failed to cross-reference ingredient lists with residents' allergies, leading to the serving of allergenic foods. The facility's own policy required that food preferences be identified and honored on tray tickets, but this was not consistently implemented.

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

A resident with a history of stroke and impaired use of her dominant right arm was repeatedly not provided with the adaptive dining equipment specified in her care plan and physician's orders. Despite clear documentation on her meal tickets and in her care plan indicating the need for built up utensils, she was served regular silverware at multiple meals. Observations showed the resident struggling to handle standard utensils, resulting in awkward and insecure grips, slow eating, and multiple attempts to pick up food. The resident herself reported difficulty using regular utensils and stated that built up utensils would make eating easier. Interviews with staff, including the Dietary Manager, confirmed that the resident was supposed to receive built up utensils with all meals as ordered. The facility's policy also required culinary staff to provide adaptive equipment for residents who would benefit from their use. Despite these requirements, the resident was not provided with the necessary adaptive utensils during the observed meals, leading to ongoing difficulty with eating.

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 maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During multiple tours of common areas, including the East Day room, East Hall Spa, and various shower rooms, surveyors observed accumulations of food crumbs, paper trash, and debris under and around seat cushions, as well as on furniture. In spa and shower areas, dried bowel movement was found on commodes, and there was an accumulation of dirt and debris behind toilets. Clean linens such as wash cloths and towels were improperly stored on shower chairs and paper towel holders, rather than in designated cabinets, and personal hygiene products were stored alongside cleaning disinfectants. Staff interviews confirmed that these practices were not in accordance with facility protocols, as these areas and items should be cleaned and stored properly to maintain sanitation. Additionally, during a facility-wide inspection, several exit doors were found to have gaps and spaces between the doors, frames, and weatherstripping, allowing visible light, air, and potential pest entry. These deficiencies were observed at multiple exit points, including hall doors and the dining room exit. The combination of unsanitary conditions, improper storage of linens and hygiene products, and compromised building integrity contributed to an environment that was not safe, sanitary, or comfortable for residents, staff, or visitors.

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

A resident was observed alone in her room with eight pills in a disposable medication cup placed next to her meal tray. The medications had been provided by an LPN prior to breakfast, but the resident had not yet taken them, and no staff were present in the room or nearby. The LPN later confirmed she had given the medications to the resident and was unaware they had been left unattended. Upon discovering the situation, the LPN removed the medication cup containing buspirone, duloxetine, ferrous gluconate, furosemide, lisinopril, metformin, metoprolol, and Tylenol from the resident's room. Review of the resident's record revealed that no medication self-administration assessment had been completed, and there was no physician order authorizing self-administration. The facility's policy requires a self-administration evaluation and physician authorization before a resident is permitted to self-administer medications. The resident was cognitively intact according to a recent mental status score, but the required assessment and documentation were not in place, resulting in the resident being left alone with medications contrary to facility policy.

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

A deficiency occurred when a resident with a documented Do Not Resuscitate (DNR) order received cardiopulmonary resuscitation (CPR) from facility staff. The resident had a clearly documented DNR order, signed by both the resident and the attending physician, indicating that no resuscitation should be attempted in the event of cardiac or respiratory arrest. On the day of the incident, the resident became unresponsive and staff could not detect a pulse after a transfer using a hoyer lift. A Licensed Practical Nurse (LPN) responded to calls for help and, unable to immediately confirm the resident's code status, initiated CPR. The LPN reported that she began compressions because staff were unable to quickly provide the resident's code status, and she acted as she would in a situation where code status was unknown. Approximately 45 seconds of compressions were performed before other staff confirmed the DNR status, at which point CPR was stopped. The resident subsequently regained a pulse and began breathing again. Interviews with staff revealed that the process for verifying code status was not efficient, as the information was only available in the computer and not readily accessible during emergencies. The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that CPR was performed on a resident with a DNR order and that no incident report or immediate follow-up education was completed after the event. The facility's policy required staff to validate code status before initiating CPR, but this was not followed due to delays in accessing the information.

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 received an accurate clinical assessment reflective of their actual status at the time of assessment. Specifically, the Minimum Data Set (MDS) assessments for the resident on two separate occasions documented an active medical diagnosis of schizophrenia. However, a review of the resident's electronic health record showed no diagnosis of schizophrenia, no documented behaviors, and no treatment orders related to schizophrenia. The resident's PASARR evaluation also indicated no mental illness, and behavioral care notes described diagnoses of major depressive disorder and dementia without behavioral or psychotic disturbances. Interviews with facility staff confirmed that the resident did not have any orders for psychotropic medications and did not exhibit behaviors indicative of schizophrenia. The MDS-Registered Nurse acknowledged that the schizophrenia diagnosis was entered in error on multiple MDS assessments. This inaccurate documentation resulted in the resident's clinical status being misrepresented in official records.

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

Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with an abdominal feeding tube and moderate cognitive impairment. During high-contact care activities, including transferring the resident from a wheelchair to bed, assisting with positioning, and checking the resident's incontinence brief, two Certified Nursing Assistants (CNAs) wore gloves but did not wear gowns as required by the facility's EBP policy. Signage on the resident's door clearly indicated that both gloves and gowns were required for high-contact care activities such as transferring and changing briefs. The CNAs involved acknowledged that they had received training on EBP but one CNA admitted to forgetting the resident was on these precautions and sometimes not noticing the posted signage. The Director of Nursing/Infection Preventionist confirmed that the resident was on EBP and that staff were required to wear both gowns and gloves during high-contact care. Review of the facility's policy and physician orders confirmed the requirement for EBP, including the use of gowns and gloves for specified care activities.

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 employ a full-time Registered Dietitian or a Certified Dietary Manager to oversee kitchen and clinical nutritional services. During a kitchen tour, it was observed that the current Dietary Manager had not yet completed the Certified Dietary Manager certification, despite being in the position for over a year. The Dietary Manager believed he was allowed the full duration of the certification course, which is 18 months, rather than the one year permitted upon hire. Additionally, the dietitian only visits the facility two days a week, and a review of staff records confirmed there was no full-time Certified Dietary Manager or full-time Dietitian on staff.

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 staff members possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly in the case of a resident with complex medical and psychological conditions. This resident, a female with diagnoses including spina bifida, chiari syndrome, anxiety, depression, and mood disorders, experienced inappropriate interactions with staff. An incident was reported where an LPN used inappropriate language towards the resident, telling her to "get your ass in your room," which was witnessed by other staff members. The resident expressed dislike for the LPN and another CNA, indicating a strained relationship. Further investigation revealed that the staff lacked training specific to handling residents with severe behavioral and mental health concerns. Interviews with various staff members, including CNAs and LPNs, highlighted a gap in training for dealing with residents who have mental health issues beyond dementia and Alzheimer's. The staff reported feeling unequipped to manage the resident's behaviors, and there was a lack of documented interventions in the resident's care plan to address such situations. The facility's social worker, who was temporarily filling in, also noted that staff did not have a deep understanding of the residents' triggers and effective interventions. The Director of Nursing acknowledged that the staff did not implement person-centered behavioral interventions as outlined in the care plan. The care plan suggested moving the resident to a quiet place to calm down, but the staff's actions of forcing the resident into her room were not part of the care plan. The facility's administrator recognized the challenges faced by the staff in dealing with a younger population with mental health concerns and noted that previous incidents might have influenced staff responses. Despite some training efforts, the facility's staff were not adequately prepared to handle the specific behavioral health needs of the resident, leading to unmet care needs and inappropriate staff-resident interactions.

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 prevent involuntary seclusion of a resident, identified as Resident #102, who has a complex medical history including spina bifida, chiari syndrome, anxiety, depression, and other conditions. The resident's care plan highlighted past trauma and specific triggers, such as being alone with males and loud noises, which could lead to increased anxiety and agitation. Despite these known triggers, the staff did not effectively manage the resident's behavior, leading to an incident where the resident became agitated and was involved in a physical altercation with staff. On the day of the incident, Resident #102 became frustrated with another resident and a visitor, leading to a situation where staff attempted to escort her to her room. The resident resisted, resulting in a physical struggle where she scratched and attempted to bite staff members. The staff involved did not attempt to redirect the resident or implement other interventions from her care plan, and instead focused on physically moving her to her room, which escalated the situation. Interviews with staff revealed a lack of training specific to handling residents with severe behavioral and mental health issues, contributing to the inadequate response. The facility's training on abuse and neglect was found to be insufficient, with a significant number of staff not having completed the required education. Additionally, staff reported not receiving training on handling mental health crises or performing physical restraints, which are not used by the facility. The lack of appropriate training and intervention strategies for dealing with residents with complex behavioral needs was a significant factor in the failure to prevent the involuntary seclusion of Resident #102.

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 maintain an effective infection control surveillance plan, as evidenced by the lack of accurate and timely data collection and interpretation for residents with infections. The Infection Preventionist (IP) reported using a computer-based program for infection control surveillance but was unable to provide a current list of residents on antibiotics or confirm their inclusion in the program. The IP acknowledged that there were eight residents with infections but had not yet collected all necessary information. The infection control report was found to be inaccurate, as it did not reflect the current status of several residents, including those who were still receiving antibiotic treatment. Specific deficiencies were noted in the cases of four residents. One resident's antibiotic treatment was inaccurately reported as completed, while another resident's ongoing treatment was not included in the report. Additionally, two residents with infections were omitted from the surveillance report entirely. The Director of Nursing (DON) confirmed that infections and antibiotics are discussed daily in morning meetings and should have been accurately reflected in the infection control report. The Nursing Home Administrator was informed of the ongoing non-compliance, which precluded acceptance of past compliance efforts.

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 follow professional standards of practice for medication administration and documentation for six residents. During an observation, a Registered Nurse (RN) was seen administering medications to two residents simultaneously without confirming their identities or the medications. The medication cups were not labeled, and the RN did not follow the proper procedure for documenting medication administration. Additionally, the RN documented medications for three residents that were either refused, already administered, or given by another nurse, which is against the facility's policy. Further observations revealed that the RN did not compare medications with physician orders or check off medications as they were pulled from the cart. The RN admitted to not knowing the facility's policy on medication documentation and did not see an issue with administering medications to two residents at the same time. The Director of Nursing (DON) confirmed that the facility's procedure requires nurses to verify medications with orders, identify residents before administration, and document immediately after administration. The DON also stated that preparing medications for multiple residents simultaneously is not allowed and poses a risk of medication errors.

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 an environment that promoted resident dignity for a resident with a history of breast cancer and reconstructive surgery. The resident reported feeling self-conscious about the difference in the size of her breasts and expressed a preference for wearing a bra to make them appear more equal. However, the resident's bras had been going missing, and although the facility replaced them, the process took time, leaving the resident without a bra on multiple occasions. This situation caused the resident to feel humiliated and embarrassed, impacting her sense of dignity and self-worth. Interviews with staff revealed that the facility's laundry department had been experiencing staffing issues, leading to delays and problems in returning residents' personal items, including the resident's bras. The Certified Nursing Assistant (CNA) and Housekeeping Manager (HKM) both acknowledged the challenges in managing the laundry due to recent staff turnover and the need to label new residents' clothing promptly. Observations of the laundry area confirmed that there were significant amounts of personal laundry in various stages of processing, further indicating the backlog and inefficiencies in the system. The Director of Nursing (DON) confirmed that the laundry department had been understaffed due to retirements and resignations, which contributed to the delays in returning personal items to residents. The DON also noted that the nursing staff had not addressed the resident's concern on the day it occurred, and she was unaware of the situation until it was reported to her. This lack of timely response and communication further exacerbated the resident's distress and feelings of indignity.