Benedictine Health Center Innsbruck

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 a dignified dining experience for 1 resident with severely impaired cognition and diagnoses of dementia and encephalopathy. The resident’s quarterly MDS indicated he required substantial assistance with dressing. During observation, the resident was sitting in the dining room at a table with 3 other residents wearing only a shirt and hip protectors, which staff described as nude-colored compression shorts with padding on the hips and meant to be worn under clothing. During the observation, a TMA confirmed the resident was in the dining room wearing only hip protectors and stated residents do not normally sit in the dining room just wearing them because they are meant to be worn under clothes. The TMA did not cover the resident with a blanket or take him back to his room for pants. A social services staff member later placed a blanket over the resident’s lap after noting he was only wearing the hip protector. Multiple staff members, including NAs, an LPN, an RN, and the DON, stated hip protectors are meant to be worn under clothing and should not be worn in common areas or the dining room without clothing over them.

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 a resident’s wishes for resuscitation were accurately documented throughout the medical record for one resident reviewed for inconsistent advance directives. The resident had severe cognitive impairment, required substantial to maximal assistance with most ADLs, and was receiving hospice care. Her diagnoses included dementia, adult failure to thrive, and encounter for palliative care. Multiple clinical assessments, care plan entries, admission documents, and an active provider order identified the resident’s advance care planning as DNR, and the order history showed DNR/DNI with a reference to a POLST signed by a provider and family member. Despite those entries, the POLST scanned into the EHR and found in the hard chart and hospice binder indicated Attempt Resuscitation/CPR and Full Treatment with intubation, advanced airway interventions, and mechanical ventilation. The resident’s provider note stated the POLST was reviewed with the patient and spouse and that they wanted her to be full code. However, the resident’s health care directive stated that if she were terminal and unable to express her wishes, she wanted to be allowed to die naturally and not be kept alive by artificial means or heroic measures. Staff interviews showed that LPN, RN, RN-C, HUC, hospice nurse, and DON all located DNR in parts of the record, but none could explain why the POLST in the chart did not match the DNR documentation elsewhere. The original POLST in the hard chart was signed as full code but had a red diagonal line and the word VOID written on it, and RN-B could not explain when it had been voided. RN-C found a copy of the same POLST in the hospice binder that did not show it was voided, and HUC stated the resident had returned from the hospital multiple times and was admitted from the hospital as DNR each time. The DON stated the POLST should match the EHR documentation and that the provider was responsible for ensuring the POLST was complete and accurate, noting that hospice should have reviewed and updated it upon admission and that the uploaded POLST should have been voided and replaced if needed.

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 implement interventions for one resident who required alternate means of communication due to English as a second language. The resident’s quarterly MDS indicated severe cognitive impairment, aphasia, dementia, hemiplegia and hemiparesis following a CVA affecting the right dominant side, reduced mobility, minimal hearing difficulty, and Vietnamese as the resident’s language. The care plan dated 3/11/26 noted behavioral symptoms including placing self on the floor and non-compliance with medication administration related to possible cognitive deficits, and stated the resident preferred to speak English unless otherwise noted and was dependent on staff for emotional, intellectual, physical, and social needs. During interview, the resident stated that when he asked staff for something, it was not received, and that when he tried to speak English to receive pain medication, he did not receive any. He reported he had no additional ways to communicate with staff, no picture communication board, no pain pictures to point at, and that staff did not obtain an interpreter. A family member stated communication was a problem, the facility had not offered an interpreter even for care conferences, and the resident’s communication needs were not met. Observation in the dining room showed the resident gesturing for something, staff brought a roll, and the resident indicated that was not what he wanted. Staff interviews confirmed interpreter services were expected but were not being used for this resident, and one RN stated the resident received care by asking and no other communication assistance was used.

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 facial hair was removed for one resident who required assistance with hygiene and was reviewed for ADL care. The resident had severe cognitive impairment, a history of cerebral infarction with aphasia and left-sided hemiplegia/hemiparesis, and the MDS indicated maximal assistance was needed for upper and lower body care and total dependence on staff for personal hygiene. The care plan, revised on 2/5/26, identified ADL self-care deficits related to the stroke and directed staff to provide maximal assistance with dressing, bathing, and personal hygiene, including daily shaving of the resident’s facial hair. The resident had a personal electric shaver available, and the medical record did not show any refusal to be shaved. During interviews and observations, the resident’s family member stated the resident needed assistance with all cares and wanted to be shaved daily. On one observation, the resident nodded yes when asked if he wanted to be shaved and was shaved. On later observations, the resident had multiple white facial whiskers about 1/8 inch long, then a full face of white whiskers about 1/4 inch long, and indicated he did not like having whiskers and wanted to be clean shaven. A NA stated she had not provided morning care, confirmed the facial hair looked long, and acknowledged the care plan required daily shaving. The DON and RN stated staff were expected to follow the care plan, document refusals, and assist residents with grooming tasks such as shaving when they were unable to do so independently.

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 coordination of care through ongoing communication with hospice services for a resident receiving hospice care when the resident’s code status documentation was inconsistent and not resolved in a timely manner. The resident had severe cognitive impairment, required substantial to maximal assistance with most ADLs, and had diagnoses including dementia, adult failure to thrive, and encounter for palliative care. The resident’s care plan stated that the code status would be honored and that hospice services and end-of-life wishes would be coordinated with hospice providers. The resident’s records contained conflicting code status information. Multiple clinical documentation assessments, admission documents, and an active provider order identified the resident as DNR, and the order history showed DNR/DNI with no evidence that Full Code or CPR had ever been ordered. However, a POLST scanned into the EHR and kept in the hard chart and hospice binder indicated Attempt Resuscitation/CPR and Full Treatment. A provider note stated the POLST was reviewed with the patient and spouse and that they wanted the resident to be full code, while the resident’s health care directive stated a wish to die naturally and not be kept alive by artificial means or heroic measures. During interviews, facility staff located DNR in the EMAR, resident header, orders, and face sheet, but could not explain why the POLST in the chart and hospice binder did not match the documented DNR status. Hospice staff stated the discrepancy had been identified earlier and that the hospice social worker had been trying to reconcile it with the family for months, but the resident’s son had not responded. The DON stated the POLST should match the EHR documentation and that hospice, as the provider, should have reviewed and updated the POLST upon hospice admission, but the discrepancy remained unresolved when surveyors identified it.

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 up on a resident’s broken eyeglasses and did not document what was being done about them. The resident’s quarterly MDS indicated severely impaired cognition, dementia, Type II diabetes, Parkinson’s disease, and dependence on staff for most ADLs. An eye consult dated 6/3/25 stated the resident should continue with the same eyeglasses and be encouraged to use them full time for distance and reading, but the medical record lacked documentation about the glasses being broken or any action taken regarding them. During observation and interview, the resident was sitting in his wheelchair in his room, stated he had turned in his glasses because they were broken, and said he still had not gotten them back. He was not wearing glasses, and they were not in his room. A nursing assistant stated the resident had glasses that broke about a month earlier and that she told the supervisor. The RN verified the glasses were broken and said social services was aware because the nursing assistant had given the broken glasses to them. Social services stated awareness of the broken glasses but did not provide documentation or additional information regarding when the issue occurred or whether replacement glasses had been ordered.

Penalty

No penalty information released

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

Summary

The facility failed to ensure fall interventions were in place for a resident with severe cognitive impairment, dementia, and a history of right leg fracture who required substantial to maximal assistance with most ADLs and mobility. The resident’s quarterly MDS indicated two or more falls without injury and one fall with injury since admission, and the care plan identified the resident as at risk for falls with interventions including hip protectors at all times, a floor mat beside the bed, and the call light in reach when in the room. During observation, the resident was asleep in bed with the bed in a low position, but the floor mat was folded and stored in the corner of the room instead of beside the bed, and the call light was on the floor and not in reach. Nursing staff confirmed the resident was supposed to wear hip protectors at all times but sometimes refused them, and staff observed that the resident did not have the hip protectors on, the mat was not on the floor by the bed, and the call light was not in reach. Staff interviews further stated that if the resident refused the hip protectors, the other interventions, including the mat next to the bed, were especially important, and refusals to wear the hip protectors should be documented.

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

Provide safe and appropriate respiratory care for a resident when needed. The facility failed to ensure oxygen therapy was administered and maintained according to physician orders for 2 residents reviewed for respiratory therapy. R49 had diagnoses including acute respiratory failure with hypoxia, shortness of breath, and congestive heart failure. Her physician ordered continuous oxygen wean as able via nasal cannula to keep oxygen saturation at or above 90%, with oxygen flow at 2 LPM every shift. During multiple observations, R49 was found with her oxygen set at 3 LPM instead of the ordered 2 LPM, and RN-F verified the oxygen rate was incorrect and should have been set at 2 LPM per the physician's order. R9 had diagnoses including COPD and acute and chronic respiratory failure with hypoxia and was ordered oxygen therapy at 2 liters per minute via nasal cannula, with nebulization tubing, humidifier, and oxygen tubing to be changed every Sunday and as needed. During observations, R9's oxygen tubing was unlabeled and the humidifier was labeled 1/26/26. R9 stated staff were not good at changing the tubing or humidifier and often said they could not find any to replace them with. RN-A and RN-C stated the tubing and humidifier should be changed weekly and labeled, and RN-A stated not changing them timely could lead to respiratory infection. The DON stated oxygen therapy was expected to be maintained per provider orders and tubing/humidifier should be changed weekly.

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 medication orders were transcribed correctly for one resident who had been prescribed doxycycline for prurigo nodularis. The resident’s after-visit summary and progress note documented a new order for doxycycline 100 mg by mouth twice daily for 10 days with meals, and the physician’s orders also directed monitoring for adverse reactions to the antibiotic every shift. The resident’s MDS indicated intact cognition, and the care plan noted the resident was taking doxycycline for prurigo nodularis as ordered by the physician. The MAR showed the resident received doxycycline 100 mg twice daily through 4/15/26 and then once on 4/16/26, even though the medication should have been discontinued after 10 days. During interview, the resident stated she believed the antibiotic was only supposed to be taken for 10 days but was still receiving it. Staff interviews confirmed the order had been entered with a discontinuation date of 5/10/26 instead of 4/10/26, and staff described a process requiring one nurse or HUC to enter new orders and another nurse to verify them for accuracy. The DON stated the error occurred when staff entered the order and that the double-check process was intended to prevent mistakes like this.

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 a resident’s antibiotic was discontinued according to the physician’s order. R9 had intact cognition and a diagnosis of prurigo nodularis. After a 3/31/26 appointment, R9 returned with an order for doxycycline 100 mg by mouth twice daily for 10 days with meals, and the physician’s orders also directed staff to monitor for adverse reactions to the antibiotic every shift. However, the MAR showed doxycycline continued beyond the 10-day course, with administration documented through 4/15/26 and again on 4/16/26, even though the medication should have been discontinued on 4/10/26. R9 stated she believed the antibiotic was only for 10 days but was still receiving it. RN-C confirmed the order had been entered incorrectly with a discontinuation date of 5/10/26 instead of 4/10/26. The facility also failed to ensure anticoagulation monitoring was in place for R35, who had moderately impaired cognition and diagnoses of CHF and atrial fibrillation and was receiving warfarin on a routine basis. R35’s physician’s orders specified warfarin 2 mg on Monday, Tuesday, Wednesday, and Friday and 3 mg on Sunday, Thursday, and Saturday. The MAR and TAR lacked documentation of anticoagulation monitoring, and the care plan did not include anticoagulation monitoring. RN-F stated she could not find an order or documentation for anticoagulant monitoring, and RN-C stated residents receiving anticoagulants should have monitoring documented in the MAR or care plan. The DON stated the overnight nurse had accidentally discontinued the anticoagulation monitoring order after R35 returned from the hospital.

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 update and implement a comprehensive care plan addressing a resident's communication and language needs. Record review showed that the resident's face sheet identified Vietnamese as the resident's language, with diagnoses including intracranial hemorrhage, hemiplegia and hemiparesis, chronic kidney disease, hypertension, aphagia, and pain, and a social services assessment documented Vietnamese as the preferred language. Despite this, review of the resident's care plan on 2/3/25 showed no identification of, or interventions related to, the resident's language or communication needs, even though facility policy required assessment of communication needs and use of that assessment to develop and revise a person-centered care plan. During an interview, the resident immediately requested an interpreter, stating they could not understand the interviewer and felt the facility did not care for them. The resident reported not understanding what was happening with their care and not knowing how to communicate with staff, which they found very frustrating. A nursing assistant reported they typically communicated with the resident using broken English and hand gestures and confirmed there was nothing in the care plan about communication methods, stating such information would be useful. The DON acknowledged that while the resident could express needs, it was the resident's right to fully understand what was happening, and that communication needs should be included in the care plan. The administrator confirmed the expectation that communication and language preferences be included in each resident's care plan.

Penalty

Inspection fine: $15,646

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 adhere to physician orders for a resident who was designated as nothing by mouth (NPO) due to risks of aspiration. Despite the care plan indicating the resident was at risk for aspiration and required tube feedings for nutrition, a nursing assistant provided the resident with a pastry, orange juice, and coffee. This action was contrary to the physician's directive, which explicitly stated no food, water, or ice chips by mouth. The resident, who had diagnoses including acute respiratory failure and pneumonitis, later exhibited symptoms of respiratory distress, including emesis, crackles in the lungs, and low oxygen saturation, leading to hospitalization for probable recurrent aspiration pneumonia and acute hypoxia respiratory failure. The incident occurred when the nursing assistant, unaware of the resident's NPO status, served the resident food and drink. The oversight was discovered when a coworker informed the nursing assistant, who then notified a registered nurse. The nurse assessed the resident's lung sounds, which were initially clear, but later noted crackles and other symptoms of respiratory distress. The facility's policy required staff to check assignment sheets for dietary orders, but this protocol was not followed, resulting in the resident receiving inappropriate food and drink, contributing to the resident's subsequent medical emergency.

Removal Plan

• Education to all staff regarding dietary orders
• Review of dietary policy and procedure
• Audits on all residents to ensure those with NPO status did not receive anything by mouth
• Ensure residents on special textured diets received the proper diet texture foods

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 storage, labeling, and disposal of refrigerated food items, as well as the use of hair restraints in the kitchen. During an observation, a gallon of 1% milk was found in the refrigerator past its best-by date, which the dietician acknowledged needed to be discarded. Additionally, a cook was observed preparing food without a beard net, which was confirmed by the dietician as a violation of the facility's personal hygiene policy. Further observations in the Villa and transitional care unit kitchenettes revealed several food items that were either undated or past their recommended storage duration. These included a nutrition supplement and a nutritional shake, both of which lacked open dates, making it impossible to determine their expiration. The dietary manager confirmed that while the kitchen provides supplements, it is the nursing staff's responsibility to label, date, and dispose of items according to the directions on the container. The facility's policies on food storage and personal hygiene were not adhered to, contributing to these deficiencies.

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 vital signs were taken as ordered for a resident receiving antipsychotic medication. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was supposed to have vital signs monitored weekly due to the risk of complications from psychotropic drug use. However, there was a significant gap in the documentation of vital signs, with no records from March to August, except for one instance in May. Interviews with nursing staff confirmed that vital signs should have been taken weekly, and the lack of documentation was acknowledged by the Director of Nursing. Another deficiency involved the failure to monitor a resident's weight as ordered. The resident, who was cognitively intact and at risk for nutritional issues, was supposed to have their weight monitored weekly. However, only one weight measurement was documented over a month-long period. The resident expressed concern about potential weight loss, and staff interviews confirmed that weights should have been taken weekly, even if the resident refused a shower. The Registered Dietician and Director of Nursing both confirmed that the protocol was not followed. The facility also failed to monitor and document skin alterations and administer medications as ordered. One resident with facial bruising did not have their skin alterations monitored after an initial assessment, and another resident repeatedly missed scheduled medications due to sleeping, with no documentation of these omissions in the progress notes. Additionally, skin assessments for several residents were inaccurately documented, missing critical information about existing conditions and required treatments. Interviews with nursing staff and the Director of Nursing highlighted inconsistencies in documentation and a lack of adherence to protocols for monitoring and documenting skin conditions.

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 comprehensively assess and address the wandering behaviors of several residents, leading to a deficiency in ensuring resident safety. One resident, identified as R15, exhibited behaviors indicating potential wandering, yet the facility did not conduct a thorough assessment of these behaviors or implement adequate interventions. R15, who had severe cognitive impairment and was on hospice care, attempted to leave the facility to obtain traditional Hmong medication, resulting in an elopement incident. Despite being on hospice and having a history of cognitive impairment, R15's care plan lacked information on whether he was safe to go out into the community. The facility's documentation and interviews revealed that R15's wandering behavior was not adequately monitored or addressed. R15's care plan did not include interventions for wandering, and the facility failed to ensure the placement and monitoring of a wander guard, which R15 repeatedly removed. The facility's staff, including registered nurses and nursing assistants, were not fully aware of R15's elopement risk, and there was a lack of consistent communication and documentation regarding R15's cognitive status and decision-making capacity. The facility's failure to conduct a proper elopement risk assessment and implement appropriate interventions contributed to R15's ability to leave the facility unsupervised. Additionally, the facility did not have a clear process for assessing residents' capacity to make decisions or determining their safety to leave the facility. Interviews with staff indicated confusion and inconsistency in the procedures for handling elopement risks and assessing residents' cognitive abilities. The lack of a comprehensive assessment and care plan for R15, combined with inadequate staff training and communication, resulted in a deficiency in ensuring a safe environment for residents prone to wandering.

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 implement enhanced barrier precautions for two residents, R83 and R24, who were observed to have indwelling catheters. R83's care plan did not include interventions for the Foley catheter or enhanced barrier precautions, and there was no signage outside R83's room to indicate the need for such precautions. Staff interviews confirmed the absence of signage, which is typically used to inform staff of precautionary measures. Despite the presence of a new infection preventionist, the issue remained unresolved as of the last observation. For resident R24, the facility failed to ensure appropriate hand hygiene during assistance with activities of daily living. Observations revealed that a nursing assistant did not consistently use soap when washing hands and donned gloves without properly cleansing hands. This was despite R24 being on enhanced barrier precautions due to the presence of an indwelling urinary catheter. Interviews with staff confirmed the expectation for proper hand hygiene and the use of personal protective equipment during resident care. Additionally, the facility did not store ice packs separately from food in two unit refrigerators, which was observed in the Villa kitchenette and the transitional care unit. Ice packs were found next to food items such as ice cream and lasagna, which was acknowledged by the dietician and a registered nurse as unsanitary. The director of nursing was informed of the issue but did not provide a policy on ice pack storage.

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 clean and sanitary environment in one of its dining rooms, specifically the Villa unit. Observations on multiple occasions revealed that the dining room floor was covered with dried food, spilled liquids, and was sticky to walk on. Despite the presence of housekeeping staff who were supposed to clean the area, the floor remained visibly soiled and sticky. Interviews with staff, including a licensed practical nurse and environmental services personnel, confirmed the condition of the floor and indicated that the cleaning schedule was not being effectively followed. The environmental services staff were observed mopping the floor, but sticky spots and spills remained. The director of environmental services acknowledged the poor condition of the floor, noting a buildup of dirt and food spills over more than one day. The facility's cleaning schedule indicated that dining rooms were to be mopped twice daily, but sign-off sheets to confirm this were not provided. Additionally, a facility policy regarding cleaning was requested but not received, further highlighting the lack of adherence to cleaning protocols.

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 develop a comprehensive and individualized care plan for a resident identified as R88, who was reviewed for psychotropic medication use. R88's admission Minimum Data Set (MDS) indicated moderate cognitive impairment and diagnoses including sepsis, metabolic encephalopathy, delirium, and age-related cognitive decline. The care plan, revised after the survey began, noted the use of quetiapine for delirium but lacked non-pharmacological or personalized interventions to support signs of delirium or delusions. The nursing task sheet did not indicate any behaviors or confusion for R88. Interviews with staff revealed a lack of awareness and documentation regarding R88's behavioral concerns and interventions. A nursing assistant acknowledged R88's occasional confusion but noted no alerts or interventions on the task sheet. A registered nurse mentioned using distraction techniques for agitation but was unaware of any specific behaviors or personalized interventions for R88. The Director of Nursing confirmed the care plan's lack of individualized interventions and emphasized the expectation for care plans to be tailored to each resident. The facility's policy on comprehensive assessment and care planning directed that person-centered care plan interventions be implemented by qualified personnel and communicated through various means.

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 routine showers for a resident, identified as R90, who was reviewed for activities of daily living (ADLs). R90 was cognitively intact and had medical conditions including cellulitis, lymphedema, and a fracture of the right foot. The resident required substantial assistance for lower body dressing and supervision for personal hygiene. Despite these needs, R90's care plan indicated that staff were to assist with bathing weekly, but the treatment administration record showed that R90 did not receive a bath on the scheduled days. The discrepancy in the documentation led to R90 not receiving a shower for almost two weeks, which was confirmed by the resident during interviews. Interviews with nursing assistants and a registered nurse revealed inconsistencies in the documentation of R90's bath days. The care sheet and nursing order did not match, leading to confusion about the correct bath day. The Director of Nursing acknowledged the miscommunication and confirmed that the shower day should have been coordinated with occupational therapy due to R90's edema wraps. The facility's policy directed staff to assist residents with ADLs, including bathing, but this was not adhered to in R90's 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 implement a walking program as prescribed for a resident, identified as R73, who was reviewed for walking programs. R73 had intact cognition, no behaviors or rejection of care, and required partial to moderate assistance for transfers. Diagnosed with stroke and aphasia, R73's care plan included a walking program to be conducted at specific times with the use of a gait belt, right AFO, and quad cane. However, documentation from the Point of Care (POC) system revealed that the walking program was not consistently carried out as ordered, with significant gaps in the frequency of ambulation recorded. Interviews and observations further highlighted the deficiency. R73 expressed a desire to walk more often and confirmed that staff did not walk with her daily. Nursing assistants admitted to not noticing the walking program on assignment sheets and failing to document the ambulation activities. Observations showed that R73 was not offered opportunities to walk during meal times as per the care plan. The facility's physical therapy assistant and outpatient physical therapist emphasized the importance of the walking program for R73's functional improvement, yet the program was not executed as required. The Director of Nursing (DON) and regional registered nurse acknowledged the lack of documentation and completion of the walking program. Despite the nursing order for the walking program being acknowledged, it was not effectively implemented by the nursing assistants responsible for its execution. The facility's policy required that care and services be provided in accordance with the plan of care, including mobility support, but this was not adhered to in R73's case, leading to the identified deficiency.

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 comprehensively assess and implement a trauma-informed care plan for a resident with PTSD symptoms. The resident, who had a history of depression and bipolar disorder, was admitted to the facility and had previously indicated a preference to be left alone when upset. However, the trauma screening was incomplete, lacking information on triggers and management strategies, and there was no follow-up screening. The care plan did not include individualized trauma-informed interventions or identify triggers to prevent re-traumatization. The deficiency was highlighted when the resident experienced PTSD symptoms after a male caregiver provided personal care, triggering flashbacks of childhood abuse. Despite the resident's request to avoid male caregivers, this preference was not documented in the care plan or communicated to all staff. Interviews with staff revealed a lack of awareness about the resident's PTSD and the absence of trauma-informed care strategies in the care documentation. The facility's social services director acknowledged the need for updated trauma screenings and care plan interventions, as per the facility's policy on trauma-informed care.

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 adequate assistance to a family member in determining the mental capacity of a resident, identified as R15, who was on hospice care. R15 had a complex medical history, including anxiety disorder, cardiogenic shock, acute respiratory failure, and heart failure, and was receiving hospice services. Despite these conditions, the facility did not conduct a Brief Interview for Mental Status (BIMS) upon admission, which would have helped assess R15's cognitive abilities. The care plan lacked information on whether R15 could make his own decisions, and there was confusion about R15's decision-making capacity, as noted in various medical and progress notes. R15 exhibited behaviors such as elopement and combativeness, which raised concerns about his safety and decision-making abilities. On one occasion, R15 left the facility unaccompanied, intending to purchase traditional Hmong medication, and was intercepted by police. The facility placed a wander guard on R15, but it was later removed, and there was inconsistency in staff understanding of R15's cognitive status and decision-making capacity. Interviews with staff revealed a lack of clarity and communication regarding assessments of R15's ability to make decisions and the appropriate interventions to ensure his safety. The facility's social services department did not adequately address the family's request for assistance in determining R15's mental capacity. The social services director acknowledged that R15 had severe cognitive impairment but did not provide clear guidance or support to the family. The facility's policies and job descriptions indicated that social services should assist with legal and financial matters, including decision-making capacity, but these services were not effectively provided in R15's 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 ensure that the provider's response to a pharmacist's medication review recommendation was followed and that appropriate monitoring was in place for a resident using antipsychotic medication. The resident, who had moderate cognitive impairment and several diagnoses including sepsis and delirium, was prescribed quetiapine for delirium. However, the pharmacist noted that the medication lacked an allowable diagnosis and recommended an update. The nurse practitioner selected 'delusional disorder' as the diagnosis, but the resident's medical records and orders were not updated to reflect this change. Additionally, the facility did not implement monitoring for target behaviors or side effects associated with the use of quetiapine. The care plan for the resident was revised after the survey began, but it still did not specify which behaviors to monitor. Interviews with the consulting pharmacist and the Director of Nursing revealed that there was a lack of monitoring in place, and the necessary updates to the resident's records were not made, possibly due to staff oversight during a vacation period. The facility's policy required that recommendations be acted upon and documented, which was not adhered to 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 ensure that a resident receiving antipsychotic medication had an appropriate indication and diagnosis for the medication. The resident, who had moderate cognitive impairment and a history of sepsis, metabolic encephalopathy, and delirium, was prescribed quetiapine for delirium. However, the facility did not monitor the resident for target behaviors or side effects related to the medication, nor did they implement non-pharmacological interventions. The resident's care plan was revised after the survey began, indicating the use of quetiapine for delirium, but it lacked specific behaviors to monitor. Despite recommendations from the hospital to consider stopping the medication and a pharmacist's suggestion to review the diagnosis, the facility continued the medication without proper documentation of behaviors or non-pharmacological strategies. Interviews with staff revealed a lack of awareness and monitoring for delusional or delirium-related behaviors, and the resident was noted to be pleasant and oriented without delusions or hallucinations. The Director of Nursing confirmed that there was no order for behavior monitoring related to quetiapine use and acknowledged the absence of non-pharmacological interventions in the care plan. The facility's policy required collaboration with medical providers to ensure the lowest possible dose of psychotropic medication for the shortest period, with a care plan that includes both pharmacological and non-pharmacological interventions. However, these steps were not adequately followed for the resident in question.

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 implement care planned interventions to prevent the worsening of existing pressure ulcers for a resident with severe cognitive impairment and a history of dementia, anxiety, muscle weakness, and a stage II pressure ulcer. The resident's care plan included the use of an air mattress and bilateral Prevalon heel protectors to prevent further pressure injuries. However, observations revealed that the resident was not wearing the Prevalon boots while seated in a wheelchair in the dining room on multiple occasions, and the air mattress was not present on the resident's bed. Interviews with staff confirmed that the resident was supposed to be wearing the Prevalon boots, but there was no documentation of the resident refusing to wear them. The facility's policy on the prevention and treatment of skin breakdown required licensed nurses to evaluate and revise care plans for residents with impaired skin integrity. Despite this, the resident's medical record lacked evidence of refusal to wear the Prevalon boots, and the air mattress had not been replaced after being removed when the resident was discontinued from hospice care. The failure to adhere to the care plan and document refusals contributed to the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.

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 conduct a thorough root cause analysis and implement individualized interventions to prevent falls for a resident who experienced multiple falls since admission. The resident, who had a history of falls, cognitive deficits, and required assistance with mobility and toileting, was not identified as at risk for falls despite sustaining several falls. The care plan included interventions such as keeping the call light within reach and offering toileting assistance, but these measures were not effective in preventing further falls. The resident experienced multiple falls, often while attempting to use the bathroom or retrieve personal items, and did not consistently use the call light for assistance. Despite meetings by the interdisciplinary team to review each fall, the facility did not identify effective interventions or address the resident's impaired cognition, which contributed to the falls. The care area assessment and care plan lacked detailed analysis of the root causes and contributing factors for the falls, leaving many sections blank. Interviews with staff revealed a lack of familiarity with the resident's fall interventions and inconsistent application of the care plan. The director of nursing acknowledged the need for further analysis and intervention but had not yet implemented additional measures. The facility's policy required individualized care plans based on fall risk assessments, but this was not adequately followed, leading to repeated falls and injuries for the resident.

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 dignity of a resident (R2) who required assistance with activities of daily living. R2, who had severe cognitive impairment and required moderate assistance with personal hygiene, was observed on multiple occasions with soiled clothing and dirty fingernails. Despite having a care plan that indicated the need for assistance with grooming and bathing, R2 was seen in the dining room with food stains on his clothes and a brown substance under his nails. Family members and staff acknowledged that R2 would not have liked to be seen in such a state and that it affected his sense of pride and well-being. Interviews with nursing assistants and the director of nursing revealed that nail care was expected to be performed during bath time and as needed, and that soiled clothing should be changed promptly. However, R2's nails remained dirty, and his clothes were not changed even after staff acknowledged the issue. The facility did not provide a policy on dignity when requested, further indicating a lapse in maintaining the resident's dignity and self-respect.

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 implement the comprehensive care plan for a resident (R2) who had severe cognitive impairment and required assistance with eating. Despite the care plan indicating that R2 needed supervision and encouragement during meals, observations on multiple occasions showed that staff did not provide the necessary assistance. On one occasion, R2 was observed in the dining room with a plate of food, but only managed to eat a bun and drink water and milk without any staff encouragement to eat the rest of the meal. Similarly, during another meal, R2 spilled soup on his shirt and attempted to clean it himself without any staff intervention or encouragement to eat his fruit. Interviews with staff and family members further highlighted the lack of adherence to the care plan. A family member noted that staff only assisted residents they were seated next to, and a nursing assistant stated that they were unaware R2 needed encouragement with meals. The Director of Nursing confirmed that staff should assist residents who require help with eating, as per the facility's policy on care planning. This failure to follow the care plan resulted in R2 not receiving the necessary assistance and encouragement during meals, as required by their care plan and provider orders.

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 quarterly interdisciplinary team (IDT) care conferences for one resident (R6) who had severe cognitive impairment. The resident's medical record indicated that care conferences were held on 3/23/23 and 6/22/23, but none were held since that time. Registered Nurse (RN)-C acknowledged that R6 missed several care conferences, and the social worker (SW)-A confirmed that there were no notes for R6's care conferences after 6/22/23 and no future care conferences were scheduled. The Director of Nursing (DON) also stated that care conferences should be held quarterly and as needed. The facility's policy dated 11/28/2017 directed that residents have the right to participate in planning their care and treatment.

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 nail care and feeding assistance was provided for a resident (R2) with severe cognitive impairment. R2's care plan and provider orders indicated the need for supervision and assistance with eating and personal hygiene, including nail care. However, observations revealed that R2 was not consistently encouraged or assisted with meals. On multiple occasions, staff did not provide the necessary support, resulting in R2 eating only parts of his meal or not eating at all. Additionally, R2's nails were observed to be dirty, and staff acknowledged the issue but did not address it adequately. Interviews with staff and family members confirmed that R2 required assistance with eating and nail care. Despite this, staff failed to provide the necessary support during meals, and R2's nails remained unclean. The Director of Nursing (DON) acknowledged that residents requiring assistance should be helped according to their care plans and that nail care should be performed on shower days and as needed. The facility's policy on Activities of Daily Living directed that residents unable to carry out ADLs independently should receive services to maintain good grooming and personal hygiene, which was not adhered to in R2's 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 follow safeguards to ensure residents received the correct medications, resulting in a medication error for one resident (R4). R4, who was cognitively intact and diagnosed with glaucoma, was supposed to receive brimonidine eye drops as per the provider's orders. However, on one occasion, R4 administered dorzalamide eye drops, which were intended for another resident. This error occurred because an LPN left the wrong eye drops on R4's tray table and did not verify the medication before leaving the room. R4 realized the mistake after administering the drops and flushed her eyes, experiencing no ill effects. The incident was confirmed by both R4 and the nursing staff. RN-B acknowledged that R4 had not been assessed to ensure she could safely administer her own eye drops and that the LPN should not have left the room before verifying the medication. The director of nursing also verified the medication error. The facility's policy on administering medications, which requires licensed nurses or trained associates to ensure the right resident receives the right medication, was not followed in this instance.