Browns Valley Health Center

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 dignity for 2 residents who required staff assistance with ADLs, including personal hygiene and shaving. One resident had moderate cognitive impairment, diagnoses including heart failure, hypertension, and diabetes, and was dependent on staff for dressing, toileting, personal hygiene, shaving, and combing hair. Although the care plan and care sheet identified the resident needed assistance with personal hygiene, observations on 4/20/26 and 4/21/26 showed approximately 1 mm of facial hair on the chin. The resident was unable to verbalize whether the facial hair bothered her. The resident's family member stated facial hair would bother her and expected staff to keep her shaved. NA-B and LPN-A both verified the resident needed assistance with ADLs and should have been shaved per her preference, and the DON stated shaving residents per preference was important to dignity. The second resident had severe cognitive impairment, diagnoses including dementia, hypertension, and arthritis, and was dependent on staff for personal hygiene and dressing. The resident's care plan identified a self-care performance deficit related to aggressive behavior and dementia, and the resident was totally dependent on staff for personal hygiene. Review of progress notes from 3/21/26 to 4/21/26 lacked documentation of refusal of facial hair removal. Observations showed a large amount of white facial hair across the chin and above the lip, approximately 6 to 7 mm long, during both an activity and breakfast. The resident's family member stated visible facial hair would bother the resident and expected staff to remove it if present. NA-A, TMA-A, and LPN-A all verified the facial hair was present and stated residents should be shaved, with re-approach or another person trying if a resident refused. The DON stated shaving should be done with morning cares and was important for dignity.

Penalty

Inspection fine: $26,685

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 a cognitively impaired resident from physical and verbal abuse by a nurse aide and to respond appropriately once the allegation was reported. On the evening in question, two nurse aides were providing toileting and peri-care to the resident, who had non-Alzheimer’s dementia, depression, a psychotic disorder, and moderately impaired cognition with long- and short-term memory loss. The resident functioned at an estimated developmental level of an 8-year-old, had unclear speech, responded only to simple direct communication, and was dependent on staff for all ADLs including toileting and hygiene. During care, the resident became combative, yelling and swinging her arms, and one aide (NA‑B) responded by raising her voice, using foul and aggressive language, and striking the resident on the bare buttocks while stating that if the resident wanted to act like a child, she would be treated like one. A trained medication assistant (TMA‑A) standing outside the closed door heard NA‑B yelling at the resident to hurry up and grab the “fucking bar” and to walk to bed, and later learned from the other aide (NA‑A) that NA‑B had swatted the resident’s buttocks. NA‑A, who was in the room, described NA‑B’s tone as loud, aggressive, and intimidating, and reported that the resident was grunting and appeared nervous. NA‑A stated that after the resident yelled and grunted during brief placement, NA‑B told the resident that if she wanted to act like a child she would be treated like one, then smacked her on the right buttock with an open hand, skin-to-skin, producing a loud smack. NA‑A reported feeling very uncomfortable and believed the conduct was verbal and physical abuse. After leaving the room, NA‑A immediately told TMA‑A what had happened and, within about five minutes, located the charge nurse (LPN‑A) and reported the incident. NA‑A completed an Employee Concern form describing the incident and placed it in the DON’s box. TMA‑A also informed LPN‑A during the evening medication count that she had heard raised voices, swearing, and the resident crying, and that NA‑B had smacked the resident’s buttocks. Despite these reports, LPN‑A did not read the written complaint, did not conduct an immediate assessment of the resident, did not contact the on‑call nurse, and allowed NA‑B to continue working the remainder of the 12‑hour shift, caring for the resident and other residents without additional supervision. In the hours and days following the incident, the resident demonstrated changes in behavior and mood that were documented by staff. The next morning, staff noted the resident was tearful, withdrawn, and refusing food and drink, including favorite beverages, and she cried while in her wheelchair in a common area. Nursing notes and behavior monitoring entries over the subsequent days documented increased yelling, hitting, scratching, cursing, and physical aggression during care, as well as episodes of sadness, tearfulness, withdrawal, and isolation. Staff familiar with the resident, including RN‑A and NA‑E, reported that this withdrawn, tearful, and non‑eating behavior was not typical for her and that she usually did not cry without a reason. Although a full body assessment was later documented as showing no bruising and no verbalized pain, the facility’s own records and interviews describe that the resident became more tearful, had decreased appetite, and increased crying following the incident, and that she appeared different than normal—quiet, exhausted, withdrawn, and refusing to participate in usual activities and intake. These events, combined with the failure of the charge nurse to act on the initial reports and remove the alleged perpetrator from resident care, led to the cited deficiency for failure to protect the resident from abuse.

Removal Plan

• Reported abuse to the State Agency (SA).
• Investigated allegations of physical and verbal abuse and implemented resident protection.
• Re-educated staff on abuse and neglect, reporting, abuse prevention, resident rights, dementia, and vulnerable adults.
• Verified education through interviews and training records.

Penalty

Inspection fine: $26,685

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 report an allegation of abuse to the State Agency within the required two-hour timeframe after the allegation was made. On 2/21/26 in the evening, a trained medication assistant (TMA-A) stood outside a resident’s closed door preparing medications and heard the resident and a nursing assistant (NA-B) yelling. TMA-A heard NA-B say in a rude and aggressive tone, “hurry up and grab the fucking bar you know how to fucking walk so walk to the bed.” After NA-A and NA-B exited the room, NA-A told TMA-A that NA-B had swatted the resident on the butt. TMA-A considered this verbal and physical abuse and reported what she heard and what NA-A told her to the charge nurse (LPN-A) during a medication count shortly after 7:00 p.m., assuming LPN-A would notify the on-call nurse. NA-A reported that while assisting the resident in the bathroom, the resident became combative and yelled after NA-B told her to stand up. NA-B responded, “if you want to act like a child then you will be treated like one,” and with an open hand smacked the resident on the right buttock, skin-to-skin, producing a loud smack. NA-B then grabbed the resident’s walker and directed her to walk to bed. NA-A described NA-B’s tone as loud, aggressive, and accompanied by foul language, and stated the resident was whining, whimpering, and making grunting sounds as if nervous. After leaving the room, NA-A and TMA-A reported the incident to LPN-A, who provided NA-A with a complaint form. NA-A completed the form and placed it in the DON’s box, believing the incident would be handled and reported. The resident involved had non-Alzheimer’s dementia, depression, and a psychotic disorder, with unclear speech, limited verbal and non-verbal skills, disorganized thinking, and moderately impaired cognition with long- and short-term memory loss. She was dependent on staff for personal and toileting hygiene, transfers, bathing, and lower body dressing, and was always incontinent of bladder and frequently incontinent of bowel. Despite the information provided by TMA-A and NA-A, LPN-A did not read the written complaint, did not further question staff about the incident, and did not immediately assess the resident or contact the on-call nurse. The facility’s incident report was not submitted to the State Agency until 2/22/26 at 4:22 p.m., well beyond the policy requirement to report suspected maltreatment, including abuse, to the State Agency immediately but no later than two hours after the allegation is made. During this time, NA-B continued to work the remainder of the shift and care for residents.

Penalty

Inspection fine: $26,685

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 sufficient protections and assessment following an allegation of staff-to-resident abuse, and failure to conduct a thorough investigation. A resident with non-Alzheimer’s dementia, depression, a psychotic disorder, moderately impaired cognition, disorganized thinking, unclear speech, and dependence on staff for all cares and transfers was allegedly subjected to verbal and physical abuse by a nursing assistant during evening cares. According to staff interviews, the nursing assistant spoke loudly, aggressively, and with profanity, telling the resident to hurry up and grab the bar and to walk to the bed, and stated that if the resident wanted to act like a child, she would be treated like a child. Staff reported that the nursing assistant used an open hand to smack the resident’s bare buttock, which sounded like a loud smack, while the resident was whining, whimpering, and making grunting sounds. The incident was reported by two staff members to the charge nurse on the evening of the alleged abuse. A trained medication assistant reported hearing the loud, aggressive, and profane language from outside the resident’s closed door and, after speaking with another nursing assistant who had been in the room, learned of the smack to the resident’s buttock. That nursing assistant also directly reported to the charge nurse that the staff member had been verbally aggressive and had smacked the resident’s right buttock. The charge nurse responded verbally but did not immediately contact the on-call nurse as required by facility policy, did not ensure the resident’s immediate safety, and did not initiate the required assessment and protective measures at that time. The resident’s medical record contained no documentation of a skin assessment or behavior assessment on the date of the incident, and there was no evidence of a documented skin check following the initial report of the allegation or the following day. The facility’s investigation process was also deficient. The alleged perpetrating staff member continued to work with residents for the remainder of the shift and into the next morning after the incident, and the allegation was not brought to the attention of supervisory nursing staff until the following day. When the investigation was initiated, the clinical coordinator interviewed a limited number of residents who were verbally responsive and in their rooms, totaling 11, and did not verify that skin checks or behavior chart reviews were completed for residents who could not be interviewed. Night staff who had worked with the accused nursing assistant, including the nursing assistant on the night shift with her, were not interviewed. The DON acknowledged that the charge nurse did not follow the facility’s maltreatment reporting guidelines, which required immediate reporting, suspension of the involved staff, and initiation of an investigation including resident and staff interviews, observations, and medical record review. The DON also acknowledged that resident skin monitoring and behavior chart review were not completed as expected, and that the facility’s policy was not followed by the charge nurse regarding communication of the incident and immediate protective actions.

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 food safety and hygiene practices in the kitchen, which had the potential to affect all 28 residents receiving food and beverages. During an observation, the dietary manager was seen handling clean dishes without wearing a hair restraint, despite having hair approximately 1/4 inch in length. This was against the facility's policy that required all dietary staff to wear hair restraints to prevent hair from contacting exposed food or clean dishes. The dietary manager was unaware of the need for a hair restraint due to the short length of his hair. Additionally, the facility did not adhere to proper food labeling and storage practices. Several food items in the kitchen refrigerator, freezer, and resident refrigerator were found without proper labeling, dating, or were past their expiration dates. Items such as slices of ham, hamburger patties, apple pie, salsa, mayonnaise, and various other food products were either not dated or had expired, which was contrary to the facility's policy on perishable food management. The dietician confirmed that all food items should have been dated when opened and discarded after their shelf life or expiration date to prevent foodborne illness.

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 properly disinfect a multi-use glucometer after use for two residents who required blood glucose monitoring. This deficiency was observed during the care of two residents, both of whom had cognitive impairments and required assistance with activities of daily living. The registered nurse (RN) and licensed practical nurse (LPN) involved in the incidents did not follow the manufacturer's guidelines for disinfecting the glucometer between uses, which is necessary to prevent the spread of blood-borne infections. The RN did not disinfect the glucometer after using it on one resident, while the LPN incorrectly used an alcohol wipe, believing it was sufficient for disinfection. The facility's infection preventionist and director of nursing confirmed that the glucometer was used for multiple residents and acknowledged that the use of an alcohol wipe was not appropriate for disinfection. The manufacturer's guidelines specified the use of an EPA-registered disinfectant or a bleach solution for proper disinfection. The facility's policy also required decontamination of reusable equipment between residents according to the manufacturer's instructions. This oversight in infection control practices had the potential to affect all residents requiring blood glucose monitoring.

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 professional standards of practice were followed during the administration of insulin to a resident with severe cognitive impairment and diabetes mellitus. The resident's care plan required staff to administer diabetic medications as ordered. However, during an observation, a registered nurse (RN) prepared and administered 8 units of Humalog insulin to the resident without priming the insulin pen as per the manufacturer's instructions. The RN did not prime the pen, which involves wasting 2 units of insulin to remove air bubbles, because she believed it was unnecessary since she had administered insulin to the resident earlier in the day. Interviews with the consultant pharmacist and the director of nursing confirmed the importance of priming the insulin pen to ensure the correct dosage is administered. The manufacturer's package insert and the facility's medication administration policy both emphasize the need to prime the pen before each injection to avoid administering too much or too little insulin. The failure to prime the pen was a deviation from these guidelines, leading to a significant medication error in the administration of insulin to 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 submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter, as required by CMS specifications. This deficiency was identified during a review of the Payroll Based Journal (PBJ) Report, which highlighted several dates where there was a failure to have licensed nurse coverage 24 hours per day. The review of staffing schedules and time cards from October 1, 2023, through December 31, 2023, showed that licensed nursing staff, including registered nurses (RNs) and licensed practical nurses (LPNs), were present and worked on the dates in question. However, discrepancies were found between the PBJ report and the facility's staffing records. During an interview, the facility administrator confirmed the findings and acknowledged that the PBJ report was inaccurate. The administrator explained that the LPN staff and trained medication aides (TMAs) were not coded correctly in the PBJ system, which led to the inaccuracies. The facility's policy on PBJ, dated April 1, 2019, mandates the electronic submission of staffing information based on payroll data to ensure compliance with regulatory requirements. The Employment System Department (ESD) is responsible for reviewing all PBJ data for accuracy before submission to CMS, but this process was not followed correctly, resulting in the 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 ensure proper wheelchair positioning for a resident with severe cognitive impairment and multiple diagnoses, including dementia, arthritis, and low back pain. The resident was observed multiple times with her feet dangling from the wheelchair, indicating a lack of proper support and positioning. Interviews with staff revealed that the resident had not been assessed for wheelchair positioning, and there was no recent therapy evaluation to address this issue. The facility's policy required referrals to occupational or physical therapy for wheelchair assessments, but this was not followed. Additionally, the facility did not comprehensively assess and implement interventions for a resident with edema, who had diagnoses including heart failure, hypertension, chronic kidney disease, and diabetes mellitus. The resident's care plan included monitoring for edema, but there were inconsistencies in the assessment records, with some entries left blank. The resident expressed a preference for wearing compression stockings, but staff reported difficulties in applying them, and there was no physician's order for their use. The facility's policy required continuous assessment and monitoring of lower extremities when using compression stockings, which was not adequately documented or communicated to the primary care physician. Interviews with the director of nursing confirmed that the facility's usual process for wheelchair assessments was not followed, and the resident's feet should not have been dangling. The director also acknowledged the lack of a physician's order for compression stockings and the need for proper measurement and fitting. The facility's failure to adhere to its policies and procedures for adaptive equipment and compression stockings contributed to the deficiencies observed in the care of these residents.