Bywood East Health 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 deficiency involves the facility’s failure to protect a resident from physical abuse by a contracted laboratory technician. The resident had diagnoses including disorganized schizophrenia, dementia, a history of traumatic brain injury, and mild cognitive impairment, and was documented as rarely understood with moderately impaired cognition. The resident’s care plan identified a focus on potential for abuse, neglect, and/or exploitation related to vulnerable adult status, with interventions directing staff to follow the Vulnerable Adult (VA) policy to keep the resident free from exploitation, abuse, and/or neglect. A general condition note documented that the resident was hit at 2:00 p.m. by an external vendor, resulting in slight redness to the left cheek. Video footage from the date of the incident showed the resident sitting in a wheelchair by the elevator doors with several other residents and staff in the area. A tall male, identified by the DON as a contracted laboratory technician, approached the elevator, motioned for the resident to move back, and then stepped forward and slapped the resident’s face with an open right hand. The technician later stated he slapped the resident because the resident said something derogatory about his mother and that he would slap anyone who did so. The DON stated that a slap on the face is considered abuse and acknowledged that facility staff did not supervise laboratory technicians and that residents were supposed to be protected from abuse by contracted staff through VA abuse prevention training. The DON and administrator both stated that the facility did not provide or verify VA abuse prevention training for contracted laboratory staff, and the VA Abuse Prevention policy did not address VA abuse prevention education for contracted 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 implement and operationalize written policies and procedures to prohibit and prevent abuse, neglect, and theft by contracted staff. Video footage showed a contracted laboratory technician approach a resident seated in a wheelchair near the elevator, motion for the resident to move back, and then slap the resident’s face with an open hand in the presence of other residents and staff. The technician later stated to the ADON that the resident had said something derogatory about his mother and that he would slap anyone who did so. The ADON questioned what the technician might do in a resident room with a resident who could not speak up for themselves. Interviews with the lab supervisor, DON, and administrator revealed that contracted laboratory technicians did not receive VA abuse prevention training, and the facility did not verify VA abuse prevention education for these contracted staff before they worked with residents. The DON and administrator both stated that residents were protected from abuse by contracted staff through VA abuse prevention training, yet acknowledged that the facility neither provided this training to lab technicians nor verified that they had received it elsewhere. Review of the VA Abuse Prevention policy, revised 10/1, showed it did not address protocols for assuring verification of abuse prevention education for contracted staff, even though the policy stated the facility does not tolerate abuse or misappropriation of resident property by anyone, including staff of other agencies serving the individual.

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, develop, or implement effective interventions to reduce the risk of ongoing physical and mental abuse between two residents. One resident with moderate cognitive impairment, schizoaffective disorder, and a history of behavioral disturbances repeatedly harassed and physically grabbed another resident, who also had moderate cognitive impairment, dementia, anxiety disorder, and a history of delusional thinking. Despite over 20 documented behavioral incidents involving the aggressor, the facility's records lacked detailed descriptions of the behaviors, the specific interventions attempted, and their effectiveness. The primary intervention used was redirection, which was consistently noted as ineffective, and there was no evidence that alternative strategies were considered or implemented. Direct care staff and medication aides reported that the aggressor persistently sought out and targeted the other resident, engaging in behaviors such as hair pulling, grabbing, and entering her room, which caused significant emotional distress. Staff interviews revealed that these incidents had been ongoing for several months, and that management was aware of the situation. However, the care plans for both residents did not include specific interventions or strategies to address the repeated interactions or to protect the victim from further harm. Documentation also showed that the aggressor's care plan lacked a behavioral focus or interventions related to her actions toward other residents. The victim experienced increasing anxiety and distress as a result of these interactions, leading to multiple calls to 911, involvement of law enforcement, and eventual hospitalization for psychiatric care. Despite these outcomes and repeated documentation of the aggressor's behaviors, the facility did not conduct a comprehensive assessment or implement effective interventions to ensure the victim's safety. The facility's abuse prevention policy required identification and investigation of patterns or trends that may constitute abuse, but there was no evidence that the ongoing incidents were reported or investigated as potential abuse, nor that the required immediate interventions were put in place.

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 immediately report a resident-to-resident physical altercation to the State agency as required. One resident, who had moderate cognitive impairment and a history of anxiety, delusional thinking, and psychiatric disorders, was repeatedly subjected to hair pulling and grabbing by another resident. Progress notes and staff interviews confirmed that these behaviors had been ongoing for several months, with staff attempts at redirection proving largely ineffective. The affected resident expressed fear and agitation as a result of these incidents, which ultimately contributed to her psychiatric hospitalization. Despite multiple documented incidents and staff awareness of the ongoing interactions, the facility did not report the altercation or the resident's reaction to the State agency within the mandated two-hour timeframe. Staff and management interviews revealed that the events were not recognized as reportable abuse, even though the facility's own policy defined abuse to include nonverbal contact causing fear or mental anguish. The care plan for the affected resident did not include specific interventions related to the other resident's behaviors, and staff had not been provided with new strategies to address the situation. The facility's Vulnerable Adult Abuse Prevention Policy required immediate reporting and investigation of all allegations of potential abuse, including those causing mental anguish. However, the ongoing pattern of physical and psychological distress experienced by the resident was not reported as required, and the facility did not initiate a formal investigation using its Behavioral Assessment Form. Staff interviews confirmed that management was aware of the situation, but no action was taken to escalate or report the incidents to the appropriate authorities.

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 schizophrenia, diabetes, major depression, obsessive-compulsive personality disorder, and lung disease was assessed as having mild cognitive impairment and required moderate assistance with eating. The resident was on a prescribed Level 1 Dysphagia pureed diet, which required smooth, pudding-like food textures to prevent choking. There were no prior issues with choking while the resident was maintained on this diet. On the day of the incident, a registered nurse assisted the resident in purchasing a sticky bun from a vending machine, despite the resident's dietary restrictions. The nurse did not consider the resident's ordered diet at the time of the purchase. After receiving the sticky bun, the resident began eating it in the dining room, subsequently started to choke, became unresponsive, and fell from his chair. Staff initiated CPR and emergency services were called. Food was found lodged in the resident's throat and was removed during resuscitation efforts. The resident was transported to the hospital, where he was found to have suffered a witnessed aspiration event, cardiac arrest, cervical and rib fractures, anoxic brain injury, and seizure activity. He was later placed on comfort care and pronounced brain dead. The failure to adhere to the prescribed pureed diet and the provision of an inappropriate food item directly led to the choking incident and subsequent fatal outcome.

Removal Plan

• Vending machines were locked in the conference room.
• No staff would assist a resident to get food out of the vending machine.
• If a resident requested an item against his prescribed diet orders, staff would notify the charge nurse, offer a safe snack, and always verify the diet before offering food or drink.
• All snacks for residents must be approved by the dietician and come from dietary services.
• Facility policy updated to require staff to check resident's code status prior to performing CPR, initiate CPR if full code, call 911, and remove visible obstruction during every pulse check.
• Staff are re-educated on choking procedures annually.
• Nursing and dietary staff receive additional training regarding the different types of mechanical soft diets, where to find a resident's diet type, and feeding assistance/aspiration prevention techniques.
• DON completed random diet order checks for ten residents twice a week.

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 was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.

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 was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific nature of the hazards, the supervision provided, or the condition of any residents involved are included in the report.

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 immediately report an allegation of sexual abuse involving two residents, one of whom was cognitively impaired, to the state agency as required. The incident occurred when a cognitively intact resident was found engaging in a sexual act with a cognitively impaired resident, with an allegation that a cigarette was offered in exchange for sex. The cognitively impaired resident had a care plan indicating vulnerability to abuse, neglect, or exploitation. Upon discovery, there was confusion among staff regarding the identity of the involved resident, leading to an initial interview with the wrong individual who was alert and oriented. The Director of Nursing (DON) did not realize the correct resident involved was cognitively impaired until later the following day, at which point the appropriate internal and external notifications were made, including contacting the police, case manager, and responsible party. The DON acknowledged that the report to the state agency was delayed due to the confusion over resident identity and confirmed that the incident should have been reported immediately as per facility policy. The facility's policy requires immediate internal reporting of suspected mistreatment of vulnerable adults.

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 was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.

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 laundry was handled and transported in a manner that would prevent the spread of infection. Observations and interviews revealed that staff did not wear gowns when handling dirty laundry, only gloves and masks. Clean linens and personal laundry were transported to resident floors in large, uncovered bins and metal carts, and were not covered during transport. In one unoccupied room with an open door to the hallway, multiple open-top bins containing clean linens were found, with linens exposed and some scattered within the bins. Additional clean linens were stacked on top of an armoire alongside various medical equipment, and the room was cluttered with both clean and soiled items. Staff were observed entering this room to retrieve linens due to supply shortages and lack of assigned personnel to restock the linen closet, resulting in staff rummaging through the bins for needed items. Interviews with staff, including nursing assistants and LPNs, confirmed that the room intended for clean linen storage was often used inappropriately, with clean linens left uncovered and the door left open. The infection preventionist acknowledged that the expectation was for all clean linen to remain covered and for the room door to be closed, but confirmed that reeducation was needed. The facility's infection control policy required active efforts to control and prevent communicable diseases, but these practices were not consistently followed, potentially affecting all 70 residents in the facility.

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 food was reheated to the appropriate temperature as required by both manufacturer instructions and professional standards. During meal preparation, a cook removed multiple bags of chicken pot pie filling from a steam cooker, mixed them, and did not take the temperature at that time. Later, the cook was observed taking the temperature of the chicken and dumplings at the steam table, which measured 90°F, significantly below the required 165°F. The director of nutritional services (DNS) then reheated the food in the oven, but it only reached 145.3°F before being served to residents. The temperature log indicated a reading of 170°F, but both the cook and DNS could not confirm when or how this measurement was taken, and the DNS suspected the log entry was inaccurate. Further review revealed that the DNS was unaware of the manufacturer's instructions requiring the food to be reheated to 165°F and acknowledged uncertainty about whether this protocol was being followed. The cook admitted she was never sure the food had reached the required temperature and had only assumed it was 170°F. Additionally, when asked, the facility was unable to provide a policy regarding reheating food. As a result, 12 residents consumed food that may not have been reheated to a safe temperature, contrary to established standards and 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 ensure that allegations of verbal and/or mental abuse were reported to the administrator and State agency (SA) in a timely manner for three residents who reported or were observed to have experienced potential abuse. One resident, who had intact cognition but demonstrated delusional thinking, reported feeling abused by her roommate, who allegedly called her derogatory names and swore at her. The resident stated she had not reported the abuse previously, and a nursing assistant confirmed overhearing the roommate calling the resident names about a month prior but did not report it, assuming nurses present had witnessed it as well. There was no evidence that this allegation was reported to the SA until the surveyor brought it to the attention of the administrator and DON, who were previously unaware of the situation. Two additional residents, both with intact cognition and various medical and psychiatric diagnoses, were involved in separate incidents where a facility physician reported allegations of staff verbal abuse to the DON. The physician's progress notes indicated that one resident was called a derogatory name by an unknown staff member and was left uncomfortable and agitated, while the other resident experienced rudeness from staff. Although the DON was informed of these allegations, he did not report them to the SA, and the administrator was not made aware until later, during the survey process. The facility's Vulnerable Adult Abuse Prevention Policy defined verbal and mental abuse and required mandated reporters to immediately report any knowledge or belief of abuse to the administrator, DON, or their designee. Despite this policy, staff failed to report witnessed or alleged abuse in a timely manner, resulting in delayed notification to both facility leadership and the State agency, as required by regulation and 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

The facility failed to ensure the Minimum Data Set (MDS) was accurately coded regarding the administration of specific medications for two residents. For one resident, the MDS indicated that no hypoglycemic medications were administered during the assessment period, despite the Medication Administration Record (MAR) showing that semaglutide, a hypoglycemic medication used for diabetes mellitus, was given within the review period. For another resident, the MDS recorded that no antianxiety medications were administered, while the MAR documented that buspirone, an anxiolytic medication, was given multiple times during the same period. These discrepancies were confirmed through interviews with the registered nurse responsible for completing the MDS, who acknowledged the errors after reviewing the medical records. The nurse verified that the medications in question should have been coded on the MDS based on their pharmacological classification and actual administration as documented in the MAR. The facility did not provide a policy on MDS completion and accuracy when requested.

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 comprehensive and up-to-date care plans were developed and implemented for three residents, resulting in deficiencies related to continuity of care. For one resident with a long-term indwelling urinary catheter, the care plan did not include Enhanced Barrier Protection (EBP) measures as recommended by CDC guidelines for residents at high risk of multidrug-resistant organism (MDRO) transmission. Observations confirmed the absence of PPE signage or equipment outside the resident's room, and staff interviews revealed reliance on care plans for guidance, yet the necessary infection control interventions were not documented or implemented. Another resident with diagnoses of alcoholic cirrhosis and alcohol dependence had multiple documented episodes of alcohol use within the facility, including possession and consumption of alcohol in their room. Despite repeated incidents and staff awareness, the care plan did not address the resident's substance use, associated risks, or interventions for monitoring and assessment. Staff interviews confirmed that care plans are used to inform monitoring practices, but the lack of documentation meant new or unfamiliar staff would not have clear guidance on managing the resident's ongoing alcohol use. A third resident with multiple chronic conditions, including diabetes, depression, and hypertension, as well as an active discharge plan, had a care plan that lacked essential information. The care plan did not address the resident's abilities with activities of daily living (ADLs), use of assistive devices, discharge planning, medication management, or the management of their medical and psychiatric diagnoses. Interviews with staff and the director of nursing confirmed that these omissions were inconsistent with facility policy and expectations for comprehensive care planning.

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 develop individualized interventions to promote acceptance of bathing and personal hygiene care for a resident with impaired memory and cognitive function. The resident was observed to be disheveled, with greasy hair, soiled and long fingernails, and a visible brown substance on his hands. Documentation showed a pattern of the resident refusing showers and personal hygiene care, with staff offering alternative methods such as basin and wipes, which were also refused. Despite these repeated refusals, there was no evidence in the medical record that the facility had assessed or evaluated alternative approaches to facilitate the resident’s acceptance of care. Interviews with staff revealed that some nursing assistants had more success with the resident by using specific approaches, such as offering care when the resident returned from smoking or having the shower water running and hot. However, these successful strategies were not documented in the care plan, and other staff did not consistently re-approach the resident to provide care. Staff also noted that nail care was not consistently offered or documented, and there was uncertainty about whether it was being performed or recorded appropriately. The resident’s care plan identified a need for assistance with personal hygiene and bathing due to mental illness and impaired cognition, and set a goal for the resident to be clean and well-groomed. However, the care plan lacked specific interventions or strategies to address the resident’s repeated refusals or to promote acceptance of care. The facility’s personal hygiene policy required assistance based on individual needs and preferences but did not address how to manage or evaluate repeated refusals of 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 adequately assess and respond to repeated complaints of pleuritic and gastrointestinal distress, specifically heart pain, for a resident with moderate cognitive impairment and significant medical history including heart failure and use of anticoagulants. The resident had a standing as-needed order for Maalox to treat indigestion or heartburn, which was administered multiple times by staff. However, documentation in the medical record did not consistently include the symptoms prompting administration, nor did it provide evidence of assessment to distinguish between cardiac and gastrointestinal causes of the pain. Vital signs and symptom characteristics were not always recorded, and there was a lack of follow-up to determine the effectiveness of the intervention or to reassess the resident after medication was given. Staff interviews revealed that the resident had a history of voicing complaints such as "my heart hurts" and "my stomach hurts" over a long period, with staff typically providing Maalox in response. Some staff reported occasionally taking vital signs, but not consistently with each complaint. There was also uncertainty among staff regarding whether the resident's physician was aware of the ongoing symptoms, despite the repeated use of as-needed medication. The care plan included interventions for cardiac and respiratory conditions but did not address the resident's gastroesophageal reflux disease or provide specific interventions for this diagnosis. The medical record lacked evidence that the resident's symptoms were evaluated in real-time or retrospectively to determine their cause, nor was there documentation that the physician or medical team had been notified about the persistent symptoms and repeated use of as-needed medication. The director of nursing confirmed that the expected process for assessment, documentation, and physician notification was not followed, and acknowledged that the medical record did not reflect appropriate evaluation or communication regarding the resident's ongoing complaints.

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 the facility failed to act upon and assess a resident's voiced complaints and observed difficulties with hearing. The resident, who had impaired memory and was identified as hard of hearing, was observed struggling to hear during interactions and did not use hearing aids. The care plan acknowledged the resident's hearing issues and included interventions such as minimizing background noise and offering an audiology appointment. Despite these interventions, there was no evidence in the medical record that a comprehensive hearing assessment was completed or that the resident was evaluated for potential reversible causes of hearing loss, such as earwax buildup. Staff interviews revealed that hearing assessments were only performed if a complaint was made and not on a routine basis, and there was uncertainty about the availability of necessary equipment for ear examinations. Additionally, although a family member requested an audiology appointment and documentation indicated that one was scheduled, there was no evidence that the appointment was completed, refused, or rescheduled. The facility's documentation lacked follow-up regarding the outcome of the scheduled audiology appointment, and no policy on hearing evaluations was provided when requested. These inactions resulted in the resident's hearing concerns not being adequately addressed, despite both family and staff noting ongoing hearing difficulties.

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 who had multiple incidents of smoking indoors was reassessed for safe smoking, as required by policy. The resident, who was cognitively intact and independent with activities of daily living, had a care plan and assessment indicating she was a safe smoker and only smoked in designated areas. However, progress notes documented at least three separate incidents over a period of 6-7 months where the resident was found smoking in her room, in violation of the facility's smoking policy. On each occasion, the resident was educated on the risks and signed the smoking policy, but no reassessment for safe smoking was conducted. Observations showed the resident kept a significant number of cigarettes and a lighter at her bedside. Staff interviews confirmed awareness of the resident's indoor smoking incidents and indicated that, while staff would sometimes hold onto smoking materials and provide education, the resident was still able to access her own cigarettes. The social services designee and DON both acknowledged that a reassessment should have occurred after the incidents, but it was not completed. The facility's policy required immediate action and reporting when indoor smoking was observed, but this was not fully implemented in the resident'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 a resident received timely in-person physician visits as required, specifically every 60 to 70 days, to promote continuity of care and reduce the risk of disease complications. The resident in question had moderate cognitive impairment and multiple medical conditions, including non-traumatic brain dysfunction, heart failure, and schizophrenia, and was prescribed several medications such as antipsychotics and anticoagulants. Despite these complex needs, the medical record showed that the last in-person physician visit was documented over 70 days prior, with the most recent psychiatric progress note dated more than three months earlier. The facility's own policy required physician visits at least every 60 days after the initial 90-day period post-admission. Observations and interviews revealed that the resident had ongoing symptoms, such as chest pain, and was receiving medications for these complaints. Staff, including the DON and consulting pharmacist, confirmed that the resident's primary care was managed by a VA provider and that there was a lapse in scheduling and tracking required physician visits. The DON acknowledged that the resident had not been seen by a physician in the required timeframe and that the facility did not have a system in place to ensure compliance with the 60-day visit requirement, resulting in the resident not being seen as 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

Staff failed to implement manufacturer-directed steps to prevent post-administration complications for a resident receiving a steroid-infused inhaler. During a medication administration observation, a trained medication aide provided a resident with a mometasone furoate (Asmanex) inhaler, which was clearly labeled with instructions to rinse the mouth thoroughly after each use. The aide administered the inhaler but did not offer or assist the resident with a mouth rinse before proceeding to give oral medications. The omission was only identified when the surveyor intervened and questioned the aide, who then acknowledged forgetting the step and subsequently assisted the resident with rinsing. The resident involved had moderate cognitive impairment and a history of pneumonia and asthma, as documented in their quarterly MDS. Interviews with the DON and consulting pharmacist confirmed that a mouth rinse should be completed after using an inhaled corticosteroid to prevent oral thrush, and that such instructions should be visible on the MAR for staff reference. The facility did not provide a policy on metered-dose or steroid-infused inhaler use, and there was no evidence of recent staff education or audits regarding proper inhaler administration procedures.

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 consulting pharmacist recommendations for laboratory monitoring of a resident receiving digoxin were acted upon and addressed in a timely manner. A resident with moderate cognitive impairment, heart failure, and schizophrenia was prescribed digoxin for chronic diastolic heart failure, with daily administration documented and pulse checks recorded. The resident's care plan included general interventions for cardiac complications but did not specify how or when digoxin levels should be monitored. The consulting pharmacist identified the absence of a digoxin level in the medical record and recommended obtaining a digoxin level and basic metabolic panel. Although the physician indicated acceptance of the recommendations, there was no documentation that the digoxin level was obtained or that a rationale was provided for not doing so. Subsequent medication regimen reviews by the consulting pharmacist did not identify further irregularities, but the medical record continued to lack evidence of digoxin level monitoring. Interviews with the DON and consulting pharmacist confirmed that the recommendation for laboratory monitoring was not addressed, and there was no follow-up or documentation explaining the omission. The facility was unable to provide a policy on consulting pharmacist recommendations, and the process for ensuring such recommendations were implemented was not clearly documented or followed.

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's drug regimen was free from unnecessary drugs by not appropriately monitoring the resident's use of digoxin, a cardiac glycoside medication. The resident, who had moderate cognitive impairment and multiple medical conditions including heart failure and schizophrenia, had been prescribed digoxin for chronic diastolic congestive heart failure. Despite ongoing daily administration of the medication, there was no evidence in the medical record that a digoxin level had been checked or obtained within the last 12 months. The care plan did not specify how often digoxin levels should be monitored, and the facility was unable to provide documentation of any recent laboratory testing for digoxin levels. Observations and interviews revealed that the resident had experienced chest pain, which staff attributed to heartburn, and that the consulting pharmacist had repeatedly requested digoxin level checks without success. The director of nursing confirmed the absence of digoxin level results in the medical record and acknowledged the need for such monitoring. The facility also failed to provide a policy on medication management and monitoring when requested. These actions and omissions resulted in a lack of appropriate monitoring for potential digoxin toxicity, as required by standard care practices.

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 current standards for pneumococcal vaccination for one resident over the age of [AGE]. According to the resident's electronic medical record, the only pneumococcal vaccine received was PPSV23, administered in 2011. The CDC recommends that individuals over a certain age receive at least one dose of PCV15, PCV20, or PCV21 at least one year after the last PPSV23 dose. The resident's immunization record did not show any additional pneumococcal vaccines, and the vaccine consent or declination form did not indicate whether the resident consented to or refused the vaccine. During an interview, the infection preventionist confirmed that all residents should be offered influenza, pneumococcal, and COVID vaccines upon admission, but the facility only provided the influenza vaccine on-site and sent residents out for the other two. The infection preventionist also confirmed that the resident had consented to the pneumococcal vaccine and was due for it, but was not yet on the list to receive it. The facility's immunization policy states that it will follow CDC and state recommendations, but this was not followed in the case of this 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 respond appropriately to allegations of verbal and/or mental abuse for three of four residents reviewed. One resident, who had intact cognition but demonstrated delusional thinking, reported feeling abused by her roommate, who allegedly called her derogatory names and swore at her. The resident stated she did not always feel safe in her room and had not reported the incidents previously. A nursing assistant confirmed overhearing the roommate calling the resident names in the dining room about a month prior, but did not report the incident, assuming nurses present had witnessed it as well. There was no evidence in the care plan or medical records that the facility had investigated these allegations or implemented interventions to ensure the resident's safety, despite the behavior being witnessed by direct care staff. Additionally, two other residents reported allegations of staff verbal abuse, which were submitted to the State Agency by the facility physician. Both residents had intact cognition and various medical and psychiatric diagnoses. Progress notes indicated that the director of nursing (DON) was informed of the allegations, but there was no documentation of an investigation or any follow-up in the electronic medical record. Interviews with the residents revealed that they felt staff were rude or had made derogatory statements, but they were unable to identify the specific staff member or the timing of the incidents. The DON acknowledged being informed of the allegations but admitted to failing to initiate or document an investigation. Interviews with facility staff, including medication aides and LPNs, confirmed the expectation that all allegations or observations of abuse should be reported immediately to management for investigation. However, the administrator and DON both stated they were unaware of the allegations until informed by others, and no investigation or documentation was completed as required by facility policy. The facility's abuse prevention policy outlined the need for immediate assessment and investigation upon receiving a report, but this was not followed in these cases.

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 state survey results were kept in a location that was readily accessible to all residents. During interviews, one resident with intact cognition and another with severely impaired cognition both confirmed they were unaware that survey results were available for them to read, with the cognitively intact resident expressing interest in viewing them. Observation revealed that the survey results were stored in a binder inside a locked office at the first-floor nursing station, and the administrator stated that the binder had been kept there since his tenure began due to concerns about residents potentially taking or damaging the binder. A policy regarding the posting of survey results was requested but not provided.

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 discharge Minimum Data Set (MDS) assessments were completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for three residents. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, discharge assessments must be transmitted within 14 calendar days of the MDS completion date. For each of the three residents, documentation showed that they had been discharged from the facility, with corresponding progress notes indicating their discharge status, such as leaving against medical advice, not returning from a leave of absence, or being discharged to another care center. Despite these discharges, the medical records for all three residents lacked evidence that a discharge MDS had been started, completed, or transmitted to CMS, even though several months had passed since their discharge dates. During an interview, the registered nurse responsible for MDS completion confirmed that the discharge MDS assessments for these residents had not been completed, citing issues with the electronic system and missed notifications of resident discharges. The facility was unable to provide a policy on MDS completion when requested.

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 shared resident rooms provided the required minimum of 80 square feet per resident, as mandated for multiple occupancy rooms. Specifically, 23 rooms were identified as having only 232.72 square feet total, resulting in 77.57 square feet per resident when three residents occupied the space. Documentation and direct observation confirmed that these rooms either currently housed three residents or were set up to accommodate three, affecting all 69 residents who currently or potentially could occupy these rooms. The Aspen Central Office database also indicated that the facility had shared rooms below the required square footage, and no construction or room size changes had occurred since the previous survey. During interviews, one resident expressed confusion and dissatisfaction about sharing a room with two others, stating the space felt suitable for only one person. Another resident reported having enough space for her bed but noted insufficient closet and storage space, with all three closet cubbies observed to be overflowing. The administrator acknowledged that all rooms were the same size and that three residents could be assigned per room, and stated there had been no complaints from current residents about the room arrangements. Facility policy indicated that residents are informed if a room does not meet the 80 square foot minimum requirement.

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 appropriately transfer a resident following an unwitnessed fall with potential head injury. The resident, who had a history of traumatic brain injury and used a manual wheelchair, was involved in an altercation with another resident, resulting in his wheelchair being flipped backward and the resident striking the back of his head on the elevator floor. Progress notes indicated that the resident complained of head pain and was later sent to the hospital for evaluation, but initial on-site assessment documented no apparent injury. Video footage of the incident revealed that three staff members responded quickly, but two staff members manually assisted the resident off the ground and into his wheelchair without performing a comprehensive assessment or using a gait belt, contrary to facility policy and staff statements. Interviews with the DON, TMA, and LPN confirmed that the expected protocol was to conduct a full assessment—including range of motion, head and body checks, vital signs, and neurological checks—before moving the resident. However, the video evidence showed that these assessments were not completed prior to transferring the resident. Facility policy required a nurse to assess the seriousness of any accident or incident, especially those involving unwitnessed falls or potential head injuries, and to document vital signs and neurological checks. The policy did not specifically address the method of transferring a resident after a fall, but staff and leadership interviews consistently stated that a comprehensive assessment should occur before any movement. The failure to follow these procedures led to the deficiency cited in the report.

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 comprehensive assessments and interventions were implemented for a resident who was assessed to be unsafe in the community and at risk of elopement. This deficiency resulted in an immediate jeopardy situation when the resident left the facility without supervision for appointments, became lost, and was gone for over five hours before staff were aware. The resident was eventually found by a family member outside a hospital in a highly trafficked area. The resident had a recent diagnosis of traumatic brain injury, diabetes, schizoaffective disorder, seizure disorder, and substance abuse issues. Despite being identified as at risk for elopement and requiring an escort, the resident was sent to appointments without supervision. The facility's social worker had verbally informed the medical records staff that the resident needed an escort, but there was a communication breakdown, and the resident attended appointments unsupervised. Interviews with facility staff revealed that the resident's absence was not noticed until hours after the scheduled appointments. The director of nursing was informed late in the evening, and a missing person report was filed. The facility's policy required assessments and care plans to be updated for residents at risk of wandering, but these procedures were not effectively followed, leading to the resident's unsupervised departure.

Removal Plan

• Ensuring R1 was care planned to require an escort while in the community.
• All residents were re-assessed for need for an escort while in the community and care plans were updated accordingly.
• All nursing staff were educated regarding appointment/escort procedures.
• All residents with any significant change in condition had elopement risk assessments completed.
• Any resident deemed for elopement risk had interventions in place and care planned for elopement.
• A list of residents requiring escorts was newly posted at each nurse's station.
• The facility social worker was educated to update the list of residents requiring escorts when changes requiring supervision by an escort were required.

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 adequately address and monitor a known rodent infestation, which affected all 68 residents. Interviews and observations revealed that residents, including R3 and R4, frequently encountered mice in their rooms. R3 was observed feeding the mice, which led to an accumulation of food and mouse feces in her room. Staff were aware of R3's behavior but struggled to manage it effectively, as R3 resisted their attempts to clean her room. The maintenance director was aware of the issue but did not have a comprehensive plan to address it. The facility's pest control measures were insufficient, relying primarily on sticky traps that were ineffective. The maintenance director admitted to placing traps in rooms where mice were found but lacked a systematic approach to track and change them. The pest control company was supposed to provide monthly services, but there was a lack of communication and coordination between the facility and the company. The pest control company had not visited the facility since August, and the maintenance director was unaware of the specifics of their services. The facility's Quality Assessment and Performance Improvement (QAPI) program failed to address the rodent issue effectively. Despite documenting the presence of mice in their quarterly reports, there was no plan to reduce or eliminate the problem. The administrator acknowledged the deficiency and recognized the need for a more proactive approach, but at the time of the report, no effective measures had been 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

The facility failed to implement effective and timely pest control measures to address a mouse infestation, affecting all 68 residents. Observations and interviews revealed that mice were frequently seen on the second floor, particularly in a resident's room where food was intentionally left to feed them. The room was found to have an excess of mouse feces and food debris, indicating a severe infestation. Staff members, including a trained medical assistant and a licensed practical nurse, confirmed the presence of mice and the resident's habit of feeding them, which had been ongoing for a significant period. Interviews with other residents and staff highlighted the widespread nature of the problem. Another resident reported seeing mice coming from baseboard heaters and expressed frustration with the ineffective sticky traps used by the facility. The maintenance director admitted to placing traps and using steel wool to block holes but lacked a systematic approach to tracking and addressing the infestation. The director also acknowledged the limited involvement of the pest control company, which had not visited the facility since August 2024. The facility's pest management policy outlined responsibilities for the maintenance director, including coordinating with pest control contractors and recording pest sightings. However, the policy was not effectively implemented, as evidenced by the ongoing mouse problem and the lack of regular pest control services. The director of nursing was unaware of the severity of the issue, particularly the presence of mice in a resident's bed, which could have implications for resident health and safety.

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 timely notification to a provider and guardian for a resident who went missing after being sent to an appointment without an escort. The resident, who had a history of non-traumatic brain dysfunction, cognitive impairment, and was not safe in the community, was missing for seven hours. The resident's care plan indicated that he should not leave the facility without an escort due to his cognitive impairment and risk for falls. Despite this, the resident was sent to an appointment alone and was found by a family member in a confused state, wandering downtown. The facility's staff did not realize the resident was missing until two and a half hours after his scheduled medication time, as they were unaware of his return time from the appointment. The family member was not notified of the resident's disappearance until several hours later, and the nurse practitioner was informed weeks after the incident. The facility's policy required immediate notification of significant changes in a resident's condition to the physician and designated contacts, which 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 protect a resident's property from loss or theft and did not provide a lock box for personal property and/or monies, resulting in the loss of $50.00. The resident, who had a recent traumatic brain injury and memory issues, withdrew $50.00 from his account after returning from the hospital. The resident's family member expressed concern about the facility allowing the withdrawal given the resident's cognitive impairment and noted that the promised lock box was never provided. Despite being informed of the missing money, the facility did not investigate the loss or implement measures to prevent future occurrences. The resident's medical history included non-traumatic brain dysfunction, diabetes mellitus, asthma, anxiety, and schizophrenia, with a care plan indicating cognitive impairment and a history of substance abuse. Interviews with facility staff confirmed the withdrawal and the lack of clarity on how the money was spent. The facility administrator acknowledged awareness of the unaccounted money and agreed that a lock box should have been provided. No policy related to personal property was available at the end of the survey.

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 timely report an allegation of a missing resident, identified as R1, who had a traumatic brain injury and was cognitively impaired. R1 was at risk for elopement and was not safe in the community without an escort. Despite this, R1 was allowed to attend appointments without an escort, leading to his disappearance. The facility's Wandering and Elopement Risk Assessment and Care Plan both indicated that R1 required an escort for safety, but this was not communicated effectively among staff. On the day of the incident, R1 left for appointments at a hospital but did not return as expected. The facility staff did not realize R1 was missing until 7:30 p.m., despite R1 being scheduled to receive medications at 5:00 p.m. The staff assumed R1 was still at his appointments and did not verify his return time. It was only after a family member found R1 in a downtown area that the facility was notified of his whereabouts. The family member expressed concerns about R1's mental state and potential access to illicit substances due to his history of substance abuse. Interviews with facility staff revealed communication breakdowns regarding R1's need for an escort. The social worker claimed to have informed the medical records staff, who did not receive a clear answer. The director of nursing was notified of R1's absence after 8:00 p.m. and instructed staff to search the facility and contact the police. The facility's Vulnerable Adult Abuse Prevention Policy requires reporting within two hours of any suspected abuse or neglect, 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 comprehensively assess and implement interventions to prevent falls for three residents, leading to an immediate jeopardy situation for one resident. This resident, diagnosed with orthostatic hypotension and impaired cognition, experienced multiple unwitnessed falls resulting in a traumatic brain injury and subarachnoid hemorrhage. Despite the falls, the facility did not conduct necessary neurological checks or update the resident's care plan to include new interventions to prevent further falls. Another resident, with diagnoses including osteoporosis and dementia, was found lying on the floor after feeling weak. Although neurological assessments were reportedly completed, there was no documentation to support this. The resident's care plan included interventions such as wearing non-skid shoes and using a call light, but these measures were not sufficient to prevent the fall. A third resident, with a history of epilepsy and head injury, fell in the community and required follow-up care, which was not documented or communicated to the primary care provider. The facility lacked a protocol for neurological assessments and did not update the fall risk assessments or care plans for any of the residents after their falls, contributing to the deficiency.

Removal Plan

• Update Fall Risk Assessment Policy and Procedure
• Update protocol for neurological assessments
• Update neurological assessment form
• Train nursing staff about new neurological assessments and post-fall procedures
• Review falls for all residents who fell
• Update care plans for residents who fell
• Perform post-fall assessments for residents who fell
• Complete Falls Risk Assessment for each resident identified

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 timely notification to a medical provider for changes in condition related to falls or treatment after falls for three residents. One resident, with a history of schizophrenia, anxiety, depression, diabetes, and orthostatic hypotension, experienced multiple falls. After a fall near the elevator, the resident reported hitting their head, and although neuro checks were ordered, the resident refused hospital transfer initially. Later, the resident fell again, was found with low vital signs, and was eventually sent to the hospital with a brain bleed. Despite these incidents, the medical provider was not updated promptly about the resident's condition or the subsequent hospital admission. Another resident, diagnosed with schizoaffective disorder, osteoporosis, and dementia, was found lying on the floor, claiming weakness. Although neurological assessments were completed, the nurse practitioner was not notified of the fall. A third resident, with epilepsy and a history of head injury, fell in a community store and was taken to the hospital. The hospital recommended follow-up lab work, but the primary provider was not informed. The facility's policy required notifying the physician of any significant change in condition, including head trauma, which was not adhered to in these cases.

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 policy and procedure for the delegation of tasks by physicians to physician assistants, nurse practitioners, or clinical nurse specialists. This deficiency was identified during a review of facility policies on 9/6/24, which revealed the absence of a procedure for physician delegation of tasks. The administrator confirmed the lack of such a policy or procedure when interviewed on the same day at 5:22 p.m. This oversight had the potential to affect all 69 residents residing at the facility.

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 policy and procedure for the delegation of tasks by physicians to the dietitian. This deficiency was identified during a review of facility policies, which revealed the absence of a procedure for physician delegation of tasks to the dietitian. The administrator confirmed the lack of such a policy or procedure when interviewed, indicating that no documentation could be found to address this delegation process. This oversight had the potential to impact all 69 residents residing at the facility.

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 establish and implement a policy regarding the responsibility of the administrator to report to and be held accountable by the Governing Body. This deficiency was identified during a review of facility policies and procedures, which revealed the absence of a policy related to the Governing Body. On September 6, 2024, the administrator confirmed that the facility did not have such a policy in place. This oversight had the potential to affect all 69 residents residing in the facility.

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 policy and procedure defining the responsibilities of the Medical Director. During a review of facility policies on 9/6/24, it was found that there was no policy or procedure in place for the responsibilities of the Medical Director. Additionally, the facility lacked a position description for the Medical Director. This deficiency was confirmed by the administrator during an interview on the same day at 5:22 p.m., who acknowledged the absence of a policy addressing the Medical Director's responsibilities.

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 notify the State Agency (SA) as required when the current Director of Nursing (DON) was hired. This deficiency was identified during an extended survey conducted on September 6, 2024, when evidence was requested to demonstrate that the SA had been informed of the new DON's hiring. The facility administrator confirmed that the SA was not notified of this change in administrative personnel, which had the potential to affect all 69 residents in the facility.

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 newly admitted residents received a physician visit every 30 days for the first ninety days, as well as routine physician visits every 60 days for long-term residents. Specifically, one resident, identified as R5, did not receive the required physician visits every thirty days after admission. The clinical records showed that an NP conducted the initial visit, and the physician only examined the resident once after admission. The Director of Nursing confirmed that R5 did not receive the necessary physician visits as required for a newly admitted resident. Additionally, the facility did not ensure routine physician visits for long-term residents, as evidenced by the cases of residents R1 and R6. R1's medical records indicated a lack of routine 60-day visits and alternating visits by a physician, with the last physician visit recorded several months prior. Similarly, R6's records showed a lack of routine 60-day visits, with the physician examining the resident only twice over several months. The Director of Nursing confirmed these deficiencies, and the facility administrator acknowledged the absence of a policy addressing physician delegation of tasks.

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 report allegations of verbal abuse immediately to the State Agency as required. Two residents, identified as R1 and R3, were involved in separate incidents of verbal abuse by staff members. R1, who was cognitively intact, experienced an incident with a maintenance worker, M-A, on 6/19/24, where M-A used curse words and made threatening gestures. This incident was reported to the State Agency nearly 48 hours later, on 6/21/24. R3, who had mild cognitive impairment, reported being verbally abused by a nursing assistant, NA-A, on 6/23/24. This incident was reported 16 hours later, on 6/24/24. The facility's policy requires that any suspected or known abuse be reported within two hours. However, in both cases, the staff failed to notify the administration immediately. R2, another resident, corroborated the incident involving R1 and M-A, stating that they reported it to the administration right away. The staff development director witnessed the altercation between R1 and M-A and intervened by asking M-A to leave the facility. Despite these actions, the delay in reporting these incidents to the State Agency constitutes a deficiency in adhering to the facility's abuse prevention 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

The facility failed to ensure that 54 of 72 residents with personal funds accounts had access to their funds as soon as possible to meet their individualized needs, especially after hours and on weekends. Interviews and document reviews revealed that residents and their family members were unaware of how to access funds outside of the limited business office hours. For instance, a family member expressed concern that a resident was not receiving his monthly income and was stressed about not knowing where his money was. Other residents reported difficulties in accessing their funds due to the restricted hours of the business office, which was only open from 8:00 a.m. to 9:00 a.m. on weekdays. Some residents were unaware of their account balances or how to access their money, while others had to wait in long lines during the limited window of time the office was open. The business office manager confirmed that residents could only access their funds during the specified hours and that there was limited access to the safe. On weekends, a cash box with $100 was available for emergencies, but this was insufficient for the residents' needs. The administrator acknowledged that the decision to limit access to funds was made for the convenience of the facility rather than the residents. The facility's policy indicated that residents could access funds during business hours and required advance notice for larger withdrawals, but this policy did not adequately address the residents' needs for timely access to their money. The administrator also noted that staff needed further education about resident funds and availability.

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 statements for resident personal fund accounts for 54 of 72 residents. Interviews with residents revealed that many were unaware of their account balances and had not received any statements. For instance, a cognitively intact resident stated she did not remember getting a statement but would like one, while another resident, also cognitively intact, mentioned he had not received any statements and did not know his account balance. Other residents, including those with moderate cognitive impairments, expressed similar concerns about not receiving statements and being unaware of their financial status within the facility. One resident even mentioned a specific issue with a cigarette program due to a lack of funds and not receiving any statements, which would have been helpful for him to understand his financial situation better. Interviews with facility staff, including the business office manager (BOM), administrator, and chief financial officer (CFO), revealed a lack of clarity and responsibility regarding the issuance of these statements. The BOM indicated that the CFO was responsible for running the quarterly statements, while the CFO stated that the BOM should be sending them out. The administrator was unsure when the last statements were sent out. The facility's policy mandates that residents and/or their representatives receive a written quarterly statement, including all deposits, withdrawals, and interest, but this was not being adhered to, leading to the deficiency.