Edenbrook Rochester West

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 sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by repeated delays in responding to call lights and assistance requests for two residents who required extensive help with toileting, transfers, and incontinent care. The report identified that one resident had Parkinsonism, polyneuropathy, chronic pain syndrome, urge incontinence, Crohn’s disease, CKD stage 3b, protein-calorie malnutrition, and an ileostomy, and was dependent for toileting hygiene and transfers, required a mechanical lift, and was frequently incontinent of bladder. Another resident had CHF, COPD, chronic respiratory failure with hypoxia, morbid obesity, weakness, diabetic neuropathy, CKD stage 3b, atrial fibrillation, urinary retention, and oxygen dependence, and required substantial to maximal assistance with toileting hygiene and toilet transfers. Both residents stated staff were respectful but the facility needed more staff, and both described prolonged waits for toileting and call light response. One resident reported being left on the bedpan for prolonged periods, having pain to the buttocks, and having urinary incontinence because assistance took too long. The other resident reported being left on the commode for up to an hour, soreness to the buttocks, bowel incontinence because he could not wait long enough for toileting help, and urinals that were full overnight. Their call light logs confirmed repeated prolonged waits, including multiple delays over 15 minutes and several waits lasting 1 hour or longer, with one resident experiencing waits up to 2 hours and 18 minutes. Staff interviews and staffing records showed the facility was operating with staffing levels that did not match resident acuity. The staffing coordinator stated the facility had residents requiring two-person assistance and mechanical lifts, that nursing assistants did not have radios, and that delays were worse when a float aide was not scheduled. The coordinator said staffing was about 3.2 hours per patient day instead of the approximately 3.5 hours needed based on acuity, and that ideal staffing would include a float aide on day and evening shifts. The DON and RN acknowledged residents should not wait an hour for assistance, that response times should generally be within 10 to 15 minutes, and that the facility needed enough staff to meet resident needs timely. The facility assessment and staffing policies also identified a resident population with complex care needs, the need for prompt response to toileting requests, and staffing patterns to be based on census and acuity.

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 physician orders were in place for ostomy treatment and monitoring for a resident with an ileostomy. The resident had a history of Crohn’s disease, limited range of motion, and required substantial to maximal assistance with personal hygiene. Her care plan referenced ileostomy care as ordered, but it did not include direction or interventions for how to care for the ileostomy, and after earlier ostomy-related orders ended, no updated orders were entered to guide ongoing care. The resident’s records showed repeated problems with the ileostomy site, including redness, pain, swelling, leakage, skin irritation, erosion, bleeding, and an opening around the stoma. Nursing skin assessments documented ongoing redness and irritation over multiple weeks, and progress notes described severe pain and a red, bleeding stoma. The resident also required two courses of antibiotics for cellulitis. During observation, the resident stated the ostomy was leaking, the area was reddened, and she had a burning sensation almost all the time, with pain and anxiety because she felt the facility was not doing enough to reduce her discomfort. Staff confirmed the resident did not have specific orders for ostomy supplies or dressing changes and that they used whatever supplies were available in the room. The DON stated the facility had been trialing new ostomy supplies since the resident’s readmission and planned to enter orders once a set of supplies worked, but there was no documentation that the recommended hospital wound-ostomy supplies were tried or that they did not work. The medical director confirmed the resident did not have orders for ostomy appliance changes, including the size and type of appliance and treatment procedure, and stated those orders should have been entered after the resident returned from the hospital.

Penalty

No penalty information released

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

Summary

The facility failed to ensure direct-care nursing staff were appropriately trained and competent in the assessment and care of ostomies for one resident with an ileostomy. The resident was admitted with no cognitive impairment, limited range of motion in both upper and lower extremities, and substantial to maximal assistance needed for personal hygiene. The resident's MDS identified an ileostomy for fecal excretion, and the care plan listed ileostomy care as ordered, but it lacked direction or interventions describing how to care for the ileostomy. During interviews, RN-B and RN-A stated the resident did not have orders for specific ostomy supplies or dressing changes and that staff used whatever supplies were available in the room. Both nurses were unsure whether they had completed ostomy training or annual competency. LPN-B stated she did not know whether there was specific Relias training for ostomy care and was unsure if she had completed recent training. The DON stated the facility did not have specific ostomy training and confirmed staff had not received specific training on how to assess and care for the resident's ostomy. The facility assessment stated it could provide specialized treatment and care for ostomies, but ostomy care was not included in the standard list of in-services and required nursing competencies, and requested nurse staff competency transcripts were not received.

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 all dietary staff working in the food and nutrition service had training on equipment use, safe temperatures, and sanitation processes. During the initial kitchen tour, a dietary aide entered the kitchen without a hair net, and another dietary aide could not state the normal temperature ranges for the refrigerators and freezers, could not explain how to complete temperature checks for the new dishwasher, and stated it was acceptable to serve uncovered food from the freezer, keep food in the refrigerators without labeled expiration dates because it was used quickly, and store staff beverages in the main kitchen refrigerators. On follow-up, the dietary manager stated she had been hired two weeks earlier and had not verified the educational backgrounds of the current dietary staff, and she was unsure what education the dietary aides and cooks were required to complete. She confirmed that dietary staff should have education on proper food handling, covered containers, labeling, normal refrigerator and freezer temperatures, and how to check the dishwasher temperature. A dietary aide later stated the new dishwasher had been purchased a couple of weeks earlier and staff had not yet been shown how to verify temperatures, and the facility did not have the temperature strips. The administrator stated dietary staff complete food safety education at hire, annually, and when updates are needed, including food safety, infection control, appropriate temperatures, food storage, and how to use and measure temperature on the new dishwasher.

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 infection control practices in the kitchen when dietary staff were observed without proper hair and beard coverings while preparing food. During the initial kitchen tour, a dietary staff member greeted the surveyor inside the kitchen, then exited and applied a hairnet before returning to the stove to finish cooking lunch vegetables; the staff member stated the hairnet should have been put on before entering the kitchen and did not have a beard cover while at the stove. During the second kitchen walk-through, the dietary manager confirmed that everyone entering the kitchen was expected to wear a hairnet and beard cover if applicable, and the administrator later stated the same expectation for all staff entering the kitchen. The facility also failed to monitor a new commercial dishwasher and failed to properly label, date, cover, and discard food stored in refrigerators and freezers. Staff stated the dishwasher had been installed only a few weeks earlier, but there was no temperature tracking sheet and no monitoring had been done since installation because staff had not been trained to perform it. Surveyors also observed frozen omelets in an opened undated bag with ice crystals, uncovered prepped ice cream, pudding dated 10/31, cranberry sauce dated 11/4, undated thawing chicken, undated mayonnaise, an undated bag of lettuce turning brown, undated ham, and undated sausage. The dietary manager and administrator confirmed the expectations for dishwasher monitoring and food dating and disposal, and the facility policy required proper hair and beard coverings, labeling and dating of food items, food covering, and equipment 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 comprehensively assess and initiate a plan of care for a resident with an ileostomy. The resident’s MDS, dated 09/12/25, identified no cognitive impairment and noted an ileostomy used to manage fecal excretion. The care plan dated 6/24/2025 identified an ileostomy and alteration in elimination, with an intervention of ileostomy care as ordered, but it lacked direction or specific interventions for how to care for the ileostomy. During observation and interview on 11/18/25, the resident stated the ileostomy was leaking, needed to be changed, and that the skin around the ostomy was reddened with a burning sensation almost all the time; the resident also stated the condition caused pain and anxiety because the facility was not doing enough to reduce the discomfort. An RN stated the ostomy appliance had been changed 3 times in the prior 12 hours and that she used whatever supplies were in the room, confirming there were no active orders for specific ostomy supplies and no care plan detailing ostomy care. The DON confirmed there were no current orders for specific ostomy supplies and no active ostomy-specific care plan, stating staff were trialing supplies and would enter orders and initiate a complete care plan once they found supplies that worked. The DON also confirmed staff should use the care plan to know what supplies were being used and that an ostomy-specific care plan should have been done to ensure correct supplies were used and to outline what was normal or abnormal for the resident’s ostomy. The MD confirmed the resident had Crohn’s disease with an ileostomy and would expect nursing to notify him if the ileostomy had complications such as redness, pain, or swelling; he also confirmed there were no current orders for ostomy appliance changes and no care plan for the ostomy.

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 professional standards of practice when staff completed ostomy treatments and later entered ostomy care orders in the MAR/TAR without verification from an authorized prescriber for a resident with an ileostomy. The resident’s MDS dated 09/12/25 identified no cognitive impairment, limited range of motion in both upper and lower extremities, and the need for substantial to maximal assistance with personal hygiene. The resident’s care plan dated 6/24/2025 identified an alteration in elimination and listed ileostomy care as ordered, but it lacked direction or interventions for how to care for the ileostomy. The resident’s TAR and MAR lacked ostomy change orders, ostomy site assessments, ostomy supplies, dates and times of appliance changes, and the staff completing the changes. During interview and observation, RN-B stated the resident did not have orders for specific ostomy supplies or dressing changes, that the resident required frequent, almost daily dressing changes, and that staff used whatever supplies were in the room. RN-B also stated that, without an order, staff sometimes documented in a progress note. The DON confirmed the resident had only one ostomy care order and that it was not sufficient, then stated she created and entered generic ostomy care and treatment orders without first conferring with a provider. The MD confirmed that a provider writes ostomy care orders and that the resident did not have orders for ostomy 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 ensure that a resident with an ileostomy had active physician orders for the resident’s care and treatment. The resident’s MDS assessment identified no cognitive impairment, limited range of motion in both upper and lower extremities, and the need for substantial to maximal assistance with personal hygiene. The resident’s care plan identified an alteration in elimination and referenced ileostomy care as ordered, but it did not include direction or interventions for how to care for the ileostomy. The resident was initially admitted with orders for ostomy monitoring and care, including instructions to call the MD for specific signs and symptoms, change the ostomy flange and bag every 3 days and as needed, empty the pouch every shift or when one-third full, cleanse the area with warm water and gentle soap, and apply skin prep after cleansing. Those orders ended on 8/1/25, and no additional updated orders were entered for ostomy care. RN-B stated the resident did not have orders for specific ostomy supplies or dressing changes and that staff used whatever supplies were available in the room. The DON confirmed the resident did not have active orders or an established ostomy care plan, and the MD stated the resident did not have orders for ostomy appliance changes or treatment procedure, even though he was familiar with the resident’s ileostomy related to Crohn’s disease.

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 consulting pharmacist recommendations were addressed or acted upon for one resident reviewed for unnecessary medications. The resident’s MDS assessment identified no cognitive impairment, limited range of motion of both upper and lower extremities, and diagnoses including metabolic encephalopathy, Lewy body dementia, parkinsonism, psychotic disturbances, major depressive disorder, and moderate anxiety. The resident’s medication orders included cyanocobalamin 1000 mg orally daily and diclofenac sodium external gel 1% applied to the right chest and arms four times per day. Pharmacy recommendations were issued on multiple monthly reviews to change cyanocobalamin to 1000 mcg orally daily, change diclofenac sodium gel to apply 2 g to the right chest and arms four times per day, and verify the need for clobetasol propionate external solution because it was not reordered after hospital re-admission. The resident’s MAR showed cyanocobalamin 1000 mg was administered daily and diclofenac sodium gel was administered four times per day over several weeks, while clobetasol remained unordered. The medical record lacked evidence that the pharmacy consultant recommendations were addressed and corrected in a timely manner, and the DON stated the recommendation process breaks down when the form is not returned from providers.

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 respiratory equipment was properly maintained for 2 residents who used oxygen therapy. R27’s records showed a diagnosis of saddle embolus and obstructive sleep apnea, with orders for oxygen at 2 liters per nasal cannula at rest and 4 liters with activity, along with CPAP use and daily distilled water changes. During multiple observations, R27’s oxygen concentrator in the room had broken plastic housing where the tubing connected, with a metal connector hanging outside the machine and internal green tubing visible. The broken condition remained unchanged across repeated observations, and the oxygen supply company representative stated broken concentrators should be reported and replaced, but there was no documentation that the facility requested a new concentrator for R27. R2’s records showed mild cognitive impairment, independence with most activities of daily living, and oxygen therapy orders including weekly tubing and humidifier bottle changes, oxygen saturation checks, respiratory assessments, and oxygen at 2 lpm via nasal cannula as needed for respiratory distress. During observation, R2 was lying in bed wearing nasal cannula while the oxygen concentrator on the floor had broken casing at the humidifier bottle attachment point. Bright pink and white emery boards were protruding from the machine and were being used by R2 to hold the water bottle in place. R2 stated she had placed the emery boards there because staff changed the tubing and filled the humidifier bottle, and she could not recall how long they had been in the machine. Staff who observed the equipment did not identify the broken casing or the emery boards as a problem at the time. An LPN stated she was not aware the concentrator casing was broken and did not know what the protruding object was. An RN stated the machine was functioning because only the plastic was broken and acknowledged the oxygen supply company had been made aware of the broken concentrator, though she was unsure when. The DON later observed both residents’ concentrators, stated she had not been aware R27’s concentrator was broken, and said she would expect broken equipment to be replaced and locked out so others cannot use it. The facility’s oxygen policy did not provide direction for broken equipment.

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 appropriate discharge information was communicated to the receiving assisted living facility and failed to obtain provider discharge orders before the resident left the facility. The resident had multiple diagnoses including respiratory failure, diabetes, COPD, depression, sleep apnea, heart failure, kidney disease, and dependence on oxygen, and was receiving scheduled insulin with sliding scale coverage, wound care, oxygen, and CPAP therapy. The resident’s discharge MDS showed assistance needs for bathing, dressing, toileting, transfers, and bed mobility, and the medication record included multiple routine and PRN medications, insulin, and other treatments at the time of discharge. Care conference notes showed the resident, family, DON, therapy staff, and social worker discussed discharge back to the prior assisted living apartment, including requests for scripts for a hospital bed and bariatric shower chair. Progress notes later documented the resident packing belongings and planning to leave, and then being discharged with family. The receiving assisted living director stated that when the resident arrived, there were no provider orders for medications or treatments, and she had to obtain orders from the primary provider after the fact. She stated the facility did not send the resident’s medications with her and identified needed discharge orders for medications, therapy, CPAP, wheelchair, and a hospital bed. Facility documentation and interviews showed the discharge paperwork was incomplete at the time of transfer. The assisted living director’s notes stated the resident returned without medications, paperwork, and requested tasks completed, including discontinuation of sliding scale insulin, a hospital bed, and doctor’s orders. The DON confirmed the discharge orders were faxed but the facility could not provide proof of transmission and the resident’s record did not contain signed provider orders. The DON also confirmed a DME order for the hospital bed was not written. The facility policy required the attending physician to write a discharge order including medication disposition and required a discharge summary with medication reconciliation and other medical information for the receiving provider.

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 nurse staffing data sheet was posted in a place readily accessible to residents, families, and visitors. During observation on 11/17/25 at 11:28 p.m. and again on 11/18/25 at 12:28 p.m., no staff posting was observed in the facility. During interview on 11/19/25 at 1:48 p.m., the administrator stated the staff posting was usually posted on the wall near the kitchen, but it had been replaced by directional signage for visitors, and the facility did not find a different location for the staff posting. The facility policy titled Staff Posting, revised 10/19/23, stated the facility shall post daily, for each shift, the actual hours and total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care, and that the posting must be verified at the beginning of each shift in a clear and readable format.

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 identify, assess, monitor, and follow physician orders for signs and symptoms of hypoglycemia in a resident with diabetes, resulting in an immediate jeopardy situation. The resident, who had a diagnosis of diabetes mellitus and rhabdomyolysis, experienced multiple episodes of low blood sugar that were not properly addressed according to physician orders and facility protocols. Blood glucose levels were not consistently monitored, and there was a lack of timely intervention and notification to the provider when hypoglycemia was identified. On the day of the incident, the resident's blood sugar was recorded as 81 in the morning, and diabetes medications were administered. Later in the day, the resident's blood sugar dropped to 54, but there was no documented assessment for hypoglycemia symptoms, no recheck of blood sugar after a meal, and no notification to the physician. Despite a further drop in blood sugar to 39, the required interventions, including administration of glucagon and continuous monitoring, were inconsistently documented and not all actions were taken as ordered. The resident continued to receive diabetes medications without appropriate blood sugar checks, and staff failed to notify the provider or reassess the resident as required. Interviews with nursing staff revealed a lack of education and understanding regarding diabetic monitoring and hypoglycemia management. Staff did not follow hypoglycemic protocols, did not consistently document interventions, and failed to notify the provider in a timely manner. The resident ultimately became lethargic and was transferred to the emergency department, where a critically low blood sugar was confirmed, requiring intensive treatment. The facility's own policies and physician orders for hypoglycemia management were not followed throughout the incident.

Removal Plan

• Educated licensed nursing staff and agency staff about diabetic management of hypoglycemia and hyperglycemia monitoring, assessing, treatments, physician notification and standards of documentation with competency testing.
• Reviewed all residents with diagnosis of diabetes to ensure blood glucose levels were within range, had diabetic protocols in place, care plans were accurate and provider orders were followed.
• Reviewed facility Diabetic Monitoring and Change of Condition policies for accuracy.

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 nutritional needs were adequately met, as evidenced by the lack of comprehensive assessment of food preferences, unavailability of physician-ordered nutritional supplements, and failure to obtain daily weights as ordered by the physician. The resident, who had chronic kidney disease stage 5 and was dialysis-dependent, experienced significant weight loss over several months. Despite having orders for daily weights and nutritional supplements like Boost Breeze and ProHeal, these were not consistently provided or documented. The resident's care plan did not address goals for the nutritional supplements or food preferences, leading to inadequate nutritional support. The resident expressed dissatisfaction with the facility's food, preferring Mexican cuisine, and often relied on food brought by family members. Interviews with staff revealed that the resident frequently refused facility meals and supplements, citing nausea and preference for juice-based supplements over milk-based ones. Despite these refusals, there was no documentation of physician notification or alternative interventions being implemented. The facility's failure to provide the ordered nutritional supplements and daily weights, along with the lack of communication with the physician regarding the resident's refusals and weight loss, contributed to the deficiency. Staff interviews indicated a lack of awareness and follow-through on the resident's dietary needs and preferences, further exacerbating the resident's nutritional risk. The facility's policy on diet orders and monitoring was not adhered to, resulting in inadequate nutritional care for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to consistently monitor food temperatures before serving, which could lead to foodborne illness. During a kitchen tour, it was observed that the resident refrigerator had loose debris and an unknown sticky substance, and items were not labeled. The freezer in the basement had loose frozen carrots, ice buildup, and frost around the door. The dietary manager admitted there was no cleaning log or schedule, and the refrigerator and freezer were shared by nursing and dietary staff. Additionally, during meal service, food temperatures were not consistently checked, with puree pasta and chicken being served at temperatures below the required holding temperature. The review of Service Line forms from October 1 to October 22 revealed multiple instances where food temperatures were not documented, particularly for pureed foods. Interviews with staff, including the dietary manager, regional dietary manager, dietician, and director of nursing, confirmed the expectation that food temperatures should be monitored to ensure safe serving temperatures. The dietician expressed concern about the cleanliness of the resident refrigerator and acknowledged the risk of foodborne illness if food is not held at appropriate temperatures.

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 accurately assess a resident's oral health and dietary needs, leading to inappropriate meal provisions. The resident, who was moderately cognitively impaired and diagnosed with conditions including moderate protein calorie malnutrition and dementia, was observed having difficulty chewing due to missing teeth. Despite this, the resident's nutritional assessment inaccurately reported no difficulty chewing or swallowing, and the care plan did not address the need for a mechanically altered diet. Observations revealed the resident struggled to chew and consume meals, indicating a significant oversight in the assessment process. The registered dietitian admitted to not pursuing further evaluation after a preference assessment and did not observe the resident eating as part of the assessment. The dietitian also acknowledged that the resident should have been evaluated by speech therapy for chewing difficulties. The facility's nutritional assessment guidelines emphasize the importance of assessing oral health and dentition, which was not adequately done in this case. This deficiency highlights a failure in the facility's assessment process, resulting in the resident receiving meals that were not suitable for her condition.

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 administration of insulin using a FlexPen for a resident receiving sliding scale insulin. During an observation, a registered nurse (RN) prepared to administer 8 units of Novolog Aspart insulin to a resident with a blood glucose reading of 264. The RN checked the pen against the medication administration record, dialed the pen to 2 units, and depressed the plunger without attaching the needle, which is contrary to the manufacturer's instructions. The RN was unaware that the needle should be attached before priming the pen, indicating a lack of knowledge about the correct procedure. The director of nursing and a corporate nursing consultant confirmed that the facility had a policy on medication administration, including insulin, and that staff had been trained accordingly. The facility's policy, as well as the manufacturer's instructions, clearly outlined the correct steps for insulin pen use, including attaching the needle before priming. Despite this, the RN did not follow the correct procedure, leading to a significant medication error. The incident highlights a gap in the RN's understanding of the insulin administration process, despite having received training.

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 proper use of personal protective equipment (PPE) for a resident under enhanced barrier precautions (EBP). The resident, identified as R8, was cognitively intact and had several medical conditions, including Parkinson's disease, severe protein-calorie malnutrition, and gastrostomy status. R8 required a feeding tube and was on EBP due to the presence of this indwelling medical device. During an observation, a nursing assistant (NA-A) was seen wearing gloves and a hospital gown instead of the required disposable blue gown while providing care to R8. This included assisting the resident with mobility, hygiene, and changing linens, which are high-contact activities necessitating the correct PPE. Interviews with the infection preventionist (IP) and the director of nursing (DON) confirmed that the facility's policy required the use of specific PPE, including disposable blue gowns, for residents on EBP to prevent the spread of multidrug-resistant organisms (MDROs). The IP and DON both acknowledged that NA-A did not adhere to the facility's PPE policy. The facility's policies on EBP and PPE clearly outlined the necessity of using appropriate gowns and gloves for high-contact care activities and the disposal of gowns in the correct waste receptacle.