Hillcrest Health Care, Llc

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 body pillows used as positioning devices were not implemented as physical restraints for 3 of 3 residents reviewed for restraints. R5 had diagnoses including a right femur fracture, osteoarthritis, dementia, osteoporosis, and a history of falling. After a witnessed fall, staff placed a body pillow under the sheets to prevent further self-ambulation, and the fall care plan was revised to include the body pillow under the sheets. R5 later had another incident in which she was found on the floor at the foot of the bed after family had placed her in bed without staff assistance. R11 had diagnoses of hemiplegia and hemiparesis affecting the left side and dementia. Her fall review identified her as at risk for falls due to scheduled narcotics, psychotropics, bowel and bladder incontinence, and being alert but unaware of mobility limitations. Her care plan included a body pillow for repositioning when in bed. During observation, staff placed a body pillow between R11 and the side of the bed underneath the sheet and tucked it securely into place, and the NA stated the body pillow was used to keep R11 in bed. R10 had diagnoses of hemiplegia and hemiparesis following cerebral infarction. Her MDS identified moderate cognitive impairment, daily physical and verbal behaviors, daily rejection of care, and need for substantial to maximum assistance with bed mobility and transfers. Her care plan included body pillows to outline the mattress parameter. During observation, a body pillow was tucked under the mattress sheet on the side of the bed, and the NA stated it was placed tightly so R10 would not remove it and so he would not attempt to get out of or roll out of bed. The nurse manager and DON stated body pillows should never be placed under the sheets to keep residents from getting out of bed and that doing so made the body pillow a restraint.

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 a fall with major injury to the state agency for one resident who was reviewed for falls. The resident had diagnoses including a right femur fracture, osteoarthritis, dementia, osteoporosis, and a history of falling. The resident’s admission MDS identified severe cognitive impairment, use of a walker/wheelchair, need for assistance with transfers and bed mobility, a recent fall with fracture prior to admission, and prior surgical repair of a fracture. The resident’s care plans identified the resident as a vulnerable adult and a fall risk due to impaired cognition, poor safety awareness, impulsiveness, and prior falls, with interventions including 15-minute checks and reporting suspected abuse or neglect according to facility policy. On 5/23/26, the resident was found on the floor at the foot of the bed lying on the left side after being placed in bed by the daughter without staff assistance. Staff reported the resident had last been checked and toileted at 1:15 p.m., and the resident was found at 1:45 p.m. with limited range of motion of the left upper extremity, yelling for help, and with pain rated 8/10 on the FLACC scale. The provider ordered transfer to the ED, and the resident was sent at 2:30 p.m. During interview, the DON stated the facility investigation confirmed the resident had not been checked every 15 minutes as required by the care plan and that there was no documentation showing eyes-on checks every 15 minutes. The DON also stated the fall was not reported to the SA because corporate nurses told her it did not need to be reported, but she acknowledged it should have been reported as a serious injury. The facility policy stated serious injuries determined to be the result of abuse, neglect, exploitation, or misappropriation must be reported to the state agency.

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 complete a comprehensive fall analysis, evaluate and revise the care plan, and implement fall interventions for two residents with severe cognitive impairment and high fall risk. One resident had diagnoses including dementia, osteoporosis, a prior femur fracture, and a history of falling. The resident’s assessments and progress notes documented impulsivity, attempts to stand or walk alone, need for supervision, and repeated falls or unsafe self-transfers. Although the record reflected interventions such as hourly checks, 15-minute checks, a fall mat request from family, a low bed, a body pillow, and wheelchair safety measures, the documentation did not consistently show that these interventions were assessed, revised, or implemented as the resident’s condition changed. For the first resident, the record showed multiple falls and repeated changes in behavior and mobility, including agitation, attempts to stand from the wheelchair, and later a witnessed fall that resulted in a left humeral fracture. The incident reviews did not include a comprehensive analysis of all relevant factors such as last known well time, pain, or toileting needs. The care plan was revised several times, but the record showed inconsistencies between the incident analyses, progress notes, and care plan interventions, including failure to include or maintain interventions such as the fall mat, bed height considerations, and wheelchair locking as identified in the documentation. The facility also documented 15-minute checks on the treatment record as one entry per shift rather than documenting each 15-minute check, and the resident later fell after not being checked for 30 minutes. For the second resident, the record identified severe cognitive impairment, hemiplegia/hemiparesis, dependence for transfers and bed mobility, and fall risk related to narcotics, psychotropics, incontinence, and lack of awareness of mobility limitations. After the resident was observed slipping from a Broda chair and sitting on the floor, the care plan was revised to include repositioning with a total mechanical lift and limiting time in the chair. However, during observation the resident was in bed without the fall mat on the floor and without the body pillow positioned as documented in the care plan. Staff acknowledged that the fall mat should have been placed when the resident was transferred to bed and that the body pillow was not supposed to be tucked under the sheet, but these interventions were not in place at the time of observation.

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 monitor fluid intake to ensure adequate hydration for a resident with malignant neoplasm of the brain, type 2 diabetes, moderate protein-calorie malnutrition, and an absence of the right leg below the knee. The resident’s care plan identified a goal to maintain adequate hydration and included offering fluids at and between meals, but the clinical nutrition evaluation did not identify fluid requirements and instead documented daily intake as 1500-2000 cc. The fluid intake record contained inconsistent entries, and there was no indication that 24-hour totals were calculated or evaluated to determine whether the resident met hydration needs, even though multiple days reflected totals below 1000 mL when calculated. On 4/12/26, the resident had an unresponsive episode after transferring on a mechanical standing lift, with dizziness, hypotension, and low oxygen saturation. The resident was sent to the ED, where testing showed signs of dehydration and the resident received IV fluids. The ED summary identified loss of consciousness, dehydration, and acute kidney injury, and instructed the resident to increase water intake. The resident’s record did not identify a revised care plan to address signs and symptoms of dehydration, acute renal failure, and syncope, and it did not identify a reassessment of daily fluid needs or a defined amount of fluid staff were to encourage. After the ED visit, the resident continued to have fluid intake documentation that was inconsistent and often low when totaled for the day. The record included multiple days with documented intake well under 1000 mL, along with entries such as resident refused, not applicable, or resident not available. On 5/7/26, the resident again had hypotension, shallow respirations, altered responsiveness, and was sent to the ED, where dehydration was favored, BUN was elevated, IV fluids were given, and the headache resolved with fluids and Tylenol. Interviews with NA, dietary, nursing, and the DON showed staff were unclear who monitored total daily fluid intake, how water passed outside meals was tracked, and what the plus/minus symbols on the TAR meant. The DON stated the documentation did not give a good idea of fluid intake or specify how many mL were offered and consumed, and there was no corresponding documentation that the IDT had reviewed the resident’s fluid intake.

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 safely store medications by allowing medications to be removed from their original labeled containers, leaving loose and unidentified medications in medication carts, failing to properly label medications after opening, and keeping expired medications in active stock on 2 of 2 medication carts observed. During an observation, an RN had three residents' medications set up in white souffle cups in the top drawer of the medication cart and stated she placed the room numbers on the bottom of the cups so she would know whose medications they were. She also stated she set medications up in advance so they would be ready to give if she was busy. During another observation, an LPN found Refresh Tears eye drops without an open date, a loose lidocaine patch, and a souffle cup with four unidentified pills in the cart and stated she did not know whose medications they were and would destroy them. On another cart, a TMA found Refresh eye drops with no date, inhalers stored together instead of separately, and Latanoprost eye drops with an open date of 4/27/26 and an expiration date of 6/8/26. During the cart audit, the ADON found two loperamide tablets in individual packages, 18 Tylenol tablets in a medication cup, two rosuvastatin tablets not in packaging, one expired nicotine patch, 10 loose bisacodyl tablets, two random eye drops, and multiple loose tablets including bupropion, carbidopa-levodopa, cymbalta, gabapentin, sertraline, seroquel, and haloperidol. The facility policy stated medications are kept in their original containers, may not be transferred to another container, must be dated when opened, and expired medications must be removed from active supply and destroyed.

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 hand hygiene was performed and enhanced barrier precautions (EBP) were used during incontinence care and a transfer for a resident with diabetes, dementia, chronic kidney disease, urinary retention, an indwelling catheter, and a wound. The resident’s MDS identified moderate cognitive impairment, dependence for toileting hygiene and transfers, substantial to maximum assistance for bed mobility, and use of a wheelchair. The care plan identified the resident was on EBP for catheter care and wound care, with interventions requiring staff to use gown and gloves for high-contact care activities. During observation, two nursing assistants entered the resident’s room and began attaching the resident to a full body mechanical lift without wearing gowns or gloves, despite the resident’s EBP sign outside the room and the resident’s wound and indwelling catheter. The assistants transferred the resident to bed and requested the ADON to perform wound care; the ADON entered with gown and gloves and instructed staff that gown and gloves were required for high-contact cares. One nursing assistant then put on gown and gloves without performing hand hygiene, removed stool from the resident’s bottom, removed gloves and put on new gloves without hand hygiene, and applied cream and a new brief using the same gloved hands. The DON stated it was her expectation that staff use gown and gloves for high-contact care activities and perform hand hygiene at the appropriate times.

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 failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.

Penalty

Inspection fine: $17,605

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 and respond appropriately to a significant change in condition for a resident, leading to a severe outcome. The resident, who had a history of congestive heart failure, cardiomyopathy, and other cardiac-related conditions, experienced a rapid weight gain of 37 pounds over 13 days. This weight gain was not reported to the physician as required by the resident's care plan, which specified notification for a weight increase of three pounds in one day or five pounds in one week. The lack of notification and comprehensive assessment of the resident's condition contributed to the resident suffering a heart attack, respiratory failure, and ultimately death. The resident's care plan included daily weight monitoring and specific instructions for notifying the physician of significant weight changes. Despite these orders, the facility did not consistently record or report the resident's weight changes, nor did they adequately assess the resident's edema and respiratory status. Interviews with staff revealed confusion and inconsistency in following the resident's Lasix medication orders, which were intended to manage fluid retention. The facility's failure to reconcile and clarify these orders with the cardiology team further exacerbated the resident's condition. Throughout the period leading up to the resident's death, there were multiple missed opportunities for intervention. Staff interviews indicated a lack of awareness and communication regarding the resident's deteriorating condition, including significant weight gain, increased edema, and respiratory distress. The facility's failure to adhere to the care plan and communicate effectively with healthcare providers resulted in a critical delay in addressing the resident's worsening heart failure, ultimately leading to the resident's hospitalization and death.

Removal Plan

• New process for daily weights which included updating all daily weight orders to include what the daily weight was, the difference between that weight and the prior days weight, what the seven day look back period was.
• Reviewed all the residents with daily weight orders.
• Added another level to the morning meeting and review weights from the previous day.
• Education to NA's that weights are collected prior to breakfast.
• Educated nurses on daily weight process, documentation, reporting changes.
• Educated leadership team on the whole process.
• Education that anytime a change of condition is identified the physician is notified.
• Updated care plans to reflect edema 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 adhere to the care plan for a resident requiring a full body mechanical lift for transfers, resulting in harm. The resident, who had a history of traumatic brain injury, dementia, and other conditions, was dependent on staff for transfers and required maximum assistance. Despite this, a nursing assistant attempted to transfer the resident alone, contrary to the care plan that specified two staff members were needed for such transfers. During the transfer, the resident, who was agitated and moving, fell from the lift, sustaining a subgaleal hematoma and a head laceration requiring staples. The incident occurred when a contracted nursing assistant, who was not fully oriented to the facility's procedures, responded to the resident's call light while covering for another staff member on break. The assistant, unaware of the resident's transfer requirements, attempted to transfer the resident alone using a mechanical lift. The resident was agitated and moving during the transfer, which led to the fall. The assistant did not seek help from other staff members, despite the resident's behavior and the facility's policy requiring two staff for such transfers. Interviews with staff revealed gaps in the orientation process for new and agency staff, as the assistant had not been adequately trained or informed about the specific needs of residents in the facility. The assistant had not completed a competency check for using mechanical lifts and was not aware of the requirement for two staff members for transfers. This lack of proper orientation and communication contributed to the incident, highlighting a breakdown in the facility's procedures for ensuring safe resident handling.

Removal Plan

• NA-A was suspended pending investigation.
• Facility-wide education with competencies on mechanical lifts began.
• Machine used for the transfer was locked out and inspected by facility maintenance department, along with manufacturer inspection of all mechanical lifts at the facility.
• Identification of the system breakdown for orientation of new hires and agency staff with an ad hoc meeting attended by DON, Administrator, and nurse scheduler.
• R1's care plan was updated to reflect trauma/risk of trauma from the fall from the lift.
• R1's orders were updated to include treatment to head wound, monitoring of site for infection, monitoring for signs and symptoms of emotional distress, skin assessment, cognition, depression screening, and trauma questionnaires completed and on-going as needed.
• Social services followed-up with R1 daily.

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 an allegation of staff-to-resident sexual abuse to the State Agency within the required two-hour timeframe. A resident, who had a history of sexual abuse and was diagnosed with depression, major depressive disorder, social phobia, and anxiety disorder, reported that a male staff member inappropriately touched her while she was using a mechanical lift. The incident was reported to a licensed practical nurse (LPN), who then informed the LPN supervisor. Despite the nurse practitioner's directive to notify the police and offer emergency department services, the LPN supervisor instructed otherwise, delaying the report to the authorities. The facility's administrator, upon being informed of the incident, did not consider it as abuse or assault, categorizing it instead as a customer service issue. This decision was contrary to the facility's Abuse Prohibition/Vulnerable Adult Policy, which mandates prompt reporting and investigation of all suspected abuse incidents. The medical director expected adherence to the protocol for reporting such incidents, which was not followed in this case. The failure to report the incident promptly and appropriately led to a deficiency in the facility's compliance with regulatory requirements.

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 person-centered comprehensive care plan for a resident who requested no male caregivers due to a history of sexual abuse. Despite the resident's clear communication of her preferences to multiple staff members, including registered nurses and nursing assistants, the care plan was not updated to reflect these preferences until after an incident occurred. The resident, who was admitted with diagnoses of depression, major depressive disorder, social phobia, and anxiety disorder, required significant assistance with daily activities and had no cognitive impairment. The resident's preference for female caregivers was communicated verbally during shift reports but was not documented in the care plan or progress notes, nor was a trauma assessment completed. The deficiency was highlighted when the resident reported an incident of inappropriate touching by a male staff member, which occurred after her preferences were known but not formally documented in her care plan. The care plan was only revised after this incident to include interventions such as female staff only for personal care, two staff present during all care, and the use of trauma-informed care. The facility's care planning policy required a person-centered care plan to be developed within 21 days of admission, but this was not adhered to in the resident's case, leading to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to implement a comprehensive process for reviewing antibiotic use, which is crucial for determining appropriate indications, dosage, duration, and monitoring trends of antibiotic use and resistance. The Director of Nursing (DON), who also serves as the infection preventionist, acknowledged that while the facility uses McGeer's criteria, staff do not consistently complete this documentation in the medical records. The DON has been in her role for a year and noted that there was no tracking form when she started. She is currently using the Minnesota Department of Health Infection Control Assessment and Response (ICAR) form for documentation, but the form was found to be incomplete for several months, with missing information on symptoms, test results, and resolution dates for infections. The review of the ICAR form from January to May 2024 revealed numerous incomplete entries, with missing data on symptoms, test results, and resolution dates for residents receiving antibiotics. The DON admitted that she has not been able to access hospital electronic medical records to verify culture results for residents who were hospitalized or tested in the emergency department. This lack of follow-up on culture results means that the facility cannot ensure residents are on the correct antibiotics. The facility's Antibiotic Stewardship Program outlines the need for reviewing antibiotic orders for appropriateness and completeness, but the current practices do not align with these guidelines, leading to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper cleaning of a mechanical transfer lift after use by three residents, leading to a deficiency in infection prevention and control practices. Resident 9, who has diagnoses including obesity and bipolar disorder, was observed being transferred using a mechanical lift by nursing assistants NA-E and NA-F. After the transfer, NA-F did not clean the lift before moving it to another room, which he later confirmed was an oversight. Similarly, Resident 26, who has a history of traumatic brain injury and dementia, was transferred using a lift by NA-A, who also failed to disinfect the lift after use. Additionally, during an observation, NA-A was seen cleaning a hoyer lift in Resident 45's room using inappropriate cleaning materials, specifically Mckessen Stay Dry disposable washcloths instead of disinfectant wipes. NA-A admitted to using resident wipes due to a lack of available disinfectant wipes, as they were instructed not to use bleach wipes. The Director of Nursing confirmed that lifts should be cleaned after each use and that resident wipes are not suitable for sanitizing equipment. The facility's Infection Prevention and Control Program policy emphasizes the importance of proper cleaning and disinfection to prevent infection spread.

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 cleanliness and sanitation in several areas, including hallway vents and resident rooms. Observations revealed that vents in the 400 and 500 hallways were covered with a black substance, which was identified as dirt and grime due to inadequate cleaning practices. The maintenance director admitted that the vents had not been thoroughly cleaned in years, and the current cleaning method was insufficient to reach all areas of the vents. Interviews with staff, including the environmental services director and maintenance director, confirmed the lack of a regular and effective cleaning schedule for these vents. In addition to the vents, numerous resident rooms were found to be in unsanitary conditions. Rooms had strong odors of urine, overflowing wastebaskets with soiled briefs, and rusty toilet bowls. Floors were dirty, with scuff marks and debris, and some rooms had dead insects and dusty surfaces. Interviews with residents and family members highlighted concerns about the cleanliness and maintenance of these rooms. The environmental services director acknowledged the shortage of housekeeping staff, which contributed to the inability to clean all rooms daily as expected. The facility also had issues with maintenance and repair, such as missing call light covers, unpatched and unpainted walls, and potential trip hazards near the main entrance. The maintenance director was aware of some of these issues but lacked a clear plan or schedule for addressing them. Interviews with staff and the administrator revealed that the facility had previously been cited for similar issues, but there was no evidence of a comprehensive plan to rectify these deficiencies. The administrator admitted that staffing shortages and performance issues with housekeepers were ongoing challenges that impacted the facility's ability to maintain a clean and safe environment.

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 was observed to have medications in his room, was appropriately assessed and deemed safe to self-administer medications. The resident, who had a history of stroke and severe cognitive impairment, was dependent on staff for activities of daily living. Despite this, medications including eye drops and topical ointments were found in the resident's room without a self-administration order. The resident's care plan indicated that he was inappropriate for self-medication administration, except for a specific balm to be administered by his wife as needed. Observations revealed that the resident's family member was administering medications, including eye drops and ointments, to the resident. Interviews with staff confirmed that the resident did not have a self-administration order and was resistant to staff administering medications, preferring his family member to do so. The facility's policy required that any unauthorized medications found at the bedside be turned over to the nurse in charge, but this was not adhered to, as medications were left in the resident's room for the family member to administer.

Penalty

No penalty information released

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

Summary

The facility failed to update the care plan and Kardex with behavioral interventions for a resident diagnosed with metabolic encephalopathy, bilateral below the knee amputations, and depression. The resident was cognitively intact and independent in some activities but refused oral care and bathing. Despite having physician orders for psychotropic medication monitoring, the care plan did not include mood and behavior monitoring or specific interventions for the resident's behaviors. The resident's care plan, dated over a year prior, indicated potential mood and behavior alterations but lacked specific interventions for managing these behaviors. The Kardex, used by nursing assistants, also failed to include necessary interventions for the resident's behaviors and refusals of care. Progress notes documented a pattern of problematic behaviors, including being argumentative, rude, and refusing medical care, but these were not reflected in the care plan or Kardex. Interviews with facility staff, including the DON and LPN, revealed that while the resident's behaviors were discussed in interdisciplinary team meetings, they were not consistently added to the care plan or Kardex. The LPN admitted to not identifying the missing behavioral interventions in the care plan, and the DON acknowledged the importance of having such information to guide staff effectively. The facility's care planning policy emphasized the need for person-centered care plans to meet individual resident needs, but this was not adequately implemented for the resident in question.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely incontinence care for a resident, identified as R42, who was dependent on staff for assistance with activities of daily living (ADLs). R42 had multiple diagnoses, including disorientation, malnutrition, Parkinson's disease, and epilepsy, and was at high risk for skin breakdown. The resident's care plan required staff to assist with all ADLs, including pericare after each elimination or incontinent episode, and to reposition the resident every two hours. However, observations revealed that R42 was left unattended for extended periods without being checked for incontinence or repositioned, despite being at high risk for skin breakdown. On multiple occasions, R42 was observed with a urine smell in the room and a soiled brief on the floor, indicating a lack of timely incontinence care. During a continuous observation period, R42 was not approached by nursing staff for toileting or repositioning, even when the resident attempted to move himself in his wheelchair and expressed discomfort. Interviews with staff, including a nursing assistant, LPN, RN, and the director of nursing, confirmed that R42 was not consistently checked or repositioned as required by the care plan. The facility's policy on activities of daily living emphasized the importance of providing person-centered care and ensuring residents receive necessary services to maintain hygiene and comfort. Despite this policy, the facility failed to adhere to the care plan for R42, resulting in inadequate incontinence care and a potential risk for skin breakdown. The deficiency highlights a gap in the facility's implementation of its ADL policy and the need for consistent staff adherence to care plans for residents with high care needs.

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 repositioning for a resident, identified as R42, who was dependent on staff for repositioning and was at high risk for pressure ulcers. R42 had multiple diagnoses, including disorientation, malnutrition, Parkinson's disease, and epilepsy, and was assessed to have moderate cognitive impairment and behaviors such as rejection of care. The resident required substantial to maximal assistance for transfers, bed mobility, toileting, and personal hygiene, and was noted to be at high risk for skin breakdown. Despite having a care plan that required repositioning every two hours, R42 was observed for several hours without being repositioned or checked for incontinence, which was contrary to the care plan. During the observation period, R42 was transferred to a wheelchair and taken to the dining room for lunch, where he remained for several hours without being repositioned or offered toileting assistance. Staff did not check R42's brief for incontinence during this time. Interviews with nursing staff, including a nursing assistant, an LPN, an RN, and the director of nursing, confirmed that R42 was at high risk for skin breakdown and should have been repositioned and checked for dryness every two hours. However, the staff were unaware that these actions were not performed as required by the care plan.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that staff were educated and following fall risk interventions for a resident identified at risk for falls, leading to multiple incidents. The resident, who had diagnoses including age-related cognitive decline, epilepsy, and Parkinson's disease, was assessed as being at risk for falls due to generalized weakness, impaired mobility, and cognitive decline. Despite having a care plan with specific interventions to prevent falls, such as using a grabber and ensuring the call light was within reach, these measures were not consistently implemented or followed by the staff. The resident experienced several falls, with incident reviews indicating that the resident slid from a recliner while attempting to throw something away, slipped out of a chair due to slippery shoes, and was found on the floor after attempting to get up from bed. In each case, the incident reviews noted contributing factors such as the resident's inability to realize limitations and the absence of necessary interventions like the grabber or garbage can within reach. Staff education and care planning were mentioned as necessary follow-up actions, but there was a lack of evidence that these were effectively carried out. Observations revealed that staff failed to consistently check on the resident or ensure that fall prevention interventions were in place. For instance, the resident was observed without a grabber or garbage can next to the chair, and staff were unaware of the specific interventions required. Interviews with staff indicated a lack of awareness and understanding of the resident's care plan, highlighting a deficiency in communication and adherence to fall prevention protocols. The facility's policy on fall prevention and management was not adequately followed, contributing to the repeated falls experienced by 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 provide timely assistance with toileting and changing soiled clothing for a resident, identified as R57, who required assistance with these activities. R57 had moderately impaired cognition and was occasionally incontinent of the bladder, with a care plan indicating the need for assistance with personal hygiene and toileting every two hours. Despite these documented needs, observations revealed that R57 was left in visibly soiled clothing for extended periods, with no offers of assistance from staff. Multiple observations noted R57 in soiled pants, with a strong odor of urine present, indicating a lack of timely intervention by the staff. Interviews with staff members, including nursing assistants and registered nurses, confirmed that R57 was not offered assistance with toileting as required by the care plan. Staff acknowledged the presence of urine odor and the need for assistance, yet R57 was observed using the bathroom independently and remaining in soiled clothing throughout the day. The facility's policy on Activities of Daily Living (ADLs) required that residents unable to carry out these activities receive necessary services to maintain hygiene and grooming. However, the staff failed to adhere to this policy, as evidenced by the lack of assistance provided to R57. Interviews with the director of nursing and other staff members highlighted a failure to consistently offer toileting assistance every two hours and to change soiled clothing immediately, as outlined in the resident's care plan 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 personal privacy for a resident (R6) who required staff assistance with personal care. R6, who had diagnoses including type 2 diabetes, obesity, dementia, and unspecified psychosis, was care planned to receive assistance from two staff members due to behavioral issues. On 3/27/24, a nursing assistant (NA-D) entered the room to change the roommate and, while the curtain was drawn, yelled about R6's behavior and wet sheet. NA-D expressed frustration and left the room angrily, contrary to the protocol of reapproaching the resident after 10 minutes as advised by the LPN-A. NA-D admitted to being upset and acknowledged the care plan requirement for two staff members during care due to R6's behaviors. The director of nursing (DON) stated that administration had educated NA-D and held a staff meeting on 3/27/24 covering customer service and dignity, but NA-D did not attend the meeting. The DON and Administrator confirmed that NA-D had not attended the meeting, and there was no paperwork verifying that NA-D received the education. This incident highlights the failure to maintain personal privacy and follow the care plan for R6, leading to a deficiency in the resident's right to a dignified existence and self-determination.

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 initiate, comprehensively assess, monitor, and treat skin conditions for four residents reviewed for impaired skin integrity. For Resident 2 (R2), the facility did not consistently follow treatment orders for skin care, resulting in missed treatments on multiple dates. R2's care plan included interventions such as monitoring skin integrity daily, weekly skin inspections, and applying specific wound care treatments. However, these interventions were not consistently implemented, and R2's skin condition worsened over time. Additionally, R2's wheelchair and recliner did not have pressure reduction cushions, contributing to the development and persistence of wounds. Despite recommendations for a larger wheelchair, R2 disagreed, and the facility did not ensure proper pressure relief measures were in place. Family members were not informed about R2's wound condition or the need for a larger wheelchair. The facility also failed to conduct weekly skin assessments as required, and there were inconsistencies in documenting and following up on R2's wound care needs. During wound care rounds, the appropriate wound care products were not used, and staff were not adequately educated on the correct treatments. The facility's failure to consistently implement and monitor R2's care plan and wound care treatments resulted in ongoing skin integrity issues and pain for R2. For Resident 3 (R3), the facility did not consistently follow the care plan for pressure ulcer prevention and treatment. R3's care plan included interventions such as using heel lift boots, placing pillows between knees, and conducting weekly skin inspections. However, these interventions were not consistently implemented, and R3's pressure ulcers worsened over time. During observations, R3 was found without heel lift boots, and pillows were not placed between the knees as required. The facility also failed to conduct weekly skin assessments and document wound care treatments accurately. R3's bed was found unmade, and the wound care treatment administration record was not signed out. The facility's failure to consistently implement and monitor R3's care plan and wound care treatments resulted in ongoing skin integrity issues and discomfort for R3. For Resident 4 (R4), the facility did not consistently follow the care plan for skin integrity and wound care. R4's care plan included interventions such as monitoring skin daily, weekly skin inspections, and applying specific wound care treatments. However, these interventions were not consistently implemented, and R4's skin condition worsened over time. The facility also failed to conduct weekly skin assessments and document wound care treatments accurately. During wound care rounds, an open, undated package of dressing was found in R4's wound supplies, indicating improper wound care practices. The facility's failure to consistently implement and monitor R4's care plan and wound care treatments resulted in ongoing skin integrity issues and discomfort for R4. For Resident 5 (R5), the facility did not consistently follow the care plan for skin integrity and wound care. R5's care plan included interventions such as monitoring skin daily, weekly skin inspections, and applying specific wound care treatments. However, these interventions were not consistently implemented, and R5's skin condition worsened over time. The facility also failed to conduct weekly skin assessments and document wound care treatments accurately. R5's readmission assessment identified a surgical incision on the right knee and skin tears on the left forearm, but weekly skin assessments were not completed for these areas. The facility's failure to consistently implement and monitor R5's care plan and wound care treatments resulted in ongoing skin integrity issues and discomfort for R5.