Villas At Bryn Mawr 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 deficiency involves the facility’s failure to adequately assess, care plan, implement interventions, and provide supervision for a resident who was NPO and dependent on G-tube feedings, despite known food-seeking behaviors and severe cognitive impairment. The resident’s admission MDS documented severe cognitive impairment, dependence on staff for ADLs, incontinence, and G-tube nutrition, with NPO status due to dysphagia and a history of silent aspiration. On 2/19, the care plan and a risk-versus-benefit form identified that the resident self-sought food and fluids while NPO, required reminders and redirection, and was at risk for aspiration, pneumonia, loss of airway, hospitalization, and possible death if consuming oral intake. The RD documented that the resident was self-seeking food and fluids, had impaired cognition, and could not repeat back understanding of the NPO education, and an order was added to the TAR to observe for self-seeking food and provide re-education as needed. Subsequent clinical notes showed ongoing concerns that the resident was eating and drinking despite strict NPO orders. On 2/25, the NP documented that staff reported continued food- and fluid-seeking, and the resident nodded yes when asked if she was eating or drinking; a chest X-ray was ordered, which was normal. On 3/4, the NP again documented silent aspiration, cough, coarse lung sounds, and that the resident continued to report oral intake despite strict NPO, and another chest X-ray was ordered and read as normal. An email exchange on 2/24 showed the IDT was aware of the resident’s low SLUMS score indicating dementia, wandering, and the need for a memory care bed, but no new interventions were established beyond continued monitoring when no memory care bed was available. Staff interviews and documentation revealed multiple unaddressed episodes of food-seeking and wandering into areas where food was present. A staff member reported seeing the resident eating a gummy jolly rancher given by another resident and observing her wandering into other residents’ rooms and attempting to eat food from leftover trays, as well as being in the dining room during and after meals; the record lacked evidence of any action taken in response to these events. Another staff member also reported seeing the resident wandering all over the unit and in the dining room during and after meals. The SLP stated the resident had severe cognitive deficits, wandered around the unit, did not understand what NPO meant, and was at high risk for aspiration if she ate regular food or fluids, based on a prior hospital video swallow study recommending NPO. The NP later stated she was never informed about the resident eating gummy candy and would have expected immediate notification for further assessment and monitoring. Ultimately, the resident was found unresponsive with heavy breathing and a very high temperature, was sent to the ED, and was diagnosed with acute hypoxic and hypercarbic respiratory failure with aspiration pneumonia; large food material was suctioned from the oropharynx, and the resident required intubation and CPR for a brief cardiac arrest. The surveyors concluded that the facility failed to assess, develop, and implement appropriate interventions and supervision for this known NPO, food-seeking resident, resulting in an immediate jeopardy situation.

Removal Plan

• Completed a full house audit of residents with modified diets
• Audited care plans for residents with modified diets
• Provided training to staff on modified diets and changes made to care plans

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 adequately assess and plan care to ensure that a resident’s tube feeding needs were met, resulting in significant weight loss in less than 30 days. The resident’s admission MDS documented diagnoses of malnutrition, anxiety disorder, and depression, with severe cognitive impairment and NPO status, and indicated that tube feeding provided nutrition. The care plan noted that the resident self-sought food and fluids while NPO, required reminders and redirection due to poor cognition, and had actual alteration in nutrition with weight loss over 30 days related to inadequate caloric intake, evidenced by disconnecting the feeding prior to the end time. A Risk vs. Benefits form completed by the RD stated that the tube feeding met 100% of the resident’s nutrition and hydration needs and that disconnecting the tube feeding prior to the prescribed time could result in continued weight loss, malnutrition, dehydration, return to hospitalization, or possible death. Dietary documentation showed that the RD identified a weight drop from 168 lbs to 155 lbs in less than 30 days, confirmed by reweight, and staff reported that the resident often disconnected the feeding before completion, leading to inadequate caloric intake. Staff also reported that the resident moved frequently in bed, placing the tube at risk of being tugged or pulled. The RD documented that the resident had poor cognition and was difficult to assess for understanding of the risk vs. benefits discussion. The RD re-estimated the resident’s nutritional and fluid needs and recommended a bolus tube feeding regimen with specified formula volumes and water flushes to meet calculated caloric, protein, and fluid requirements, and noted that the provider was notified of the weight loss related to the resident’s noncompliance with the feeding regimen. Weight records in the facility’s electronic system showed multiple entries over the period in question, including an entry that the RD later struck out as incorrect after obtaining a second weight that confirmed 155 lbs. The RD acknowledged that she discovered the weight loss on the same day she learned from staff that the resident was disconnecting the tube feeding, and that she did not speak with the RN about the incorrect weight or re-educate staff on handling incorrect weights. Interviews indicated uncertainty among staff about how long the resident had been disconnecting the tube feeding, and at least one NA reported never seeing the resident disconnect the feeding. The facility’s weight policy required accurate weights and monitoring to ensure residents’ nutritional parameters were maintained, with more frequent monitoring for high-risk residents at the discretion of the interdisciplinary team and/or physician, but the documentation and interviews showed gaps in accurate weight documentation and timely response to the resident’s behavior of disconnecting the tube feeding in the context of significant weight loss.

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 promptly assess and treat newly developed skin breakdown and to timely implement ordered interventions for pressure ulcer care for one resident. The resident initially had intact skin documented on a weekly skin inspection at the end of November, and a significant change MDS in early December showed no unhealed pressure ulcers, though it noted a recent fall with wrist fracture and increased need for assistance. A Braden assessment shortly after the fall scored the resident as low risk, despite dementia, diabetes, stage III kidney disease, incontinence, and increased dependence with mobility and transfers. On 12/6, a weekly skin inspection documented an “ongoing open area on left buttock” but did not include measurements, wound characteristics, or any treatment provided. A subsequent CAA signed 12/11 stated the resident did not have any pressure ulcers, even though it identified the resident as at risk for skin breakdown. On 12/11, another weekly skin inspection noted redness and a wound to the scrotum, again without clarifying whether this was the same area as previously documented or whether the earlier area had healed, and without documenting any treatment. On 12/12, skin issues were formally measured and recorded as MASD on the sacrococcygeal area and left gluteus, and another note the same day identified MASD to the scrotum and left buttocks with a plan for barrier cream, but there was no corresponding documentation on the TAR to show that barrier cream was consistently applied. On 12/16, a wound care PA evaluated the resident and documented scattered erosions over the right buttock and sacrum, with MASD to the buttock/sacrum, and recommended meticulous pericare, Triad paste BID and PRN, repositioning per Braden protocol, initiation of an APM, and RD review of nutritional needs. The record shows Triad paste treatments beginning 12/17, but the APM and RD evaluation were not implemented at that time. By 12/23, the sacrococcygeal area had progressed to an unstageable pressure ulcer with necrotic tissue, and the wound care PA again documented that the requested APM was not in place, re-requested it, and again asked for RD evaluation and wound-healing supplements. The care plan was not updated with new skin interventions until 12/24, and the APM was not documented as in place until 12/29, despite being readily available. Throughout December, provider regulatory visits did not address the resident’s skin condition, and Braden scoring continued to rate the resident as low risk. By 12/30, skin assessments documented multiple unstageable pressure ulcers and additional MASD areas, with the sacral wound significantly enlarged and new pressure ulcers on the buttocks, while the IDT did not complete a comprehensive assessment of the initial buttock wound identified on 12/6 or its progression from MASD to pressure ulcer until after the resident was hospitalized in early January. The facility’s own policy on Skin Assessment & Wound Management required that when a new pressure wound is found, staff notify the provider, initiate a skin and wound evaluation, refer to dietary as needed, and review and update the care plan interventions. The record lacked evidence that these steps were carried out when the first open area was documented on 12/6 or as additional areas and worsening wounds were identified. The TAR showed that the first documented treatment for the developed skin breakdown did not begin until 12/17, despite earlier documentation of open areas and MASD. Recommendations from wound care providers for an APM and RD evaluation were not acted upon for weeks, and the IDT did not complete a pressure injury root cause analysis or comprehensive review of the wounds until after the resident had been transferred to the hospital and did not return. Interviews with nursing staff and leadership confirmed that the root cause analysis process was not initiated when the wounds first developed and that the RD was not notified in a timely manner of the need for nutritional evaluation related to the resident’s wounds.

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, depression, and back pain was admitted to the facility with significant mental health needs and a self-care deficit. The resident consistently refused assessments, hygiene care, and interventions from staff since admission, including skin checks and bathing. Despite being identified as at risk for skin breakdown, malnutrition, and having altered mobility, the resident's refusals were documented, and staff reported ongoing concerns about her hygiene, malodor, and declining condition. The care plan included interventions such as regular skin assessments, turning and repositioning, and nutritional support, but these were not effectively implemented due to the resident's persistent refusals. Over a period of several weeks, the resident's condition deteriorated. Staff, including nurses and providers, noted malodor, suspected wounds, and poor hygiene, but were unable to perform thorough assessments or provide adequate care due to the resident's lack of cooperation. The resident remained mostly in bed, was unkempt, and had poor oral hygiene. Despite these observations and the resident's ongoing refusal of care, the facility did not escalate her care to a higher level or seek alternative interventions to address her worsening condition. Communication among staff, providers, and the interdisciplinary team acknowledged the refusals, but no decisive action was taken to ensure the resident's safety and well-being. The situation culminated when the resident called EMS due to dizziness, vomiting, and inability to move her lower extremities. Upon EMS arrival, the resident was found adhered to her mattress, covered in urine and feces, and in a severely neglected state. Hospital admission revealed malnutrition, maggots in the groin area, an embedded bra hook causing deep tissue injury, multiple pressure ulcers ranging from stage one to stage four, and significant skin tears. The facility and its staff were aware of the resident's refusals and deteriorating condition but failed to provide necessary care or transfer her to a higher level of care, resulting in a finding of neglect.

Removal Plan

• Completed a full house skin check audit.
• If a resident had refused, a skin check was done.
• Audited all care plans for refusing skin checks.
• Updated target behavior orders to include a section regarding refusal of cares, showers, and skin checks.
• Clinical team attends ACP meetings to discuss concerning behaviors and update care plans.
• Morning meeting agenda includes a section for refusal of care.
• In case of refusal staff updates the individual department team meetings, schedules care conference, does a behavior contract or other individual specific interventions.

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 a resident with profound cognitive impairment and a history of elopement, who resided on a locked unit and required 24/7 supervision, was able to leave the facility without staff knowledge. The resident had a severe traumatic brain injury, lacked decision-making ability, and was identified as being at high risk for elopement, as documented in their hospital discharge summary, care plan, and elopement risk evaluation. The care plan included interventions such as monitoring a wanderguard, promptly answering door alarms, and keeping the guardian informed. On the day of the incident, the resident participated in an outdoor activity in the facility's parking lot to pet baby goats. During this activity, the activity director left the area to escort another resident back to the locked unit and asked the activity assistant to supervise the remaining residents, including the high-risk resident. The activity assistant, who was responsible for multiple residents, was not able to provide adequate supervision and did not notice when the resident left the area. The resident was later found by police on a busy street approximately a half mile from the facility. Interviews with staff, including the activity director, activity assistant, nursing assistant, LPN, and others, confirmed that the resident required close supervision due to impulsivity, mobility, and a tendency to elope. Staff acknowledged that the root cause of the incident was a lack of adequate supervision, particularly when responsibility for the resident was transferred between staff members. The facility's elopement policy required interventions for residents at risk, but these were not effectively implemented during the outdoor activity, resulting in the resident's unsupervised departure from 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 report a reasonable suspicion of a crime, specifically an allegation of sexual abuse, to law enforcement as required by regulation and facility policy. A resident with significant vulnerabilities, including hemiplegia, cognitive impairment, and a history of trauma, reported being inappropriately touched by another resident. The incident was documented by the social services director and reported to the state agency, and the resident's provider and guardian were notified. However, there was no documentation or evidence that law enforcement was notified of the allegation. Interviews with facility staff, including the administrator and social services director, confirmed that the incident was not reported to law enforcement. The administrator stated that the decision not to report was based on the resident's refusal to involve the police, despite the facility's policy requiring the reporting of suspected crimes such as sexual abuse. Facility records, including incident reports and progress notes, consistently lacked any indication that law enforcement had been contacted regarding the allegation.

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 revise the care plan to include a critical elopement-safety intervention for a resident with a history of wandering and severe cognitive impairment due to traumatic brain injury. The resident was admitted with orders to reside in a locked unit and was identified as being at high risk for elopement, requiring 24/7 supervision. Despite these known risks and a previous elopement incident at another facility, the care plan did not reflect the need for 1:1 supervision when the resident was taken off the locked unit. On the day of the incident, the resident was taken outside with staff to see animals and subsequently went missing from the front parking lot. Elopement protocols were initiated, and the resident was returned by police without injury. Interviews with staff and leadership confirmed that the root cause of the elopement was inadequate supervision and that the care plan had not been updated to include the newly implemented intervention of 1:1 supervision when off the locked unit, despite this being recognized as necessary after the incident.

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 assess a resident with a history of post-traumatic stress disorder (PTSD), adjustment disorder, and other mental health diagnoses for additional trauma or psychosocial needs following an allegation of sexual abuse. The resident, who had been in the facility since 2004, was reported to have been touched inappropriately by another resident. Although the incident was reported to the state agency, and the resident's provider and guardian were notified, there was no documentation that a trauma assessment was completed after the incident. The resident's care plans identified her as being at risk for behavioral alterations related to trauma and PTSD, and interventions included considering past trauma and collaborating with psychology and social services. Despite these documented risks and the facility's policy on trauma-informed care, the most recent trauma assessment on record was over a year old and predated the incident. Interviews with facility staff confirmed that trauma assessments were expected after such incidents, but none was completed in this case. The social services director acknowledged the importance of trauma assessments post-incident but had only spoken with the resident, who declined to discuss the event further. Additionally, the resident's psychology provider was not notified of the incident, contrary to facility expectations and best practices. The provider stated she would typically be informed of such events to assess for signs of distress or behavioral changes. Facility policy required identification and care planning for trauma history, but the lack of a timely trauma assessment and communication with the psychology provider after the allegation constituted a failure to provide appropriate treatment and services for the resident's mental and psychosocial well-being.

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 a diagnosis of nicotine dependence and traumatic brain injury received physician-ordered nicotine lozenges to address nicotine cravings. The resident had an active order for 2 mg nicotine lozenges to be given by mouth every hour as needed, but the medication administration record showed that from the beginning to the end of the month, no doses were administered. During interviews and observations, the resident expressed a desire for cigarettes, and staff confirmed that the nicotine lozenges were not available and had never been administered, despite the order being present in the system. Multiple staff members, including an LPN, the unit manager, the DON, and the administrator, were unaware that the prescribed nicotine lozenges were not available or being given. The facility's policy on medication errors did not specifically address the unavailability of physician-ordered medications as a medication error. The lack of access to the ordered medication was identified through record review, staff interviews, and direct observation of the resident's requests and staff responses.

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 physician's orders for daily weight monitoring for a resident with a diagnosis of malnutrition, anemia, hip fracture, difficulty swallowing, and multiple pressure ulcers. The resident was admitted with a care plan that required daily weights, monitoring for signs of malnutrition, and reporting significant weight loss to the medical doctor. Despite these orders, the medical record showed only three weights documented over a two-week period, with no evidence of daily weight checks as required. The resident's condition was complex, including a history of poor nutrition, substance abuse, past gastric bypass, and ongoing wounds requiring increased protein intake. The resident was on a mechanical soft diet, received nutritional supplements, and had orders for a low sodium diet and diuretic therapy for edema. Staff interviews revealed that the resident typically ate 50-75% of meals, had difficulty swallowing due to missing teeth, and was considered frail by staff. However, staff did not notice any significant weight loss, and the registered dietician's notes did not provide direction for weight monitoring. Hospital records indicated a significant weight loss between the last documented facility weight and the hospital admission weight, with a drop from 101.1 lbs. to 77 lbs. within a short period. The facility's director of nursing acknowledged that staff failed to enter the daily weight orders correctly, resulting in the lack of daily weight monitoring. The facility's weight policy required accurate and regular weight monitoring to prevent avoidable decline in nutritional status, but this was not followed for the resident in question.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper food storage and hygiene practices in the kitchen, which had the potential to affect all 98 residents, staff, and visitors consuming food from the main production kitchen. During an initial kitchen tour, it was observed that culinary staff were not wearing hair nets or facial hair covers, and personal staff items such as jackets were stored next to food items. Opened food items were not properly wrapped, labeled, or dated, and some were past their use-by dates. The walk-in cooler had fans with visible fuzzy matter, indicating a lack of cleanliness. The dishwashing process was also found to be inadequate. The dish machine did not reach the required temperature for sanitization, with readings as low as 102 degrees Fahrenheit, below the minimum required 120 degrees Fahrenheit. The sanitizer level was also found to be inadequate at times, and dishes were not allowed to air-dry properly before being stacked, which could lead to bacterial growth. Staff confirmed these observations and acknowledged issues with maintaining proper dishwashing temperatures and sanitizer levels. Interviews with the culinary director and dietary aides revealed a lack of adherence to facility policies regarding food labeling, storage, and hygiene practices. The facility's policies required food items to be labeled and dated, personal items to be stored separately from food, and staff to wear appropriate hair and facial hair restraints. The facility's failure to comply with these policies and maintain sanitary conditions in the kitchen posed a risk to the health and safety of residents, staff, and visitors.

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 care plan for a resident's social and emotional well-being, specifically for a resident who wished to help in the dining area. Despite the resident's care plan indicating that assisting in the dining room was therapeutic, staff members repeatedly discouraged the resident from helping, leading to the resident feeling like they were in a prison. The care plan lacked detailed instructions on how the resident could assist, and staff were inconsistent in allowing the resident to help, citing concerns about state regulations. Another deficiency involved the facility's failure to assess and accommodate a resident's food preferences and dietary needs. The resident, who had a history of stroke and mild cognitive impairment, frequently refused a modified diet and requested regular-textured foods. Despite an order for a video swallow study to assess the resident's ability to safely consume regular foods, there was no evidence that the study was scheduled or completed. The facility also failed to explore alternative interventions to encourage the resident to adhere to dietary recommendations, leading to frequent disruptions during mealtimes. The facility also neglected to properly assess and document a resident's skin condition, particularly regarding dry, scaly skin on the resident's feet. Despite weekly skin inspections, the condition was not documented, and there was no evidence of interventions to address the issue. Additionally, the facility failed to coordinate care for a resident undergoing dialysis, resulting in missed insulin doses and blood sugar checks during dialysis days. There was a lack of communication with the dialysis center and the resident's provider regarding these missed treatments, which could potentially impact the resident's health.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the first-floor shower room in a clean and sanitary condition, as evidenced by the presence of brown staining on the shower ceiling. This issue was observed during a survey and was reported by residents and staff. A resident with moderate cognitive impairment and two residents with intact cognition, all residing on the first floor, expressed concerns about the staining, with one resident fearing it might be black mold. The stain was described as a one-foot by one-and-a-half-foot area of small, various spaced and sized, black/brown stains above and to the right of the shower head. Interviews with staff revealed that the stain had been present for an extended period, with a housekeeping aide noting its presence since he started working at the facility a year ago. Despite attempts to clean the stain, it remained, and maintenance had been notified but did not address the issue. The regional director of maintenance, who was filling in after the previous director left, acknowledged a communication breakdown that may have contributed to the unresolved issue. The facility's maintenance request policy did not specify a timeline for completing such requests, which may have further delayed addressing the problem.

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 reasonable access to private phone use for a resident with moderately impaired cognition, who relied on the facility phone for communication. The resident expressed that staff allowed him to use the phone at the nursing station, but only for a few minutes, as it was frequently needed by staff for other calls. The resident also mentioned that sometimes he was not allowed to use the phone at all, which limited his ability to communicate with his family and discuss personal matters, causing him distress. Interviews with facility staff, including a nursing assistant and a licensed practical nurse, revealed that the only phone available for residents without personal phones was the one at the nursing station. This phone was located in a shared, non-private area at the intersection of three hallways, with no enclosed walls, and was often in use by staff. The facility administrator acknowledged that residents could use her office or the director of social services' office for private calls but admitted that staff had not been recently educated on offering these options. A policy regarding resident access to a private phone 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 the quarterly Minimum Data Set (MDS) was completed thoroughly for two residents, focusing on areas of cognition and depressive symptoms. For one resident, the quarterly MDS identified several medical conditions, including delusional thinking, depression, and schizophrenia. However, the sections for cognitive patterns and mood were left blank and not completed, indicating that the Brief Interview for Mental Status (BIMS) and mood interview were not conducted. The medical record lacked evidence of these evaluations being completed during the quarterly assessment reference date (ARD). Another resident, admitted with complex medical conditions such as seizure disorder, non-Alzheimer's dementia, depression, bipolar disorder, and post-traumatic stress disorder, also had incomplete MDS sections. The cognitive patterns and mood sections were marked as not assessed, and the medical record did not show evidence of these evaluations being completed during the ARD. The corporate director of reimbursement confirmed that the assessments were not completed, attributing the oversight to a newer social worker still learning the role. The facility's policy on MDS completion 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 a Level I Pre-Admission Screening (PAS) and, if necessary, a Level II Pre-admission Screening and Resident Review (PASARR) were completed for a resident (R17) to screen for mental health needs. The resident's admission Minimum Data Set (MDS) indicated intact cognition, and the medical diagnoses included depression, anxiety, and post-traumatic stress disorder. However, the medical record lacked evidence of a final PASARR determination from the lead agency, Hennepin County, which was necessary for the resident's admission. Interviews with the senior linkage line representative and facility staff, including the receptionist and social services director, revealed that the PAS notice was not final, and the facility had not yet reached out to the county for the final determination. The facility's Pre-Admission Screening policy required social services to ensure the resident met the level of care for medical assistance payment before admission, and the nursing facility was responsible for maintaining a copy of the preadmission forms in the resident's medical record. The absence of the final PASARR in the medical record indicated a failure to comply with these 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 provide necessary assistance and equipment for personal hygiene care, specifically nail care, for a resident with moderate cognitive impairment. The resident, who required set-up assistance for grooming, was observed with long fingernails and expressed a desire to have them clipped. Despite this, the facility's records indicated that nail care was marked as 'not necessary' during weekly skin inspections, and there was no documentation of offers or refusals of nail care in the resident's medical record. The care plan for the resident lacked specific information regarding their preferences for nail length, and staff interviews revealed a lack of clarity and consistency in providing and documenting nail care. Staff members, including a nursing assistant and an LPN, acknowledged the resident's need for assistance with nail care and the availability of clippers, yet there was no evidence in the medical record of any attempts to address the resident's long nails until after the surveyor's observation. The facility's policy on maintaining abilities for activities of daily living, which includes grooming, was not adhered to, as evidenced by the lack of proper documentation and follow-up on the resident's nail care needs. This deficiency highlights a failure in the facility's processes to ensure residents receive appropriate care to maintain their abilities in daily activities.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate activities of daily living (ADLs) care, including nail care and routine bathing, to two residents, R19 and R31. R19, who was dependent on staff for most ADLs due to a stroke, was observed with long, dirty fingernails and was not provided nail care before being taken to the dining room for breakfast. Despite the expectation that nail care should be done at least weekly during a resident's shower or bath, and that nails should be kept clean and trimmed in between, R19's nails remained unclean. R31, who was cognitively impaired and had a history of refusing care, was observed with dull, greasy hair. Despite her care plan indicating the need for encouragement and reapproach for bathing, there were no additional interventions in place to address her refusal to bathe. Staff acknowledged the difficulty in providing care for R31 and confirmed that her hair was dirty, yet no alternative methods, such as using dry shampoo caps, were attempted. The facility's policy on ADLs emphasizes the importance of person-centered care and maintaining residents' quality of life through proper grooming and hygiene. However, the observations and interviews revealed that the facility did not adhere to these standards, resulting in the residents' unkempt appearance and lack of personal hygiene 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 coordinate cataract surgery for a resident with impaired vision, identified as R3, who had been complaining about poor eyesight. Despite the resident's guardian repeatedly expressing the need for cataract surgery and the resident's history of paranoia requiring accompaniment to appointments, the facility did not effectively communicate or coordinate with the guardian. The health information manager scheduled a cataract surgery consult without consulting the guardian, leading to the resident refusing to attend the appointment. The facility's phone system issues further complicated communication, and no policy on vision appointments was provided. Additionally, the facility did not address the loss of hearing aids for another resident, identified as R28, who had moderate cognitive impairment and had been fitted with hearing aids. The resident reported the hearing aids missing, and the audiology provider instructed the staff to search for them before requesting replacements. However, the facility's records lacked evidence of any follow-up actions to locate or replace the hearing aids. Interviews with staff revealed a lack of awareness and action regarding the missing hearing aids, and no policy on hearing aid replacement was provided. These deficiencies highlight the facility's failure to ensure access to necessary vision and hearing services for residents, as evidenced by the lack of coordination and follow-up on critical health appointments and equipment. The facility's communication issues and absence of relevant policies contributed to these lapses in 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 timely referral of a resident with long, hard toenails to the onsite contracted podiatry service. The resident, who had delusional thinking and required assistance with personal hygiene, was observed with long toenails and expressed a desire to see the foot doctor. The resident's guardian also noted the long toenails and had requested the care center to arrange a podiatry visit, but there was a delay in scheduling. The resident's care plan identified a potential for skin breakdown due to medical conditions, including hallux valgus, and recommended podiatry visits. However, the last recorded podiatry visit was several months prior, and the resident's medical record lacked evidence of any recent podiatry services being offered or refused. The health information manager, responsible for arranging podiatry visits, was aware of the resident's need but could not confirm why the resident was not on the list for the most recent podiatry visit. Interviews with staff revealed a lack of communication and documentation regarding the resident's need for podiatry care. The nursing assistant and licensed practical nurse manager were unsure of the resident's podiatry visit status, and the interim director of nursing was not informed of the issue. The facility did not provide a policy on podiatry appointments, indicating a systemic issue in managing podiatry services for residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide routine range of motion (ROM) exercises for a resident with severe cognitive impairment and physical limitations due to conditions such as aphasia, stroke, and hemiplegia. The resident was dependent on staff for all activities of daily living (ADLs) and had a care plan intervention that directed staff to provide gentle ROM as tolerated with daily care. Despite this, there was a lack of documentation indicating that nursing staff provided the necessary ROM exercises, and interviews with staff revealed a lack of awareness and communication regarding the resident's need for ROM exercises. The resident's therapy evaluations and discharge summaries indicated goals to improve standing tolerance and transfer status, with recommendations for a functional maintenance program to maintain contractures. However, the resident's family member expressed concerns that the facility did not provide continuous ROM or exercises, leading them to perform stretching exercises during visits. Observations confirmed that the resident's right hand was limp, and they used their left hand to move it, indicating a lack of improvement in ROM. Interviews with nursing assistants and licensed practical nurses revealed a disconnect between therapy and nursing staff regarding the resident's exercise needs. The director of nursing confirmed that the care plan and kardex directed daily ROM, but the medical record lacked documentation of such care. The therapy program manager noted that the resident's care plan for ROM was in place before their current role, and there was no facility policy on ROM, contributing 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 comprehensively assess and implement behavioral interventions for a resident with a history of throwing dining ware. The resident, who had severe cognitive impairment, hallucinations, delusions, and schizophrenia, was noted to have behaviors such as throwing plates and food in the dining area. Despite these behaviors being documented in the care plan, there was a lack of consistent monitoring and documentation of the resident's behavior. The care plan included an intervention to offer plastic plates as needed, but there were no clear parameters for when this should be implemented, and staff were unsure of the resident's triggers. Observations and interviews revealed that the resident's behavior of throwing dining ware was a common occurrence, yet it was not consistently documented in progress notes. Staff, including the culinary director and nursing staff, acknowledged the behavior but did not have a clear understanding of the reasons behind it or consistent strategies to address it. The director of nursing was unaware of the behavior until recently and questioned the documentation practices. The facility lacked a specific policy for behavioral management and tracking, contributing to the deficiency in providing necessary behavioral health care and services to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure appropriate personal protective equipment (PPE) was used for a resident who was on enhanced barrier precautions due to the presence of a feeding tube. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed being assisted by two nursing assistants. During the assistance, one nursing assistant wore gloves without a gown, while the other did not wear gloves or a gown. Both nursing assistants' scrubs came into contact with the resident's bed, and they did not wear gowns during the transfer of the resident from the bed to a wheelchair using a hoyer lift. Interviews with staff revealed a lack of consistent understanding and adherence to the enhanced barrier precautions. One nursing assistant acknowledged the requirement to wear gloves and gowns but admitted to not wearing a gown during the assistance. A licensed practical nurse indicated that gowns were only necessary for feeding tube care, not for transfers or personal care, which contradicted the facility's policy. The director of nursing expected staff to wear gowns and gloves during transfers and close care for residents on enhanced barrier precautions. The facility's policy required the use of gowns and gloves during high-contact resident care activities, including transferring, dressing, and device 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 the privacy and confidentiality of resident information, as required by HIPAA standards. During an observation, a clipboard containing a care sheet with sensitive information about 48 residents was left in public view on the top counter of the nursing station. This care sheet included residents' full names and detailed information about their care needs, such as levels of assistance required, participation in special programs, behavioral issues, special precautions, and elopement risks. Residents and family members were observed walking past the clipboard, which was easily accessible and visible to them. Interviews with staff confirmed the breach of confidentiality. An LPN acknowledged that the clipboard was improperly placed in public view and contained private information that should not be accessible to everyone. The LPN suggested that the clipboard should be placed face down to prevent unauthorized viewing. The DON also confirmed that the facility's expectation was to keep any documents containing resident information out of public view to comply with HIPAA regulations. Despite a request, the facility did not provide a policy on HIPAA, indicating a potential gap in their documentation or training regarding privacy 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 ensure timely reordering of a pain medication for a resident, leading to the resident experiencing withdrawal symptoms. The resident, who had a history of diabetic neuropathy and pain due to a left toe amputation, was prescribed Belbuca Buccal Film for pain management. However, the medication was not reordered in a timely manner, resulting in the resident not receiving the medication as scheduled from 1/1/25 to 1/2/25. The resident's medical record lacked evidence of follow-up with the pharmacy or notification to the provider about the medication shortage from 12/30/24 to 1/1/25. On 1/1/25, the resident experienced withdrawal symptoms and called 911, leading to hospitalization. The facility's staff, including LPNs and the Director of Nursing, acknowledged the failure to reorder the medication when a 5-7 day supply remained, as per facility policy. The pharmacist confirmed that a new prescription was needed, but it was not received until 1/2/25. The nurse practitioner was not informed of the situation until 1/2/25, and the resident reported that the nursing staff did not act when informed about the low medication supply.

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 monitor two residents following unwitnessed falls, leading to a deficiency in care. Resident 1, who had severe cognitive impairment and a history of stroke, experienced a fall on January 4, 2025, resulting in a bump on the forehead. The nursing note for this incident lacked details such as the size and description of the injury, and there was no documentation of treatment or ongoing monitoring, including neuro checks and vital signs, in the electronic medical record. Similarly, Resident 4, who had intact cognition and a diagnosis of type 2 diabetes mellitus, was found on the floor next to his bed on January 6, 2025. The nursing note did not indicate any injury or treatment, and there was no documentation of ongoing monitoring for injury or neuro checks following the fall. Interviews with facility staff, including an LPN, RN, and regional nurse consultant, confirmed the lack of proper documentation and monitoring following the falls. The staff acknowledged that neuro checks should be conducted for all unwitnessed falls and head strikes, and nurse's notes should be written every shift for 72 hours post-fall. The facility's Fall Prevention and Management policy also required neuro checks and monitoring for 72 hours after a fall. The failure to adhere to these protocols resulted in inadequate monitoring and documentation for both residents following their falls.

Penalty

Fine: $54,245

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 have a system in place to train staff on the process for unlocking the main entrance doors for emergency medical services (EMS) personnel after hours. This deficiency was highlighted when a resident, who was cognitively intact and required assistance for transfers, experienced difficulty breathing. Staff called 911, but when EMS arrived, they were unable to gain entrance to the building for approximately ten minutes due to locked doors. The delay was caused by the inability of staff, including agency staff, to locate and use the key to unlock the doors. Interviews revealed that the facility's front doors were locked at night due to security concerns, and only the nurse on the first floor had the key to unlock them. However, agency staff, who frequently covered shifts, were not trained on how to unlock the doors. This lack of training and communication led to confusion and delays in emergency response. Staff members assumed others would report the issue to administration, resulting in a lack of awareness among facility leaders about the problem. The fire department had experienced similar access issues during previous calls, indicating a recurring problem. Despite the facility's policy of locking doors for security reasons, there was no documented procedure or training for staff on how to manage emergency access. The deficiency placed all residents at risk for serious harm due to delayed EMS response, as evidenced by the incident involving the resident with breathing difficulties.

Penalty

Fine: $54,245

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

Summary

The facility failed to provide adequate privacy for residents sharing rooms, as evidenced by the lack of functional privacy curtains. Three residents, identified as R1, R3, and R6, were affected by this deficiency. R1, who was cognitively intact, reported never having a privacy curtain and expressed discomfort at having to watch his roommate being dressed and undressed by staff. This lack of privacy made R1 feel embarrassed and uncomfortable, especially during meal times. Observations confirmed that R1's room had a torn and unusable privacy curtain that did not shield him from his roommate's view. Additionally, R3 and R6's shared room was observed to lack privacy curtains entirely. R3, who had severe cognitive impairment, was exposed to R6's inappropriate behavior, as R6 was seen masturbating in the room. A nursing assistant acknowledged the lack of privacy and attempted to cover R6, who resisted. The facility's administrator admitted to not ordering privacy curtains, and the director of nursing confirmed that all rooms should have functional privacy curtains. Despite requests, the facility did not provide a policy for privacy curtains.

Penalty

Fine: $54,245

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 three out of five staff members, specifically nursing assistants NA-G, NA-H, and NA-I, received the required annual training on behaviors associated with Alzheimer's disease or related disorders, problem-solving with challenging behaviors, and communication skills. A review of their training transcripts revealed a lack of documentation indicating completion of this essential training. The Facility Assessment dated 7/3/24 indicated that the facility accepted residents with psychiatric and mood disorders and impaired cognition, and it stated that staff were to be trained annually on dementia management and care for cognitively impaired residents. During an interview on 8/12/24, RN-C and the Director of Nursing acknowledged that the mentioned nursing assistants had not received the necessary annual behavioral health training. Additionally, a behavioral health training policy was requested but not provided.

Penalty

Fine: $54,245

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

Summary

The facility failed to provide adequate training for staff on communicating with non-English speaking residents, despite identifying two such residents in their care. A review of staff training records revealed that five staff members, including nursing assistants and nurses, lacked this specific training. Interviews with additional nursing assistants confirmed that they could not recall receiving any training on this topic, even though they acknowledged the presence of a non-English speaking resident in the facility. The Facility Assessment indicated that the facility accepted residents requiring interpreter services, yet it did not show that staff were trained annually on communication with non-English speaking residents. During an interview, a registered nurse and the director of nursing admitted that this area of training had been overlooked.

Penalty

Fine: $54,245

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 mandatory training on its Quality Assurance and Performance Improvement Program (QAPI) to all staff, which included the goals, various elements of the program, and how the facility intended to implement it. The deficiency was identified through interviews and document reviews, revealing that five staff members, including nursing assistants and nurses, had not received any QAPI training. During interviews, several nursing assistants were unable to recall what QAPI was or any training related to it, indicating a lack of awareness and understanding of the program among staff. Further investigation showed that the facility's Quality Plan, dated August 23, 2023, outlined the need for quality improvement and communication of revisions to the governing board, residents, families, and employees. However, the QAPI meeting minutes from July 18, 2024, which detailed nursing responsibilities for various initiatives, did not indicate that mandatory training had been provided to staff. The director of nursing acknowledged the oversight in training, and the administrator was unaware of the lack of mandatory QAPI 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 dishware was cleaned and sanitized properly, posing a risk of cross-contamination and foodborne illness for all 88 residents. During an initial kitchen tour, the dietary manager (DD) demonstrated the use of a low-temperature commercial dishwasher and chlorine testing for sanitization. The observed wash temperature was 118 degrees Fahrenheit, below the required 120 degrees, and the chlorine sanitizing strips provided inconclusive results. The facility's log for dishwasher temperature and chlorine measurements had multiple missing entries over several days, indicating a lack of consistent monitoring and documentation. DD admitted to being unaware of any issues with the dishwasher until the surveyor's observation. Interviews with various staff members, including dietary aides and the maintenance director, revealed that while they were aware of the testing and documentation procedures, there was a lack of communication and follow-through regarding the dishwasher's malfunction. The dietary aides confirmed that they were trained to test the dishwasher's sanitization properties at every meal and document the results, but the log showed significant gaps. The registered dietician and dishwasher representative emphasized the importance of proper sanitization to prevent illness. The facility's policy on dishwasher use did not provide clear instructions on using sanitizing strips, contributing to the oversight.

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 transmission-based precautions (TBP) for a resident with symptoms of a respiratory illness, potentially affecting 23 residents on the unit. The resident, diagnosed with chronic obstructive pulmonary disease (COPD), exhibited increased coughing and other symptoms over several days. Despite these symptoms and negative COVID-19 tests, the resident was not placed on TBP, and staff did not wear personal protective equipment (PPE) when interacting with the resident. The resident was observed coughing in common areas without a mask, and staff did not take measures to limit the resident's movement or enforce respiratory hygiene protocols. Additionally, the facility failed to provide infection control education to two residents who were assessed for smoking. Both residents were observed sharing cigarettes, a practice that poses a risk of spreading infections. The staff member supervising the smoking area was unaware of the infection risks associated with sharing cigarettes and had not received training on this issue. The residents themselves were not informed about the potential infection risks of sharing cigarettes. The facility's policies on TBP and smoking did not adequately address the observed deficiencies. The TBP policy required the use of masks and private rooms for residents with respiratory symptoms, but these measures were not implemented. The smoking policy prohibited residents from giving or borrowing cigarettes but did not address the infection risks of sharing cigarettes. The Director of Nursing (DON) acknowledged the lapses in infection control practices and the lack of resident education on these issues.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a self-administration of medications (SAM) assessment was completed for a resident who stored medication at their bedside. The resident, who had a history of delusional disorders, epilepsy, major depressive disorder, mild intellectual disabilities, insomnia, somatization disorder, bradycardia, history of falling, and thrombocytopenia, was observed self-administering medications without a current assessment or physician's order. The resident's quarterly Minimum Data Set indicated she was independent in making her own decisions and did not exhibit signs of delirium or hallucinations. However, her electronic medical record lacked an assessment for self-administration of medications, and her clinical physician orders did not include orders for self-administration of medications. During an interview, the resident stated that she took her medications on her own while eating, and a Licensed Practical Nurse (LPN) confirmed that the medications were left at the resident's bedside for her to take at her own pace. The LPN was unaware of any current assessment or order for the resident to self-administer medications. The Director of Nursing (DON) later revealed that the resident had a self-administration assessment done in 2016, which indicated she was unable to safely administer her own medications, and acknowledged that a current assessment and order were lacking. The facility's policy required an interdisciplinary team to assess each resident's cognitive and physical abilities to determine if self-administration of medications was safe and clinically appropriate, 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 ensure maintenance services were provided in a timely manner to address broken window blinds, compromising the privacy and homelike environment for two residents. Both residents, who had intact cognition, reported that the window blinds in their room had been broken for several months, exposing their room to public view. Despite multiple requests from the residents, no temporary measures were taken to cover the window, and the issue remained unresolved for an extended period. On two separate occasions, the broken blinds were observed by the surveyor, and both residents confirmed that no temporary solutions had been offered. A registered nurse and the maintenance director also verified the disrepair of the blinds. The maintenance director mentioned that parts had been ordered to fix the blinds but was unsure how long they had been broken. The work order for the blinds was created two months prior, but no actions had been taken to resolve the issue. The administrator acknowledged awareness of the broken blinds and the delay in getting them fixed, citing issues with custom-made parts and limited maintenance staff. The administrator mentioned that the facility had considered moving the affected residents to a different unit but had not yet done so. The administrator emphasized the importance of timely repairs to ensure residents' privacy and comfort but admitted that the issue had not been addressed promptly.

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 necessary nail care for a resident (R28) who required assistance with personal hygiene. R28, who had intact cognition and needed extensive assistance with activities of daily living due to a stroke, diabetes, and muscle weakness, was observed with overgrown and dirty fingernails. Despite R28's repeated requests for assistance with nail trimming, staff did not provide the necessary care. The resident expressed frustration over the condition of his nails, which had been long for a while and were bothersome to him. During interviews, staff members, including a nursing assistant and a registered nurse, acknowledged the resident's need for nail care but failed to provide it. The registered nurse noted the overgrown nails during a weekly skin inspection but did not document any refusal from the resident. The director of nursing confirmed that nail care should have been completed on bath days and as necessary, and emphasized the importance of regular nail care to prevent infection. However, the facility's nail care policy did not specify the frequency of nail care, contributing to the oversight.

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 care for residents with gastrostomy tubes, leading to deficiencies in infection control practices. Resident R19, who had multiple medical conditions including hemiplegia, stroke, and dysphagia, was observed with a piston syringe and graduated cylinder dated 4/22, which had not been changed daily as required. The medication administration record (MAR) and treatment administration record (TAR) indicated that water flushes were not consistently documented, and the equipment was not replaced daily, as confirmed by staff interviews and observations. Licensed Practical Nurse (LPN)-B and LPN-A both acknowledged the failure to change the equipment daily, with LPN-A admitting to using the dated equipment without checking it first. Similarly, Resident R67, who also had a gastrostomy tube due to conditions like stroke and dysphagia, was found with a piston syringe and graduated cylinder dated 4/22. The MAR/TAR for R67 lacked orders for changing the equipment every 24 hours, and observations confirmed that the equipment had not been replaced as required. Interviews with LPN-B, LPN-A, and the Director of Nursing (DON) revealed that the equipment should be changed daily to prevent infection, but this practice was not followed. The DON confirmed that the orders for R19 were unclear and that there were no orders for R67 to change the equipment daily. The facility's policy on Enteral Tube Feeding via Syringe, dated 3/24, required syringes to be labeled with the resident's name and marked with the date and time, and to be disposed of if older than 24 hours. The failure to adhere to this policy and the lack of clear orders for R67 led to the deficiency. The DON acknowledged that the nurses were likely just rinsing the equipment instead of replacing it, which increased the risk of infection for the residents.

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 past trauma and implement care plan interventions utilizing a trauma-informed approach for three residents diagnosed with PTSD. Resident 18's care plan lacked a description of trauma and potential triggers, and the resident reported that loud noises were a trigger. The resident's Kardex also lacked information on past trauma and potential triggers. Resident 34's care plan similarly lacked details on trauma and triggers, and the resident indicated that discussing family matters caused anxiety and distress. Resident 34's Kardex was also missing this critical information. Resident 74's care plan and Kardex did not include information on PTSD or potential triggers, and the resident reported that being rushed during conversations was a significant trigger. Staff interviews revealed a lack of awareness and training on trauma-informed care and specific resident triggers, which further contributed to the deficiency. The facility's policy on trauma-informed care was not effectively implemented, as evidenced by the absence of individualized strategies in the care plans and Kardexes of the affected residents. The administrator and social services director acknowledged the need for better trauma-informed care education and documentation. The nurse manager also admitted to not being aware of the residents' PTSD diagnoses and the lack of individualized interventions in the care plans.

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 offer or provide the recommended pneumococcal vaccine to a resident reviewed for immunizations. The National Center for Immunization and Respiratory Diseases recommends that adults with certain risk conditions, such as chronic heart disease and cardiomyopathies, receive the pneumococcal vaccine. The resident in question had multiple diagnoses, including anoxic brain damage, cardiomyopathies, and cardiac arrest, which made them eligible for the vaccine. However, the resident's medical and immunization records lacked documentation indicating whether the vaccine was offered or declined, or any rationale for not offering the vaccine. During interviews, the resident was unsure if the staff had discussed the pneumococcal vaccine with her, and the Director of Nursing stated that the vaccine was offered based on age and provider recommendations. The facility's policy indicated that all residents should be offered the pneumococcal vaccine to prevent infections, following guidelines from the Advisory Committee on Immunizations Practices (ACIP), Centers for Disease Control (CDC), and the state Department of Health. Despite this policy, the facility did not adhere to the guidelines in this 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 ensure required nurse staffing information was posted on a daily basis, including over the weekend. Upon entering the nursing home for a recertification survey, the survey team observed that the posted nurse staffing information was dated Friday, April 26, 2024, and there was no information posted for April 27, 28, or 29, 2024. The receptionist confirmed that the staffing coordinator was responsible for posting the information and acknowledged the outdated posting, stating they would alert the staffing coordinator to update it. The administrator later verified that the staffing coordinator should post the information during the week, and the receptionist or overnight nurse should handle it on weekends. The administrator also mentioned that the postings had been printed but were accidentally left in the printer and not posted. The facility's Nursing Hours Posting policy, dated October 2022, required the care center to post nurse staffing data daily at the beginning of each shift, as mandated by Federal law. The administrator confirmed that the front display case was the only location where the information was typically posted and emphasized the importance of ensuring the postings were done so that people could see the staffing for the day. Despite identifying this issue during a mock survey a few months prior, the facility had not yet resolved the problem, leading to the deficiency noted during the recertification survey.