Brandon Community Care Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain an environment as free as possible from accident hazards and to provide adequate supervision and assistance to prevent accidents, resulting in a resident fall with injury. Facility policies titled “Safety and Supervision of Residents” and “Homelike Environment” state that resident safety, supervision, and a safe environment are priorities. Despite these policies, a housekeeper entered a resident’s room at approximately 10:30 AM, found the resident asleep, and proceeded to clean and mop the floor without placing any wet floor signage. The housekeeper reported believing the resident was bedridden and did not expect the resident to get up unassisted, and also stated that no wet floor signs were available and that it was their first time working on the unit. Progress notes and witness statements document that shortly after the room was mopped, staff heard the resident crying and found her lying face down on the wet floor in a pool of blood, with no wet floor sign in place. The resident sustained multiple injuries, including a 2 cm laceration to the top of the head, a 0.75 cm laceration to the forehead, a 0.25 cm laceration on the bridge of the nose, discoloration and contusions around both eyes, and discoloration to the left knee. A Family Nurse Practitioner documented that the resident was seen on the floor with blood pooled around her head and lacerations to the forehead and nose, with a contusion forming over the left eye. Hospital records further documented facial trauma, an orbital fracture, and suspected concussion, with suturing required for the laceration and imaging confirming an acute orbital blowout fracture of the left orbital floor. Interviews with staff confirmed that the floor was wet from recent mopping and that no caution signage had been placed. The Director of Nursing stated that the resident was last seen around 10:55 AM and was found around 11:00 AM lying face down on the wet floor, confirming that the housekeeper had assumed the resident was not mobile. A CNA reported having assisted the resident with a shower and returning her to her room, where the resident was sitting up watching television prior to the incident, and later found the resident on the wet floor with no sign present. An LPN described entering the room after hearing the resident crying, stumbling on the wet floor, and finding the resident face down with blood on her face and hair. The Licensed Nursing Home Administrator confirmed that the housekeeper mopped the floor without posting a wet floor sign and that staff did not identify the wet floor as a potential hazard prior to the incident. Record review showed the resident had Alzheimer’s disease, unsteadiness on feet, and documented memory problems with some difficulty in new situations, indicating known cognitive and mobility issues at the time of the fall.

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 abuse within the required timeframe for one resident. The resident had an admission history including epilepsy, cerebral edema, neurofibromatosis, unspecified visual loss, and unspecified hearing loss, and the MDS indicated the resident was rarely or never understood. The facility policy stated alleged violations involving abuse or neglect are to be reported immediately, but no later than 2 hours after the allegation is made. During a bed bath or shower care episode, CNA #1 and CNA #2 were assisting the resident when the resident’s foot was found stuck in the bedrail. The resident became combative during care. Accounts differed regarding what occurred next: CNA #2 stated CNA #1 hit the resident on the arm after the resident swung at staff, while CNA #1 denied hitting the resident and stated the resident kicked, scratched, and spit on her. The DON stated she was initially told only that the resident’s foot had been stuck in the rail and that she did not learn of the allegation of CNA #1 hitting the resident until later, after reviewing a written statement. The facility investigation summary indicated the investigation was initiated when CNA #2 notified the DON, but the initial submission to the State Agency was not faxed until several days later, with the incident date listed as the earlier date. Interviews with the ED, DON, and assistant administrators showed confusion about who was responsible for reporting abuse allegations, and the ED stated she was not aware of the alleged incident until she received the written statement. The police report was also completed after the incident date, reflecting that the allegation was not reported immediately as required.

Penalty

No penalty information released

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

Summary

The facility failed to honor a resident’s preference to be returned to bed after therapy, despite the resident’s repeated requests and known need for comfort related to her spinal condition. Resident #216, who was admitted with diagnoses including spondylosis of the lumbar region and idiopathic scoliosis of the thoracic region and had a BIMS score of 15, reported that she typically attended therapy in the morning and asked her CNA to put her back to bed afterward because sitting in her wheelchair for extended periods caused pain and discomfort. The resident stated that some CNAs refused or delayed the request for hours, even after she used her call light multiple times, and that staff sometimes entered her room, turned off the light, and left without explanation. On one occasion, she reported being left in her wheelchair until about 1:30 PM after finishing therapy around 11:00 AM. CNA #1 confirmed that the resident’s preference to lie down after therapy was commonly known among staff and that some CNAs waited until routine rounds instead of honoring the request. CNA #2 acknowledged being assigned to the resident and knowing her preference, but did not return her to bed until approximately 1:30 PM. Therapy staff also reported ongoing difficulty getting assigned CNAs to honor the resident’s request, and the resident’s daughter stated her mother frequently called in tears after therapy because she was not returned to bed.

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 was transferred in a manner that could prevent accidents and potential injury. During an observation, a CNA transported Resident #11 from her room to the day room on the 400-hall using a wooden chair with no wheels, while pushing the chair from behind and without any method to stabilize it or catch the resident if she fell. Resident #11 typically sat in a rolling padded chair to support her trunk, and by the end of the transport she had slid dangerously low in the wooden chair after being jostled and required repositioning. The CNA confirmed that she had pulled and pushed the resident in the wooden chair to get her to the dining room and stated the resident refused to sit in her rolling chair and kept trying to get out of it. An LPN stated that the proper way to transport a resident was using a wheelchair or rolling chair and that using a wooden chair posed a risk for falling, especially for a resident who could not support herself. The DON stated the resident was put at risk by being transported in this manner and could have fallen out of the chair and been hurt. Resident #11 was admitted with dementia, had a BIMS score of 03 indicating severe cognitive impairment, and used a wheelchair for mobility.

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 a diet that took into consideration a resident’s preferences for 1 of 35 sampled residents. Resident #42, who was cognitively intact with a BIMS score of 15 and had diagnoses including type 2 diabetes mellitus and chronic kidney disease, repeatedly expressed food preferences that were not met. The facility policy stated residents have a right to reasonable accommodation of preferences unless doing so would endanger health or safety. During a meal observation, Resident #42 was served a tray with turkey, dressing, and a sweet potato. She asked a CNA to exchange her meal for a turkey sandwich, but the CNA returned with an alternate tray containing ham, broccoli and cheese, mandarin fruit cup, and black-eyed peas after being told by kitchen staff that sandwiches were unavailable. The alternate tray also included metal silverware, even though the resident had previously told staff she preferred plastic silverware because metal did not seem clean to her. The resident stated she had been trying to get a salad since moving into the facility in April, but staff did not follow up on her preferences and she was not given a menu or choice before meals arrived. Additional interviews showed the resident often requested a salad and rarely received one, and a CNA reported that staff frequently were told the kitchen was out of items residents wanted, including sandwiches. The CNA stated this happened often and that residents were not given a process to choose meals ahead of time. The Dietary Manager stated residents could receive alternate trays and said sandwiches were always available, but she confirmed the resident should have received a sandwich when requested instead of the alternate meal. The Administrator stated staff were expected to follow facility policy regarding dietary preferences and resident rights.

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 practice hand hygiene in accordance with professional standards for food services when the District Dietary Manager (DDM) used her bare finger to poke holes in the aluminum foil covering pans on the hot food line and peel it back to expose the food. During tray preparation, the DDM was also observed holding plates in a way that allowed rolls to touch her bare hands at the thumb. The facility policy, Proper Hand Washing and Glove Use, stated that all employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines and that gloves are to be used whenever direct food contact is required. In interview, the DDM did not acknowledge the need for glove use during tray service and stated that gloves were not required unless hands might come into contact with foods being served or ready-to-eat items such as sandwiches. When told she had been observed touching the rolls multiple times, she stated that gloves would have prevented possible contamination. The Infection Preventionist Nurse confirmed that dietary staff should wear gloves during plating and serving because they may be asymptomatic with illnesses such as COVID and flu, and the Administrator acknowledged the unsanitary handling of ready-to-eat food in the kitchen and stated it was her expectation that policy be followed to protect 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 protect a resident's right to be free from neglect by not implementing measures to prevent elopement for a resident who had recently begun exhibiting exit-seeking behaviors. The resident, who had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, began displaying new behaviors such as packing belongings and waiting at the front door, believing her family was coming to get her. Despite these documented behaviors, staff did not update the resident's care plan or implement additional supervision or wander management interventions prior to the incident. On the day of the incident, the resident exited the facility unnoticed and unsupervised. She was found approximately fifteen minutes later by a CNA, sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard. Staff were unaware of the resident's absence until she was brought back inside. There was no incident report completed at the time, and no head count or missing resident protocol was initiated following the event. Interviews with staff confirmed that the resident's care plan had not been updated to reflect her new exit-seeking behaviors, and that elopement drills or additional supervision had not been implemented. The facility's policy required identification and intervention in situations where neglect was more likely to occur, including increased supervision for residents at risk. However, despite multiple staff members observing and documenting the resident's exit-seeking behaviors in the days leading up to the incident, no changes were made to her care plan or supervision level. The lack of timely intervention and failure to follow facility policy resulted in the resident being able to leave the facility unsupervised, placing her at risk.

Removal Plan

• The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for residents with behavioral changes that verbalize leaving the facility, exit seeking, wandering, and packing belongings should be immediately assessed and elopement precautions implemented.
• The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
• An audit was completed for all residents who were determined to be at risk for elopement to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
• A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent residents from leaving the facility without staff knowledge.
• The Executive Director and Director of Nurses reinterviewed Resident #1 to confirm details of the elopement.
• Letters were mailed to family members by Social Services as a reminder to use precautions when entering and exiting the facility and to notify staff if a resident verbalizes thoughts of leaving the facility.
• The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. All routine staff who cover the receptionist area were also in-serviced.
• A 100% audit of elopement binders was conducted by the Social Service Department to ensure the binders' information was reflective of all residents who are deemed as elopement risk.
• An Emergency Quality Assurance Committee was held with key facility leadership and the Medical Director to review the incident and corrective actions.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that an allegation of neglect and an incident of elopement involving one resident were reported to the appropriate agencies, including the State Agency, as required by state and federal law. On the date of the incident, a resident with a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, who had recently exhibited new exit-seeking behaviors, exited the facility unnoticed and unsupervised. The resident was missing for approximately fifteen minutes before being found by a CNA sitting in the passenger seat of the CNA's car in the facility parking lot, which was located near a busy four-lane boulevard with no barrier or crosswalk. The resident was then escorted back into the facility. Facility records, including the accident/incident log and progress notes, showed that the event was not documented as an elopement, and no incident report was completed. The progress notes indicated that the Unit Manager, DON, Social Worker, and Executive Director were notified of the incident. However, the Executive Director determined that the event was not an elopement because the resident stated she was waiting for her brother, despite the facility's policy requiring anyone taking a resident out to sign them out at the nurses' station. No one had signed the resident out or made arrangements for her to leave, and the resident had exited the building with a group of nursing students without staff knowledge. Interviews with staff confirmed that the incident was not reported to the State Agency or other required authorities at the time. The Executive Director, DON, and Receptionist all acknowledged awareness of the incident but did not initiate the required reporting procedures. The facility's policies on abuse prevention, missing residents/elopements, and investigation and reporting of violations all require immediate reporting of such incidents to the appropriate authorities, which was not followed in this case.

Removal Plan

• The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
• The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
• An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
• A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
• The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
• Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
• The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
• 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
• An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.

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 a thorough investigation into an allegation of neglect and an incident of elopement involving one of six sampled residents. On the specified date, a resident exited the facility unsupervised and was found sitting in a staff member's car in the facility parking lot. The resident had left the building unnoticed by staff during a shift change and was able to access an area adjacent to a busy four-lane boulevard. The staff member who discovered the resident escorted her back into the facility and notified the appropriate personnel, including the Executive Director and the Director of Nursing Services. Despite the incident, there was no documentation of the elopement in the facility's accident/incident log, and no incident report was completed. Multiple staff members, including LPNs and the Unit Manager, confirmed that they were aware of the resident's unsupervised exit but did not participate in any investigation or initiate missing resident procedures. No head count of residents was conducted, and the event was not reported to the State Agency as required. The Executive Director stated that the incident was not considered an elopement because the resident claimed she was waiting for her brother, and therefore, no report was made to any agencies. The resident involved had a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, but her most recent assessment indicated no cognitive impairment and no documented wandering or exit-seeking behaviors. The facility's policies required immediate investigation and reporting of such incidents, but these procedures were not followed. The failure to conduct a thorough investigation and report the incident placed the resident and others at risk, as identified by the State Agency, which cited the facility for failing to meet regulatory requirements regarding the investigation and prevention of alleged violations.

Removal Plan

• The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
• The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
• An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
• A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
• The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
• Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
• The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who cover the receptionist area, the receptionist was in-serviced by the Executive Director.
• 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
• An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social Service Assistants and Medical Director. The IP nurse was present by phone.

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 and implement comprehensive care plans for two residents, resulting in significant deficiencies. For one resident with a history of bipolar disorder, anxiety disorder, schizophrenia, and major depressive disorder, new wandering and exit-seeking behaviors were documented for at least a week prior to an incident where the resident eloped from the facility unnoticed and was outside unsupervised for approximately fifteen minutes. Despite staff observations and documentation of these behaviors, including packing belongings and attempting to leave, the care plan was not updated to address elopement or wandering risk. Progress notes indicated that interventions such as one-on-one observation and the application of a wander management device were initiated only after the elopement occurred, but these were not reflected in the resident's care plan. Multiple staff interviews confirmed that the care plan was not updated in response to the resident's behavioral changes, and the interdisciplinary team did not coordinate to ensure the care plan addressed the new risks. Another resident was admitted with a nephrostomy tube for urinary drainage due to obstructive uropathy. The hospital discharge summary and admission nursing assessment noted the presence of the nephrostomy tube, but the initial and comprehensive care plans did not include any focus, goals, or interventions related to nephrostomy tube care. There were no instructions for site care, flushing, dressing changes, or infection prevention, and the facility did not contact the physician or specialist for guidance on nephrostomy care upon admission. Staff interviews revealed that nursing staff relied on general practice rather than formal guidance, and the MDS Coordinator acknowledged that the absence of a care plan for the nephrostomy tube was an oversight. The DON and Medical Director both confirmed that the lack of a care plan for this specialized medical device was a failure in the care planning process and could result in missed or inconsistent care. The facility's policies required that care plans be person-centered, updated upon changes in condition, and include measurable goals and staff approaches for each identified problem or need. However, in both cases, the facility did not follow its own policies or regulatory requirements to ensure that care plans were comprehensive and updated in response to significant changes in residents' conditions or care needs. This failure led to a lack of clear instructions for staff and placed residents at risk for inadequate supervision and care.

Removal Plan

• The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
• The Executive Director notified the Mississippi Department of Health of the incident regarding Resident # 1 exiting the facility unaccompanied and unnoticed by staff.
• An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
• A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
• The Executive Director and Director of Nurses reinterviewed Resident# 1. Resident# 1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a decription.
• Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
• The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
• 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
• An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clincial Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.

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 supervision and a secure environment to prevent the elopement of a resident who had documented new wandering and exit-seeking behaviors for at least a week. The resident, who had diagnoses including bipolar disorder, anxiety, schizophrenia, a history of falls, and was assessed as at risk for falls and requiring supervision for walking, exited the facility unnoticed and was found sitting unsupervised in a staff member's car in the parking lot. The resident had been observed packing belongings, expressing confusion, and making statements about leaving, but these behaviors were not identified as exit-seeking or elopement risk by staff. Despite multiple staff members observing the resident's behavioral changes, including repeated trips to the front entrance and packing bags, the care plan was not updated to reflect the new risk, and no interventions such as wander management devices or increased supervision were implemented prior to the elopement. Documentation of the resident's change in behavior was reported to the primary healthcare provider, who ordered a urinalysis, but the facility did not recognize or address the increased risk of elopement. Staff interviews revealed a lack of awareness and action regarding the resident's behaviors, and no incident report was completed after the resident exited the facility. Additionally, facility policies and procedures were not followed, as evidenced by the absence of an updated care plan, missing elopement binders at the nurses' station, and lack of head counts or elopement drills following the incident. The front entrance could be opened with a code, and the receptionist, who was aware of the resident's behaviors, left the desk unattended without ensuring coverage. The facility did not report the incident to the State Agency in a timely manner, and there was no thorough investigation or immediate implementation of elopement precautions for the resident prior to the event.

Removal Plan

• The President in-serviced the Social Services Department on ensuring that care plans and interventions are implemented for Residents with behavioral changes that verbalizing to leave the facility, exit seeking, wandering and packing belongs should be immediately assessed and elopement precautions implemented.
• The Executive Director notified the Mississippi Department of Health of the incident regarding Resident #1 exiting the facility unaccompanied and unnoticed by staff.
• An audit was completed for all Residents who were determined to be at risk for elopement risk to ensure accuracy of the care plan and appropriate interventions by the Director of Nurses.
• A sign was placed on all exit doors reminding staff and visitors to be cautious when entering and exiting the facility in an effort to prevent Residents from leaving the facility without staff knowledge.
• The Executive Director and Director of Nurses reinterviewed Resident#1. Resident#1 confirmed that she exited the facility from the front door by following other people out. Resident #1 could not recall how many people she followed or give a description.
• Letters were mailed to family members by Social Services as a reminder to use precautions when entering and the facility in an effort to prevent Residents from exiting the facility unaccompanied or unnoticed by staff. The letter also requested that family members notify the staff of the facility if a Resident verbalizes thoughts of the leaving the facility.
• The Receptionist who vacated the front desk was in-serviced by the Executive Director to ensure that coverage is requested by another staff member prior to leaving the front desk. In addition to all routine staff who the receptionist area was in-serviced by the Executive Director.
• 100% audit of elopement binders were conducted by the Social Service Department to ensure the binders information was reflective of all Residents who are deemed as elopement risk.
• An Emergency Quality Assurance Committee was held with the following staff in attendance: President, Executive Director, Regional Director of Clinical Services, Director of Nurses, Assistant Executive Directors, Social Service Director, Social vice Assistants and Medical Director. The IP nurse was present by phone.

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 appropriate care and services for a resident with a nephrostomy tube. Upon admission, the resident had a urinary obstruction requiring a nephrostomy tube, as documented in hospital discharge records and admission notes. However, there were no physician orders for nephrostomy tube care, such as flushing or dressing changes, and no care plan was developed to address the device. Throughout the resident's stay, there was no documentation of any nephrostomy tube dressing changes or flushes in the clinical record, and nursing notes did not indicate that these essential care tasks were performed. Interviews with nursing staff revealed that neither the RN nor the LPN responsible for the resident's care had performed or documented dressing changes or tube flushes. The RN stated she had not received specific orders or a schedule for nephrostomy tube care and assumed another provider was managing it. The LPN confirmed she only visually monitored the site and did not perform routine maintenance, as there were no care plan instructions or physician orders. Both staff members acknowledged that routine care should have been in place and documented, but it was not. The Director of Nursing confirmed that the facility's standard practice requires physician orders and regular care routines for invasive devices, including scheduled dressing changes and tube flushes, with documentation for each instance. Upon review, the DON acknowledged the absence of orders and documentation for nephrostomy care and described this as a failure in care. The Medical Director also stated that nephrostomy tubes require routine care and monitoring, and expected nursing staff to proactively obtain necessary orders and provide care. The lack of documentation and care for the nephrostomy tube was confirmed as a failure to follow professional standards of practice.

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

Facility staff failed to implement care plan interventions for a resident with diabetes mellitus and end stage renal disease, specifically neglecting daily skin and foot assessments as required by the resident's care plan. The care plan included interventions to check the resident's body for skin breaks and to inspect feet daily for open areas, sores, pressure areas, blisters, edema, or redness. Despite these directives, staff did not identify or document developing wounds on the resident's right foot. The wounds were first discovered and treated at an outside dialysis center, where significant skin breakdown and discoloration were noted, and the facility was notified of the findings. Upon the resident's return from dialysis, facility staff completed a weekly skin assessment but failed to document the wounds or the dressing applied by the dialysis center. The LPN responsible for the assessment could not confirm whether the skin check was actually performed. The wound care physician and wound care nurse were not consulted or made aware of the wounds until several days later, and the wounds remained untreated by facility staff for five days after being discovered by the dialysis center. Interviews with facility leadership confirmed that staff did not follow the care plan or respond appropriately to the external notification of the resident's condition.

Penalty

No penalty information released

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

Summary

Facility staff failed to provide necessary care and services and did not respond appropriately to changes in a resident's condition when wounds were identified and treated by a dialysis clinic. The dialysis staff discovered wounds on the resident's right foot, including missing skin and black discoloration, and notified the facility on the same day. Despite this notification, the facility did not assess or initiate treatment for the wounds until five days later. The resident reported that only the dialysis staff had changed his dressing, and no one from the facility had checked or treated the wounds during this period. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's foot wounds. The unit manager and wound care nurse were unaware of any issues, and there was no evidence in the 24-hour nursing reports or electronic medical record that the physician had been notified or that any interventions had been implemented. The facility's policies required weekly skin audits and prompt intervention for identified skin conditions, but the weekly skin assessment completed after the resident returned from dialysis did not document the wounds, and the wound care nurse could not confirm if the assessment had actually been performed. The resident had a history of end-stage renal disease and severe cognitive impairment. Observations at the dialysis center confirmed that the same dressing applied by dialysis staff remained unchanged for several days, and the facility's wound care physician did not receive a consultation order until five days after the initial notification. Facility leadership acknowledged that staff failed to ensure appropriate wound care, monitoring, and follow-up actions, despite being informed of the resident's condition by the dialysis clinic.

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 care plan intervention for a resident who receives hemodialysis, specifically regarding the timely removal of a pressure dressing from the resident's dialysis access site. The care plan, dated 10/15/24, required that the pressure dressing be removed four hours post-dialysis unless otherwise specified, and the physician's order directed removal six hours after returning from dialysis. However, during an observation on 04/01/25, the resident was found to still have the bandage in place from a dialysis treatment that occurred the previous day, indicating the dressing had not been removed as required. Interviews with facility staff, including the Unit Manager, DON, and LPNs, confirmed that the care plan and physician's orders were not followed. The DON and LPNs acknowledged the failure to remove the bandage and to consult the care plan for guidance. The resident involved had a history of dependence on renal dialysis and was cognitively impaired, with a BIMS score of 6. The deficiency was identified through observation, record review, and staff interviews, all of which confirmed the lapse in following the established care plan and physician's orders.

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

Facility staff failed to ensure the timely removal of a pressure dressing from a dialysis access site for a resident dependent on renal dialysis. The resident had a physician's order and specific instructions from the dialysis unit to remove the pressure dressing within four to six hours after returning from dialysis. Documentation on the Dialysis Information Update Transfer Form repeatedly indicated the required timeframe for dressing removal. Despite these clear instructions, the dressing remained in place well beyond the specified period, as confirmed by observation and staff interviews. The resident, who was visually impaired and unable to remove the dressing independently, reported notifying nursing staff to remove the bandage, but it was not done. The dialysis nurse stated that she had previously educated facility staff, including the DON and Administrator, about the importance of timely dressing removal. Both the DON and Administrator acknowledged that staff failed to follow the physician's order and dialysis instructions, and neither was aware that this was a recurring issue until it was brought to their attention.

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 and implement comprehensive care plans for two residents, resulting in unmet care needs. For one resident with a history of bladder incontinence and an indwelling urinary catheter, the care plan did not address catheter care or include interventions related to the presence of the catheter. Observations confirmed that the resident's urine collection bag was left uncovered in a public area, and multiple staff members, including the MDS Nurse and Unit Manager, were unaware of the catheter's presence or the need for a care plan addressing catheter care and privacy measures. Another resident, who was dependent on staff for activities of daily living due to dementia, did not consistently receive scheduled showers as outlined in the care plan. The care plan specified assistance with showers three times weekly, but the resident reported not receiving showers on scheduled days and expressed dissatisfaction with having to request them. Staff interviews revealed confusion regarding the resident's shower schedule, and the CNA assigned to the resident was unable to confirm when the last shower was provided. The MDS Nurse acknowledged that care plans are developed and updated by nursing staff and that instructions are made available to CNAs through the facility's computer system. However, discrepancies between the care plan and the weekly shower list contributed to missed care. The Director of Nursing and Administrator confirmed the lack of a catheter care plan for the first resident and acknowledged the inconsistency in shower scheduling for the second 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

A deficiency was identified when a resident with chronic kidney disease, neuromuscular dysfunction of the bladder, and prostatic hyperplasia was found to have an indwelling Foley catheter in place without a corresponding physician order documented in the medical record. The resident had been admitted with the catheter in place, and staff interviews confirmed that the catheter had remained since admission. Despite facility policy requiring all physician orders to be written and signed, there was no order for the catheter itself, only an order for catheter care that was initiated after the resident had already been in the facility for an extended period. Observations revealed the resident seated in a wheelchair with an uncovered urine collection bag, and staff, including an LPN and the MDS nurse, were unaware of the need for a catheter order or the presence of the catheter. The DON and Administrator both confirmed that care should be provided according to physician orders and that the lack of a documented order for the catheter did not meet professional standards of care. The deficiency was further supported by the absence of a physician order in the resident's record and staff's lack of awareness regarding catheter care and 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

A deficiency occurred when a resident's urinary catheter bag was left uncovered and visible in a public common area, specifically the Unit 2 Dining Room, with approximately eighty milliliters of urine visible. Multiple observations confirmed that the catheter bag was not covered, and this was witnessed by both facility staff and the survey team. The facility's policy on resident rights, which emphasizes privacy and dignity, was not followed in this instance. Interviews with staff revealed a lack of awareness and monitoring regarding the resident's catheter care. The LPN assigned to the resident was new to the facility and unaware of the need for a catheter bag cover. The MDS Nurse was also unaware that the resident had a catheter until it was pointed out during the survey. The Unit 2 Manager confirmed that the resident had an indwelling catheter since admission. The resident in question had severe cognitive impairment and diagnoses including chronic kidney disease, neuromuscular dysfunction of the bladder, and prostatic hyperplasia.

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 care for hygiene, bathing, and grooming for two of eight sampled residents. One resident was observed with a long mustache and beard, with facial hair long enough to interfere with eating and cause discomfort. The resident expressed that the mustache hairs were bothersome and wished for them to be trimmed. Facility policy required residents to be free of facial hair unless otherwise documented in the care plan, and staff interviews confirmed that grooming, including shaving, was to be performed during AM and PM care or as needed. However, the resident's grooming needs were not met as required by policy. Another resident reported not receiving scheduled showers for at least two weeks, despite being dependent on staff for bathing and being scheduled for showers three times weekly. The resident stated that staff told him he could not be showered due to the lack of a shower bed, although observations confirmed that both a shower bed and a shower chair were available for use. Staff interviews revealed confusion regarding the resident's shower schedule and an inability to confirm when the last shower was provided. The resident continued to request showers, indicating that his hygiene needs were not being met according to facility policy and his care plan.

Penalty

Inspection fine: $97,55337 days payment denial

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 a safe, functional, and sanitary environment for its residents, as evidenced by multiple observations during the survey. Resident #7's room was found with dried, glossy, tan-colored spots on the oxygen concentrator, infusion pole, and over-the-bed table. Additionally, the Day Room on Unit 4 was cluttered with trash, including food and other debris, while a resident was present in the room. Resident #8's room was observed to have a floor littered with various items, including candy wrappers, crayon wrap paper, and food remnants. The room also had a dusty and dirty air conditioner, a stained bed frame, and a privacy curtain with brown spots. Notably, there were roaches observed crawling on the floor and wall near the resident's bed. The Assistant Administrator confirmed the need for cleaning and acknowledged the presence of pests. Further observations revealed that Resident #2's room had numerous dried, glossy spots on the air conditioner, and Resident #4's room was littered with trash and had stained walls and furniture. Interviews with the Housekeeping Director and Maintenance Director highlighted issues with staffing and maintenance logs, contributing to the unsanitary conditions. The facility's Administrator acknowledged the conditions and mentioned hiring new housekeeping staff to address the issues.

Penalty

Inspection fine: $97,55337 days payment denial

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 and routine incontinence care for a resident who required assistance with toilet use and hygiene. The resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was not checked or provided care for incontinence needs for a period of three and a half hours. This lapse occurred between 12:30 PM and 4:00 PM, during which time the resident was observed with wet incontinence briefs and clothing that smelled of urine. The facility's policy required that incontinent residents be checked at least every two hours, as needed, and upon request, but this was not adhered to in the case of the resident. Interviews with staff revealed that the Certified Nurses' Aide (CNA) assigned to the resident's care left after lunch without making rounds or checking on incontinent residents. The subsequent CNA, who took over at 1:30 PM, did not check the resident until 4:00 PM. The Licensed Practical Nurse (LPN) and the Director of Nurses (DON) confirmed that the resident was not monitored for incontinence during this period, and acknowledged that the delay in care was too long. The facility's failure to ensure timely incontinence care was further compounded by staffing issues, as repeated episodes of staff not working scheduled hours were noted to potentially affect resident care.

Penalty

Inspection fine: $97,55337 days payment denial

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 care and services to a resident with a feeding tube according to the resident's needs and consistent with the practitioner's orders. The deficiency was identified for a resident who relied on enteral feeding for nutrition. The facility's policy on enteral nutrition, dated 2017, outlined that tube feeding should be individualized, allowing for potential downtime for personal care or rehab therapy sessions. However, observations revealed that the resident's enteral feeding pump was turned off for over four hours, contrary to the physician's order to hold the feeding for only 30 minutes prior to meals. The Licensed Practical Nurse (LPN) expressed confusion regarding the physician's orders for the resident's enteral feeding, stating that the feeding was supposed to be turned off for an hour before the delivery of the resident's supper tray. The Director of Nursing (DON) confirmed that the feeding should not have been held for more than 30 minutes, as prolonged interruption could affect the resident's nutritional and hydration needs. The resident, admitted with diagnoses including Aphasia, Gastrostomy status, Diabetes, and Metabolic Encephalopathy, was observed with the enteral feeding pump off and the feeding bottle unchanged for several hours, indicating a failure to adhere to the prescribed feeding schedule.

Penalty

Inspection fine: $97,55337 days payment denial

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 sufficient nursing staff to meet the needs of residents on eight out of sixteen staffing days reviewed in December 2024. Observations and interviews revealed that staff shortages led to inadequate care, such as delayed incontinence monitoring and care for residents. An anonymous complaint highlighted a lack of housekeeping staff and inadequate direct care staff, which was corroborated by staff interviews and record reviews. Certified Nursing Assistant (CNA) #1 reported being unable to provide timely care due to an increased workload after another CNA left mid-shift. Interviews with staff indicated that late arrivals and call-ins were common, affecting the facility's ability to maintain adequate staffing levels. The Staff Development Director admitted to not using the Facility Assessment Tool for scheduling, relying solely on census numbers, which contributed to the staffing issues. The Director of Nurses (DON) confirmed that call-ins were problematic and that staff sometimes left residents in bed or skipped showers due to low staffing levels. Additionally, CNAs were occasionally reassigned to work in the laundry due to a lack of housekeeping staff, further impacting resident care. Resident #1, who was admitted with diagnoses of Heart Failure, Chronic Obstructive Pulmonary Disease, and Diabetes, reported waiting up to an hour for assistance on multiple occasions. The facility's staffing grid showed that the number of CNAs and licensed nurses often fell short of the required numbers based on the Facility Assessment Tool. The Administrator acknowledged the issues and confirmed that the Staff Development Director was expected to use the Facility Assessment Tool for staffing decisions, but this was not being done effectively.

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 a safe, clean, and homelike environment for its residents, as evidenced by the conditions observed in the rooms of two residents, a shower room, and a hallway. Resident #3's room was found to be dirty, with trash and stains on the floor, dusty windows, and a black substance on the windowsills. The resident expressed dissatisfaction with the housekeeping services, and the Housekeeping Supervisor confirmed that the room should have been cleaned daily. Additionally, a family member of Resident #3 reported consistent issues with cleanliness during their weekly visits. Resident #4's room and the surrounding hallway were noted to have a strong urine odor. The resident, who had a history of urinary incontinence, was waiting for assistance from a CNA to change her bedding. Both the CNA and an RN confirmed the presence of the odor, and the Administrator suggested that the mattress might need cleaning or replacement. This indicates a failure to promptly address the resident's incontinence needs and maintain a clean environment. The shower room on the back hall was observed to have brown stains on the floor, which were easily wiped away, indicating a lack of regular cleaning. The assigned housekeeper admitted to not cleaning the floor on the days in question due to her workload. Additionally, the hallway outside a resident's room had decorative items covered in thick dust and dirty hand sanitizer dispensers, which the Housekeeping Supervisor acknowledged needed cleaning. The Administrator confirmed that housekeeping services were expected daily, but staffing challenges were impacting the facility's ability to maintain cleanliness.

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 foods were stored safely in the walk-in refrigerator and freezer. During an initial tour of the kitchen, it was observed that clear containers with unknown substances were neither labeled nor dated with use-by dates. Additionally, containers and boxes of food were stored on the floor in the walk-in freezer. The facility's policies on labeling and dating foods, as well as food storage, were not followed, which require all foods to be properly labeled and stored at least six inches above the floor to prevent contamination. Interviews with the Registered Dieticians (RD #1 and RD #2) and the Administrator revealed that the Dietary Manager, who was responsible for labeling and dating potentially hazardous foods (PHFs) and ensuring proper food storage, had been out sick and decided not to return. The Administrator confirmed that the facility had recently undergone a Mississippi State Department of Health (MSDH) food establishment inspection and received a C rating. The dietary staff was expected to follow the food storage and labeling policies in place, but these expectations were not met, leading to the observed deficiencies.

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 attending physician was notified of repeated medication refusals for a resident. The resident, who had diagnoses including Metabolic Encephalopathy, Unspecified Dementia, and Atrial Fibrillation, refused medications eight out of 29 days in February 2024 and only took medications for three out of 13 days in March 2024. Despite the facility's policy requiring notification of the physician and responsible party after repeated medication refusals, this was not consistently done. The Director of Nursing confirmed that the nurse should document refusals and notify the physician and responsible party, but this procedure was not followed in this case. Interviews with the Pharmacy Consultant, the resident's Physician, and the Nurse Practitioner revealed that they were not aware of the extent of the resident's medication refusals. The Pharmacy Consultant stated he does not always review the eMAR, and the Physician and Nurse Practitioner were not informed of the numerous missed doses. The resident's Physician emphasized the importance of the missed medications, particularly Eliquis, which is critical for preventing further complications. The Nurse Practitioner noted that the facility's use of agency staffing might contribute to the inconsistency in medication administration. The resident's Resident Representative (RR) also confirmed that she was not notified of the medication refusals. The facility's documentation showed only three notes indicating that the Nurse Practitioner was notified and only one note stating that the Resident Representative was informed. The Director of Nursing and the Administrator admitted they were unaware of the extent of the medication refusals and confirmed there was no system in place to address the issue. The resident's Quarterly Minimum Data Set (MDS) indicated severe cognitive impairment, further highlighting the need for diligent medication management and communication with the responsible parties.

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 a clean, homelike environment by not ensuring clean linen was available for two residents. Resident #120 was observed lying in bed with a strong odor in the room, indicating a need for incontinent care. Despite turning on the call light, the resident did not receive the necessary care for 30 minutes, and the CNA revealed that there were no clean sheets available. The resident had to sit up in a chair because of the lack of clean sheets, a situation that reportedly occurred several times a week. Resident #120 had severe cognitive impairment and multiple diagnoses, including seizures and diabetes mellitus. Resident #194 was found lying in bed without a fitted sheet on the mattress and stated that the facility often ran out of sheets. The resident, who was cognitively intact and required moderate assistance for mobility, confirmed that this issue was recurrent. Interviews with the DON, laundry supervisor, and other staff revealed that the facility had linen available, but staff were either unaware of its location or used the lack of linen as an excuse not to change beds. The facility had previously conducted an in-service training on linen locations, but many of the trained staff no longer worked at the facility.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate of less than 5%, as evidenced by not administering medications per physician's orders for four out of 33 medications, resulting in a 12.12% medication error rate. Specifically, a Licensed Practical Nurse (LPN) administered Aspirin, Sertraline, Multivitamin with minerals, and Amlodipine to a resident via a PEG tube, despite the physician's orders indicating these medications were to be given by mouth. The LPN confirmed the error after reading the medication orders post-administration. The Director of Nursing (DON) reviewed the medication orders and confirmed that the medications were indeed ordered to be given by mouth. The DON stated that any variation from the physician's orders would be considered a medication error. The resident's physician orders, dated from November 2023, specified the oral administration of the medications, which was not followed, leading to the identified 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 serve food in a manner that was appealing and palatable for two residents. Resident #5, who has Type 2 Diabetes Mellitus and Iron Deficiency Anemia, stated that the food tasted like slop and only consumed cold cereal and milk. This resident was cognitively intact with a BIMS score of 15. Similarly, Resident #362, who has diagnoses including Encounter for other Orthopedic Aftercare and Essential Hypertension, complained that the food tasted bad and was not appealing. This resident also had a BIMS score of 15, indicating cognitive intactness. On a subsequent day, a lunch tray was tested with the Dietician, revealing that the vegetables were bland and lacked taste. The Dietician acknowledged that the carrots could be sweeter and noted that some residents complain about the food being too salty or spicy. Resident #362 ate only 50% of the lunch meal and had previously complained to a CNA about the food, preferring fresh fruits and vegetables, which she kept in her personal refrigerator. These observations and interviews indicate that the facility did not meet the requirement to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature.

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 residents who smoked were allowed to exercise their right to smoke during the designated smoking times. Resident #6 reported not receiving scheduled smoking breaks and observed staff engaging in horseplay instead of assisting residents. Resident #6, who has a diagnosis of Nicotine Dependence and is cognitively intact with a BIMS score of 15, expressed frustration and felt disrespected by the staff's inaction. Similarly, Resident #27 reported inconsistent smoking breaks, with delays of up to an hour or missed breaks entirely. Resident #27, also diagnosed with Nicotine Dependence and cognitively intact with a BIMS score of 13, observed staff idling at the nurse's desk during scheduled smoking times, further contributing to feelings of frustration and disrespect. Interviews with staff, including a CNA and the Director of Nursing, confirmed that residents were often ready for their smoke breaks, but staff were not available to assist them. The Director of Nursing acknowledged the issue and indicated that Unit Managers were responsible for assigning CNAs to take residents out for their smoke breaks. The Administrator, who had only been at the facility for three weeks, stated that he was still acclimating to the facility but expected staff to honor residents' preferences. The failure to provide scheduled smoking breaks negatively impacted the residents' feelings and their right to 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 resolve a grievance related to Activities of Daily Living (ADL) care and showering for a resident with severe cognitive impairment. The resident, who has diagnoses including cerebrovascular disease, type 2 diabetes mellitus, unspecified convulsions, and essential hypertension, reported not receiving scheduled showers on multiple occasions. Despite being scheduled for showers three times a week, the resident only received bed baths during the observed period, leading to discomfort and complaints about dirty and itchy hair. Interviews with various staff members, including CNAs, social services, and nursing supervisors, revealed inconsistencies in the care provided to the resident. The resident's daughter had previously filed a grievance regarding the lack of proper ADL care, which led to an interdisciplinary team meeting and staff in-service. However, the grievance remained unresolved as the resident continued to miss scheduled showers, and staff were unaware of the ongoing issue. The facility's grievance policy requires prompt resolution of grievances, but the staff failed to follow through effectively. Social services and nursing leadership were not adequately monitoring the situation, and there was a lack of communication and documentation regarding the resident's care needs. The facility's reliance on agency staff further contributed to the inconsistency in care, as new staff were unfamiliar with the resident's specific 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 ensure timely incontinent care for a resident, leading to the resident being left soiled for extended periods. Resident #167, who is dependent on staff for activities of daily living and is incontinent of bowel and bladder, reported having to wait long periods to be changed, especially during the night shift. Observations confirmed that the resident was found heavily soiled with urine and bowel movement, with a pillowcase placed between her legs to absorb the urine. The resident and her daughter had previously complained to staff about the issue, but the problem persisted. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in care practices and a lack of timely response to the resident's needs. The DON confirmed that residents should be checked and changed every two hours or more frequently as needed, but this standard was not met. The facility's policy on incontinent care was not followed, leading to the resident's prolonged discomfort and potential health risks. The facility's interdisciplinary team was aware of the complaints but failed to address them effectively.