The Citadel At Myers Park, Llc

Penalty

No penalty information released

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

Summary

The facility failed to implement its abuse policy effectively following an incident of resident-to-resident physical abuse, which placed all residents on the secured unit at risk. On January 27, Nurse #6 witnessed Resident #64 physically assault Resident #84 by lifting and throwing him out of the room, resulting in Resident #84 hitting his head on the floor. Despite this serious incident, the facility's response was inadequate, as they only implemented 30-minute monitoring checks for Resident #64, which proved ineffective in preventing further abuse. On February 1, Resident #64 was involved in another incident where he pushed Resident #18 as she walked past his room. This incident highlighted the failure of the facility's initial protective measures, as Resident #64 continued to pose a threat to other residents. The Director of Nursing (DON) and the Administrator were not fully informed of the severity of the initial incident until the following day, which delayed the implementation of more effective protective measures. The facility's policy on abuse, neglect, and exploitation was not adequately followed, as it required increased supervision and potential room or staffing changes to protect residents from the alleged perpetrator. The facility's failure to implement these measures promptly and effectively resulted in ongoing immediate jeopardy, as the risk of further abuse remained present and unaddressed.

Removal Plan

• Resident #64 was placed on 1:1 supervision via nurse aides or designee during wake hours until further notice and 1-hour checks by nurse and 30-minute checks by nursing assistant or designee to be completed while resident is sleeping.
• A follow-up call to the NP for resident #64 was placed by the DON and new orders were received for labs and psych consult due to escalated behaviors.
• The NP for resident #64 started the resident on Seroquel (antipsychotic medication) 25 mg daily for behavior management and diagnosis of adjustment disorder with depressed mood.
• A Root Cause Analysis was completed by the LNHA and the DON with input from Interdisciplinary Team (IDT) and consultants.
• Resident #64 was placed on 1:1 supervision by his nurse.
• The facility's policy titled Abuse, Neglect, and Mistreatment was reviewed by the administrator with no changes indicated.
• The abuse policy was reviewed again by the LNHA and the regional clinical consultant and no changes were made.
• Verbal education was provided by the Regional Director of Operations and Regional Clinical Consultant to LNHA and DON regarding procedures of thoroughly completing an investigation of alleged abuse, unusual events, monitoring for and identifying precipitating behaviors that could lead to possible resident to resident altercations and ensuring protection for all residents.
• Nurse aides and licensed nurses received education from the Licensed Nursing Home Administrator/Designee that included direction to stay with the aggressive resident to promote and maintain safety for other residents within the facility.
• Immediate verbal education was initiated by LNHA/designee related to types of abuse including resident to resident altercations, abuse identification, abuse prevention, abuse reporting, and maintaining resident safety, with all nursing facility staff.
• Additional ongoing whole nursing home staff education is being coordinated by the Regional Director of Operations with psych providers or designee related to dealing with difficult behaviors and monitoring interventions, to be completed monthly with all staff.

Penalty

No penalty information released

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

Summary

The facility failed to protect a cognitively impaired resident, Resident #84, from physical abuse by another resident, Resident #64. On the day of the incident, Resident #84, who had a history of wandering due to severe cognitive impairment, entered Resident #64's room. Resident #64, also cognitively impaired, reacted aggressively by lifting Resident #84 and throwing him out of the room, resulting in Resident #84 hitting his head on the floor. Despite the presence of staff, including Nurse #6 who witnessed the incident, immediate protective measures were not effectively implemented to prevent such an altercation. Resident #64 had a documented history of potential physical aggression due to poor impulse control, as noted in his care plan. However, the facility's monitoring records indicated no behaviors of concern in the days leading up to the incident. This lack of documented behavioral issues may have contributed to the staff's unpreparedness for Resident #64's aggressive response. Additionally, the care plan for Resident #84 identified his wandering behavior, yet interventions to protect him and others were insufficiently executed, as evidenced by his unsupervised entry into Resident #64's room. The facility's response to the incident was delayed and inadequate. Although Nurse #6 reported the incident to the Director of Nursing and Unit Manager, the initial assessment and subsequent actions did not immediately address the severity of the situation. Resident #84 was not promptly sent for a medical evaluation despite exhibiting signs of potential injury, such as guarding his arm and head. The facility's failure to recognize and act upon the immediate jeopardy posed by the resident-to-resident altercation highlights a significant deficiency in ensuring resident safety and preventing abuse.

Removal Plan

• Resident #64 was placed on increased monitoring via nurse aides and via licensed nurse.
• Resident #64's orders and care plans were reviewed and updated by the DON and Unit Manager to reflect checks by nurse aides and checks by licensed nurses.
• Resident #64 was escalated to a 1 on 1 supervision during wake hours via nurse aide or designee.
• Education was initiated by Licensed Nursing Home Administrator/designee related to types of abuse including resident to resident altercations, abuse identification, abuse prevention, and maintaining resident safety, with all nursing home staff.
• Education included scenarios and quizzes for demonstration of staff competency.
• Education further included redirecting residents, monitoring for and identifying precipitating behaviors that could lead to possible resident to resident altercations.
• No staff will work without having had this education.
• Additional ongoing whole nursing home staff education is being coordinated by the Regional Director of Operations with Telos psych providers or designee related to dealing with difficult behaviors and monitoring interventions, to be completed with all staff.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the safe transportation of a cognitively intact resident who was receiving dialysis and prescribed an anticoagulant. During transport, the driver from a contracted transportation company did not secure the resident with a lap and shoulder belt, leading to the resident being thrown from his wheelchair to the floor of the van after hitting bumps in the road. The driver did not contact emergency services and left the resident on the floor of the van until they returned to the facility. Upon arrival, a nurse assessed the resident and found no injuries, but the incident had a high likelihood of causing serious harm. The facility also failed to complete an accurate safe smoking assessment for a resident with a history of smoking-related incidents, resulting in the resident being unsupervised while smoking. Observations revealed the resident smoking without supervision, with cigarette ashes on his coat, indicating a potential safety hazard. The facility's policy required residents with a history of smoking-related incidents to be supervised, but the assessment inaccurately deemed the resident as an independent smoker. Additionally, the facility did not have electronic monitoring devices in place for two residents with a history of wandering, despite physician orders and care plans indicating the need for such devices. The devices were on backorder, and the facility implemented increased monitoring as a temporary measure. However, the lack of electronic monitoring devices posed a risk of elopement for these residents. Another resident on a secured unit was found to have wandered unattended to another floor, highlighting a lack of adequate supervision to prevent accidents.

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 electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) for the fourth quarter of fiscal year 2024. This deficiency was identified during a review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database. The Administrator was unaware of the reporting error, as the responsibility for submitting the data lay with the corporate team. The President of Operations confirmed that the corporate office was responsible for submitting the PBJ staffing data for all facilities within the corporation and acknowledged that the data sheet was created but not submitted due to an error by the corporate office.

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 safety and sanitation standards in its kitchen and nourishment rooms. During an inspection, expired and spoiled food items were found in a reach-in cooler, including mayonnaise, coleslaw dressing, barbeque sauce, yogurt, mushrooms, tomatoes, and turkey lunchmeat. These items were either past their expiration dates or not labeled and dated as required. The Cook acknowledged the oversight, attributing it to leftover items from previous staff and a lack of proper labeling and dating practices. Additionally, the nourishment rooms on the first and second floors were found to be unclean, with leftover meal trays and food debris present. Meal trays from previous days were left on counters, and refrigerators contained expired and improperly stored food items. Interviews with staff, including a Nurse Aide, the Dietary Manager, and the Director of Nursing, revealed a lack of clarity regarding responsibilities for maintaining cleanliness and monitoring food safety in these areas. The Administrator expected adherence to policies and procedures, but the deficiencies indicated a breakdown in communication and accountability among the staff.

Penalty

No penalty information released

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

Summary

The facility failed to maintain sanitary conditions around two outdoor trash receptacles located next to the kitchen exit. Observations on two separate days revealed that one of the dumpsters had its top lid open, and there was a significant amount of trash debris lying on the ground around the dumpsters. Additionally, old furniture, including a clothing closet, bedside table, nightstand, and eight wooden pallets, were found leaning against the building and the dumpsters. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the area was not being maintained according to the facility's policies and procedures. The DON explained that the facility was in the process of refurbishing rooms, which led to the accumulation of old furniture outside. Both the DON and the Administrator expected the dumpster doors to be closed and the area to be clean, but this was not the case during the observations.

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 nail care for a resident who was unable to perform activities of daily living independently. The resident, who was admitted with diagnoses including cerebrovascular accident, diabetes mellitus, dementia, and Alzheimer's disease, required substantial to maximal assistance with all activities of daily living except eating. Observations over several days revealed that the resident had brown colored debris under her fingernails, indicating a lack of proper grooming and hygiene care. Despite multiple observations of the resident's dirty fingernails, staff members, including nurse aides and the unit manager, did not take immediate action to clean the resident's nails. Interviews with staff revealed that they had not noticed the debris or had not prioritized cleaning the resident's nails, even when it was brought to their attention. The unit manager acknowledged the issue but deferred cleaning the nails until the resident's scheduled shower later in the day. The Director of Nursing and the Administrator expressed expectations for daily grooming and care, especially for residents with dementia who are unable to care for themselves. However, the staff's inaction and lack of immediate response to the resident's grooming needs resulted in a deficiency in providing necessary care and assistance for activities of daily living.

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 effectively communicate changes in a resident's code status, leading to a discrepancy between the physical and electronic medical records. Resident #25, who had a history of cerebral infarction, diabetes, and chronic obstructive pulmonary disease, was admitted with a CPR/Full Code status as indicated on the Medical Orders for Scope of Treatment (MOST) form. However, after transitioning to Hospice care, the resident's code status was changed to Do Not Resuscitate (DNR) in the electronic medical record (EMR), but this change was not reflected in the physical MOST form. Interviews with facility staff revealed a lack of communication and coordination regarding the update of the resident's code status. The Medical Records Coordinator was unaware of the change and did not update the EMR, while the Social Worker, responsible for updating the care plan, was also uninformed about the transition to Hospice and the code status change. The Director of Nursing acknowledged the discrepancy and noted that the Unit Manager had updated the EMR alert banner, but the physical documents were not aligned. The Administrator expected consistency between the physical and electronic records but was unsure why the discrepancy occurred.

Penalty

No penalty information released

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

Summary

The facility failed to notify the physician with specific details of a resident abuse incident that resulted in a fall and potential head injury. Resident #84, who has Alzheimer's disease and dementia, was thrown to the floor by another resident, hitting his head. Nurse #6 witnessed the incident and heard a cracking sound as the resident's head hit the floor. Despite this, the nurse did not provide detailed information about the fall and head injury to NP #1, who was only informed of an altercation and advised to use nursing judgment for further evaluation. Consequently, NP #1 was not aware of the head injury and did not order an immediate evaluation. Later, NP #2 assessed Resident #84 and, upon learning of the fall and head impact, recommended sending the resident to the emergency department for evaluation. The emergency department conducted a CT scan and chest x-ray, which showed no abnormalities, and the resident was discharged back to the facility in stable condition. The administrator expected that NP #1 would have been informed of the fall and head injury, indicating a communication breakdown in the notification process.

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 wheelchairs and window blinds in good repair, affecting two residents and one room. Resident #38, who has moderately impaired cognition and impairment on one side of the lower extremity, was observed sitting in a wheelchair with a damaged left armrest. The armrest had a torn, cracked, and ripped covering with sharp edges, which the resident's left arm came into contact with. Despite frequent care from staff, the disrepair went unnoticed until the survey, and the resident expressed a desire for the issue to be fixed. Additionally, the window blinds in Resident #38's room were in disrepair, with missing components that prevented them from being adjusted. The resident reported feeling exposed due to the inability to control the blinds, which had been broken since his admission. Staff members, including a nurse aide and a nurse, failed to notice the issue or report it to maintenance, resulting in the blinds remaining unfixed. Resident #87, also with moderately impaired cognition, was observed in a wheelchair missing a left armrest, causing discomfort as she rested her arm on the metal frame. Despite regular care, staff did not notice the missing armrest until the survey. The Maintenance Director, new to the position, acknowledged the need for repairs but relied on staff to report issues. The Director of Nursing and the Administrator both expressed expectations for all equipment and living environments to be maintained in good repair to prevent issues such as skin irritation and to protect residents' privacy.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its abuse policies and procedures by not immediately reporting an allegation of resident abuse to the Administrator. Nurse #6 witnessed Resident #64 use physical force to remove Resident #84 from his room, resulting in a fall. Despite receiving abuse training, Nurse #6 did not report the incident as abuse at the time it occurred, instead informing the Director of Nursing (DON) that it was an unwitnessed fall. The Administrator was not made aware of the details until the following day, and the initial 24-hour report contained incorrect information regarding the date the facility became aware of the incident and lacked sufficient details about the abuse. In another incident, the facility failed to report an allegation of resident-to-resident sexual abuse involving Resident #82 and Resident #88. Nurse #1 documented the incident in the nursing progress notes but did not notify the Administrator or the DON. The incident was not investigated, and the facility's abuse prevention policy was not followed. The Administrator was unaware of the situation until reviewing the notes months later, indicating a lapse in communication and oversight. Both incidents highlight the facility's failure to implement its abuse policies and procedures effectively, affecting the safety and well-being of the residents involved. The lack of immediate reporting and accurate documentation in both cases demonstrates a significant deficiency in the facility's handling of abuse allegations.

Penalty

No penalty information released

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

Summary

The facility failed to update the care plan for two residents, leading to deficiencies in their care management. Resident #63, who was admitted with Alzheimer's disease, heart failure, and seizure disorder, had a severe cognitive impairment and was identified as a wanderer. Despite having a physician's order for an electronic wander guard alarm to be checked every shift, the care plan did not include this intervention. The MDS Coordinator acknowledged the omission and stated that the wander guard should have been included in the care plan. Interviews with nurse aides and the Director of Nursing confirmed the necessity of the wander guard for Resident #63's safety, yet it was not documented in the care plan. Similarly, the facility failed to update the care plan for Resident #25 to reflect a change in code status to Do Not Resuscitate (DNR) after transitioning to hospice care. Despite the DNR form being signed and the resident's severe cognitive impairment, the care plan was not updated to indicate the new code status. The MDS Nurse and Social Worker both acknowledged the oversight, with the Social Worker indicating a change in responsibility for updating care plans. The Director of Nursing and the Administrator both expected the care plan to be updated timely, but it was not, resulting in a deficiency.

Penalty

52 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 update an advanced directive to reflect the wishes of a resident and his Responsible Party (RP) for the resident not to be intubated for mechanical ventilation. This failure resulted in the resident, who had a history of Alzheimer's disease and was severely cognitively impaired, being intubated during an Emergency Department evaluation. The intubation was against the resident's and the RP's documented wishes due to being transferred with an outdated Medical Orders for Scope of Treatment (MOST) form. The resident was admitted to the facility with a diagnosis of Alzheimer's disease and had been readmitted multiple times. A physician's order for Do Not Resuscitate (DNR) was in place, but the MOST form on file indicated full scope of treatment, including intubation. Despite a discharge summary from a previous hospitalization indicating the RP's wishes for Do Not Intubate (DNI), the facility did not update the MOST form. The interdisciplinary team failed to discuss the specifics of the MOST form during a care conference, and the social worker did not verify the RP's wishes regarding intubation. The resident experienced an unwitnessed fall and was later found unresponsive, leading to a transfer to the hospital with the outdated MOST form. The hospital intubated the resident based on the MOST form, contrary to the RP's wishes. The facility's staff, including the Director of Nursing and Administrator, were unaware of the code status change requested by the RP. The failure to update the MOST form and communicate the RP's wishes resulted in the resident being intubated and later extubated, with the RP having to make the difficult decision to discontinue life support.

Removal Plan

• A full review of all resident MOST forms was conducted by the Administrator or designee with the responsible party, for compliance with the MOST form accurately reflecting the resident's wishes.
• A review of Advance Directives policy procedure will be completed by the Administrator or designee, and changes, as needed, will be made by the QAA committee.
• The administrator or designee will educate the interdisciplinary care plan team and all licensed professional nurses on the requirements of completing and maintaining an accurate MOST form at least annually and following hospitalizations, quarterly, or annually, as indicated or discussed with the responsible party before the staff's next worked shift.
• In the event that the information on the MOST form is updated, the previous MOST form will be placed into archived documents within the medical record by the Medical Records staff or designee.
• Current and accurate MOST forms will be provided to EMS staff and sent with the transferring resident, by the licensed nurse or designee, at the time of transfer from the facility.
• The Administrator or designee will track the completion of all education provided to ensure the staff completes it before they work.
• The facility administrator assumes responsibility for the immediate jeopardy removal plan.

Penalty

52 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 staff failed to complete ongoing neurological assessments after an unwitnessed fall for a resident with severely impaired cognition. The incident occurred when a nurse aide heard a loud noise and found the resident on the floor beside his wheelchair. The resident was assessed by a nurse who noted no signs of injury, and the resident was assisted back into his wheelchair and then to bed. However, no further neurological checks were documented in the medical record after the initial assessment. During the night, the resident was checked for incontinence every 2 to 3 hours by a nurse aide, who noted that the resident was snoring but roused easily until the last round. The following morning, the resident was found unresponsive to tactile and verbal stimuli, prompting the dispatch of emergency medical services. A CT scan at the hospital revealed a life-threatening subdural hematoma, and the resident was intubated for mechanical ventilation. The resident's condition deteriorated, leading to a decision to transition to hospice care, where the resident later died. Interviews with facility staff revealed that there was a lack of communication and follow-through regarding the need for ongoing neurological assessments after the fall. The nursing staff assumed that the weekend Nursing Supervisor would continue the assessments, but this was not done. The Director of Nursing later acknowledged that the resident's vital signs, neuro checks, and assessments should have been continued since the fall was unwitnessed, indicating a miscommunication between the staff involved.

Removal Plan

• A full review by the DON or designee of all unwitnessed falls incident reports, documented neurological assessments and progress notes will be completed.
• The facility has identified residents who are at risk for an adverse outcome because the facility has not provided ongoing neurological assessment after an unwitnessed fall.
• The director of nursing will complete this review.
• The DON or designee instructed all licensed nurses with verbal education to complete a head-to-toe assessment on any identified resident who is at risk for an adverse outcome.
• Following the assessment, the licensed nurse is required to notify the resident's physician of the findings.
• A review of the Fall policy and procedure and the Neurological Assessment policy and procedure will be completed and communicated to the QAA committee by the Administrator or designee.
• Changes, if needed, will be made as identified by the QAA committee.
• All licensed professional nurses will receive education from the Administrator or designee on the policy and procedure regarding neurological assessment completion after an unwitnessed fall before their next shift via verbal education.
• Any licensed professional nurses not having had this education will be removed from the schedule until education is received.
• All certified nursing assistants will receive education from Administrator or designee on symptoms to look for after an unwitnessed fall and the reporting process if any of the symptoms are identified.
• Certified Nursing Assistants will be notified by the licensed nurse or designee, that an unwitnessed fall with ongoing neurological assessment is actively being completed on a specified resident.
• All certified nursing assistants not having had this education will be removed from the schedule until education is received.
• For all education provided, the administrator or designee will track completion to ensure the education is completed before the staff working.
• Staff will complete a written quiz to validate competency of all licensed nursing staff and certified nursing assistants.
• The quiz will be administered and reviewed by the administrator or designee.

Penalty

No penalty information released

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

Summary

The facility failed to identify and immediately report an injury of unknown origin for a resident who sustained significant injuries, including bilateral traumatic periorbital ecchymosis and a nasal fracture. The resident, who was under hospice care and had a history of Alzheimer's dementia and wandering, was found with these injuries after being removed from another resident's room. The incident was unwitnessed, and the staff did not report it to the administration or Adult Protective Services (APS) within the required timeframe. The incident report and nurse progress notes indicated that the resident was found with a nosebleed and discoloration around both eyes, but the staff did not consider these injuries as resulting from abuse or an unknown origin. The resident was described as having wandered into another resident's room, where it was suspected that he was kicked by the other resident, although this was not witnessed. Despite the severity of the injuries, the staff did not immediately notify the administration or initiate an abuse investigation, and the incident was not reported to APS. Interviews with various nursing staff revealed a lack of clarity and communication regarding the incident. The staff involved did not witness the event and had differing opinions on whether the injuries were due to a fall or potential abuse. The facility's Director of Nursing and Administrator acknowledged that the incident should have been investigated as abuse and reported immediately, but this did not occur. The failure to report and investigate the incident promptly led to a deficiency in the facility's handling of potential abuse cases.

Penalty

Inspection fine: $5,715

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 the whereabouts of a cognitively intact resident diagnosed with dementia, leading to an incident where the resident left the facility unannounced. The resident, who had a history of smoking-related incidents and required supervision while smoking, left the facility to purchase cigarettes from a convenience store located 0.8 miles away. Despite being independent in mobility, the resident's unsteady gait and history of seizures raised concerns about his safety when ambulating alone. On the day of the incident, the resident expressed a desire to smoke and was informed by the staff that he would have to wait for supervision. However, the resident became frustrated and decided to leave the facility on his own. Staff members, including a nurse aide and a nurse, observed the resident in the hallway shortly before his disappearance but did not prevent his departure. The facility initiated a search and notified the police after discovering the resident's empty wheelchair by the elevator. The resident was eventually found at a behavioral health emergency clinic and returned to the facility by the police. Interviews with staff and the resident revealed that the resident left because he was upset about not being able to smoke when he wanted. The facility's failure to supervise the resident adequately and ensure his safety resulted in the resident leaving the premises without notifying staff or signing out, which was against the facility's policy.

Penalty

Inspection fine: $16,801

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 treatment and care for Resident #12 following a fall from her wheelchair in a transportation van. Resident #12, who had a history of non-Alzheimer's dementia, mild neurocognitive disorder, end-stage renal disease, and bilateral lower extremity amputation, was left unsupervised in a parked van with the engine and air conditioning on. During this time, she unbuckled her seatbelt and fell face down on the floor of the van. Driver #1, who was responsible for the transportation, witnessed the fall and observed a knot forming on Resident #12's forehead. Despite the visible injury, Driver #1 moved Resident #12 back into her wheelchair before calling 911, contrary to the facility's policy of leaving residents in place for clinical assessment after a fall. The incident report and interviews revealed that Driver #1, a certified nursing assistant, was the only staff member on the van at the time of the incident. After securing Resident #12 in her wheelchair, Driver #1 left the van to assist another resident, during which time Resident #12 fell. Upon returning to the van, Driver #1 moved Resident #12 from the floor to her wheelchair, citing the hot floor as a reason for the move. This action was taken before emergency medical services arrived, which was against the facility's protocol that required residents to remain in place until assessed by a licensed professional. Interviews with the facility's staff, including the Director of Nursing and the Administrator, confirmed that the standard procedure was not followed. The Administrator instructed Driver #1 to make Resident #12 comfortable and call 911, but was not aware that Resident #12 had been moved before the paramedics' arrival. The Director of Nursing and the Medical Director acknowledged the deviation from protocol but understood the rationale given the circumstances. However, the failure to adhere to the established procedure resulted in a deficiency in the quality of care provided to Resident #12.

Removal Plan

• The Administrator re-educated Driver #1 on facility van transportation policies and completed a Transportation Skills Assessment of the Transportation Aide/ CNA with no concerns noted.
• An Ad Hoc meeting was held with the following in attendance: the Administrator, the Director of Nursing, the Nurse Managers, the Rehab director, the MDS nurse, the Activity Director, and the Wound Care Nurse. The Medical Director was updated by the Administrator of the meeting's agenda and findings. Other resident incidents were reviewed during this meeting. There were no incidents identified in which a resident was moved before being assessed by licensed professionals.
• The President of Clinical Services provided education to Director of Nursing (DON) and Nursing Home Administrator (NHA) regarding facility policy of the following: In the event of a transportation related incident, resident is not to be moved until a licensed professional can assess for injuries. No changes to policy were necessary.
• DON provided in person one on one education to facility Driver #1 regarding facility policy of the following: In the event of a transportation related incident, resident is not to be moved until a licensed professional can assess for injuries in person. Driver #1 is an employee of the facility; no other drivers are employed. Driver #1 is directly supervised by the facility Administrator, who received in person education regarding facility policy by the President of Clinical Services.
• Individual interviews were conducted with all residents with a BIMS 13 or above who were transported by the facility transporter by the DON and Assistant Director of Nursing (ADON) to ensure no unreported incidents occurred during facility transportation requiring assessment by a licensed professional.
• Education was started with all staff, including agency staff by the ADON/Nurse Managers on the following: If the transport driver notifies the facility regarding a transportation related incident, inform them to contact emergency services and not move resident until a licensed professional can assess them. The facility Administrator and Director of Nursing's contact information is posted at all three nurse's stations. No staff will be allowed to work, including any new hires and agency staff, without receiving this education. This information will also be added to the new hire orientation. The Administrator will notify the Assistant Director of Nursing and/or Nurse Manager of this responsibility.
• Any newly hired facility van drivers will be educated during orientation by the DON/Administrator regarding facility policy: In the event of a transportation related incident, resident is not to be moved until a licensed professional can assess for injuries.
• An in person Ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held. The Administrator, the Director of Nursing, the Nurse Manages, the Rehab director, the MDS nurse, and the Wound Care Nurse attended this meeting to review the incident and credible allegation for the removal of the immediate jeopardy.
• The Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Penalty

Inspection fine: $16,801

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 supervise a resident diagnosed with dementia and bilateral amputations, leading to a fall incident. The resident was left unsupervised in a transportation van by the driver, who was also a CNA, while the van was parked with the engine running. During this time, the resident unbuckled her seatbelt, leaned forward, and fell face down onto the floor of the van. The driver returned to the van upon hearing the horn sound and found the resident on the floor, complaining of head pain. The resident was subsequently transported to the hospital, where she was diagnosed with a tiny acute hemorrhage and a subcutaneous hematoma. Another deficiency involved the facility's failure to supervise a resident who required supervision when smoking cigarettes. This resident, who was assessed as an unsafe smoker, managed to smoke a cigarette in her room unsupervised. The resident admitted to taking smoking materials back to her room after a supervised smoke break, as staff had left the residents unsupervised during the break. This incident was not reported to upper management by the nurse supervisor on duty at the time. Both incidents highlight the facility's failure to provide adequate supervision to prevent accidents, as evidenced by the unsupervised fall of a resident in a transportation van and the unsupervised smoking of another resident in her room. These deficiencies were identified during observations, record reviews, and interviews with residents and staff, indicating a lack of adherence to the facility's policies and procedures for resident supervision.

Removal Plan

• The Administrator re-educated Driver #1 on facility van transportation policies and completed a Transportation Skills Assessment of the Transportation Aide/CNA with no concerns noted.
• An Ad Hoc meeting was held with the Administrator, the Director of Nursing, the Nurse Managers, the Rehab director, the MDS nurse, the Activity Director, and the Wound Care Nurse to discuss the incident and findings.
• The number of residents the transportation aide/CNA would now transport for appointments will be two residents, allowing the driver to keep the residents in eyesight during boarding and offloading.
• Any resident with a predetermined need for additional supervision due to cognitive impairment, history of behaviors, or functional limitations will be escorted by facility staff/designated individuals during transportation.
• The Administrator initiated audits of the boarding and off-loading residents onto the van to ensure that the residents were secured appropriately in their chairs. This audit was weekly for a total of four weeks with no concerns noted.
• The Director of Nursing provided one on one education to the transportation aide/CNA regarding the need for supervision for residents who are identified as requiring supervision during transportation.
• The transportation aide/CNA will be accompanied by an additional staff member, a CNA or a personal care assistant (PCA) for the supervision of more than 1 resident who require supervision as determined by a review to the resident's cognitive status, past or current behaviors and their latest functional ability assessment.
• The Director of Nursing assessed all residents with a BIMS of 9 or below, past or active behaviors, and the resident's most recent functional ability assessment to determine the need for supervision during transportation.
• All residents identified as needing supervision will be supervised by facility staff/designated individuals during transportation.
• A CNA or a personal care assistant (PCA) will be scheduled to serve as an additional staff member for the supervision of the residents.
• This information will be posted on the transportation schedule that is posted at each nursing station daily.
• Care plans were updated as appropriate by the Director of Nursing/Assistant Director of Nursing and the Administrator, for any resident requiring this supervision.
• The Administrator held an in person Ad Hoc Meeting with the Interdisciplinary Team (IDT) to discuss incident and the credible allegation for the immediate jeopardy removal plan.
• The Assistant Director of Nursing, and the Nurse Managers began training all facility staff including agency staff on the facility process for residents who are transported by the facility van that have the need for supervision.
• Staff will use the resident's most recent BIMs and the most recent functionality assessment which shows how a resident.
• This education included that when transporting more than one resident, there will be an additional staff member provided, how this information is determined, and where this information is posted for staff information.
• No staff will be allowed to work, including any new hires and agency staff, without receiving this education.
• This education will also be added to the new hire orientation for the facility.
• The Administrator notified the Assistant Director of Nursing and the Nurse Managers of this responsibility.
• The Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance.

Penalty

Inspection fine: $16,801

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 follow up on a hospital recommendation for an ophthalmology consultation for a resident who was admitted with neurovascular glaucoma and ocular hypertension of the left eye. After a fall, the resident was taken to the hospital, where a discharge summary recommended an outpatient ophthalmology consultation due to swelling and pain in the right eye. Upon returning to the facility, the resident was assessed by the assigned nurse and the nurse supervisor, but neither reviewed the hospital discharge summary or processed any new physician orders, including the recommendation for an ophthalmology consultation. The unit manager later stated that she faxed a request for an eye consultation but did not keep the fax confirmation and did not follow up when the facility did not receive a return call to schedule the appointment. The director of nursing confirmed that the facility did not follow up on the eye doctor appointment until much later, acknowledging that there should have been earlier follow-up. The resident was observed with mild swelling around the eyes but did not report any pain at the time of the observation. Interviews with the nurse practitioner and the medical doctor revealed that they expected the facility to make the necessary referral and follow up to ensure the appointment was made. The medical doctor noted that while ophthalmology consults could take months to schedule, he expected better follow-up from the facility to secure the appointment. The lack of timely follow-up on the hospital's recommendation for an ophthalmology consultation constitutes a deficiency in the facility's care for the resident.

Penalty

Inspection fine: $16,801

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 food in a form that met the individual needs of residents with physician orders for mechanically altered diets. Specifically, six residents with orders for mechanically chopped or ground meats were served large pieces of stew beef that were not in compliance with the National Dysphagia Diet (NDD) guidelines. These guidelines require meats to be ground or minced into pieces no larger than one-quarter inch, moist, and easily mashed with a fork. Observations revealed that residents struggled to cut and chew the large pieces of beef, resulting in inadequate food intake. Resident #338, who had a history of oropharyngeal dysphagia and cognitive impairments, was observed having difficulty with the stew beef served during lunch. Despite attempts to cut the meat with a fork, the resident was unsuccessful and consumed less than 25% of the beef. Similarly, Resident #337, with a history of swallowing problems and cognitive deficits, also struggled with the large pieces of beef and required assistance from staff to cut the meat, which was still too tough to chew. Both residents had diet orders for mechanically soft diets, which were not adhered to during the meal service. Additional residents, including Resident #41, Resident #27, Resident #57, and Resident #7, were also served large cubes of stew beef contrary to their diet orders for mechanically altered diets. Observations indicated that these residents either refused the meat or required assistance to cut it into smaller pieces. Interviews with staff, including the Certified Dietary Manager and the Speech Therapist, confirmed that the stew beef did not meet the required texture for a mechanical soft diet. The facility's dietary staff attributed the issue to the quality of meat received from the vendor, which did not turn out as tender as expected.

Penalty

Inspection fine: $16,801

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 sanitary conditions in the dumpster area, as observed during a survey. On multiple occasions, the doors of two commercial dumpsters were found open, and the surrounding area was littered with trash, including an incontinent brief and blue latex gloves. These observations were made in the presence of the Certified Dietary Manager and the Director of Maintenance, who acknowledged the issues. The Director of Maintenance stated that the Maintenance Assistant was responsible for monitoring and cleaning the area but was occupied with overseeing construction during the time of the survey. Further interviews revealed that the Maintenance Assistant was on vacation, and the Floor Technician was assigned to monitor the area in his absence. However, the Floor Technician was not working on one of the days when the issues were observed. The Administrator confirmed that both maintenance and housekeeping staff were responsible for ensuring the dumpster area remained clean and that the dumpster doors were closed. Despite these responsibilities, the area was not adequately maintained, leading to unsanitary conditions.

Penalty

Inspection fine: $16,801

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 for a resident with nicotine dependence and hypertension, who was identified as an unsafe smoker requiring supervision. The resident was admitted to the facility and was cognitively intact, requiring extensive assistance for most activities of daily living. A quarterly smoking assessment conducted on June 29, 2024, indicated that the resident was an unsafe smoker needing supervision. However, the care plan, last revised on March 7, 2024, inaccurately reflected the resident as an unsupervised smoker. Interviews with the MDS coordinator, Director of Nursing, Assistant Director of Nursing, and the Administrator confirmed that the care plan should have been updated to reflect the need for supervision following the smoking assessment results.

Penalty

Inspection fine: $16,801

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

Summary

The facility failed to adhere to a physician's order for a resident who was dependent on tube feeding. The resident, who had a history of cerebral infarction, hypertension, and hypotension, was admitted with a care plan that included a risk for dehydration. The physician's order specified that the resident should receive 150 ml water flushes every four hours to prevent dehydration. However, observations on two consecutive days revealed that the resident's pump was set to deliver only 75 ml every four hours, contrary to the physician's order. Interviews with nursing staff revealed a lapse in following the physician's order. Nurse #1 acknowledged the error upon reviewing the resident's orders and noted that the third shift had changed the tube feeding and hydration bag but failed to set the pump correctly. Nurse #2, who worked the third shift, admitted to possibly not setting the pump as per the order. The facility's Registered Dietician confirmed the order for 150 ml flushes and noted that despite the error, there were no significant hydration concerns due to additional flushes with medication. The Director of Nursing and the Administrator both expressed that the expectation was for staff to follow the resident's orders accurately.

Penalty

Inspection fine: $16,801

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 discontinue aspirin for a resident as recommended by the hospital, leading to a deficiency in medication management. The resident, who had end-stage renal disease, chronic heart failure, and hypertension, was admitted to the facility with a prescription for low-dose aspirin. After a fall resulting in a head injury, the hospital recommended discontinuing the aspirin due to the resident's fall risk. However, upon returning to the facility, the aspirin was not discontinued, and the resident continued to receive it for several days. The deficiency occurred because the hospital discharge summary, which included the recommendation to discontinue aspirin, was not properly reviewed or acted upon by the facility staff. Both the assigned nurse and the nurse supervisor failed to process the new orders from the hospital discharge summary. The nurse supervisor mentioned that residents sometimes returned without an after-visit summary, which might have contributed to the oversight. Despite the hospital's clear instructions, the aspirin was administered to the resident on multiple occasions after their return. Interviews with facility staff, including the DON, NP, and MD, revealed a lack of communication and follow-through in implementing the hospital's recommendations. The DON acknowledged the error but did not recall re-educating the staff involved. The NP and MD both agreed that the aspirin should have been discontinued upon the resident's return, as continued administration posed a risk, albeit small, for further bleeding. This oversight highlights a breakdown in the facility's process for reviewing and implementing hospital discharge instructions.