White Oak Manor - Burlington

Penalty

No penalty information released

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

Summary

The facility failed to develop a baseline care plan addressing the immediate needs of a resident with a diagnosis of post-traumatic stress disorder (PTSD) within 48 hours of admission. Documentation from the resident's previous facility and the FL2 form both indicated a diagnosis of PTSD, and physician orders included medication for this condition. However, the baseline care plan completed by the MDS Nurse did not include any goals or interventions related to PTSD or associated behaviors. Interviews with staff revealed that the omission was due to either lack of awareness of the diagnosis or waiting for additional information regarding trauma history and triggers from the discharging facility. Staff interviews further indicated that the expectation was for PTSD and related behaviors to be included in the baseline care plan, but this was not done. The DON was not aware of the resident's PTSD diagnosis at the time of admission and expected to be notified of such diagnoses and related information. The MDS Nurses acknowledged that PTSD and its associated behaviors should have been addressed in the baseline care plan, but this was not completed due to incomplete information at the time of admission.

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 follow occupational therapy recommendations for a resident with a left-hand contracture, specifically the application of a soft hand splint for 4-6 hours daily as outlined in the OT discharge summary. Multiple observations over several days revealed the resident's left hand remained contracted, with the prescribed splint consistently found unused on the nightstand. The resident confirmed that staff had not been applying the splint for an extended period, though he could not specify the duration. Interviews with facility staff, including the Rehabilitation Director, Restorative Nurse, Occupational Therapist, DON, and Administrator, revealed a breakdown in communication and documentation regarding the transition from therapy to restorative nursing services. The Restorative Nurse reported not receiving a restorative services request for the resident, and the DON was unaware of any formal process or documentation for relaying restorative nursing needs. The Administrator acknowledged that therapy recommendations should be followed until reassessment, but cited recent staff changes as a possible reason for the lapse in care.

Penalty

No penalty information released

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

Summary

The facility failed to maintain and post daily nurse staffing sheets for five specific days within a 62-day review period. Record review showed that nurse staffing information was missing for two days in July and three days in August. Interviews with the Nursing Staff Scheduler revealed that while she prepared and provided weekend staffing postings to the weekend supervisor, she did not receive the completed weekend staffing sheets back and was unaware of their whereabouts. The Nursing Staff Scheduler also could not explain the absence of weekday staffing sheets. The Director of Nursing confirmed that the Nursing Staff Scheduler was responsible for the daily posted staffing sheets, with the weekend supervisor handling weekends, but could not account for the missing documentation. The Administrator stated his expectation that staffing sheets be accurate and posted daily, but the missing records remained unexplained.

Penalty

Inspection fine: $109,6682 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 timely physician notification for significant changes in condition for multiple residents, resulting in delayed assessment and intervention. In one case, a resident with severe cognitive impairment and multiple comorbidities, including dementia, congestive heart failure, and atrial fibrillation, was found by a nurse aide to have unexplained bruising, swelling, and discomfort on his arm and chest. The nurse aide did not notify a nurse, and the staff member assigned as a nurse was not actually licensed. The physician was not notified until the following shift, at which point a broader area of bruising was discovered and the resident was later transferred to the hospital for further evaluation. Another resident with diabetes and Alzheimer's dementia experienced multiple episodes of severely elevated blood glucose levels, with readings exceeding 400 on several occasions. Despite these critical values, there was no documentation that the physician or nurse practitioner was notified, and no orders were obtained to address the hyperglycemia. Staff interviews revealed a lack of clarity regarding notification parameters, and some staff were unaware of the need to notify the provider for such high readings. The resident eventually suffered a fall after a high blood sugar episode and was hospitalized with a subdural hematoma. A third resident, also severely cognitively impaired and on anticoagulant therapy, experienced falls while receiving Eliquis. The staff member assigned as a nurse at the time was not licensed and did not notify the physician following the falls. There was no documentation of physician notification or assessment after these incidents, despite the increased risk of bleeding due to anticoagulant use. In all three cases, the lack of timely and appropriate communication with the physician regarding significant changes in condition constituted a deficiency in care.

Removal Plan

• The Director of Nursing (DON) conducted education with all licensed nurses and Medication Aides on blood glucose parameters and the necessity of notifying the provider of any reading above 400. All nurses and Medication Aides were contacted either face to face or via phone communication.
• The Staff Development Coordinator was educated by the DON that all newly hired nurses, medication aides and agency nurses will receive this training in orientation by the Staff Development Coordinator.
• The Quality Information Manager (QIM) audited and entered the verbiage to each blood sugar order on the MAR: blood sugar greater than 400 call provider.
• The Director of Nursing educated licensed nurse to add blood sugar greater than 400 call provider to newly admitted resident with finger stick blood sugar orders for proper notification to the provider.
• The QIM was educated by the Director of Nursing to include in the current QIM admission order review process to ensure blood sugar greater than 400 call provider has been added by the nurse to those residents with finger stick blood sugar orders for proper notification to the provider.
• The DON and Staff Development Coordinator (SDC) completed education with all nurses, CNAs, activities (life enrichment), social services and therapy staff on recognition and reporting of significant changes, and proper chain of communication to the provider for reporting bruising or other resident changes in condition. Education was completed either by face to face or phone communication.
• The SDC will also educate all newly hired nurses, CNAs, Activities (Life enrichment) staff, therapy and social services staff on the recognition and reporting of significant changes, and proper chain of communication to the provider for reporting bruising or other resident changes in condition as part of the facility orientation process.
• The DON conducted an audit of all nursing progress notes to ensure that the provider had been notified of any residents with a significant change in condition.
• A complete audit of the Vital Signs (Blood Glucose Values) for elevated blood glucose levels over 400 with proper physician notification was completed by the DON.
• Identified elevations without proper physician notification were communicated by the DON to the provider.

Penalty

Inspection fine: $109,6682 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 implement its abuse prevention policy by not properly screening and verifying the credentials of an employee who was hired and worked as a licensed nurse without a valid nursing license. The employee provided the facility with license information belonging to another individual with a similar name, and discrepancies in the name and date of birth were not identified or investigated prior to her being allowed to perform licensed nurse duties. The personnel file lacked evidence of reference checks, education verification, or proper license verification before the employee began work. The employee was assigned to provide care to residents, including performing assessments, administering medications, and making clinical judgments for which she was not qualified. During her employment, the unlicensed employee was responsible for the care of several residents, including one with unexplained bruising and swelling, another with dangerously high blood sugar readings, and a third with severe cognitive impairment who experienced falls while on anticoagulant therapy. In these cases, the employee failed to notify physicians of significant changes, did not document assessments or interventions, and was not qualified to make the necessary clinical decisions. For example, a resident with bruising and swelling did not receive timely assessment or physician notification, and another resident with a high blood sugar reading did not receive appropriate treatment or physician notification. The employee also documented performing neurological assessments and making decisions about physician notification for a resident on anticoagulants after falls, despite lacking the qualifications to do so. Additionally, a nurse aide failed to follow the facility's abuse policy by not reporting injuries of unknown origin to the nurse on duty after observing bruising and swelling on a resident. The aide assumed the injuries had already been reported and did not immediately notify anyone, resulting in a delay in addressing the resident's condition. These failures in policy implementation and staff actions placed residents at risk for harm and constituted a deficiency in the facility's abuse prevention and credential verification processes.

Removal Plan

• The Human Resource (HR) manager conducted a complete audit of all nursing licenses and CNA certifications to ensure no discrepancies in name spelling or state of residence.
• The HR manager performed an audit of nursing licenses and noted a discrepancy in the spelling of Employee #1's name on her identification (ID) and the name on the presented Georgia LPN license. It was also noted that employee #1 had a North Carolina address on her ID and was practicing with a GA LPN license. Employee #1 was questioned by the HR manager and the DON related to the discrepancies and was immediately removed from resident care duties and terminated.
• The Director of Nursing submitted a complaint to the North Carolina Board of Nursing (NCBON) related to unlicensed employee #1 and the suspicion that she had falsified her credentials as an LPN.
• The NCBON contacted the Director of Nursing and informed her that they had completed their investigation and unlicensed employee #1 had falsified her LPN credentials and advised the DON to contact law enforcement.
• The DON contacted the NC Police and filed a report with the findings from the facility internal investigation and the NCBON investigation.
• The HR manager has continued to evaluate licenses and certifications for any potential nurse or CNA seeking employment to ensure there are no discrepancies with the spelling of names or state of residence. The HR manager also ensures that any potential nurse seeking employment has a valid license and is in good standing with the Board of Nursing (BON). The HR manager also checks the North Carolina Nurse Aide Registry for any potential CNA seeking employment to ensure that they have an active certification and are in good standing. This will prevent any unlicensed or uncertified staff from working in the facility.
• The HR manager received verbal and written re-education on the hiring policy and all of the above-mentioned steps from the Corporate Human Resources Manager. Any newly hired HR managers will receive this education from the Corporate Human Resources Manager as part of their orientation process.
• The decision was made by the Corporate HR Manager to review and revise the current hiring policy for this center to state that the HR Manager will obtain two professional references prior to employment. The HR Manager will also ensure that all employees undergo background checks prior to employment.
• The DON identified in her investigation of Resident #3's injury of unknown origin that NA #5 had noted bruising and discomfort but had failed to report it to any nurse. The DON then implemented education with all nurses and CNAs on unit 300 about reporting bruising or injuries of unknown origin. The education was face to face.
• The DON, SDC, and Administrator completed education with all staff on immediately reporting any injury of unknown origin to the DON or administrator. Education was presented face to face or via telephone. Newly hired agency staff will be educated during orientation by the Staff Development Coordinator to immediately report an injury of unknown origin to the DON or administrator.

Penalty

Inspection fine: $109,6682 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 that residents received appropriate assessment and care according to physician orders, resident preferences, and professional standards. In one instance, a resident with dementia, congestive heart failure, Parkinson's, atrial fibrillation, anxiety, and dysphagia was found by a nurse aide to have unexplained bruising, swelling, and discomfort. The nurse aide did not report these findings to a nurse, and the individual assigned as the nurse for the shift was later found to be unlicensed and untrained, having provided a false nursing license to the facility. As a result, no proper nursing assessment was performed until the following shift, when a physician documented extensive bruising and pain. The bruising continued to spread, and the resident was eventually sent to the emergency department, where a large hematoma and additional contusions were identified. Another resident with diabetes, Alzheimer's dementia, atrial flutter, cardiomyopathy, and congestive heart failure experienced multiple episodes of dangerously high blood sugar readings, with fingerstick blood sugars repeatedly exceeding 400. Despite these critical values, there was no evidence that staff communicated these results effectively, notified the provider, or monitored the resident for hyperglycemia. On one occasion, an unlicensed employee, who was impersonating a nurse, administered insulin without a physician's order and failed to document or communicate the event. The lack of communication and follow-up led to a situation where the resident became dizzy and fell, resulting in a head injury and subsequent hospitalization, where a subdural hematoma was diagnosed. Additionally, the facility failed to ensure that another resident received a nursing assessment following falls while on anticoagulant medication. The deficiencies were identified through record review and staff interviews, revealing a pattern of inadequate assessment, lack of communication among staff, and failure to follow professional standards of practice for multiple residents. These failures resulted in delayed treatment, unaddressed changes in condition, and adverse outcomes for the residents involved.

Removal Plan

• Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
• Body audits were completed by unit coordinators for all 3 units to identify

Penalty

Inspection fine: $109,6682 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 that nurses and nurse aides had the appropriate competencies to care for residents, as evidenced by the hiring and employment of an unlicensed individual in the role of a licensed nurse. This individual, Employee #1, was hired and worked as a nurse without a valid nursing license or documented nursing education. She performed critical nursing duties such as insulin administration, blood sugar monitoring, medication administration, and resident assessments, including for residents with complex needs such as those on anticoagulants or with severe cognitive impairment. There was no documented competency evaluation for Employee #1's nursing skills, and her personnel file lacked evidence of appropriate training or validation of her ability to perform required nursing tasks. During her employment, Employee #1 was responsible for the care of several residents, including one who developed unexplained bruising and swelling, another who experienced dangerously high blood sugar readings, and a third who suffered falls while on anticoagulant therapy. In these cases, Employee #1 was responsible for assessments, medication administration, and making clinical judgments, but there was no documentation that she notified physicians when required or performed necessary assessments. Interviews with staff and review of records indicated that Employee #1's actions and documentation were unprofessional and that she lacked the necessary skills and knowledge to safely perform her duties as a nurse. Additionally, the facility failed to verify the competencies of other newly hired nurses, as evidenced by the absence of completed competency validation forms in the personnel files of two other nurses. The staff development and orientation process did not include a formal system for evaluating and documenting nursing competencies, and the previously used competency form was no longer in use. This lack of a structured competency validation process affected multiple staff members and placed residents at risk due to unverified and potentially inadequate nursing care.

Removal Plan

• Employee #1 was terminated.
• The Director of Nursing (DON) and Staff Development Coordinator (SDC) were educated by the Assistant Regional nurse consultant on a nursing competency form.
• The Assistant Regional nurse consultant notified the SDC that the SDC will initiate the nursing competency form in orientation for all newly hired nurses.
• The newly hired nurse will be partnered with an experienced nurse and the experienced nurse will observe the newly hired nurse complete the tasks on the competency form.
• Any unsatisfactory demonstrations will be communicated to the Staff Development nurse for further training with the newly hired nurse.
• The newly hired nurse will have 90 days to complete the nursing competency form.
• The SDC will review the newly hired nursing competency form after 90 days and any areas the newly hired nurse could not complete on the competency (i.e. nasogastric tubes, tracheostomies) will be performed on the nursing training mannequin for competency.
• The SDC was educated by the Assistant Regional nurse that nurses who are partnered with the newly hired nurse will be educated on the competency form by the SDC prior to being scheduled with the newly hired nurse and their responsibility to check the newly hired nurse off on the competency when they are scheduled to work with the newly hired nurse.
• The Assistant Regional Nurse educated the Staffing coordinator that she will be responsible for notifying the SDC which nurses the newly hired nurse will be working with.
• An audit was conducted by the SDC to identify all newly hired nurses since Employee #1 was terminated to ensure that all components of the current nurse orientation process were completed. No discrepancies were identified.

Penalty

Inspection fine: $109,6682 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

A cognitively impaired resident with multiple comorbidities, including dementia, congestive heart failure, Parkinson's disease, atrial fibrillation, anxiety, and dysphagia, was found to have significant, unexplained bruising and swelling on his arm and chest, which wrapped around his torso. The injuries were first identified by staff on the morning shift, with no prior documentation of any incident or fall that could have caused the bruising. The resident was unable to provide a clear account of how the injuries occurred due to his cognitive impairment, and staff who had cared for him on previous shifts did not report any incidents or observe any injuries. The extent and pattern of the bruising, along with associated swelling and discomfort, raised suspicion of possible neglect or abuse, especially as the injuries were of unknown origin. During the night shift when the injuries were likely to have occurred, the resident was under the care of an unlicensed employee who was working under the false pretense of being a nurse. This individual had submitted fraudulent credentials and was not qualified to provide nursing care. Documentation from this shift was inconsistent, and the unlicensed employee failed to promptly report the injuries. Additionally, a nurse aide on the same shift observed the bruising and swelling but did not notify a nurse or report the findings, resulting in a delay in assessment and intervention for the resident's condition. The first formal documentation and notification of the injuries occurred only after the day shift began, further delaying appropriate medical evaluation. Subsequent medical evaluation, including imaging and laboratory tests, revealed a large subpectoral hematoma underlying the resident's pacemaker and superficial soft tissue contusions. The facility's investigation did not identify any incident or event that could explain the injuries, and there was no evidence of a fall or trauma documented in the medical record. Interviews with staff, the resident, and his roommate did not yield a clear cause for the injuries. The presence of an unlicensed individual providing care, combined with the failure of staff to report significant changes in the resident's condition, contributed to the facility's failure to protect the resident from potential abuse or neglect and to ensure timely assessment and intervention for injuries of unknown origin.

Removal Plan

• The unit 300 nurse coordinator and wound care nurse conducted body audits on all residents who received care from employee #1 on unit 300. No signs or symptoms of injuries or new skin abnormalities were noted in any resident on the 300 unit.
• A review of all resident hospital transfers and recorded incidents/events (events include reported falls, skin tears, and infections) to ensure completeness of the documentation, proper notification of the resident representative and provider, and follow-up interventions were implemented. Audit included the timeframes/shifts employee #1 worked to identify any care concerns. The review of hospital transfers and reported falls, skin tears, or infections did not reveal any obvious care concerns.
• The Director of Nursing, SDC, and Administrator completed education with all staff on recognizing and reporting injuries or changes in resident condition; including the chain of reporting.

Penalty

Inspection fine: $109,6682 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 conduct a thorough investigation into unexplained swelling, discomfort, and bruising experienced by a resident with multiple comorbidities, including dementia, congestive heart failure, Parkinson's disease, atrial fibrillation, anxiety, and dysphagia. The resident was severely cognitively impaired and required significant assistance with activities of daily living. Despite the absence of any documented falls or use of anticoagulants, the resident was found with extensive bruising and swelling on the upper body, which was first identified by staff during routine care. The initial report to the state agency noted significant bruising and swelling, but the facility's investigation did not fully account for all findings or discrepancies in staff statements and documentation. The facility's investigative process was incomplete in several key areas. The investigation did not identify or address that a hospital CT scan revealed the resident's bruising extended to the hip area, which was not recognized or included in the facility's internal review. There were discrepancies between staff statements regarding the discovery and reporting of the bruising, particularly involving an employee who falsely claimed to be a nurse and whose statements conflicted with those of other staff members. The facility also failed to clarify who obtained the resident's weight during the shift when the injuries were first identified, missing an opportunity to determine if the injury could have occurred during that process. Additionally, the facility's five-day report to the state agency omitted critical information, such as the hospital's finding of a hip contusion and the inconsistencies in staff accounts. The investigation did not include further questioning of staff to resolve these discrepancies. The facility's leadership, including the DON and Administrator, acknowledged that they did not pursue certain lines of inquiry, such as who performed the weight check, and assumed information based on documentation rather than verification. These omissions resulted in an incomplete investigation into the cause and circumstances of the resident's injuries.

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 abuse, resulting in a physical altercation between two residents. Resident #84, who was severely cognitively impaired, was verbally antagonizing Resident #82, who also had severe cognitive impairments and a history of aggressive behavior. During the altercation, Resident #82 hit Resident #84 in the mouth, causing a cut on the lip and the loss of a tooth. This incident was observed by staff, who intervened to separate the residents. Resident #84 was sent to the emergency room for treatment of the injury, which included the application of Dermabond to the lip and a referral to a dentist for the missing tooth. The facility's initial investigation revealed that Resident #84 had been verbally insulting Resident #82, which led to the physical response. Both residents had a history of cognitive impairments and behavioral issues, which were documented in their care plans. However, the facility failed to prevent the altercation despite these known risks. The report indicates that the staff was aware of the potential for resident-to-resident altercations due to the residents' behavioral histories. Despite this, the facility did not implement effective measures to prevent the incident, such as adequate supervision or intervention strategies tailored to the residents' needs. The deficiency highlights a lapse in the facility's responsibility to ensure a safe environment for all residents, particularly those with known behavioral challenges.

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 policy regarding the labeling and dating of food brought in by residents' family members, as well as maintaining cleanliness in nourishment refrigerators. Observations revealed that three nourishment refrigerators contained various food items without labels or dates, including takeout food, cut fruit, baked beans, and opened juice cartons. The refrigerators were also found to be unclean, with sticky shelves and yellow stains. The Dietary Manager indicated that it was the responsibility of the nursing staff to ensure food was labeled, dated, and discarded if stored for more than three days. Additionally, the ice scoop in one nourishment room was improperly stored on wet paper towels instead of in an ice scoop holder. Interviews with the Dietary Manager, Director of Nursing (DON), and the Administrator highlighted a lack of clarity and enforcement of responsibilities regarding the maintenance of nourishment areas. The DON stated that nurse aides were assigned to clean the pantry daily, including the refrigerators, and that the dietary department should clean spills when placing snacks. The Administrator reiterated the need for cleanliness and proper labeling and dating of food. Despite these stated responsibilities, the facility's practices did not align with its policies, 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 protect residents from the misappropriation of controlled substances and personal property, affecting three residents. Resident #9, who was cognitively impaired and had a prescription for oxycodone, experienced a misappropriation of 120 tablets of oxycodone. The medication was delivered to the facility but was not placed in the medication cart by the responsible nurse, Nurse #12, who was later suspended and terminated after an investigation. Despite the missing medication, Resident #9 did not go without pain management as there was an adequate supply available. Resident #225, who had peripheral vascular disease and lymphedema, was prescribed a combination medication of oxycodone and acetaminophen for pain management. The facility became aware of the misappropriation when the resident reported not receiving his medication. Nurse #13 admitted to taking 42 tablets of the medication, returning only 25 tablets. The nurse was terminated, and the incident was reported to law enforcement and relevant agencies. The resident was kept comfortable with alternative pain management until the medication was replaced. Resident #42, who was cognitively intact, had a physician's order for alcohol as needed. The facility failed to account for a missing bottle of alcohol, which was supposed to be stored in a locked refrigerator. The Social Worker Director had purchased a new bottle, but it was not found in the medication room. An investigation was conducted, but the staff member responsible for the missing alcohol was not identified. The facility replaced the missing bottle using facility funds.

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 policy on neglect, abuse, mistreatment, and misappropriation of resident property, resulting in deficiencies in handling allegations of abuse and misappropriation. In one instance, a resident reported being physically abused by a nurse aide, but the facility did not maintain documented evidence of a thorough investigation. The investigation lacked written statements from the involved parties and witnesses, and there was no evidence of interviews with other residents who might have had contact with the accused nurse aide. Despite the involvement of law enforcement and internal assessments, the facility was unable to locate any part of the investigation documentation. In another case, the facility failed to document and report the misappropriation of medication for a resident. A nurse admitted to diverting medication, but the facility could not provide records of the investigation or corrective actions taken. The facility's policy required detailed documentation and reporting to state agencies, which was not followed. The lack of documentation and follow-up actions highlights a significant gap in the facility's handling of such incidents. Additionally, the facility did not report the misappropriation of a resident's alcohol prescription to the state agency. The alcohol was stored in a locked medication room, and when it was found missing, the facility replaced it without identifying the responsible party. The investigation conducted by the previous Director of Nursing did not result in any findings, and no report was submitted to the state agency as required by the facility's policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident diagnosed with dementia and cancer was transported to a scheduled oncology follow-up appointment. The resident had a physician's order for Anastrozole, an oral chemotherapy drug, related to breast cancer treatment. A quarterly Minimum Data Set assessment indicated that the resident was severely cognitively impaired. The resident's responsible party reported that the resident missed a scheduled oncology appointment, and despite leaving a message with the facility, no one returned the call. The Social Services Director was unaware of the missed appointment, indicating a lack of communication within the facility. The Transportation Scheduler admitted to failing to transport the resident to the appointment, citing a transition in roles and the previous scheduler's failure to document the appointment on the calendar. The facility administrator was also unaware of the missed appointment, acknowledging the facility's responsibility to ensure residents are transported to their appointments. This oversight resulted in the resident missing a critical follow-up for cancer treatment.

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 documentation of the pharmacist's Monthly Medication Reviews (MMRs) and the physician's review and response to the pharmacist's findings for a resident. This deficiency was identified during a review of records and interviews with staff and the consultant pharmacist. The resident in question was admitted with diagnoses including epilepsy, anxiety disorder, dementia, and mild neurocognitive disorder. The resident's medical record showed a medication order for olanzapine, an antipsychotic, but lacked documentation of MMRs for several months and the physician's response to the pharmacist's recommendations. The consultant pharmacist confirmed that MMRs were completed for the missing months and noted specific recommendations, such as a cautionary note regarding olanzapine use for a resident with a history of seizures and a recommendation for a gradual dose reduction. However, these records were not found in the resident's paper medical record. The facility's administrator acknowledged that the MMRs and signed Prescriber Recommendation Forms should have been stored in the resident's paper medical record but were unable to locate them.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary nail care to a resident who was dependent on staff for activities of daily living (ADL). The resident, who was admitted with a diagnosis of diabetes mellitus and required extensive assistance with personal hygiene, was observed on multiple occasions with long fingernails and a visible dark substance underneath them. Despite the resident's request for nail trimming, the staff did not fulfill this request, leaving the resident's nails untrimmed and uncleaned. Interviews with staff members, including a nurse aide and two nurses, confirmed that the resident's nail care was neglected. The nurse aide acknowledged awareness of the resident's long and dirty fingernails and admitted that nail care was not completed. Both nurses stated that the resident's nails should be checked daily and trimmed as needed, but this was not done. The facility administrator also expected staff to monitor and trim residents' nails in a timely manner, which did not occur in this case.

Penalty

Inspection fine: $27,804

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 prevent injury to a resident who was non-ambulatory and dependent on staff for transfers. The resident, who was on blood-thinning medication, was transferred to bed using a mechanical lift by a nurse aide and the Maintenance Director. The following day, the resident was found with discoloration and swelling on the right thigh, which was later diagnosed as a large hematoma. The injury was determined to have been caused by the mechanical lift pinching the edematous areas of the resident's leg. The resident was admitted to the intensive care unit with acute blood loss and hemorrhagic shock due to the traumatic hematoma. The resident required multiple blood transfusions during hospitalization. The incident was identified as immediate jeopardy, indicating a serious risk to the resident's health and safety. The facility's failure to ensure proper supervision and safe transfer procedures contributed to the resident's injury. Interviews with staff revealed inconsistencies in the transfer process and a lack of clear communication regarding the resident's care needs. The Maintenance Director, who was not typically involved in resident care, assisted with the transfer, and there was confusion among staff about the timing and details of the transfer. The resident's care plan included monitoring for bleeding due to anticoagulant use, but the injury was not immediately recognized or reported, leading to a delay in appropriate medical intervention.

Removal Plan

• A 4-person assist when transferring Resident #1 in the Mechanical Lift and pad resident's right leg with towels while using the lift.
• Order a special sling for Resident #1 that has extra padding and extended leg coverage.
• Resident will be seen by therapy to ensure the transfer is safe.
• New interventions are listed in the Resident's Summary and updated on Resident #1's Activities of Daily Living care plan.
• Conduct interviews with interviewable residents to ask if they feel safe during transfers on the mechanical lift.
• Complete body audits for residents that are not interviewable.
• Educate nursing staff that all total lifts are a 2-person assist at all times.
• Ensure nursing staff use the correct lift sling pad that the resident is color coded for, which will be on the outside of the resident's door.
• Educate nursing staff to be cautious and careful when transferring residents at high risk for injury, such as those on anticoagulants.
• Educate staff members on vacation or employed as needed when they return to work prior to working on the floor.
• Educate new employees upon hire.

Penalty

Inspection fine: $27,804

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

Summary

The facility failed to ensure that staff performing the duties of a nurse aide were properly trained and competent, as evidenced by an incident involving the Maintenance Director assisting a nurse aide with transferring a resident using a mechanical lift. The Maintenance Director, who was not trained in the use of the mechanical lift or as a nurse aide, operated the lift to transfer the resident from a wheelchair to a bed. This incident was observed by the Activity Assistant, who noted that the Maintenance Director was not trained to operate the lift, a requirement for staff working with residents. Interviews with the Maintenance Director, nurse aide, Safety Nurse, Staff Development Coordinator, and Director of Nursing confirmed that the Maintenance Director had not received the necessary training to operate the mechanical lift. The Maintenance Director admitted to assisting with the transfer without being aware of the training requirement. The nurse aide involved was unaware of the Maintenance Director's lack of training and accepted her assistance. The Director of Nursing and Administrator acknowledged that the Maintenance Director's involvement in the transfer was outside her job scope and that she should not have assisted with the resident's transfer.