Humboldt House Rehabilitation And Nursing Center

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency in the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards and its own sanitation and food storage policies. Intermittent observations of the kitchen revealed an active ceiling leak near the walk‑in refrigerator and freezer, with a large opening in the plaster ceiling and a tarp suspended to divert water into a floor drain. An adjacent air conditioning ventilation unit was actively leaking, resulting in standing water pooled on the floor in front of the walk‑in units. Under this leaking area, staff had stationed tray catties holding numerous food covers and plate warmers, and a metal shelving unit extended under the tarp holding multiple uncovered condiments and food items such as salt, pepper, sugar, creamer packets, and containers of peanut butter. Additional observations showed widespread sanitation and maintenance problems in the kitchen. There was a significant accumulation of gray, dusty debris on ceiling pipes throughout the kitchen, including above food preparation and serving stations. The hand wash sink near the kitchen entry had an active drainpipe leak when in use, with a stack of partially wet paper towels in the basin and a non‑working paper towel dispenser above it. The wall behind the stove, oven, and two‑bay sink was heavily soiled with thick black grease and food debris and had broken and missing wall tiles, with peeled plaster in areas behind the stove, oven, and above the two‑bay sink. The commercial oven range’s exterior surfaces were heavily coated with grease and food debris, and staff acknowledged the stove should be cleaned after each meal but that it was not being cleaned properly. The walk‑in freezer also exhibited multiple structural and cleanliness issues. The freezer door gasket was not securely attached and protruded between the door and unit, and there was black debris on the freezer window, condensation and ice buildup on the interior and exterior lower sides of the door, and a large accumulation of ice on the floor and ceiling inside the unit. Interviews with the Food Service Director, Administrator, and Maintenance Supervisor confirmed that the kitchen ceiling leak and roof issues had been ongoing for months, that the freezer had required repeated service for condensation and ice buildup, and that broken and missing wall tiles had been a known issue since the prior year. Staff also acknowledged that condiments and tray catties should not be stored under the leaking ceiling, that the gasket needed replacement, that the pipes over prep areas should be cleaned, and that the wet paper towels at the hand sink should not be used, confirming ongoing noncompliance with the facility’s sanitation and food storage policies.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure a resident’s right to be treated with respect and dignity, including maintaining cleanliness and appropriate incontinence care. The resident had diagnoses of CVA, schizophrenia, and intellectual disability, was severely cognitively impaired, and required total assistance for personal hygiene and toileting, with documented bowel and bladder incontinence. The resident’s care plan and Kardex specified total assistance for hygiene and toileting but did not include specific interventions or instructions for managing bowel and bladder incontinence. On the survey date, the resident was observed in bed wearing only an incontinent brief, a small blanket, and a flat sheet that was visibly soaked and soiled with urine from shoulders to the foot of the bed. Between the bed and the wall, there were multiple soiled flat sheets, a soiled brief, a large amount of feces, and dried food debris on the floor. Later the same day, the resident remained in bed on the heavily soiled sheet while their lunch tray, which had been fully consumed, sat on the overbed table, and the soiled linens, brief, feces, and food debris remained on the floor. CNA staff reported that the resident had been washed and provided incontinence care earlier in the morning and acknowledged that incontinence care should be provided every two hours, that they had not returned to the room since the morning, and that the resident should have been cleaned before receiving lunch. Video surveillance showed that the same CNA delivered the lunch tray shortly before the resident was observed eating while still soiled. Although the bed linens were later changed, the dried food debris and large amount of feces remained on the floor behind the bed. The unit manager, corporate DON, and a family member all stated that the resident should have been provided care and that the situation was undignified, with the family member reporting that the resident was always soiled with urine and feces during visits and that prior complaints to staff had not resulted in changes.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide necessary ADL services, specifically grooming and personal hygiene, to a resident who was incontinent of bowel and bladder. The resident had diagnoses including cerebral vascular accident, schizophrenia, and intellectual disability, and the MDS documented severe cognitive impairment, total assistance needs for personal hygiene, and total assistance of two staff for toileting. Despite these needs, the resident’s care plan and Kardex did not include a bowel and bladder incontinence care plan or specific instructions for incontinent care, and there was no documentation that the resident refused care. On the survey date, observations showed the resident in bed wearing only an incontinent brief, with a small blanket and a flat sheet that was visibly soaked with urine from the shoulders to the foot of the bed. Multiple soiled flat sheets and a soiled brief were found on the floor between the bed and the wall, along with a large amount of feces and dried food debris. The resident remained on the heavily soiled sheet for at least 40 minutes, during which time the lunch tray was delivered and fully consumed while the room and the resident’s bedding remained soiled. Later observation showed that although the bed linens had been changed, the dried food debris and large amount of feces remained on the floor behind the bed. Interviews confirmed that incontinent care was expected every two to three hours and that the resident should have been cleaned before receiving lunch. The CNA assigned to the resident stated they had provided incontinent care around 7:30 a.m., had not returned since, and acknowledged the resident should have been cleaned before lunch. Video surveillance showed that this CNA delivered the lunch tray shortly before 1:00 p.m., contradicting their initial statement that they had not provided the lunch tray. The RN Unit Manager stated the resident was incontinent and required total assistance, was unsure if the resident was care planned for incontinence, and confirmed that incontinent care should occur every two to three hours and before meals. A family member reported the resident was always soiled with feces and urine during visits, and the Corporate DON stated incontinent care should be completed every two to three hours and that the resident and room should have been cleaned before lunch, noting that the facility does not document ADL completion.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide appropriate care and services for a resident with an indwelling Foley catheter, in accordance with its own urinary catheter care and enhanced barrier precautions policies. The resident had diagnoses including quadriplegia, chronic kidney disease, and depression, was cognitively intact, and had a documented history of urinary tract infections. The care plan and Kardex directed staff to monitor for signs and symptoms of urinary tract infection, position the drainage bag and tubing below the level of the bladder, provide Foley catheter care every shift, and monitor and document Foley output every shift. On multiple observations during one morning, the resident’s urinary drainage bag, containing approximately 1,000 milliliters of amber urine with a large amount of white mucus in the tubing, was seen lying directly on the floor under the bed. An LPN entered the room to administer medications and later to feed the resident breakfast, but did not correct the position of the drainage bag, which remained on the floor at 8:55 AM, 9:10 AM, 10:16 AM, and 11:26 AM. Staff interviewed acknowledged that the drainage bag should not have been on the floor and that it should have been emptied because it was full, particularly given the resident’s propensity for urinary tract infections. Later that morning, despite a sign on the resident’s door indicating the need for enhanced barrier precautions and the availability of supplies, a CNA entered the room wearing only gloves and no gown to empty the urinary drainage bag. The CNA picked the drainage bag up from the floor, placed a clean urinal directly on the floor without a barrier, opened the drainage spigot, and filled the urinal to the top. The CNA then placed the drainage bag with the spigot open back on the floor, emptied the urinal into the toilet, returned the urinal to the floor, and finished emptying the bag into the urinal. The CNA replaced the spigot into the bag holder without cleaning the spigot tip with alcohol and confirmed that 1,800 milliliters had been emptied. Facility nursing leadership and the infection preventionist stated that drainage bags should never be on the floor and that staff were expected to follow enhanced barrier precautions, including gown and glove use, when providing care to residents with Foley catheters.

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 an effective pest control program, resulting in the presence of rodents and evidence of rodent activity on three of four resident-use floors. Multiple observations revealed dead mice in traps, rodent droppings in resident rooms, and physical damage to room structures such as crumbled walls and exposed insulation. Food debris, such as cookie wrappers and crumbs, was found in resident drawers and on floors, often mixed with rodent droppings. Staff and residents reported recent and ongoing sightings of live mice in resident rooms, with some residents stating that rodents had been an issue for several months. Interviews with staff, including CNAs, the Housekeeping Supervisor, LPNs, and the DON, indicated inconsistent awareness and response to the rodent problem. Some staff were unaware of the extent of the droppings and dead rodents, while others acknowledged the need for immediate cleaning and pest control. The Housekeeping Supervisor was newly promoted and unfamiliar with the deep cleaning schedule, and the DON had not personally observed rodents but recognized the health concerns associated with their presence. Maintenance staff reported that rodent traps were checked and changed, and a licensed exterminator serviced the building every two weeks, but evidence of rodent activity persisted. The exterior of the facility, particularly the garbage compactor area, was found to be littered with food waste, soiled items, and garbage, attracting flies and creating conditions conducive to pest infestation. Interviews with the Food Service Director, Regional Maintenance Director, and Administrator revealed shared responsibility for maintaining the garbage area, but also a lack of clear policies on pest control and garbage disposal. Internal records and exterminator reports documented ongoing issues with food spillage, accessible garbage, and rodent activity, with some improvement noted after changing exterminators, but continued deficiencies in maintaining a pest-free environment.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a resident with chronic venous hypertension, lymphedema, and chronic kidney disease did not receive wound care treatments to bilateral lower extremity ulcers as ordered by the physician. The resident's care plan required treatments to be administered as ordered and for refusals to be documented and addressed, but there was no evidence in the care plan or medical record that the resident refused care. Physician orders specified cleansing the wounds with normal saline and applying Medi honey gel every evening shift, but multiple dates were identified where the treatment was not documented as completed. Observations revealed the resident's wounds were uncovered or not dressed as ordered, with visible open ulcers and dried drainage present. The resident reported that wound care was not consistently performed and that dressings were not applied on certain days. Review of treatment administration records and nursing notes confirmed that wound care was not documented as completed on several dates, and there was no documentation of resident refusal or alternative interventions. Skin and wound assessments indicated deterioration of the wounds during the period when treatments were missed. Interviews with nursing staff and facility leadership confirmed that treatments were not completed or documented as required. Staff acknowledged that the physician's orders were not always followed, and that documentation was incomplete when treatments were missed or not performed. Facility policy required all treatments to be administered as ordered and refusals to be documented, but these procedures were not consistently followed for this resident.

Penalty

No penalty information released

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

Summary

The facility failed to protect residents from sexual abuse, as evidenced by an incident involving two residents who were found engaged in sexual activity without staff knowledge. Both residents were cognitively impaired and lacked the ability to consent. The facility's policy on abuse prevention and capacity to consent clearly states that residents have the right to be free from abuse, including sexual abuse, and that consent is not valid if a resident lacks the capacity to consent. Despite this, the incident occurred, indicating a failure in monitoring and protecting the residents. Resident #1, diagnosed with dementia, depression, and altered mental status, was documented as severely cognitively impaired. Their care plan noted a risk for mood and behavior problems, and they had a history of wandering and making inappropriate sexual comments. On the day of the incident, Resident #1 was found in Resident #2's room, engaged in a sexual encounter. Staff intervention was delayed as the incident was only discovered when a Certified Nurse Aide entered the room. The resident's cognitive impairment and history of disrobing and confusion about other residents being their spouse were known to the staff, yet adequate supervision was not provided. Resident #2, with diagnoses including Wernicke's encephalopathy and vascular dementia, was also severely cognitively impaired. Their care plan noted behavior problems, including disrobing and being not always redirectable. The incident was reported to law enforcement, but the facility did not receive any feedback. Interviews with staff and family members revealed that both residents lacked the capacity to consent, yet the facility's investigation concluded the encounter was consensual. This discrepancy highlights a significant oversight in assessing and ensuring the residents' safety and protection from abuse.

Plan Of Correction

Plan of Correction: Approved January 17, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Resident #1 was discharged on [DATE] and has since passed away. a. Resident #2 had a room/floor change after the incident occurred. Resident #2's care plan has been reviewed and found to be appropriate. A psychosocial evaluation has been completed by social work and resident does not even recall the incident. b. No further incidents have occurred. II. All wandering residents who lack capacity have the potential to be affected by this deficiency. a. A 100% audit of current residents who lack capacity, that may be displaying behaviors (handholding, arms around each other, seating preferences, etc.) will be conducted. Any concerns will be brought to the IDT and the behaviors and potential relationship will be reviewed and interventions will be care planned as appropriate. III. Facility policy and procedures titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised (MONTH) 2021 and Identifying Sexual Abuse and Capacity to Consent, dated (MONTH) 2022 have been reviewed and found to be appropriate. a. A monthly “relationship meeting” will be held to include Administrator, DON, Social Work, and the Dementia Unit Manager/Designee to discuss/identify any residents that may be displaying behaviors that could suggest a developing relationship between residents. The Unit Manager/Designee will be the chairperson/spokesperson for all nursing employees assigned to the unit. Care plans and further interventions updated as indicated. b. All nursing staff will be educated on the establishment of the 4th floor “relationship meeting.” c. All nursing staff will be educated on identification and reporting any residents who are displaying behaviors such as (hand holding, arms around each other, seating preference, etc.). d. Any staff reports related to the identification of the potential for resident relationship development will be reported immediately to their immediate supervisor. Nursing Supervisory staff will be educated to begin the process of convening the IDT to audit the circumstance of this relationship to include resident capacity, family and MD notification, and care plan review. IV. Any changes in behavior or adverse interactions will be reported immediately to DON/Administrator or designee and brought to morning report daily for review and QAPI monthly. a. Administrator will audit the monthly relationship meetings to ensure completion and follow through monthly x 3 months, then quarterly thereafter. b. At monthly QAPI, the Administrator will review the results of the monthly relationship meeting and any other reported occurrences of potential relationships developing. V. The administrator is responsible for this plan.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Upon readmission, the resident, who had multiple pressure and vascular ulcers, did not receive a timely skin assessment that included measurements, descriptions, and staging of the ulcers. This delay resulted in a postponement in obtaining physician orders and initiating treatment. The facility's policy required a full assessment of pressure sores upon admission, but this was not completed for the resident, leading to a lack of documented treatment orders for the ulcers until two days after readmission. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that skin integrity assessments should be conducted by a Registered Nurse within 24 hours of admission or readmission. These assessments should include detailed documentation of the type, location, and measurements of wounds, with treatments initiated immediately upon identification of skin integrity alterations. However, in this case, the necessary assessments and treatments were delayed, as confirmed by the facility's records and staff interviews.

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 received treatment and care in accordance with professional standards of practice. Upon readmission, the resident, who had multiple pressure and vascular ulcers, did not receive a timely skin assessment that included measurements, descriptions, and staging of the ulcers. This oversight resulted in a delay in obtaining physician orders and initiating treatment. The facility's policy required a comprehensive skin examination upon admission, but this was not completed for the resident, leading to a lapse in care. The resident, who was cognitively intact, was readmitted with diagnoses including peripheral vascular disease, congestive heart failure, and protein calorie malnutrition. The resident had one Stage 3 pressure ulcer and several unstageable pressure and vascular ulcers. Despite the hospital discharge summary documenting these conditions, the initial clinical admission assessment was incomplete and unsigned, lacking necessary details about the ulcers. It was not until two days later that a Registered Nurse Assistant Director of Nursing conducted a proper skin assessment and obtained physician orders for treatment, which were initiated the following day. Interviews with facility staff confirmed that skin assessments should be conducted within 24 hours of admission, but this protocol was not followed in this case.

Penalty

Fine: $72,465

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 abuse, specifically in cases involving resident-to-resident altercations and non-consensual sexual activity. Resident #129 was verbally and physically threatened by Resident #74, who was cognitively intact, with a pair of scissors. Despite the altercation being witnessed by a Certified Nurse Aide and reported to a Registered Nurse, the facility did not take immediate action to separate the residents or remove the potential weapon, allowing Resident #74 ongoing access to Resident #129. This inaction resulted in mental anguish for Resident #129, who expressed fear for their life. In another incident, Residents #104 and #122, both severely cognitively impaired and unable to consent, were observed engaging in non-consensual sexual activity. Staff witnessed the inappropriate contact but failed to separate the residents or implement protective measures. The facility's care plans for these residents did not include strategies to prevent sexual abuse, and there was no evidence of psychological evaluations or interventions following the incident. The lack of immediate action and supervision allowed the abuse to continue, highlighting a significant oversight in resident protection. The facility's policies on abuse prevention and capacity to consent were not followed, as evidenced by the staff's failure to recognize and address the abuse situations appropriately. Interviews with staff and administrators revealed a lack of understanding and adherence to procedures designed to protect residents from harm. The incidents involving Residents #129, #104, and #122 demonstrate a systemic failure to ensure resident safety and uphold their rights to be free from abuse, resulting in immediate jeopardy and substandard quality of care.

Penalty

Fine: $72,465

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

Summary

The facility failed to report alleged violations of abuse immediately, as required by policy, for three residents during an Extended Recertification and Complaint survey. Registered Nurse #1 did not report an alleged resident-to-resident abuse incident involving Resident #74 and Resident #129 to the Administrator. This incident, which involved a verbal argument escalating to a threat with scissors, was witnessed by Certified Nurse Aide #1 but was not reported until three days later. This delay resulted in continued access between the residents and mental anguish for Resident #129. Additionally, the facility failed to report non-consensual sexual activity between Residents #104 and #122, both of whom lacked the capacity to consent. Certified Nurse Aide #2 observed inappropriate sexual touching between the two residents but did not report it immediately, considering it a common occurrence. This inaction allowed the behavior to continue, resulting in potential psychosocial harm to the residents involved. The facility's policy required immediate reporting of abuse allegations to the Administrator and appropriate officials, but staff failed to adhere to this policy. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that the incidents were not reported in a timely manner, which hindered the initiation of investigations and appropriate interventions.

Penalty

Fine: $72,465

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

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies observed during a complaint investigation. The investigation revealed significant issues with the facility's hot water system, with temperatures in resident rooms fluctuating well below the required range, making it unsuitable for resident hygiene. Despite daily temperature checks by maintenance staff, the water temperatures were inconsistent, and residents reported difficulties in accessing warm water for personal care. The maintenance director acknowledged the need for adjustments but failed to maintain consistent water temperatures across the facility. Additionally, the facility did not provide adequate access to bathroom facilities for residents, particularly on the Fourth Floor, where several bathrooms were out of service due to drainage issues. Residents without in-room bathrooms had to travel long distances to access the only available bathroom, leading to inconvenience and potential incontinence. The maintenance director admitted that the drainage problem was a large-scale issue that had not been addressed, affecting multiple floors and requiring external contractors for repairs. The facility also exhibited poor housekeeping and maintenance practices, with observations of soiled walls, mold in shower rooms, foul odors, and windows and ceilings in disrepair. Call bells in shared bathrooms were not functioning properly, posing a safety risk for residents. The maintenance director and housekeeping staff acknowledged these issues, but there was no documentation of plans to address them. These deficiencies highlight a failure to uphold the residents' right to a safe and homelike environment, as mandated by facility policies and regulations.

Penalty

Fine: $72,465

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 and drink at safe and appetizing temperatures for residents on the Second, Third, and Fourth floor Units during the Extended Recertification and Complaint survey. The policy required potentially hazardous foods to be kept at 41 degrees Fahrenheit or below when cold, or 135 degrees Fahrenheit or above when hot. However, observations and interviews revealed that meals were served at suboptimal temperatures, making them unpalatable. Residents reported issues such as cold meals, hard biscuits, and unidentifiable food, leading some to avoid eating or rely on external food sources. During the survey, test trays were used to assess the temperature and palatability of meals. On the Second floor Unit, the baked ziti was 119 degrees Fahrenheit, zucchini was 110 degrees Fahrenheit, and coffee was 124.5 degrees Fahrenheit, all below the required temperature. Similar issues were observed on the Third and Fourth floor Units, with food items like baked ziti, zucchini, milk, mandarin oranges, and coffee served at temperatures below the facility's standards. The Dietary Director acknowledged that some food temperatures were below the acceptable range, which could pose a risk of foodborne illness. Interviews with residents and family members highlighted dissatisfaction with the food quality and temperature. Residents described the food as cold, bland, and sometimes inedible, with some relying on care packages or family-provided meals. The facility's failure to maintain proper food temperatures during storage, preparation, transport, and service contributed to the deficiency, as evidenced by the observations and resident feedback.

Penalty

Fine: $72,465

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 store food in accordance with professional standards for food safety across three nourishment unit refrigerators. Observations revealed that the refrigerators contained undated, unlabeled, and expired food and drink items. Additionally, there were liquid spills and dried substances on surfaces, and the Fourth floor Unit refrigerator was not maintaining a safe food storage temperature and lacked a thermometer. The Second floor Unit refrigerator also lacked a thermometer, which is against the facility's policy that requires temperature monitoring twice a day. During the survey, it was observed that the Third floor Unit nourishment kitchen had unidentified and undated items in the freezer and fridge, including latex gloves filled with frozen liquid. The Fourth floor Unit refrigerator was found to have a thermometer displaying unsafe temperatures, and it contained unlabeled and undated items, including a bologna sandwich and nourishment bags with items that should have been distributed to residents earlier. The refrigerator was also wet with brown liquid stains, and the temperature was consistently above the safe range, reaching up to 62 Fahrenheit. Interviews with staff, including registered nurses, dietary supervisors, and technicians, revealed a lack of adherence to the facility's policies regarding food storage and temperature monitoring. The dietary staff were responsible for checking temperatures, but the records were inconsistent, and the equipment was faulty. The Interim Maintenance Director acknowledged the need for new seals for the fridge and freezer, and the Administrator confirmed that the refrigerator should be replaced due to the unsafe conditions observed.

Penalty

Fine: $72,465

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

Summary

The facility failed to ensure that a resident was informed and allowed to participate in the development and implementation of their person-centered care plan. Specifically, a resident with diagnoses including benign intracranial hypertension, chronic pain syndrome, and migraine headache, who was cognitively intact, was not informed in advance about a scheduled care plan meeting. The facility's policy required that residents be given sufficient notice to participate in care planning meetings, but this was not adhered to in this case. The resident expressed disappointment at not being able to attend the meeting, which was important to them as they wanted to share their progress with their family. Interviews with facility staff, including a social worker and a nurse practitioner, confirmed that the resident was not informed of the meeting, and it was acknowledged that the resident should have been present. The social worker responsible for notifying the resident failed to provide evidence of communication or records of notification, leading to the resident's exclusion from the care planning process.

Penalty

Fine: $72,465

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 were treated with respect and dignity, as evidenced by the behavior of a staff member towards a resident and the lack of privacy in a shared bathroom. Resident #134, who was cognitively intact and had a care plan requiring calm and reassuring care, was subjected to unprofessional behavior by Licensed Practical Nurse #6. The nurse allegedly used inappropriate language, slammed medication on the tray table, and left the room in a disrespectful manner, causing the resident to become upset and cry. This incident was corroborated by other staff members who witnessed the behavior. Additionally, the facility did not provide adequate privacy for residents using a shared bathroom on the dementia unit. The bathroom, used by both male and female residents, had three toilet stalls separated by partitions but lacked stall doors or privacy curtains. Observations confirmed that residents used this bathroom independently, raising concerns about privacy and dignity. Staff interviews revealed that the lack of privacy was a known issue, with several staff members acknowledging the problem and expressing concerns about its impact on residents. The facility's failure to address these issues violated the residents' rights to be treated with respect and dignity. The lack of privacy in the shared bathroom and the unprofessional conduct of a staff member towards a resident were significant deficiencies identified during the survey. These findings highlight the need for the facility to ensure that all residents are treated with dignity and that their privacy is respected in all aspects of their care.

Penalty

Fine: $72,465

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 all alleged allegations of abuse were thoroughly investigated for two residents. Specifically, there was a delay in the initiation of an investigation for a reported allegation of resident-to-resident abuse. The incident involved a verbal argument between two residents, which escalated when one resident threatened the other with a pair of scissors. The altercation was witnessed by a Certified Nurse Aide and reported to a Registered Nurse, who did not consider it a resident-to-resident altercation and thus did not report it to the Director of Nursing or Administrator. This resulted in a delay in the investigation, which was not initiated until three days after the incident. The investigation was incomplete as it did not include interviews with the involved residents or other potential witnesses. The Director of Nursing did not obtain a statement from the resident who was sent to the hospital and returned to a different room. Additionally, there was no documented evidence that the responsible party of the affected resident was notified of the altercation. The Director of Nursing considered the incident isolated and did not interview other residents. The Administrator acknowledged that the staff should have reported the incident immediately to allow for a thorough investigation.

Penalty

Fine: $72,465

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 care for residents who were unable to perform activities of daily living, specifically in maintaining grooming and personal hygiene. Resident #27, who was admitted with diagnoses including diabetes mellitus, anxiety, and depression, did not receive timely incontinence care. The resident's brief and bed linens were saturated with urine, and the Certified Nurse Aide (CNA) performed incomplete incontinence care without proper hand hygiene or glove changes. The CNA also touched items in the resident's room with soiled gloves, leading to potential cross-contamination and infection control issues. Resident #102, who had a history of cerebral infarction and was legally blind, was dependent on staff for personal hygiene. The resident's fingernails were observed to be long, jagged, and filled with dark debris, which posed an infection control risk, especially since the resident ate with their hands. Despite the resident's preference for short nails, there was no documented evidence of nail care being provided, and the regular CNA stated that the resident did not refuse care. The resident's contracted hand had nails pressing into the palm, causing red indentations and discomfort. Resident #105, with diagnoses including diabetes mellitus and peripheral vascular disease, also had long, jagged fingernails with dark debris. The resident expressed a desire for nail care, but staff reportedly only cleaned under the nails without trimming them. The resident's nails were noted to be long and potentially harmful, yet there was no evidence of appropriate nail care being provided. The Director of Nursing acknowledged that long nails could be an infection control issue and expected staff to consult a provider for nail care in residents with certain medical conditions.

Penalty

Fine: $72,465

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 treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. For Resident #16, there was a significant delay in the administration of antibiotics for a urinary tract infection due to inaccurately transcribed physician's orders. The resident, who had an indwelling Foley catheter, experienced a nine-day delay in receiving the correct dosage of Ciprofloxacin, which was not therapeutic for the infection. Additionally, there was no comprehensive care plan developed for the resident's Foley catheter care and urinary tract infection. Resident #305 experienced issues with the maintenance of a peripherally inserted central catheter (PICC) line. The dressing for the PICC line was not changed as ordered due to a lack of available supplies, and the dressing was observed to be peeling and loose. The facility's failure to maintain the PICC line dressing as per the physician's orders posed a risk of infection, and the Director of Nursing was not informed of the inability to complete the dressing changes as required. Resident #154 did not receive prescribed supplements for electrolyte imbalances due to a lack of communication and documentation. The resident, who had a history of hypokalemia, hypomagnesemia, and hypophosphatemia, received only a fraction of the scheduled doses of supplements. The pharmacy did not dispense the required supplements, and there was no evidence that the medical providers were notified of the unavailability of these medications. This lack of communication and documentation resulted in the resident not receiving the necessary treatment for their condition.

Penalty

Fine: $72,465

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 each resident was offered pneumococcal and influenza immunizations, as well as documented education regarding the benefits and potential side effects of these vaccines. This deficiency was identified during an Extended Survey, which revealed that four out of five residents reviewed did not have documented evidence of being offered or declining the immunizations, nor receiving education about them. The facility's policies required that assessments of pneumococcal vaccination status be conducted within five business days of admission and that education and declination be documented in the resident's medical record. However, this was not adhered to for residents with various medical conditions, including diabetes, chronic obstructive pulmonary disease, and dementia. Interviews with facility staff, including the Infection Preventionist/Assistant Director of Nursing and the Director of Nursing, confirmed that the responsibility for obtaining and documenting immunization statuses fell on the admitting nurse, with oversight by the infection preventionist. Despite this, the Regional Director of Nursing was unable to locate the necessary immunization documents for the affected residents. This lack of documentation and adherence to policy resulted in a deficiency under 10 NYCRR 415.19 (a) (1).