Katherine Luther Residential Hlth Care & Rehab

Penalty

Inspection fine: $54,304

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

Summary

A resident with a history of Parkinson's Disease, dementia, and chronic constipation experienced a significant decline in bowel function, going six days without a bowel movement. Despite facility policies requiring monitoring and intervention for constipation, there was no documented evidence that the resident was properly assessed by a registered nurse or that a medical provider was notified in a timely manner. The resident exhibited symptoms including abdominal distention, pain, and discomfort, which were reported by staff and family members, but these concerns were not adequately addressed or escalated according to protocol. The facility's bowel management protocol required that residents with no bowel movement for three days receive specific interventions and that abnormal findings be reported to a physician. However, the resident was administered bowel medications, including Milk of Magnesia, without a physician's order or proper documentation in the medication administration record. Multiple staff members, including LPNs and CNAs, noted the resident's symptoms and attempted to communicate concerns, but there was a lack of follow-through in notifying supervisors or ensuring a registered nurse assessment was completed. The medical provider was not made aware of the resident's condition until after a significant delay, and the facility's documentation was inconsistent regarding bowel movements and interventions provided. Ultimately, the resident's condition deteriorated, leading to hospitalization for a bowel obstruction that required emergency surgery. Interviews with facility staff and medical providers confirmed that the expected protocols for assessment, notification, and documentation were not followed. The failure to provide timely and appropriate care according to professional standards and the resident's care plan resulted in actual harm to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to reasonably accommodate the needs and preferences of ten residents by removing siderails without explanation or providing alternative positioning devices. The facility's policy, which was updated to be siderail-free, required that all admissions be evaluated by the rehabilitation therapy department to assess mobility and transfer needs. However, despite previous assessments recommending the use of siderails for functional independence and bed mobility, the facility removed these aids without proper communication or alternative solutions. Resident #53, who had intact cognition and required substantial assistance for bed mobility and transfers, had their siderails removed without explanation. The resident expressed difficulty in moving around in bed without the siderails and was not offered any alternative assistive device. Similarly, Resident #67, who used siderails for bed mobility and transfers, was not informed about the removal and expressed fear of falling without them. The resident's concerns were dismissed by staff, who incorrectly cited state law as the reason for the removal. Resident #2, who had intact cognition and required assistance with bed mobility and transfers, also had their siderails removed without prior discussion or alternative solutions. The resident attended a council meeting to voice their concerns, only to be told that the removal was due to state law. Interviews with staff revealed a lack of proper communication and assessment before the removal of siderails, with some staff members acknowledging the benefits of siderails for certain residents. The facility's decision to implement a siderail-free policy was based on safety concerns and a desire to align with a sister facility's policy, but it was not executed with adequate resident involvement or consideration of individual needs.

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 food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the recertification survey, it was observed that the main kitchen's walk-in cooler and freezer floors were unclean and soiled with food debris. Additionally, the dishwasher in the main kitchen was not functioning properly, with the final rinse cycle not reaching the required temperature for proper sanitation. The Food Service Director acknowledged that the booster was broken and that the dishwasher temperatures were inconsistent, which could potentially affect all residents in the building. In the nursing unit kitchenettes, several issues were identified. The refrigerator in one unit had a broken temperature gauge and was not maintaining the appropriate temperature, with a probe thermometer reading as high as 54 degrees Fahrenheit. This led to the discarding of temperature-controlled foods. Another unit's refrigerator and freezer were found to be unclean with food spills, and the microwave oven was also unclean with food debris. The freezer in this unit was not working, and there was no sign indicating its status, which could lead to its unintended use. Interviews with staff revealed lapses in monitoring and documenting temperatures and sanitation processes. The Food Service Director and a dishwasher staff member admitted to not checking or documenting the dishwasher temperatures as required. Furthermore, the Food Service Director was unaware of the machine's specifications for chemical sanitization after transitioning from heat sanitization due to the dishwasher's malfunction. These deficiencies highlight a lack of adherence to the facility's policies on cleanliness, sanitation, and food safety, potentially compromising the safety of the residents.

Penalty

No penalty information released

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

Summary

The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the recertification survey. Two residents, identified as having urinary catheters, were observed with their catheter drainage tubing lying directly on the floor, which is against the facility's policy and increases the risk of infection. Certified Nurse Aides confirmed that catheter care should include ensuring the tubing does not touch the floor, yet this was not adhered to, indicating a lapse in infection control practices. Additionally, a Licensed Practical Nurse (LPN) failed to perform appropriate hand hygiene during wound care for a resident with a Stage 3 pressure ulcer. The LPN did not wash hands between glove changes and used undated normal saline, which could compromise the sterility of the wound care process. The facility's policy requires hand hygiene between glove changes and dating of opened wound care products, but these protocols were not followed, potentially leading to wound contamination. Another LPN was observed wearing the same pair of gloves while assisting multiple residents with different tasks, including feeding and handling dirty dishes, without changing gloves or performing hand hygiene. This practice contradicts the facility's hand hygiene policy and poses a risk of cross-contamination between residents. The Infection Preventionist confirmed that such practices are not acceptable and could lead to the spread of infections within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents, as evidenced by several deficiencies observed during the survey. Water temperatures in various locations, including shower rooms and resident bathrooms, exceeded the facility's policy limit of 120 degrees Fahrenheit, posing a potential risk to resident safety. Despite daily inspections by maintenance staff, these elevated temperatures were not documented in the facility's logs, indicating a lapse in monitoring and reporting procedures. Additionally, the condition of resident rooms was found to be substandard. In one room, the bathroom floor was in disrepair, with brown stains and loose tiles, and the room itself was cluttered with dirty dishes and garbage. Despite a work order being placed months prior for the damaged floor, the issue remained unresolved, highlighting a failure in the facility's maintenance and repair processes. Housekeeping staff reported challenges in maintaining cleanliness due to a lack of a set cleaning schedule and resident refusal to allow cleaning. The cleanliness of resident wheelchairs and mechanical lifts was also inadequate. Observations revealed wheelchairs with food debris and brownish substances, and mechanical lifts with dirt and debris on the footplates. The facility lacked proper documentation for wheelchair cleaning, and staff interviews indicated that cleaning responsibilities were not consistently fulfilled. This neglect in maintaining equipment cleanliness not only compromised the homelike environment but also posed potential infection control issues.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate treatment and care according to the residents' care plans and preferences for three residents. Resident #48, who had diagnoses including dementia and muscle weakness, was observed drinking hot beverages from a mug without a lid, contrary to their care plan which specified the use of a lid to prevent spills. Despite the meal ticket indicating the need for a lid, staff failed to comply, as confirmed by interviews with a CNA, LPN, and the Director of Nursing. Resident #57, diagnosed with dementia and contractures, was not provided with palm guards as outlined in their care plan. Observations showed the resident without the required orthotic devices on multiple occasions. Interviews revealed that staff were unaware of the location of the devices and did not report their absence, which could lead to worsening contractures. The care instructions were not followed, and there was no documentation of the application or refusal of the devices in the electronic medical record. Resident #88, who had edema, was not wearing their prescribed Tubigrips during observations, despite documentation in the Treatment Administration Record indicating they were applied. Interviews with nursing staff revealed that the Tubigrips were not verified as being on the resident, yet they were signed off as completed. This oversight could lead to worsening edema, as the Tubigrips were essential for managing the resident's condition.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents with pressure ulcers or at risk for pressure ulcers received the necessary treatment and services consistent with professional standards of practice. Specifically, two residents, identified as Resident #14 and Resident #312, were found to have specialty air mattresses that were not set according to individualized settings and were not monitored to ensure appropriate settings were used. This deficiency was observed during a recertification survey conducted from August 1, 2024, to August 7, 2024. Resident #14, who had diagnoses including multiple sclerosis, diabetes, and paraplegia, was at high risk for developing pressure ulcers. Despite having a comprehensive care plan that included interventions such as turning and positioning every 2-3 hours and using a pressure-reducing mattress, there were no documented physician orders or monitoring plans for the alternating pressure mattress. Observations revealed that the mattress was set at 580 pounds, which was inappropriate given the resident's weight of 203.3 pounds. Interviews with staff indicated a lack of knowledge regarding the correct settings for the mattress. Resident #312, who had pressure ulcers on the right buttock, was also found to have an air mattress overlay that was not set according to individualized needs. The care plan included the use of an air mattress and repositioning every 2 hours, but there were no documented settings for the air mattress. Observations showed the mattress was set midway between minimum and maximum, and staff interviews revealed uncertainty about the appropriate settings. The Director of Nursing acknowledged that settings should be based on the resident's weight and documented in the care plan, but this was not done for Resident #312.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a safe environment and adequate supervision for two residents, leading to deficiencies in care. Resident #44, who had Alzheimer's disease and was non-ambulatory, experienced multiple falls due to the bed not being maintained in the low position as care planned. Despite interventions documented in the care plan, such as frequent checks and a low bed position, observations revealed that the bed was often at a higher position, posing a safety risk. Interviews with staff confirmed that the bed was not consistently kept in the low position, which was crucial for the resident's safety. Resident #106, diagnosed with dementia and moderate protein-calorie malnutrition, was dependent on staff for eating. The nursing staff reheated the resident's meal in a microwave without checking the temperature, contrary to the facility's food safety policy. The policy required food to be reheated to a specific temperature to ensure safety, but there were no instructions for reheating meals in microwaves. Staff interviews revealed a lack of training and resources, such as thermometers, to ensure food was reheated safely, leading to potential risks of burns or foodborne illness. The deficiencies highlight a lack of adherence to care plans and facility policies, resulting in unsafe conditions for residents. The facility's policies on managing falls and food safety were not effectively implemented, as evidenced by the repeated failure to maintain the bed in a low position for Resident #44 and the improper reheating of meals for Resident #106. These oversights indicate a need for improved staff training and adherence to established safety protocols to prevent future incidents.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate respiratory care to a resident, identified as Resident #88, who required oxygen therapy. The resident, diagnosed with chronic obstructive pulmonary disease and pleural effusion, was observed receiving oxygen at a flow rate of 4 liters per minute, contrary to the physician's order of 2 liters per minute. This discrepancy was noted on multiple occasions over several days, including when the resident was in their room sitting in a wheelchair or recliner chair. The facility's policy required licensed nurses to ensure physician orders were followed and documented every shift, but this was not adhered to in Resident #88's case. Licensed Practical Nurse #27 admitted to documenting the oxygen flow rate as correct without verifying it, leading to the resident receiving a higher flow rate than prescribed. The Registered Nurse Unit Manager confirmed that nurses were expected to follow physician orders and check oxygen settings, especially for residents with chronic obstructive pulmonary disease, as incorrect flow rates could be harmful. The failure to adhere to these protocols resulted in the resident receiving an inappropriate level of oxygen, which was not in line with professional standards of practice.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that food and drink provided to residents were palatable, attractive, and at safe and appetizing temperatures during the recertification survey conducted from August 1 to August 7, 2024. Specifically, during the lunch meal on August 5, 2024, on two units, food was not served at appropriate temperatures. Observations revealed that Resident #106's lunch tray, which was used as a test tray, had food items that were not at the required temperatures. The Salisbury steak was 127 degrees Fahrenheit, mashed potatoes were 122 degrees Fahrenheit, peas were 117 degrees Fahrenheit, the Mighty Shake was 50 degrees Fahrenheit, and cranberry juice was 56 degrees Fahrenheit. Similarly, Resident #363's lunch tray had peas at 100 degrees Fahrenheit, cheddar mashed potatoes at 111 degrees Fahrenheit, and a Mighty Shake at 41 degrees Fahrenheit, with the mashed potatoes and peas being cold to taste. The facility's policies required hot foods to be held at 135 degrees Fahrenheit and cold foods at 40 degrees Fahrenheit or below. However, the temperatures of the food items served did not meet these requirements. The Food Service Director acknowledged that nursing staff used microwaves on the unit to heat food and should have checked the food temperatures before serving. It was noted that no test trays had been conducted since the food service contractor left in November 2023. The deficiency highlighted the importance of maintaining proper food temperatures to ensure palatability and prevent the spread of foodborne illness.

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 permit a resident to return after hospitalization, violating their own policies and regulations. Resident #360, who had dementia, anxiety, and metabolic encephalopathy, was sent to the hospital for evaluation due to increased agitation and was medically cleared to return. However, upon arrival at the facility, the resident was refused re-entry, and the Emergency Medical Services were instructed to return the resident to the hospital. The facility's Admission Agreement and Resident Transfer and Discharge policy indicated that residents should be allowed to return after emergency transfers if they meet the required criteria. Despite this, the Registered Nurse Supervisor mistakenly believed the resident was discharged upon being sent to the hospital and did not communicate with the hospital or the resident's family about the refusal to readmit. The resident's family was not informed until days later when they were asked to collect the resident's belongings. Interviews with facility staff revealed a lack of communication and misunderstanding of policies. The Director of Admissions and Director of Nursing supported the decision not to readmit the resident, citing behavioral issues, but failed to ensure proper communication with the hospital. The facility did not provide a discharge or transfer notice until requested, and the document was unsigned and undated, further indicating procedural lapses.

Penalty

Inspection fine: $26,254

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 treatment and care in accordance with professional standards for two residents, leading to immediate jeopardy and substandard quality of care. Resident #2 experienced a fall resulting in a hematoma on the back of their head. Despite showing signs of a change in condition, such as lethargy, sluggish eye movement, slow speech, and vomiting, neurological checks were not completed as required, and a medical provider was not notified in a timely manner. This delay in response and subsequent delay in transport to the hospital resulted in the resident being diagnosed with a severe brain hemorrhage and expiring the following day. Resident #7 also experienced a fall with a hematoma to the back of their head and was sent to the emergency room for evaluation. Upon returning to the facility, neurological checks were not resumed as per the facility's protocol. The lack of monitoring placed the resident at risk, as there was no documented evidence of neurological checks being completed at the required intervals after their return from the hospital. The facility's policies on neurological checks and notification of resident conditions to providers were not followed, leading to a failure in monitoring and responding to changes in the residents' conditions. This oversight placed all residents at risk and resulted in actual harm to Resident #2, highlighting significant deficiencies in the facility's care processes.

Removal Plan

• 100% of staff on duty were educated according to the approved training plan.
• Staff including 1 registered nurse and 7 licensed practical nurses were interviewed and confirmed participation and understanding of the education.
• The facility developed a plan to educate any staff not working prior to the start of their shift.
• Neurological check policy revised.
• Neurological check procedure added to Registered Nurse/Licensed Practical Nurse Orientation checklist.
• Neurological check sheet now included section for signs/symptoms including complaints of headache, slurred speech, and vomiting.
• Incident Form was revised and now included: a section questioning if the registered nurse was notified of incident, time of registered nurse notification, time of registered nurse arrival; and a section questioning if Emergency Medical Service's was notified, time of Emergency Medical Service's notification, time Emergency Medical Service's arrived at facility and time of Emergency Medical Service's departure.
• Transfer of resident in Emergency Situation Policy implemented.
• Signage with instructions for calling Emergency Medical Service's posted at all nursing stations.
• Transportation procedure added to Registered Nurse/Licensed Practical Nurse Orientation checklist.

Penalty

Inspection fine: $26,254

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 licensed nurses had the appropriate competencies and skill sets to provide necessary care, resulting in two residents experiencing significant deficiencies in their care. Resident #2, who had diagnoses including diabetes, cirrhosis, and dementia, suffered a fall resulting in a hematoma to the back of their head. Despite initial neurological checks being conducted, there was a failure to continue these checks at the required intervals. Furthermore, when the resident exhibited changes in condition, such as lethargy and vomiting, there was a delay in notifying a medical provider and in arranging transport to the hospital, which contributed to a severe brain hemorrhage and ultimately the resident's death. Resident #7, diagnosed with Alzheimer's Disease, epilepsy, and cellulitis, also experienced a fall resulting in a head injury. After being sent to the hospital and returning to the facility, the required neurological checks were not resumed as per the facility's protocol. The nursing staff assumed that the resident was cleared at the hospital despite no diagnostic testing being performed, leading to a lapse in monitoring the resident's condition post-injury. The report highlights a lack of proper training and adherence to protocols among the nursing staff, as evidenced by the absence of documented training related to neurological checks, resident change in condition, and calling Emergency Medical Services. The facility's failure to ensure timely and appropriate responses to changes in residents' conditions and to follow established protocols for neurological monitoring contributed to the deficiencies observed in the care of Residents #2 and #7.