Astoria Skilled Nursing And Rehabilitation

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident, who was dependent on two staff members and a mechanical (Hoyer) sling lift for all transfers, was transferred by only one Certified Nursing Assistant (CNA) using the lift. During this unsupervised transfer, the lift tipped over, causing the resident to fall to the floor and sustain a right hip fracture. The resident was subsequently transferred to the hospital for treatment and did not return to the facility after discharge. The resident had a history of multiple rib fractures, syncope, and anxiety disorder, and was assessed as having an activity of daily living (ADL) deficit, requiring a mechanical lift for transfers. The care plan and facility policy both specified that at least two staff members were required for safe use of the mechanical lift. The manufacturer's guidelines also recommended two assistants for all lifting and transferring procedures. Despite these requirements, the CNA performed the transfer alone, without requesting assistance from other available staff. Interviews with staff confirmed that the CNA did not ask for help before attempting the transfer. Other CNAs and the nurse on duty were only called to assist after the resident had already fallen. The facility's investigation verified that the transfer was not conducted according to policy or manufacturer instructions, directly resulting in the resident's injury.

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 severely cognitively impaired resident, with diagnoses including senile degeneration of the brain, anxiety disorder, encephalopathy, and type 2 diabetes mellitus, was identified as high risk for wandering and elopement upon admission. The resident's assessments indicated severe cognitive impairment, disorientation, and a history of wandering, with interventions including the use of a wander guard device. On the night of the incident, the resident had experienced a seizure and was transported to the hospital by paramedics, during which the wander guard was removed. Upon the resident's return from the hospital, there was no verifiable evidence that the wander guard was reapplied, and the nurse responsible for re-admission was unaware of the need for the device. Throughout the night, staff observed the resident wandering the building, attempting to redirect him with snacks, television, and conversation, but were unsuccessful in keeping him in his room. Multiple staff members noted the resident's persistent wandering and attempts to exit, with door alarms sounding at various times. Despite these behaviors and the resident's known risk, staff did not verify the presence or function of the wander guard, and there was no documentation indicating it was reapplied after the hospital visit. Additionally, staff allowed family members of other residents to enter and exit the facility using the door code without staff assistance, which created an opportunity for the resident to follow someone out of the building. The resident ultimately exited the facility unnoticed during the early morning hours and was found by a concerned citizen walking in the middle of the road, approximately 0.55 miles away from the facility, dressed in a t-shirt, pajama pants, and without shoes, in 46-degree weather. Facility staff were unaware of the resident's absence until notified by local law enforcement. The facility's failure to ensure the wander guard was in place and to provide adequate supervision and control of exit doors directly led to the resident's elopement.

Removal Plan

• Local law enforcement called facility and spoke with Licensed Practical Nurse (LPN) #107 to notify about Resident #12 being found and taken to the hospital.
• LPN #107 and Registered Nurse (RN) #108 completed a head count of all residents to ensure all were present and accounted for.
• LPN #107 attempted to notify Resident #12's Responsible Party and left a message.
• LPN #107 notified RN Manager #109 of Resident #12 leaving the facility and being taken to the hospital; RN Manager #109 notified the Administrator.
• RN Manager #109 attempted to contact Resident #12's Responsible Party and left a message.
• RN Manager #109 called and spoke with the hospital nurse for an update on Resident #12.
• RN #111 spoke with Resident #12's Responsible Party and notified them of the incident.
• Resident #12 returned to the facility accompanied by paramedics; RN #111 obtained vital signs and assessed Resident #12.
• Resident #12's wander guard was placed back on by RN #111 and Resident #12 was placed on one-on-one (1:1) supervision.
• Facility staff were educated on the Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions were in place for residents with exit seeking behaviors, ensuring interventions were put back in place when residents returned from the hospital, and not giving residents or families the door code.
• RN #101 audited resident orders and care plans for wander guards; any variances were corrected immediately.
• Receptionist #114 and Maintenance Director #115 audited all residents with wander guards for functioning, placement, and expiration; all were placed properly, functioning appropriately, and not expired.
• Maintenance Director #115 audited all exit doors and the wander guard system at all doors to ensure proper function.
• RN #101 audited current resident progress notes to ensure if behaviors consistent with exit seeking were noted, then residents had appropriate interventions in place.
• Resident #12's Nurse Practitioner (NP) #116 was notified of Resident #12 leaving the facility and being taken to hospital by law enforcement with return to facility.
• Administrator audited the facility records of exit door function checks.
• ADON #103 completed elopement and wandering risk assessments on all in-house residents.
• An elopement drill was completed by Maintenance Director #115.
• An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the facility correction plan including ongoing compliance.
• ADON #103 educated all current resident responsible parties via phone that they were to ensure staff let them in and out the doors when the front door was locked and should not enter the code themselves or let anyone else out without staff assistance.
• SecureCare was called and the front door code was changed by Maintenance Staff #117.
• The Care Conference form was updated by the Administrator to include education for new families and a reminder for others to request staff assistance with doors when locked, not put in code themselves or assist anyone else out of facility.
• Resident #12's care plan was updated by RN #101 to include wandering and elopement risk with interventions including 1:1 as needed, monitor and report changes in behaviors, orient to new surroundings, provide diversional activities of interest as needed, redirect as needed, and wander guard with placement and function checks as ordered.
• Nursing staff would monitor the effectiveness of interventions for Resident #12 by reviewing point of care (POC) documentation and conducting a review for weekend POC.
• CNAs would report behaviors to the charge nurse if behaviors were not resolved with interventions.
• 1:1 (staff) supervision would continue for Resident #12 until discharge.
• If a call off occurred for a person doing 1:1 supervision, the Administrator would be immediately notified and re-assign floor staff, management staff, or other department staff to cover 1:1 as appropriate. The Administrator would oversee 1:1 coverage scheduling.
• All new hires and agency staff would be educated regarding the facility's Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions are in place for residents with exit seeking behaviors, ensuring interventions are put back in place when residents return from the hospital, and not giving residents or families the door code.
• The Administrator or designee would review all door checks to ensure all doors were checked and functioning appropriately. All variances would be corrected upon discovery and education/follow-up would be provided as deemed necessary.
• Maintenance Director #115 or designee would conduct elopement drills to ensure staff respond accordingly. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
• The DON or designee would assess all residents with wander guards to ensure proper placement, function and expiration. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
• The Administrator or designee would audit the wander guard system and resident accessible exit doors to ensure they were functioning properly to ensure all doors were intact and functioning properly, including alarm. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
• The DON or designee would complete elopement and wandering risk assessments for facility residents to ensure no changes in behavior patterns or acute changes in condition affecting mental status were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
• The DON or designee would audit progress notes to ensure any residents with behaviors that increase risk for elopement or exit seeking have appropriate interventions in place.
• The Administrator or Designee would interview visitors to ensure visitors were aware they were not to enter door codes when the door was locked and should wait for staff assistance to exit facility, as well as not let anyone else out without staff assistance.
• The facility Quality Assurance (QA) committee would review audits to ensure compliance. Variances would be corrected immediately upon discovery and education provided.
• Results of these audits would be reported to the facility quality assurance committee. Ongoing compliance would be maintained by recommendations of the facility quality assurance committee.

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 dressing changes for a resident's peripherally inserted central catheter (PICC) line were performed on a routine, ongoing basis as required. Upon admission, the resident had a double lumen PICC line and an order for intravenous antibiotics, but there were no documented orders regarding PICC line care at that time. Medical record review and staff interviews confirmed that there was no documentation of PICC dressing changes until the PICC line was replaced, despite the facility's policy requiring dressing changes at least every five to seven days and as necessary. The resident reported that the dressing had been changed no more than twice since admission, and the dressing in place was dated several days after the initial placement. The resident's diagnoses included methicillin-resistant staphylococcus aureus infection, bacteremia, and a post-surgical site infection, all of which require careful management of central lines to prevent further complications. A nursing note indicated the PICC line became clogged, leading to its replacement. Orders for routine dressing changes and site monitoring were only written after the replacement, and staff were unable to locate documentation of prior dressing changes. The facility's policy emphasized the importance of keeping dressings clean, dry, and intact to prevent catheter-related infections, but this standard was not met for the resident in question.

Penalty

Inspection fine: $59,833

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

Summary

A deficiency occurred when the facility failed to timely identify and respond to a significant change in a resident's respiratory condition, resulting in actual harm. The resident, who was a full code, non-verbal, and had a tracheostomy, exhibited labored breathing, tested positive for COVID-19, and was being treated for pneumonia. Despite these risk factors and a history of respiratory complications, the LPN on duty did not notify the physician about the resident's labored breathing or the absence of secretions during suctioning. The LPN, unfamiliar with the resident, relied on information from a respiratory therapist (RT) via Facetime, who indicated the resident's breathing was at her baseline, and did not escalate care or seek further assistance until the resident was found unresponsive. The resident's medical record showed multiple complex diagnoses, including respiratory failure, pneumonia, encephalopathy, and tracheostomy status. Documentation revealed that the resident had previously required frequent suctioning for thick secretions and had a history of mucous plugs, which could cause acute respiratory distress. On the night of the incident, the LPN noted labored breathing and minimal secretions during suctioning but did not recognize these as signs of a potential mucous plug or acute deterioration. The RT, who was off-site, advised that the resident's condition was normal based on prior experience, but had not personally assessed the resident that day. There was no evidence in the records that labored breathing was normal for this resident, and the physician later confirmed she was not contacted about the change in condition. The facility's policy required prompt notification of the physician and responsible party for significant changes in a resident's condition. However, the LPN did not notify the physician or seek additional help until the resident was found without vital signs, at which point CPR was initiated and the resident was transferred to the hospital. Hospital records indicated the resident was admitted for acute on chronic respiratory failure with hypoxia, with findings suggestive of a possible mucous plug and severe sepsis. The resident ultimately passed away at the hospital. Interviews with staff and review of documentation confirmed that the failure to recognize and act upon the resident's change in respiratory status, and the lack of timely physician notification, directly contributed to the deficiency.

Penalty

Inspection fine: $59,833

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 observed multiple sanitary concerns in the facility's kitchen during a tour with the Dietary Manager. Three trash cans were found dirty with a dark substance on their sides, and the bottom shelf of a steel table was soiled with an orange substance, which a staff member confirmed was present at the start of her shift. A flour container was found with a measuring cup left inside, and two black three-tiered carts were visibly dirty with a buildup of various spilled substances. The refrigerator contained two packages of American cheese wrapped in aluminum foil without any dates indicating when they were opened or their expiration, and the cheese was hard and discolored at the edges. Additionally, an opened package of deli ham slices was found with no date of opening. These issues were all verified by the Dietary Manager during the inspection. The facility's policy requires the food service area to be maintained in a clean and sanitary manner, but these observations indicated non-compliance. All residents except three who did not receive food from the kitchen were affected.

Penalty

Inspection fine: $59,833

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

Summary

A deficiency occurred when the facility failed to notify the physician of a significant change in condition for a resident with complex medical needs, including respiratory failure, pneumonia, tracheostomy, and recent COVID-19 diagnosis. The resident, who was a full code and dependent on staff for all activities of daily living, returned from a hospital stay with new orders for antibiotics and continued to require oxygen and suctioning. Documentation showed that the resident experienced labored breathing and fluctuating oxygen saturations, but there was no evidence that the physician was notified of these changes during the night prior to the resident's death. Nursing and respiratory therapy staff noted increased secretions, labored breathing, and the need for frequent suctioning. Despite these observations, the nurse on duty relied on input from the respiratory therapist, who was contacted via Facetime and indicated that the resident's condition appeared to be her baseline. The nurse did not escalate the situation or seek further assistance, and there was no documentation of physician notification regarding the resident's respiratory distress. The resident's family was not informed of the labored breathing, and the physician later confirmed she was not contacted during the critical period. Interviews with staff revealed uncertainty and lack of familiarity with the resident's baseline condition, as well as a lack of clear communication and documentation regarding the resident's respiratory status. The facility's policy required prompt notification of the physician and responsible party for significant changes in condition, but this was not followed. The resident ultimately experienced respiratory failure and was transported to the hospital, where she passed away. The deficiency was substantiated by review of medical records, staff interviews, and facility policy.

Penalty

Inspection fine: $59,833

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 linens provided to residents were free from stains and maintained in a clean, comfortable, and homelike condition. During interviews and observations, it was found that a resident reported the washcloths and towels were stained, dingy, and not white, expressing discomfort with using them for personal hygiene. Direct observation of the linen closets confirmed that the available washcloths, hand towels, and bath towels were light brown in color, had several large brown stains, and appeared worn and thin. Staff confirmed that all linens were in similar condition and attributed the staining to the use of washcloths and towels for cleaning up bowel movements after the facility stopped purchasing incontinence wipes. The laundry manager stated that the same linens had been in use for an extended period, and new supplies ordered had not yet arrived. She also noted that the facility had been experiencing shortages of washcloths and towels since discontinuing incontinence wipes, leading to repeated use and further deterioration of the linens. The affected resident had multiple chronic medical conditions, including chronic respiratory failure, diabetes, kidney disease, and cognitive impairment, and was dependent on the facility for daily living supports. The deficiency had the potential to affect all residents utilizing facility linens.

Penalty

Inspection fine: $59,833

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 transportation was arranged for a resident's postoperative appointment as ordered by the physician. The resident, who had multiple complex diagnoses including cervical disc disorder, spinal stenosis, diabetes, and recent spinal surgery, was admitted with orders for a follow-up surgical appointment. The medical record and staff interviews confirmed that the resident missed the initial postoperative appointment because transportation was not set up by the facility. The appointment had to be rescheduled, and there was a lack of communication between the facility and the neurosurgery office regarding the resident's follow-up care. When the appointment was rescheduled, the resident arrived late and was not taken to radiology for X-rays prior to seeing the surgeon, as specified in the physician's order. The resident ultimately had the X-rays completed after the appointment instead. Interviews with staff revealed uncertainty about the transportation arrangements and the requirements for pre-appointment X-rays. The resident also confirmed that he was not informed about the need for radiology prior to the appointment and that transportation arrangements were not properly communicated or executed.

Penalty

Inspection fine: $59,833

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 timely, individualized, and effective interventions for pressure ulcer care for one resident with significant risk factors and existing pressure ulcers. The resident was admitted with multiple diagnoses, including hemiplegia, contractures, incontinence, and existing pressure ulcers on both heels. Upon admission, assessments identified the resident as high risk for pressure injuries, and documentation showed the presence of unstageable and Stage III pressure ulcers with heavy drainage and necrotic tissue. The care plan included interventions such as pressure-relieving devices, nutritional supplements, moisture barriers, and assistance with mobility and hygiene. Despite these documented interventions, there were delays and inconsistencies in their implementation. The resident did not receive a low air loss mattress until eight days after admission, despite requesting it on the first day and being at high risk for further skin breakdown. The resident also reported that staff did not consistently assist with turning, repositioning, or offloading the heels unless specifically requested. Observations confirmed that the resident's heels were directly on the bed without protective boots, and interviews with staff verified that the boots were not in use at the time of observation. The resident and a family member both indicated that necessary equipment and interventions were only provided after complaints were made to external authorities. Further review of wound care notes showed that the pressure ulcers increased in size before eventually showing some improvement, and that debridement was delayed due to the resident's pain and refusal, with some interventions only initiated after repeated documentation of wound status. The facility's policy required assessment and documentation of risk factors and timely intervention, but the evidence indicated that these were not consistently or promptly followed, resulting in a failure to provide adequate pressure ulcer care and prevention.

Penalty

Inspection fine: $59,833

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 arrange a dental appointment as ordered for a resident who experienced a dental issue. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, schizoaffective disorder, and a history of dental problems, reported to nursing staff that a tooth had fallen out. Although the resident did not initially report pain, the physician was notified and ordered Clindamycin and a dental appointment to be scheduled as soon as possible. Documentation review showed that the dental appointment was not scheduled or completed following the initial order. Subsequently, the resident called 911 for toothache pain and dizziness and was transported to the hospital. Upon return, new orders for antibiotics were given for dental caries and a periapical abscess. It was only after this hospital visit that a dental appointment was scheduled, several weeks after the original physician order. Interviews with facility staff confirmed that the dental appointment was not set up until after the resident's hospital visit, despite the earlier order to do so.

Penalty

Inspection fine: $59,833

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

During an observation of incontinence care, a Certified Nursing Assistant (CNA) provided care to a resident with multiple diagnoses, including malignant neoplasm of the colon, duodenal ulcer, dementia, urinary retention, depression, chronic pain syndrome, gastritis, and moderate protein-calorie malnutrition. The CNA used two washcloths and a bath towel to perform perineal and rectal care. After washing the resident's perineal and rectal area, the CNA continued to use a visibly soiled washcloth, using a different part of the same cloth, and placed the soiled washcloth on a clean towel. The CNA then dried the resident with the towel that had come into contact with the contaminated washcloth. The CNA proceeded to wipe the resident from the perineal area to the rectum with the same soiled washcloth, and upon noticing additional feces, used tissues from the bedside stand to clean the area. The CNA then continued to use the feces-soiled washcloth to wipe the resident two more times before being stopped by the surveyor, who instructed her to obtain a clean washcloth. The CNA confirmed in an interview that she had used a feces-soiled washcloth during the care. Facility policy on perineal care requires cleanliness to prevent infection and skin irritation, which was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the proper replacement of distilled water used in respiratory therapy, specifically for a resident using a BiPAP machine. The resident, who had multiple health conditions including chronic obstructive pulmonary disease and obstructive sleep apnea, complained about the taste of the distilled water, which he claimed made him feel nauseous and affected his breathing. Despite the resident's complaints, the respiratory therapist (RT) and staff did not replace the distilled water daily as requested by the resident. Instead, the RT replaced the water once a week, contrary to the facility's policy and the manufacturer's guidance, which required the water to be changed every 24 hours or when it had an unusual taste. The RT was unaware of the facility's policy regarding the use of distilled water for respiratory equipment and believed that changing the water weekly was sufficient. The RT had informed the Administrator and the Director of Nursing (DON) about the resident's request, but they initially supported the RT's practice of weekly changes. However, the DON later stated that the distilled water should be changed every 24 hours, as per the facility's policy. The facility's policy and the manufacturer's guidance both emphasized the importance of changing the distilled water to prevent infection and ensure the safety of the resident using the BiPAP machine.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate of less than five percent, resulting in an eight percent error rate during the observation period. This deficiency affected two residents during medication administration. For Resident #50, the error involved the incorrect measurement of polyethylene glycol powder by an LPN, who filled the cap below the required white line, leading to an inaccurate dosage. The LPN confirmed the mistake upon review of the medication instructions, which specified filling the cap to the white line to achieve the correct 17 grams dosage. For Resident #3, the error occurred when an RN failed to administer the Azelastine Hydrochloride nasal spray as prescribed. The RN acknowledged forgetting to give the nasal spray during the medication pass. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered safely, timely, and as prescribed, with errors documented and reviewed by the QAPI committee. This deficiency was investigated under two complaint numbers, indicating non-compliance with the facility's medication administration 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 proper infection prevention and control practices during medication administration for two residents. During an observation, a registered nurse did not perform hand hygiene before and after glove use while administering medications to a resident. The nurse also failed to disinfect the glucometer before and after obtaining blood sugar levels for two residents. This lack of adherence to infection control protocols was confirmed during an interview with the nurse. The residents involved had multiple medical conditions, including heart disease, diabetes, and neurological conditions. The facility's policies on medication administration and blood sampling required adherence to infection control procedures, such as hand hygiene and disinfection of reusable medical devices. The Centers for Disease Control guidance also emphasized the importance of hand hygiene in healthcare settings, which was not followed in this instance.

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's medications were administered as ordered, affecting one resident out of four reviewed for medications. The resident, who was readmitted with diagnoses including pneumonia, depression, and acute respiratory failure with hypoxia, had an order for hydrocodone/Tylenol (Percocet) to be given every six hours as needed for up to five days. This order was discontinued on 10/01/24. However, a review of the Controlled Drug Record form showed that a Percocet tablet was administered on 12/08/24 at 11:45 P.M. by a registered nurse, despite the medication being discontinued. The registered nurse confirmed in an interview that she accidentally administered the Percocet without checking the computer records first. She admitted to looking in the narcotic drawer and noticing the Percocet, which led her to administer it. It was only after attempting to sign off the medication in the resident's medical record that she realized the medication had been discontinued. This incident was a violation of the facility's policy, which requires medications to be administered safely, timely, and as prescribed.

Penalty

Inspection fine: $88,061

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 incidents of sexual abuse, specifically involving a male resident with severe cognitive impairment and two female residents. On two occasions, the male resident was found in compromising situations with a female resident who was also severely cognitively impaired. The first incident occurred when the female resident was found naked in the spa room with the male resident, who was dressed. Later the same day, the male resident was observed with his pants down, engaging in inappropriate sexual behavior with the same female resident. There was no evidence that the female resident had consented or was capable of consenting to the interaction. The facility did not implement effective interventions to prevent these incidents from occurring or to protect the female resident and others from the male resident. Despite the male resident's care plan not being updated to address his sexual behaviors until after the incidents, the facility failed to ensure adequate supervision and safety measures were in place. This lack of action resulted in another incident where the male resident was observed grabbing the breast of a different female resident without her consent. The facility's policies on abuse prevention and reporting did not include definitions of sexual abuse or consent, contributing to the inadequate response to the incidents. The facility did not complete a self-reported incident for the events involving the male and female residents, as they did not believe it constituted abuse. This oversight and failure to recognize the severity of the incidents led to a deficiency in ensuring resident safety and protection from abuse.

Removal Plan

• Resident #4 and Resident #61 were immediately separated. Resident #4 and Resident #61 were placed on 1:1 supervision.
• Resident #4 and Resident #51 were immediately separated, and Resident #4 was placed back on 1:1 supervision with staff.
• Regional Quality Assurance Registered Nurse (RQARN) #800 reviewed the progress notes of Resident #4 since his admission to the facility to ensure there were no other documented occurrences of like behaviors.
• Facility Assistant Administrator (FAA) #801 completed interviews with 28 of 28 alert and oriented residents with Brief Interview of Mental Status (BIMS) scores of 12 and higher. All 28 residents denied any like concerns and denied abuse and mistreatment by staff and/or other residents.
• Unit Manager Licensed Practical Nurses (UMLPN) #802 and #803 performed skin sweeps on 33 of 33 residents with BIMS scores less than 12. No new or unidentified skin impairments, psychosocial distress or signs of abuse or mistreatment were noted for these 33 residents.
• Regional Director of Operations (RDO) #501 educated 18 of 18 administrative staff on the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and re-educated on 1:1 supervision requirements.
• The Administrator and other staff re-educated 98 of 99 facility staff on the facility Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and re-educated on 1:1 supervision requirements.
• RDO #510 visually confirmed Resident #4 to be on 1:1 supervision.
• RDO #510 educated the Administrator, Assistant Administrator #801, the DON, the ADON, and UMLPNs #802 and #803 on federal regulation F609: Reporting of Alleged Violations and F610: Response to Alleged Violations.
• The care plan of Resident #4 was updated to include the 1:1 supervision.
• RDO #510 notified the Medical Director via phone of the Immediate Jeopardy and abatement plan.
• SSD #809 performed a psychosocial assessment on Resident #51 who showed no signs of psychosocial distress.
• RQARN #800 reviewed progress notes for the last 90 days for all current facility residents for any related sexually inappropriate behaviors.
• STNA #817, who was assigned to Resident #4's 1:1 supervision, was terminated from employment at the facility for not maintaining 1:1 supervision.
• An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the facility Immediate Jeopardy and removal plan.
• The DON or designee would verify 1:1 was in place for Resident #4 and the staff person assigned to the 1:1 had full understanding of the requirement for providing 1:1, each shift seven days a week for a period of one week and each shift five times a week for a period of three weeks thereafter.
• The DON or designee would interview eight staff members five times weekly for a period of four weeks to ensure understanding of the 1:1 education provided.
• The DON or designee would review progress notes of current residents five times a week for a period of four weeks to ensure any notable changes in sexual behavior had an appropriate and timely intervention.
• The Administrator or designee would interview 10 residents weekly, for a period of four weeks regarding abuse and mistreatment.
• The DON or designee would assess 10 non-interviewable residents weekly for a period of four weeks to ensure residents remain free of signs of unknown skin impairment and abuse and/or mistreatment.
• RDO #510 or designee would review all allegations of abuse three times a week, for a period of four weeks to ensure timely follow-up, completion of full investigation, documentation of allegation, reporting, and appropriate intervention implementation.
• The Administrator would audit 100% of new hires five times a week for four weeks for education on the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy.
• RDO #510 would review all audits weekly for a period of four weeks to ensure completion and compliance.

Penalty

Inspection fine: $88,061

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 and timely care to Resident #42, who was dependent on staff for various needs, including transfers, incontinence care, and diabetes management. The resident, who had a complex medical history including Huntington's disease, diabetes, and was at risk for falls, was found unresponsive in his room, slumped over in his wheelchair with blood on his face and clothing. The last documented interaction with the resident was at 10:00 P.M. when an LPN checked his blood glucose level, which was elevated at 400 mg/dl, and administered 40 units of Glargine insulin. However, there was no follow-up or monitoring of the resident's condition throughout the night. The resident was not checked again until 4:30 A.M. when a nursing assistant found him unresponsive. Despite the elevated blood glucose level earlier, no further assessments or interventions were documented. The resident required CPR and was transported to the hospital, where his blood glucose was recorded at 607 mg/dl. He was admitted to the intensive care unit and subsequently passed away. The facility's failure to monitor the resident's condition and provide necessary care contributed to the resident's deterioration and eventual death. Interviews and record reviews revealed that the resident was supposed to be checked every two hours for incontinence care and was care planned to be in a common area when in his wheelchair due to fall risk. However, these interventions were not followed, and the resident remained in his room unattended. Staff statements indicated a lack of communication and follow-through on the resident's care needs, leading to a significant lapse in care that resulted in immediate jeopardy and actual harm.

Removal Plan

• Regional Quality Assurance Registered Nurse (RQARN) #800 audited residents with physician orders for blood sugar checks to ensure parameters for notifying the physician were included.
• Assistant Director of Nursing (ADON) #403 audited residents with physician orders for blood sugar checks to ensure compliance with physician's orders and appropriate follow-up.
• Regional Director of Operations (RDO) #510 educated facility leadership on following individualized care plans related to incontinence checks and resident monitoring.
• RQARN #800 educated nursing leadership on the facility policy Nursing Care of the Resident with Diabetes Mellitus, including obtaining follow-up blood sugar checks if indicated.
• Facility Medical Director was notified of the Immediate Jeopardy related to quality of care and treatment.
• Facility leadership educated all nursing staff on following individualized care plans related to incontinence checks and resident monitoring.
• RQARN #800, the DON, ADON #403, and UMLPNs educated all licensed nursing staff on the facility policy Nursing Care of the Resident with Diabetes Mellitus.
• Clinical Resource Specialist LPN #816 audited all current resident care plans to ensure fall interventions reflect resident preferences and refusals are addressed.
• Clinical Resource Specialist LPN #816 audited all current resident care plans to ensure incontinence care plans include resident preferences and refusals.
• RDO #510 added facility education for following individualized care plans and the facility policy Nursing Care of the Resident with Diabetes Mellitus to the facility General Orientation manual.
• Clinical Operations Specialist RN #992 completed an audit of progress notes for active residents with physician's orders for blood sugar checks.
• Ad hoc Quality Assurance Performance Improvement (QAPI) meeting held to discuss the plan of action.
• Regional Quality Assurance RN/Designee to review all residents with physician's orders for blood sugar checks.
• DON/designee to interview staff members to ensure understanding of individualized care plans.
• DON/Designee to review progress notes of current residents with physician orders for blood sugar checks.
• DON or Designee to audit new hires to ensure education on facility policy for care plans and diabetes management.
• DON or designee to audit all residents with physician orders for blood sugar checks to ensure parameters for physician notification are included.
• DON or designee to audit all residents with fall care plans to ensure interventions are in place and followed.
• DON or designee to audit all residents with incontinence care plans to ensure standard of care is followed.
• RDO #510 to review all audits to ensure completion and compliance.
• QA Committee to monitor the results of all audits and follow-up as needed.

Penalty

Inspection fine: $88,061

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 sufficient staffing levels to meet the care needs of all residents, specifically affecting Resident #42. This resident had a complex medical history, including respiratory failure, diabetes, and severe protein-calorie malnutrition, among other conditions. The care plan for Resident #42 included interventions for fall risk, incontinence, and diabetes management, requiring regular monitoring and assistance from staff. However, the facility's staffing shortages led to inadequate care, as evidenced by the resident being left unattended in a wheelchair for an extended period. On the night of the incident, staffing was insufficient, with only one State Tested Nursing Assistant (STNA) working on the unit where Resident #42 resided. The STNA was overwhelmed with responsibilities and unable to provide timely assistance to all residents. Despite being informed that Resident #42 needed to be laid down, the STNA was unable to attend to this task due to the high workload and lack of support. This situation was exacerbated by another STNA calling off, leaving the unit understaffed and unable to meet the residents' needs effectively. The deficiency was further highlighted when Resident #42 was found unresponsive in his wheelchair, having not been laid down as required. The nursing staff attempted resuscitation, but the delay in care due to staffing issues may have contributed to the severity of the situation. Interviews with staff revealed that working alone was a common occurrence, indicating a systemic issue with staffing levels at the facility. This deficiency was identified during the investigation of specific complaint numbers, underscoring the potential risk to all residents due to inadequate staffing.

Penalty

Inspection fine: $88,061

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

Summary

The facility failed to maintain a clean and sanitary kitchen environment, which had the potential to affect 58 residents receiving meals. During an observation, it was noted that extra dish racks were stored on old milk crates under the sink, and when moved, gnats were seen flying out from under the sink. There was significant water damage with missing tiles and a large hole in the wall, from which the gnats were emerging. The Dietary Manager confirmed the presence of the hole and gnats, although he was unsure of how long the damage had been present. A dietary aide confirmed that the wall had been in disrepair for some time, with water occasionally leaking into an adjacent dining room. A follow-up visit revealed that while the tile had been replaced, the wall behind it had food splatter, and a pipe above had chunks of food, with gnats still present around the dish machine. The walk-in refrigerator had mold on three shelves, food residue, paper pieces, and a broken egg on the floor. Additionally, a box of thickener in the dry storage area was improperly wrapped, labeled, and dated. The walk-in freezer had water on the floor outside it, which had been leaking for a week. The facility's policies on sanitation and pest control, dated 2008, were not adhered to, as the kitchen areas were not kept clean or free from pests, and the pest control program was ineffective.

Penalty

Inspection fine: $88,061

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

Summary

The facility failed to implement its abuse policy to thoroughly investigate and report all allegations of resident-to-resident abuse, affecting two residents. Resident #61, who had severe cognitive impairments and a history of mood and behavioral issues, was involved in an incident with Resident #4, who also had severe cognitive impairments and a history of behavioral disturbances. On multiple occasions, both residents were found in compromising situations in the spa room, with their pants down. Despite these incidents, the facility did not document or report them as abuse, nor did they conduct a thorough investigation. Resident #4 was involved in another incident with Resident #51, who had moderately impaired cognition and a history of mental health issues. Resident #4 was reported to have grabbed Resident #51's breast, but the facility did not document this incident in the progress notes or conduct a thorough investigation. The facility's policy on abuse, neglect, and exploitation did not include a definition of sexual abuse or information on consent to sexual activity, which may have contributed to the lack of appropriate response. Interviews with staff and family members revealed inconsistencies in the facility's handling of these incidents. Staff reported that Resident #4 was supposed to have 1:1 supervision, but this was not consistently provided. The facility also failed to complete a Self-Reported Incident (SRI) for the incidents involving Resident #4, as they did not believe the situations constituted abuse. The lack of documentation, investigation, and reporting of these incidents highlights a significant deficiency in the facility's implementation of its abuse policy.

Penalty

Inspection fine: $88,061

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

Summary

The facility failed to report an allegation of sexual abuse involving two residents to the State Agency, affecting two out of five residents reviewed for abuse. Resident #61, who had a history of dementia and other cognitive impairments, was found in the bathroom with Resident #4, both with their pants down. Despite being placed on one-on-one supervision, the facility did not document the incident properly or report it as a potential case of abuse. The facility's investigation noted no skin-to-skin contact or distress, but conflicting accounts from staff and family members suggested inappropriate behavior by Resident #4. Resident #4, who also had dementia and other cognitive impairments, was involved in another incident with Resident #51, where he allegedly grabbed her breast. Despite staff witnessing the incident, it was not documented in the progress notes, and the facility did not report it to the State Agency. The facility's policies on abuse prevention and reporting did not include definitions of sexual abuse or guidelines on consent, contributing to the oversight in reporting these incidents. Interviews with staff and family members revealed discrepancies in the facility's handling of the incidents. Staff reported missing witness statements, and there was a lack of consistent one-on-one supervision for Resident #4. The facility's failure to report these incidents as potential abuse cases and the lack of thorough documentation and investigation highlight significant deficiencies in their abuse prevention and reporting protocols.

Penalty

Inspection fine: $88,061

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 thoroughly investigate allegations of resident-to-resident sexual abuse involving two residents. Resident #61, who had severe cognitive impairment and a history of mood and behavioral issues, was found in the spa room with Resident #4, both with their pants down. Despite being placed on one-on-one supervision, there was no documentation of an earlier incident on the same day. The facility's investigation lacked a written statement from a key witness, and the facility did not report the incident as abuse, believing it was a misunderstanding. Resident #4, who also had severe cognitive impairment and a history of behavioral disturbances, was involved in multiple incidents of inappropriate sexual behavior. On one occasion, he was found with Resident #61 in the spa room, and on another, he allegedly grabbed the breast of Resident #51. Despite these incidents, there was no thorough investigation or documentation, and the facility did not report the incidents as abuse. The facility's policy on abuse reporting and investigation did not include a definition of sexual abuse or guidelines on consent. The facility's failure to investigate and report these incidents as abuse represents a deficiency in their handling of resident safety and compliance with regulatory requirements. The lack of documentation, missing witness statements, and inadequate supervision contributed to the facility's non-compliance. The facility's policies were insufficient in guiding staff on handling and reporting sexual abuse, leading to a lack of appropriate action in response to the incidents.

Penalty

Inspection fine: $88,061

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, identified as Resident #63, had an adequate supply of narcotic medications for a safe discharge until her post-discharge physician appointment. Resident #63, who had multiple diagnoses including ADHD, anxiety, arthritis, and fibromyalgia, was discharged to her home without confirmation of having enough medication to last until her scheduled follow-up appointment. The facility's policy required that medications be called into the resident's pharmacy of choice, but did not allow for medications to be sent home unless specifically ordered by a physician. In this case, the physician did not authorize the release of narcotics, and there was no documentation confirming whether the resident had sufficient medication at home. Interviews with facility staff revealed that the discharge process involved calling in a 10-day to two-week supply of medications to the resident's pharmacy, but did not include sending medications home with skilled Medicare residents. The Social Services Director and the Director of Nursing confirmed that medications were not sent home unless ordered by a physician. Additionally, it was noted that Resident #63 had difficulty maintaining a primary care physician due to her boyfriend's actions, which contributed to the lack of a PCP at the time of discharge. The facility's policy on discharge medications required physician authorization for releasing controlled substances, which was not obtained in this case, leading to the deficiency.