Falling Water Healthcare 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

Food was not stored, prepared, distributed, and served under sanitary conditions in the kitchen and dish areas. During observation with the RD, the dry storage area contained a bottle of vanilla with a cracked lid. In the cooking area, the large floor mixer had dried batter on the back splash and top of the mixing mechanism, and the microwave had dried food splatter inside. The reach-in refrigerator had dried food splatter on the outside and vanilla pudding that was not labeled or dated. In the cook's reach-in refrigerator, sliced American cheese, bologna, and a chef salad were not labeled or dated. In the reach-in freezer, pork chops were not wrapped properly and the unopened bag had no label or date. In the dish area, the floor was greasy and the three-compartment sink had food residue inside the empty compartments. Additional observations in the dishwashing area showed sanitation and handling concerns during warewashing. The clean side of the dish machine had clumps of oatmeal on the drain board, and when clean dishes finished the washing and sanitizing process, the racks pushed the oatmeal onto the drain board. The Dietary Manager removed a clean rack of dishes after the warewashing process and placed it on the dirty drainboard of the three-compartment pot sink. A Dietary Aide wore gloves while placing dirty dishes on dish racks for the dishmachine, then went to the clean side and touched clean dishes to put them away without changing gloves or performing hand hygiene. The Dietary Manager explained to the aide that gloves must be changed and hand hygiene performed before touching clean dishes.

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 were offered or included in care conference meetings as part of their person-centered care planning. Record reviews and interviews revealed that four residents, all of whom had quarterly Minimum Data Set (MDS) assessments completed and were either cognitively intact or had a representative, did not have documented care plan meetings beyond their initial or early admission meetings. For example, one resident was only invited to a single meeting after admission, which he missed, and had no further documented invitations. Another resident and his mother reported not receiving invitations to care plan meetings for an extended period, and the last documented meeting was several months prior. A third resident's family stated they were not contacted or invited to participate in care planning, and the last meeting on record was also several months old. The fourth resident, who was cognitively intact, reported not being involved in any care plan meetings during his year-long stay, with the last documented meeting occurring months before the review. Interviews with facility staff, including a licensed social worker and an LPN, confirmed that care plan meetings were not consistently offered or held for all residents as required. The social worker identified issues related to staffing changes and lack of a systematic approach to scheduling these meetings. The facility's own policy stated that residents and their representatives should be included in all aspects of care planning and be given opportunities to participate, but this was not followed in practice. The deficiency was identified during a complaint investigation and affected four out of four residents reviewed for participation in care planning.

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 had access to his social security allowance as required. The resident, who was cognitively intact and had diagnoses including depression and quadriplegia, had his social security check for February recalled by Social Security and not deposited until April. As a result, the system did not recognize that the resident should have received his $50.00 allowance retroactively for February. The resident did not receive this allowance, even though subsequent months' allowances were properly allotted and withdrawn by the resident as documented by signed receipts. Interview with the Regional Business Office Manager confirmed that the oversight occurred because the system did not account for the late deposit of the February check, and the resident was not given his $50.00 allowance for that month. This deficiency was identified during a review of the resident's personal fund statements and was verified through interviews and record review.

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 food that accommodated resident allergies, dietary intolerances, and preferences for three residents. One resident with an egg allergy and a preference for ground fruit cocktail was initially served regular fruit cocktail instead of the required ground version, as indicated on her tray ticket. Another resident, who was supposed to receive double portions due to a physician order, was served only a regular portion of chicken piccata, contrary to the tray ticket instructions. Both discrepancies were identified by dietary staff during meal service. A third resident, with a documented lactose allergy and a physician order for a carbohydrate control renal diet, was served chicken piccata containing milk instead of the required baked chicken breast, as specified on her tray ticket. This error was also identified by dietary management staff before the meal was delivered. All three residents were noted to have either intact or moderately impaired cognition and were independent in eating. The deficiencies were observed through direct observation, interview, and record review, and were verified by dietary staff at the time of the 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 ensure a dependent resident had access to a call light. Resident #9 had diagnoses including Parkinson's disease without dyskinesia, cerebral atherosclerosis, and dementia, and the MDS showed a BIMS score of 3 with short- and long-term memory impairment. The resident was dependent on staff for ADLs, and the care plan identified the need to place the call light within reach. A progress note also stated the resident was receiving hospice services and had significant mobility limitations, with dependence on staff for bed mobility, hydration, and feeding. During multiple observations and interviews, Resident #9 was found in bed without the call light within reach. Staff observed the resident unable to reach the call light, which was at times on the floor between two pushed-together beds, wrapped around a bed rail, or placed on a pillow next to the resident's head but still out of reach. The resident was unable to give full responses and mainly answered yes or no, and staff confirmed the resident required assistance for all care needs, including feeding and hydration. Facility policy stated residents should have a method to communicate needs to staff via call light or bell access within reach.

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 accurate advance directive orders and information were maintained throughout the medical record for one resident. Resident #86 was admitted with diagnoses including chronic kidney disease, vascular dementia, and heart failure, and the admission MDS showed the resident was severely cognitively impaired and dependent for activities of daily living. Review of the physician's orders showed CPR would be performed, but the hard chart contained a signed DNRCC-A code status dated [DATE]. During interview, an LPN checked the electronic chart and found the code status listed as CPR, while the hard chart had the signed DNRCC-A order, and the LPN verified the mismatch. The facility's undated Advance Directives policy stated it is the policy to support and facilitate a resident's right to discontinue medical treatment and formulate an advance directive.

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 administer medications as ordered, resulting in two medication errors out of 28 opportunities for a medication error rate of 7.14 percent. This affected one resident out of seven residents observed for medication administration, with the facility census at 91. Resident #10 had diagnoses including type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and chronic kidney disease with dependence on dialysis, and had physician orders for 44 units of Lantus insulin in the morning and 14 units of Fiasp insulin before meals. During observation, an LPN prepared the resident’s insulin by attaching the needle to the Lantus pen, dialing 44 units, then attaching the needle to the Fiasp pen and dialing 14 units. The LPN administered both doses to the resident’s left abdomen without priming either insulin pen. In interview, the LPN stated she did not prime either pen and was not aware that they had to be primed before dialing the dosages. Manufacturer instructions for both insulin pens stated that the pen should be primed before each injection to remove air and ensure proper dosing. The facility policy titled Medication Administration did not address insulin administration via pen.

Penalty

Inspection fine: $10,839

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 and services to prevent a second-degree burn on a resident's right hand. The incident occurred when the resident, who had moderate cognitive impairment and resided in a secured memory care unit, was handed a hot noodle soup by a CNA. The soup had been heated in a microwave by the CNA, who was aware of the facility policy against heating food for residents but had done so regularly for this resident. The resident placed the soup on her walker, and as she stepped back, she lost her balance, fell, and spilled the hot soup onto her hand, resulting in a burn. The resident's medical record indicated she was admitted with diagnoses including unspecified dementia, essential hypertension, and bipolar disorder. A hot liquid evaluation form revealed no severe cognitive impairment or other indicators that would suggest a high risk for accidents. However, the resident's quarterly MDS assessment showed moderate cognitive impairment. During the incident, the resident fell backward, hitting her head and elbow, and sustained a burn on her right hand. The burn was initially red and moist, with optimal granulation color and pain, and later developed into a second-degree burn with a blister. Interviews with staff revealed that the CNA had heated the soup for the resident despite knowing the policy against it. The LPN on duty was more concerned about potential injuries to the resident's head and elbow and did not initially notice the burn on the hand. The facility's policy stated that dietary services should handle reheating food, but in their absence, trained staff could do so, ensuring the food reached a safe temperature and was allowed to cool before serving. The incident highlighted a lapse in following these procedures, leading to the resident's injury.

Removal Plan

• LPN Unit Manager #825 completed a skin assessment on Resident #68 and noted redness to the right hand measuring one cm length by two cm width with no depth. The resident's skin was intact.
• LPN UM #825 completed interviews with unit staff. The staff reported Resident #68 lost her balance due to being distracted and talking to other residents.
• The Interim DON was notified of the incident by LPN UM #825.
• The Interim DON reviewed Resident #68's diet order. The order was for a regular/regular/regular diet with no devices.
• The Interim DON reviewed Resident #68's MDS and Care Plans and no diet modifications were noted.
• The Interim DON completed an audit by assessing all residents in house for potential for risk of injury due to hot food items/liquids. No abnormal findings were identified.
• LPN UM #825 educated all facility staff on Hot Liquids and initiated an in-service.
• NP #815 ordered an ice pack to Resident #68's right hand twice daily as tolerated, and the ice pack was added to the resident order list.
• Review of the Outside Food policy by the Administrator and DON revealed no changes were made.
• NP #815 assessed Resident #68. No swelling to the head was observed. Redness to the right hand was observed with intact skin. Neurological checks were within normal limits and range of motion was within normal limits. A verbal order for an ice pack was received and initiated.
• An interdisciplinary team meeting was held regarding the incident which included the Administrator, Interim DON, LPN UM #832, LPN UM #825, LPN MDS #861, Therapy #602, Licensed Social Worker #603.
• NP #815 followed up with Resident #68 and treatment orders were obtained and implemented.
• NP #815 ordered bacitracin ointment to the right hand twice daily.
• The Interim DON initiated ongoing monitoring audits three times a week for four weeks related to monitoring residents for risk for injury related to hot liquids/foods. The audits were being monitored for compliance by the DON in conjunction with the Administrator daily during the clinical meeting and weekly during the nursing risk meeting.
• LPN UM #825 completed Storage of Resident Food Hot policy in-service with focus on hot liquids/foods to all facility staff.
• Speech Therapy evaluation was completed by Speech Therapist #604 and an order received for ST services three times a week for four weeks for cognitive skills development.
• A skin evaluation was completed on Resident #68's right hand burn. The resident was added to wound care rounds with Wound NP #985 (routine). The burn to the right hand measured one cm length by two cm width with no depth and was red in color with no exudate and no pain.
• The physician orders were to continue the treatment of Bacitracin topically twice daily. The resident's right hand had an intact blister which was noted to the center of the burn.
• A wound assessment was completed with the facility wound nurse LPN UM #825 and Wound NP #985. The burn to the right hand measured at 1.5 cm length by one cm width with 0.1 cm depth. Dryness was noted to the periwound with scant serous exudate. The treatment orders was changed to Silverdene cream 1% twice daily and as needed.
• The treatment order for Resident #68 was changed to Silvadene twice daily and as needed by Wound NP #985.

Penalty

Inspection fine: $10,839

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 comprehensive, individualized, and effective behavioral health interventions for a resident diagnosed with dementia, who had a history of inappropriate sexual behaviors. The resident was admitted with diagnoses including vascular dementia, anxiety disorder, and depression. Despite having intact cognition upon admission, the resident was involved in multiple incidents of inappropriate sexual behavior with other residents, which were not adequately addressed by the facility's care plans. The resident's behavior care plans included interventions such as administering medications, speaking calmly, encouraging expression of feelings, and monitoring behavior episodes. However, these interventions were not updated or revised following an incident on September 29, where the resident was observed engaging in a sexual interaction with another resident. It was not until October 7 that an intervention to monitor for inappropriate sexual behaviors was added, indicating a delay in addressing the resident's behavioral issues. Further incidents occurred, including one on October 23, where the resident was found in bed with another resident, both undressed. Despite the implementation of behavior monitoring orders and a psychiatric assessment after the first incident, the facility did not provide one-to-one monitoring indefinitely, nor was this intervention included in the resident's plan of care. The facility's policies on providing resident-centered care and managing behaviors related to psychiatric diagnoses were not effectively implemented, leading to repeated incidents of inappropriate sexual behavior by 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 ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report, which revealed multiple dates across three fiscal quarters where RN coverage was insufficient. The lack of RN coverage had the potential to affect all 108 residents residing in the facility. Interviews with the facility's administrator and payroll specialist confirmed the absence of RNs on specific dates, indicating a systemic issue in maintaining adequate staffing levels. The deficiency was attributed to challenges in hiring registered nurses, as noted by the administrator who began working at the facility in April 2024. The facility experienced RN shortages on weekends, particularly Saturdays and Sundays, across several months. This issue persisted despite efforts to address staffing concerns, highlighting a significant gap in compliance with regulatory requirements for RN coverage in 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 notify a resident's family of a change in condition and subsequent hospitalization, affecting one resident. The resident, diagnosed with multiple sclerosis, diabetes mellitus II, and depression, required staff assistance with all activities of daily living. On a specific date, the resident exhibited unusual behavior, repeating phrases and appearing lethargic, which was a significant change from her usual alert and oriented state. Despite these changes and the decision to send her to the emergency room for further evaluation, there was no documentation indicating that the resident's family was informed of the situation. The facility's policy on Notification of Change in Condition mandates prompt notification of significant changes to the attending practitioner and the resident's representative, with documentation of the notification, response, and interventions in the medical record. However, an interview with the LPN/Unit Manager confirmed that the family was not notified of the resident's change in status and hospitalization. This oversight was identified during an investigation under a specific complaint number, highlighting non-compliance with the facility's policy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that dependent residents received routine showers, affecting two residents out of three reviewed for activities of daily living (ADLs). Resident #13, who has a history of traumatic brain injury, depression, anxiety disorder, and seizures, was found to have intact cognition but was dependent on staff for ADLs. Despite this, there was no documentation of Resident #13 refusing showers, and interviews revealed that the resident had to repeatedly ask for showers. A Licensed Practical Nurse (LPN) confirmed that only one shower was documented for Resident #13 in the past three months. Similarly, Resident #31, diagnosed with multiple sclerosis, major depressive disorder, and anxiety disorders, was also dependent on staff for all ADLs except eating. The resident reported not receiving showers as scheduled, and the same LPN confirmed that only one shower was documented for Resident #31 in the past three months. The facility's policy on routine care, which includes bathing, was not adhered to, as evidenced by the lack of documentation and resident reports.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to infection control measures during medication administration, affecting one resident. The incident involved a Licensed Practical Nurse (LPN) who, while preparing to administer medication to a resident with a history of traumatic brain injury, epilepsy, and alcohol abuse, directly handled levetiracetam tablets with her bare hands. This action was observed during a morning medication round. The facility's policy on medication administration, dated April 16, 2024, explicitly states that medications should not be touched with bare hands when opening a liquid or dose pack. Despite this policy, the LPN admitted to handling the tablets with her hands because they were large, indicating a deviation from the established protocol.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate assistance during personal care, resulting in a fall with major injury for a resident. The resident, who required two-person assistance for activities of daily living (ADLs), was being cared for by only one staff member at the time of the incident. This lack of sufficient assistance led to the resident rolling out of bed and sustaining a fractured left hip. The incident occurred when the resident was being changed and rolled off the side of the bed while holding onto a grab bar. The resident had a medical history that included anemia, orthostatic hypotension, chronic kidney disease, and other conditions that placed them at risk for falls. The care plan indicated the need for substantial to maximal assistance with ADLs, including two or more helpers for certain tasks. However, during the incident, only one staff member was present, which was insufficient to prevent the fall. The resident was on an air mattress, which was noted as a suspected root cause of the fall, as it may have contributed to the resident's instability. The staff member involved in the incident attempted to prevent the fall but was unable to reach the resident in time. The resident was found on the floor with multiple abrasions and bruising, and x-ray imaging later confirmed a possible fracture of the left hip. The facility's failure to adhere to the care plan's requirement for two-person assistance directly contributed to the resident's fall and subsequent 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

The facility failed to maintain a medication error rate of less than five percent, resulting in a medication error rate of 12.00%. This was due to three observed medication errors out of 25 medication administration opportunities, affecting two residents. For Resident #9, who had diagnoses including dysphagia, hemiplegia, aphasia, anxiety disorder, and reflux disease, the error involved administering a chewable aspirin tablet instead of the prescribed enteric-coated, delayed-release tablet. The LPN confirmed the error during an interview. For Resident #42, who had diagnoses including bipolar disorder, depression, chronic obstructive pulmonary disease, and coronary artery disease, the errors included administering an expired Mucinex 600 mg tablet and an iron tablet without a specified dose. The LPN confirmed she did not check the expiration date and administered the iron tablet because it was the only one available. The Clinical Manager also confirmed that the iron order did not include a dose. The facility's policy on medication administration was reviewed and found to be noncompliant with providing resident-centered care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accurate documentation in the medical record of a resident who experienced an incident during transport. The resident, who had diagnoses including cerebral infarction, stroke, and chronic kidney disease, was moderately cognitively impaired and dependent on staff assistance for transfers. On the day of the incident, the resident was returning from an eye appointment when they began to slide out of their wheelchair in the facility van, complained of chest pain, and felt weak and sick. The transporter called 911, and the resident was taken to the emergency room via EMS. However, the medical record did not include any documentation of this incident. Interviews with the transporter and the Director of Nursing confirmed the occurrence of the incident and the lack of documentation in the resident's medical record. The facility's policy on clinical documentation standards requires timely and accurate documentation of resident information, which was not followed in this case. This deficiency affected the accuracy and completeness of the resident's medical record, as the incident and subsequent hospital transport were not recorded.