Three Rivers 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

The facility failed to timely report an allegation of abuse to the state agency involving a resident with right-sided hemiplegia and hemiparesis following a cerebral infarction, who was cognitively intact and required staff assistance with activities of daily living. The resident reported that staff had been rough with her during a transfer, resulting in four discolored markings on her left forearm. She stated that she asked the CNA to stop because she was being hurt, and subsequently reported the incident to staff. Multiple staff members, including a CNA and LPN, were informed of the resident's complaint and observed the markings, but the source of the injury was unclear at the time. Despite the resident's report and visible injuries, the allegation of abuse was not reported to the state agency until several days later, after the surveyor's inquiry. The Administrator and nursing staff were aware of the resident's concerns and the facility's policy required reporting of injuries of unknown origin and alleged mistreatment within 24 hours. However, the required notification to the state agency was delayed, and the Director of Nursing was not made aware of the allegation until it was brought up by the surveyor.

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 promptly initiate an investigation into an allegation of abuse and did not take immediate steps to protect residents during the investigation process. A resident with right-sided hemiplegia and hemiparesis, who was cognitively intact and required staff assistance with activities of daily living, reported that staff had been rough with her during a transfer, resulting in discolored markings on her left forearm. The resident stated she reported the incident to staff the following day. Multiple staff members, including CNAs, LPNs, and RNs, were made aware of the resident's complaint and observed the markings, but the facility did not report the allegation to the state agency or initiate an investigation until several days later, after being prompted by a surveyor. Despite the facility's policy requiring timely investigation and reporting of injuries of unknown origin and alleged mistreatment, the alleged perpetrator was not suspended from resident care until after the survey began. The Director of Nursing was not aware of the allegation until it was brought to administration by the surveyor. The delay in reporting and failure to protect residents during the investigation were confirmed by interviews with staff and administration, and the facility did not follow its own policy for handling such allegations.

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 storage and handling of food, which could potentially lead to the spread of foodborne illness affecting 108 of 111 residents. Observations revealed multiple issues in the dry storage area, including undated and improperly wrapped food items such as baking powder, marshmallows, chocolate chips, egg noodles, and cake mix. Additionally, a jug of oil was stored directly on the floor, and bananas were left to attract gnats. The facility's walk-in refrigerator contained undated and unlabeled items like hotdogs, hamburgers, and parmesan cheese, along with outdated American cheese slices. Further observations highlighted improper practices during food preparation and serving. Dietary Aide #404 was seen incorrectly dating cereal containers, while Dietary Aide #407 handled food with gloved hands that had touched oven handles, and later with bare hands, both actions violating sanitary protocols. Additionally, lunch trays were loaded onto carts with sticky substances on them, indicating a lack of cleanliness in food service equipment. The facility's unit refrigerators also contained improperly stored items, such as outdated half and half, undated orange juice, pink lemonade, shredded cheese, and freezer-burnt popsicles. The presence of sticky substances in the refrigerator doors further demonstrated inadequate maintenance of food storage areas. These findings were confirmed through interviews with the Account Manager and Director of Nursing, who acknowledged the discrepancies with the facility's policies on food storage and cleanliness.

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 honor the dining preferences of a resident, leading to a deficiency in accommodating resident choices. Resident #19, who has diagnoses including type two diabetes mellitus, hypertension, and depression, was on a consistent carbohydrate diet. On the day of the incident, the facility's lunch menu included homestyle meatloaf with a catsup glaze for residents on this diet. However, the lunch meal ticket for Resident #19 incorrectly listed a rotisserie chicken thigh as the entree. When the resident expressed dissatisfaction with the chicken and requested meatloaf, the dietary aide incorrectly informed her that her diet did not allow for meatloaf. Despite the resident's clear preference and the facility's policy on respecting resident choices, the dietary aide and an LPN both denied the resident's request based on a misunderstanding of the diet restrictions. The Director of Nursing later confirmed that residents have the right to choose their meals, and the Director of Clinical Operation acknowledged that meatloaf was indeed permitted on the consistent carbohydrate diet. This incident highlights a failure in communication and understanding of dietary guidelines among staff, resulting in the resident's dining preferences not being honored.

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 of medication administration in the electronic medical record for a resident, leading to a deficiency. Resident #99, who had diagnoses including acute and chronic respiratory failure, obstructive sleep apnea, chronic atrial fibrillation, chronic obstructive pulmonary disease, hypertension, and heart failure, was affected. The resident had intact cognition and required assistance with activities of daily living. Physician's orders for the resident included metoprolol tartrate with parameters to hold the medication for a systolic blood pressure less than 110, and midodrine with parameters to hold for a systolic blood pressure greater than 110. However, the Medication Administration Record (MAR) showed that metoprolol was administered when the resident's systolic blood pressure was below the specified threshold, and midodrine was given when the blood pressure was above the specified threshold. Interviews with the resident and staff confirmed the inappropriate documentation and administration of these medications. The Regional Director of Clinical Operations and nursing staff acknowledged the errors in documentation, noting that both medications were documented as administered simultaneously on certain dates, contrary to physician orders. The facility's policy on medication administration emphasized that medications should be administered as prescribed, and any deviations should be documented, which was not adhered to in this case.

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 properly transfer a resident using a mechanical lift and the assistance of two staff members as outlined in the resident's care plan. On the day of the incident, a Certified Nursing Assistant (CNA) attempted to perform a hands-on pivot transfer of the resident from the bed to a wheelchair without the assistance of another staff member or the use of a gait belt. During the transfer, the resident fell to the floor, resulting in a left femur fracture. This incident affected one of the three residents reviewed for falls. The resident involved had a medical history that included cerebral infarction, chronic respiratory failure, morbid obesity, cardiac murmur, and scoliosis. The Minimum Data Set (MDS) assessment indicated that the resident had mild cognitive deficits and required extensive assistance with activities of daily living. The care plan specified that the resident was totally dependent on staff for transfers and required the use of a mechanical lift with two-person support due to conditions such as hemiplegia and obesity. Interviews and written statements revealed that the CNA was not assigned to the resident on the day of the incident and was unaware of the resident's transfer requirements. The CNA had observed other aides using a single-person pivot transfer for the resident and did not consult the care plan or ask for guidance. The CNA attempted the transfer alone, and when the resident's legs gave out, the CNA lowered the resident to the floor. The facility's policy emphasized the importance of following the care plan to ensure resident safety, which was not adhered to in this case.

Removal Plan

• LPN #42 assessed Resident #11 with findings of left leg pain.
• LPN #22 notified NP #41 of Resident #11's leg pain and gave an order to send the resident to the hospital via nine-one-one (911) emergency transport.
• UM #26 notified the Administrator of Resident #11's fall.
• The hospital called and reported to facility nurse, LPN #22, that Resident #11 has sustained a fracture to the distal end of left femur.
• The Administrator notified Resident #11's guardian of the fracture to the resident's left femur.
• The Director of Nursing (DON) conducted an audit for all residents that required two staff members' assistance regarding care concerns related to mechanical lifts.
• UM #26 initiated assessments of residents that required two staff assist including mechanical lifts for transfers to ensure no injuries occurred during transfers.
• The Administrator and the DON provided one-on-one education to CNA #35 on the Kardex, following the resident's plan of care, and mechanical lift transfers.
• Therapy Director (TD) #51 completed a transfer competency with CNA #35.
• The DON completed education with all licensed nurses, therapists, and aides on the Kardex, following the resident's plan of care, and mechanical lift transfers.
• Resident #11 returned to the facility with an order for a follow-up appointment with an orthopedic surgeon. Registered Nurse (RN) #53 completed a head-to-toe assessment and pain assessment for Resident #11.
• RN #53 notified NP #41 of Resident #11's new diagnoses of closed fracture of distal end of left femur.
• The Quality Assurance and Performance Improvement (QAPI) Committee met to review the incident involving Resident #11 with NP #41 present. Resident #11's care plan was updated to include pain management, ADLs, and falls. The DON was to initiate ongoing monitoring.
• The DON notified Resident #11's guardian of the plan of care updates and the resident's guardian was in agreement.
• MDS Nurse #54 completed a review and updated all care plans for residents identified as requiring two staff assist and/or mechanical lift for transfers.
• The DON/designee to conduct audits of transfers to be completed three times weekly for four weeks and then weekly for four weeks to ensure transfers were occurring as indicated on the resident care plan/Kardex.
• Review of facility audits of transfers completed revealed there were no further identified concerns.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an adequate supply of food during meal service and did not adhere to the facility menu, affecting four residents. Observations revealed that during meal service, certain food items listed on meal tickets, such as brownies and chocolate milk, were missing from the trays of two residents. Interviews with staff confirmed that missing food items on trays were a frequent issue, and the facility lacked a kitchen manager to oversee meal preparations. Additionally, the kitchen ran out of certain food items, such as cabbage and chicken breast, during meal service, leading to substitutions that did not align with residents' dietary preferences or needs. Residents with specific dietary dislikes, such as pork, were not provided with appropriate alternatives. For instance, one resident who disliked pork was given a pork chop as a replacement for a chicken breast, while another resident received a cheeseburger instead of the requested chicken breast. Interviews with the affected residents confirmed dissatisfaction with the meal substitutions and frequent non-compliance with their menu choices, leading to instances where residents did not consume the meals provided. This deficiency was investigated under two complaint numbers, indicating ongoing issues with meal service compliance.

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 control practices during tracheostomy care for Resident #17. The resident, who was admitted with diagnoses including centrilobular emphysema, acute and chronic respiratory failure with hypoxia, COPD, and atrial fibrillation, had intact cognition and required setup assistance with ADLs. During an observation of tracheostomy care, an LPN broke the sterile field by touching sterile gauze with clean gloves instead of sterile gloves. The LPN then used the contaminated gauze to clean the resident's tracheostomy tube, which was confirmed during an interview with the LPN. The facility's policy required maintaining an aseptic environment to reduce pathogen transmission during tracheostomy 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 serve palatable and appetizing food to its residents, as evidenced by the preparation and serving of a lunch entree that did not adhere to the facility's recipe. On the specified date, the lunch menu included Dijon pork loin, which was observed to be prepared incorrectly. A staff member identified as [NAME] #216 deviated from the established recipe by creating a thick, yellow gravy using Dijon mustard, brown sugar, salt, and pepper, instead of following the recipe that called for the pork loin to be baked in a mixture of red peppers, green peppers, mustard, vinegar, salt, and cornstarch. This deviation resulted in the gravy being described as thick, pungent, and unpalatable. Multiple residents expressed dissatisfaction with the meal, describing the mustard topping as unpalatable and inedible. Additionally, the test tray observation revealed that the potatoes served alongside the pork loin were undercooked and hard. Interviews with residents and staff confirmed the failure to follow the recipe, and the staff member admitted to not tasting the gravy before serving it. The facility's administrator also confirmed the deviation from the recipe, which contributed to the deficiency identified in the complaint investigation.

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 visual privacy for a resident during incontinence care, as observed by surveyors. Resident #37, who has diagnoses including paraplegia, spinal fusion, depression, and a history of falling, was admitted on an unspecified date and requires extensive assistance with activities of daily living. During an observation of incontinence care provided by two State tested Nursing Assistants (STNAs), it was noted that the blinds were not drawn, allowing two other residents to see Resident #37 through the window. STNA #251 acknowledged the oversight, admitting she considered closing the blinds during the care but did not do so until after the care was completed. The facility's policy on Resident Rights, dated 04/18/24, states that residents have the right to visual privacy during treatments, medication administration, or care. This policy was not adhered to in the case of Resident #37, leading to a breach of privacy during the provision of incontinence 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 that expired medications were discarded, as evidenced by an incident involving a resident who was administered an expired multivitamin with minerals. The resident, who had diagnoses including emphysema, diabetes, anxiety, depression, schizoaffective disorder, and insomnia, was admitted on an unspecified date. The resident had a physician's order dated December 20, 2023, for a daily multivitamin with minerals. During a medication administration observation on August 12, 2024, it was noted that the multivitamin was not initially available, prompting the Central Supply Coordinator to provide a bottle with an expiration date of June 2024. The Licensed Practical Nurse confirmed administering the expired multivitamin to the resident at approximately 10:30 A.M. on the same day. The facility's policy on medication storage, dated August 2023, mandates the removal and destruction of expired medications, which was not adhered to in this instance. This oversight affected one of the two residents identified by the facility as having orders for multivitamins with minerals, highlighting a lapse in the facility's medication management practices.

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 personal hygiene was adequately provided for residents, affecting three individuals reviewed for personal hygiene. Resident #72, who had activities of daily living (ADL) deficits and required assistance, was observed on multiple occasions with long, jagged nails that had a yellow-brownish substance underneath. This was confirmed by a Licensed Practical Nurse (LPN) during an interview. Similarly, Resident #89 was observed with long, jagged, and dirty nails, which the LPN also confirmed needed trimming and cleaning. Resident #102, who also had ADL deficits and required assistance, was observed during a dressing change with yellowed feet and scaly areas between the toes, indicating they had not been washed recently. This observation was confirmed by a State Tested Nurse Aide (STNA) and a Registered Nurse (RN). The facility's policy on skin care, which includes daily hand washing and nail care, was not adhered to, leading to this deficiency. This non-compliance was investigated under specific complaint numbers.

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 the correct food portions and liquids as planned by a Registered Dietitian, affecting nine residents on a puree diet. Record reviews revealed that these residents had a physician order for a puree diet, which specified the exact portions of puree oatmeal, sausage, and bread to be served. However, during an observation, it was noted that a staff member served incorrect portions, providing too little oatmeal and too much bread and sausage. The staff member admitted to not always following the spreadsheet for puree portions, which could impact residents on specialty ordered diets. Additionally, the facility failed to serve the required beverages to a resident at risk for nutrition and hydration status. The care plan for this resident included serving the diet as ordered, which specified the provision of milk, tea, or coffee. Observations on two consecutive days showed that the resident was not served any of these beverages. The dietician confirmed that the resident's meal ticket included these beverages, but they were not provided. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's policy to meet residents' nutritional 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 prepare fortified foods according to the recipe, affecting six residents who were ordered fortified meals. The fortified oatmeal recipe included oatmeal, whole milk, powdered milk, sugar, and margarine. During an interview, a staff member stated she prepares fortified oatmeal with powdered milk and butter but does not use a recipe because she has worked at the facility for a long time. She also mentioned difficulty in deciphering the recipe, which was designed for 100 portions, while only six residents required fortified meals. The facility's policy on the Fortified Food Program and Food Quality and Palatability mandates preparing food to conserve nutritive value and following fortified food recipes as a therapeutic intervention.

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 thickened liquids were served as ordered for four residents on specialized diets. Resident #72, who was at risk for nutrition and hydration issues, was observed receiving orange juice that was not at the prescribed honey-thick consistency. The dietician confirmed that the meal ticket specified honey-thick liquids, but the orange juice was not prepared accordingly. The facility's policy on food quality, which mandates serving food to meet residents' needs, was not adhered to in this instance. Further observations revealed that State Tested Nurse Aides (STNAs) were preparing thickened liquids without proper instructions or measuring devices, leading to inconsistencies in the thickness of the liquids served. Residents #79, #89, and #98 received liquids that did not match their prescribed consistencies, with some receiving honey-thick liquids instead of nectar-thick, and vice versa. Interviews with the STNAs indicated a lack of knowledge and resources to accurately prepare the thickened liquids, resulting in residents receiving inappropriate consistencies. Resident #89 reported not always receiving thickened liquids and experiencing coughing when the liquids were not prepared correctly.

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, affecting five residents. During an observation, a State tested Nursing Aide (STNA) did not remove gloves or perform hand hygiene after checking a resident for incontinence, instead leaving the room with gloves on and removing them in the hallway. The STNA admitted to not knowing the correct procedure. Additionally, a Registered Nurse (RN) wore gloves while preparing and administering medications, touching various surfaces and items without changing gloves, which she acknowledged was improper. Further observations revealed that staff did not adhere to Enhanced Barrier Precautions (EBP) for a resident with a Multi-drug Resistant Organism (MDRO), as a nurse and an STNA failed to wear the required personal protective equipment during wound care. In the dining room, two STNAs handled food with bare hands, despite acknowledging that gloves should have been used. The facility's policies on infection prevention, glove use, and EBP were reviewed, highlighting the need for adherence to these protocols to reduce infection risks.

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 the Power of Attorney (POA) for a resident who experienced a change in condition, which is a requirement according to their policy. The resident, who was severely cognitively impaired and required substantial assistance for daily activities, was admitted with multiple medical diagnoses including non-traumatic chronic subdural hemorrhage, hypertension, and non-Alzheimer's dementia. On a specific date, the resident slept all day, refused food and medication, and was subsequently sent to the hospital by an LPN due to a change in condition. However, there was no documentation indicating that the resident's POA was informed of the hospitalization. During an interview, the Director of Nursing (DON) confirmed that the LPN responsible was on vacation and could not be contacted. The facility's policy mandates that the resident, their physician, and their representative or POA must be informed of significant changes in the resident's condition. This deficiency was identified during an investigation under a specific complaint number, highlighting a lapse in the facility's adherence to its notification 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 privacy for a resident during care, affecting one resident reviewed for privacy. The resident, who was moderately cognitively impaired and required maximum assistance for toileting and bed mobility, was observed with his door open, allowing a full view from the hall. The resident was in bed without a blanket or sheets, and the privacy curtain was not drawn while his roommate was present. A State tested Nursing Aide (STNA) was checking the resident's brief for wetness without providing privacy. The STNA confirmed during an interview that she did not provide privacy and acknowledged that she should have done so. The resident expressed a desire for privacy during care. The facility's policy on Resident Rights, which was undated, stated that residents should have their privacy respected during treatment, medication, or care, including having the door closed or privacy curtain drawn. This deficiency was discovered incidentally during a complaint investigation.

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 homelike environment for its residents, as evidenced by the conditions observed in the bathrooms of two residents. Resident #2 reported that housekeeping had not cleaned the bathroom, which contained bloody urine in the toilet and blood drips down the side of the toilet to the floor, accompanied by a strong smell of urine. Despite multiple observations over two days, the bathroom remained uncleaned, with the blood and odor persisting. A housekeeper was observed dropping a glove on the floor and failing to clean the blood, later stating that cleaning blood was the responsibility of a State tested Nurse Aide (STNA). Similarly, Resident #85's bathroom emitted a strong odor of urine, which was confirmed by the resident and observed multiple times over two days. The resident stated that the housekeepers did not clean the bathroom, and an STNA confirmed the persistent odor, noting that urine had seeped into the floor tiles. These observations were part of a complaint investigation, indicating non-compliance with maintaining a safe, clean, and homelike environment for 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 ensure proper wound care for a resident with a pressure ulcer. The resident, who had a medical history including neurogenic bladder, paraplegia, and depression, was admitted with a stage pressure ulcer on the sacrum. The care plan included interventions to prevent skin breakdown due to incontinence and specific physician orders for wound care, which included cleansing the wound with wound cleanser or saline and applying silver alginate and zinc oxide. During an observation, a registered nurse did not clean the zinc oxide residue from around the wound before applying a new dressing, which was confirmed by the nurse during an interview. The facility's wound care policy required cleansing the area with wound cleanser or normal saline, which was not followed in this instance.