Johns Island Post Acute

Penalty

No penalty information released

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

Summary

The facility failed to protect one resident from physical abuse by another resident. Video footage showed one resident in a wheelchair rolling behind another resident, placing an arm around the resident’s neck, and choking him while the resident tried to pull the arm away. A CNA witnessed the incident and separated the residents. The abused resident had diagnoses including COPD, atherosclerotic heart disease, dementia, epilepsy, osteoporosis with a current pathological fracture, and needed assistance with personal care; his MDS showed severe cognitive impairment with a BIMS score of 5 out of 15. The resident who initiated the assault had diagnoses including hereditary and idiopathic neuropathy, dementia with behavioral disturbance, insomnia, and hypertensive chronic kidney disease; his MDS showed moderate cognitive impairment with a BIMS score of 9 out of 15. Following the altercation, the facility failed to provide care and services to the resident who had been choked. The resident was placed in his room after the incident, but the record and video review showed no staff entered the room for hours afterward. The facility did not assess the resident, did not complete a body audit, and did not follow up with him after the physical altercation. The resident was later found unresponsive and pulseless in his room, and EMS and the coroner responded. A later progress note documented that the resident was found pulseless after being unresponsive to verbal and physical stimuli and was pronounced expired. Interviews confirmed the lack of assessment and follow-up. The Administrator stated the resident was not assessed, and the DON stated a body audit was conducted only after the resident expired and that she was not aware of any assessment or body audit after the altercation. The RDCS stated body audits and assessments should have been done to assess for injuries. CNA1 stated the resident appeared to have no changes in breathing after the incident and that the nurse did not do any vitals. The report also documented that the facility identified the event as abuse and neglect and that the resident-to-resident altercation involved choking and failure to assess the resident afterward.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate care for a resident with severe cognitive impairment and multiple respiratory and cardiac diagnoses after the resident was choked by another resident. The resident had diagnoses including COPD, dementia, epilepsy, and heart disease, and the record showed physician orders to monitor for shortness of breath and keep the head of bed elevated due to shortness of breath when lying flat. The MAR showed the head-of-bed order was documented as administered on the night shift, but a CNA later stated the head of bed was not elevated when she entered the room in the morning. The albuterol order was also left blank for several days. The resident’s progress note documented that a CNA witnessed another resident roll behind him and begin choking him, with the CNA having to remove the other resident’s hand from around his neck. Video footage showed the other resident placing an arm around the resident’s neck and continuing to choke him until the CNA intervened. After the residents were separated, the resident was moved to a desk area and later rolled to his room. The record and interviews showed that staff did not assess the resident after the altercation. The Administrator stated the resident was not assessed, the DON stated a body audit was conducted only after the resident expired and was not aware of any assessment after the altercation, and the RDCS stated body audits and assessments should have been done. The facility also failed to provide wound care according to professional standards of practice for another resident with chronic pressure ulcers. The resident had stage 3 pressure ulcers of both buttocks and a stage 4 sacral pressure ulcer, and physician orders directed wound care with Dakins, collagen, and calcium alginate every other day and as needed. The orders were entered as daily dressing changes instead of every other day. The resident stated that the wound care nurse refused to change her dressings and told her to do it herself, and that she frequently changed her own wound dressings using Dakins solution kept at the bedside. Staff interviews showed the wound care nurse and other nurses were aware the resident sometimes did her own wound care, but the resident’s bedside supplies and refusal of care were not consistently documented in the record.

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 nurses and nurse aides, including agency staff, received orientation, training, and in-services on facility policies and procedures before working with residents. Review of the facility’s policy titled, In-Service Training, All Staff, showed that all staff are required to participate in initial orientation and annual in-service training, and that training requirements are to be met prior to staff providing services to residents. Review of the staffing policy also showed that licensed nurses and certified nursing assistants are to be available 24 hours a day, 7 days a week, and that a licensed nurse is designated as a charge nurse on each shift. During the survey, agency staff were observed working with residents without the proper documentation of orientation or training. LPN1 and LPN3 were seen interacting with residents in video footage, and LPN5 stated it was her first day at the facility and that she had not been given any training, orientation, or in-services, only a clipboard and login. CNA4 stated she was an agency CNA, had not received training, orientation, or in-services upon hire, and had not received in-services related to the ongoing survey findings. The Administrator stated agency staff are supposed to complete required orientation and training prior to starting, but the facility did not have sign-in sheets to prove completion and used a lot of agency staff. At the end of the survey, documentation of orientation completion or training and in-services for LPN1 and LPN3 had still not been provided.

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 self-administration of medications was clinically appropriate for a resident who had two medications, a nasal spray and an albuterol inhaler, at the bedside without an assessment or authorization for self-administration. The facility policy stated that residents may self-administer medications only if the interdisciplinary team determines it is clinically appropriate and safe, and that this decision must be documented in the medical record and care plan. In this case, the resident had diagnoses including paraplegia, muscle weakness, COPD, interstitial pulmonary disease, asthma, sleep apnea, sleep deprivation, cognitive communication deficit, and a need for assistance with personal care. The resident's MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness, and also noted shortness of breath when lying flat. The resident's care plan addressed respiratory risk and included administering medications as ordered, but it did not include self-administration of medications. Physician orders included albuterol sulfate inhalation aerosol and fluticasone propionate nasal suspension, with no order for self-administration. During observation, a Ziploc bag containing one fluticasone nasal spray and one albuterol inhaler was found on the resident's bedside dresser. The resident stated she administered the medications herself because the facility did not provide them and said she had not received education to self-administer. An LPN confirmed the resident administered her own nasal spray and stated there was no order allowing self-administration. The DON stated the resident should have an order to self-administer medications and confirmed that the nasal spray and inhaler were at the bedside.

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 report two incidents of resident-to-resident physical abuse to the State Agency in a timely manner. The facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, stated that allegations must be investigated and reported within federal timeframes, but the incidents reviewed were not reported within those required timeframes. In the first incident, R4, who had diagnoses including hereditary and idiopathic neuropathy, moderate dementia with behavioral disturbance, insomnia, and hypertensive chronic kidney disease, was observed on video on 04/24/26 at approximately 4:43 AM rolling behind R5 and placing an arm around R5's neck. R5, who had diagnoses including osteoporosis with pathological fracture, COPD, atherosclerotic heart disease, dementia, epilepsy, spondylosis, and need for assistance with personal care, was unable to get R4 to release the hold until CNA1 intervened. The facility's progress notes documented the choking incident, and the reportable incident form listed the event as a 2-hour reportable for physical abuse with the reportable incident time documented as 8:01 AM. During interviews, the RDCS, DON, and Administrator each described delays and confusion about who was responsible for making the report. In the second incident, R6 and R7 were involved in a physical abuse event in the dining room after lunch, when R7 rolled up to R6, used bad words, and kicked R6 in the shin. The EMR contained notes indicating social services was notified and that separation occurred, while staff interviews placed the incident around 1:00 PM after lunch. A 2-hour report and five-day follow-up were submitted to the State Agency, but the follow-up documentation and staff statements showed the incident was reported late, with the DON and RDCS acknowledging that reporting was delayed and dependent on nursing notes and the medical record.

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 thoroughly investigate an incident of resident-to-resident physical abuse involving two residents. Review of the facility policy stated that the abuse prevention program includes identifying and investigating all possible incidents of abuse, neglect, and protecting residents from further harm during investigations. Video footage showed one resident rolling behind another resident in the common area, placing an arm around the other resident's neck, and continuing to choke him until a CNA intervened and separated them. The second resident was then moved away from the area by the CNA. The reportable folder contained a typed witness statement signed by the CNA and the Operations Manager, along with other witness statements that said they did not witness the incident. The typed statement was produced while staff watched the video and asked the CNA questions about what she saw. During interviews, the DON stated the CNA was the only witness to the actual incident and that no other residents were interviewed because there were no other residents around when the footage was reviewed. The Administrator stated there were no follow-ups with other residents on the unit because it was a resident-to-resident incident, and the Operations Manager stated the statement was produced after staff called the CNA back to discuss what she witnessed.

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 create a comprehensive person-centered care plan for a resident with dementia and moderate cognitive impairment who had documented aggressive behaviors. R4 was admitted with diagnoses including hereditary and idiopathic neuropathy, dementia with other behavioral disturbance, insomnia, and hypertensive chronic kidney disease. His quarterly MDS showed a BIMS score of 9 out of 15, and the record included notes of behavioral issues such as arguing with a roommate, making threats, and staff separating the residents after conflict. R4’s care plan before the resident-to-resident physical abuse on 04/24/26 addressed insomnia, antidepressant medication, and psychosocial well-being related to dementia, with interventions such as observing for confusion, agitation, and increased agitation. However, the care plan did not include a targeted, individualized plan for his aggressive behaviors before the incident in which he rolled his wheelchair behind another resident and began choking him. The behavior care plan was initiated only after that event and described behavioral symptoms such as grabbing others and invasion of privacy due to dementia. Staff interviews reflected that R4’s aggressive behavior was known on the unit. CNAs described him as verbally and physically aggressive, including cursing at staff, pushing a bedside table into a CNA’s legs, and using a shoe helper to strike a former roommate. The LMSW and SWA stated they were not aware of his behaviors and had not observed them. The MDS Coordinator stated she did not review every care plan and assumed the psychosocial care plan covered a broad spectrum, while the DON stated she did not know why R4 was not care planned for behaviors and said there had to be a disconnect.

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 comprehensive care plan for a resident admitted with lupus, cognitive communication defect, paraplegia, and a need for assistance with personal care was not updated to reflect changes in condition and care needs. The resident’s admission MDS showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact, and the record showed the resident received IV medications and had IV access while in the facility. The care plan addressed vascular access and identified the resident as at risk for complications related to a PICC line for long-term IV antibiotic therapy for osteomyelitis, but it was not revised when the PICC line was later removed. The record also did not include interventions related to self-administration of medications, despite the resident being cognitively intact and staff acknowledging that the resident self-administered a nasal spray. A progress note and consultation report documented that the PICC line was discontinued and removed, and during interviews an LPN stated the resident still was care planned for having a PICC line and was unaware of the facility policy on residents administering their own medications. The DON confirmed the resident no longer had a PICC line and stated the MDS nurse was responsible for managing care plans.

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 transcription of physician orders for one resident with multiple pressure ulcers. The resident was admitted with diagnoses including bacteremia, sepsis, osteomyelitis of the vertebra, and stage 3 pressure ulcers of the right and left buttocks and a stage 4 pressure ulcer of the sacral region. The resident’s MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. The care plan identified the resident as having a pressure ulcer to the coccyx and left and right buttocks, with interventions to administer treatment as ordered. A consultation report from the wound provider instructed local wound care with Dakins, collagen, and calcium alginate, to be exchanged every other day or as needed. However, the physician’s orders entered into the record for the coccyx, left buttocks, and right buttocks were documented as daily dressing changes instead of every other day. During observation and interview, the WCN reviewed the wound care orders, confirmed they were entered for daily changes, and then reviewed the consultation report, stating it had not been reviewed before. The WCN confirmed the orders should have been entered every other day. The DON stated her expectation was for the WCN to follow physician orders and reviewed both the consultation report and physician’s order.

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

Provide and implement an infection prevention and control program was deficient during wound care for Resident R, who was admitted with lupus, bacteremia, sepsis, osteomyelitis of the vertebra and sacral/sacrococcygeal region, immunodeficiency, stage 3 pressure ulcers of the right and left buttocks, a stage 4 pressure ulcer of the sacral region, a colostomy, and paraplegia. The resident’s MDS indicated a BIMS score of 15 out of 15, and the care plan identified pressure ulcers to the coccyx and both buttocks with interventions including treatment as ordered and use of EBP during high-contact care activities. During an observation of wound care, the Wound Care Nurse and her helper donned gowns in the hallway before entering the room. The Wound Care Nurse washed her hands, donned gloves, and used already opened gauze from a plastic cup labeled Dakins to clean the wound bed. She discarded gauze into a plastic trash bag attached to the bedside table, then grabbed another gauze from the cup without completing hand hygiene or changing gloves and continued cleaning the wound. She later removed her gloves, washed her hands, and donned a new pair of gloves. The Wound Care Nurse was also observed opening the trash bag multiple times and moving the bedside around before using gauze to cover and dress the wound, and an air conditioner turned on and blew on the bedside table with the supplies during the dressing change. This process was observed for all three of the resident’s dressings and confirmed by the Wound Care Nurse.

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 Resident 137 was discharged to a safe environment. The resident was cognitively intact with a BIMS score of 15 out of 15 and had diagnoses including third-degree burns to the right hand, buttocks, abdominal wall, and posterior thighs, chronic pain, and need for assistance with personal care. The resident had been admitted after a burn injury and required ongoing wound care and hemodialysis. Facility documentation showed discharge planning discussions that identified the resident’s home environment as a concern, including that he lived alone and that there were questions about support after discharge. A social services note documented that the resident stated his mother’s house did not have electricity and had been without electricity for about five years. Despite this information, the resident was discharged home with discharge paperwork listing DME, community support services, and home health services, and the discharge summary stated he was going home because his health had improved sufficiently. After discharge, the resident reported that he had not received his wheelchair, remaining medications, wound care supplies, or home health services. He stated that the home lacked running water and electricity and that he had been having falls and pain with his wounds and scars. The local Ombudsman also reported concerns that the resident had been discharged to an unsafe environment without basic utilities, and the facility’s Administrator and DON stated they had not been updated by social services about the home’s condition and lack of adequate utilities.

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 medications and biologicals were properly labeled, stored, and maintained in accordance with its policy and accepted professional principles. Review of the facility policy titled, "Storage of Medications," last revised November 2020, stated that drug containers with missing, incomplete, improper, or incorrect labels are to be returned to the pharmacy for proper labeling before storing, and that discontinued, outdated, or deteriorated drugs or biologicals are to be returned to the dispensing pharmacy or destroyed. Observations of medication storage areas on 02/23/26 and 02/24/26 identified expired and improperly stored items in four of six medication carts and one wound care supply closet. On the Angel Oak Unit, Medication Cart B contained expired Glucagon Injection 1 mg/2 ml. On the [NAME] Unit, Medication Cart A contained an expired COVID-19 antigen testing kit and an amber/orange pill bottle with mixed pills labeled Rosuvastatin 10 mg tabs. The wound care supply closet contained multiple expired items, including Packing Strip Iodoform, Cotton-Tipped Applicators, Lemon Glycerin Swab sticks, Skintegrity Eco Paraben-Free Hydrogel with an opened package and no tamper-evident seal intact despite single-patient use labeling, Lidocaine 4% Topical Anesthetic Cream, Povidone-Iodine Prep Pads, and an expired COVID-19 AccessBio Test. On 02/24/26, additional expired items were found on the [NAME] Unit, including Ondansetron 4 mg tablets labeled discard after January 27, 2026, and on the Angel Oak Unit, Povidone-Iodine Prep Pads 10% with 37 remaining in the box. The DON observed and confirmed the expired medications and biologicals during the survey.

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 necessary care and services to prevent a sheering injury for a resident admitted with diagnoses including aftercare following joint replacement surgery, presence of a right artificial hip, systemic lupus erythematosus, Sjogren syndrome, mild intellectual disabilities, depression, and urinary tract infection. The resident’s MDS indicated dependence with toileting hygiene and personal hygiene, and the baseline care plan identified incontinence with the need for staff assistance and pads and briefs. The resident told staff that diapers were too tight and caused a sore area, and the resident’s POA reported the resident had been forced to wear a brief that was too small for three to four days after admission, resulting in an open, bleeding area in the right groin. An observation showed an open area in the right groin approximately three inches long with bright red drainage on the brief, and the resident stated the area was painful. The wound nurse stated the injury was likely from sheering caused by a diaper that was too tight and that residents are measured by girth to determine brief sizing, though she did not know if this resident had been measured. The UM stated the resident had not yet been measured, while the DON stated staff measure residents’ girth on admission and also said the resident had been admitted with an agency CNA and had complained that the briefs were too tight. The DON later stated she was unable to locate a policy regarding measuring residents for appropriate brief size, and also stated there was not a generalized Quality of Care 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 follow its infection control policy for hand hygiene and glove use during resident care for a resident with an indwelling catheter. The policy stated that hand hygiene is required immediately before touching a resident, before performing an aseptic task, after touching a resident, after touching the resident’s environment, and immediately after glove removal. It also identified non-sterile gloves as necessary equipment and supplies for hand hygiene. The resident had diagnoses including urinary retention, non-Alzheimer’s dementia, and vesicoureteral reflux with reflux nephropathy and bilateral hydroureter. Her quarterly MDS showed a BIMS score of 04 out of 15, indicating severe cognitive impairment, and it documented an indwelling catheter. Her care plan directed catheter care every shift, and physician orders required enhanced barrier precautions during high-contact resident care activities because of the Foley catheter. During observation, RN1 was seen touching the resident’s door and moving the bedside table with gloved hands before helping the resident with the same gloves. The Infection Control Preventionist stated staff are not allowed to put on gloves in the hallway, that gloves must be applied inside the resident’s room after hand hygiene, and that gloves applied in the hallway are considered contaminated. The DON stated staff are expected to follow infection control protocols, and that infections can occur during catheter bag changes if proper procedures are not followed.

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, identified as R1, was free from neglect, which resulted in the resident's death. R1, who had a history of adult failure to thrive, protein calorie malnutrition, dementia, and dysphagia, was on a therapeutic diet requiring pureed food and thickened liquids. On the day of the incident, R1 was left unattended in a common area where a meal tray with regular food was left on a dining room table. R1, who was known to wander and had moderate cognitive impairment, consumed food from the tray that was not suitable for his dietary needs. The staff, including two CNAs and an LPN, were at the nurse's station and did not notice R1 eating the food or later slumping over on the couch. The LPN discovered R1 slumped over with a bluish face when she returned from the nourishment kitchen with R1's bolus tube feeding. Despite attempts to perform the Heimlich maneuver and suctioning, R1 was pronounced dead by EMS shortly after. The facility's failure to monitor R1 and ensure he received the appropriate diet directly contributed to the incident. The facility's policy on recognizing signs and symptoms of abuse and neglect was not adhered to, as R1 was left unattended and consumed food that was not part of his prescribed diet. The incident highlights a significant lapse in supervision and adherence to dietary orders, which are critical for residents with specific dietary needs due to medical conditions like dysphagia. The staff's inaction in monitoring R1 and ensuring the removal of inappropriate food trays led to the tragic outcome.

Removal Plan

• Statements were written by all staff on duty.
• Nurse on duty was interviewed via phone by RDCS and DON. She stated she noted him slumped over and bluish color to face and observed what she felt to be a possible obstruction to his airway, so she initiated the Heimlich and attempted to suction his airway until EMS arrived.
• Camera footage was observed by Administrator and DON to establish a timeline and confirm he had eaten food from a tray sitting in the common area.
• Education was initiated with all staff regarding picking up all trays timely and not leaving any food trays unattended on a unit.
• Audits were initiated of all residents who wander or have behaviors to ensure all are care planned for wandering and staff are aware of this behavior and risk for getting food that is not theirs.
• An audit was initiated for all residents on a mechanically altered diet to ensure orders are correct and tray cards and care plans also reflect correct diets as ordered.
• Standup/stand down imitated to track progress of the abatement plan.
• Audits initiated for all residents on a mechanically altered diet to ensure that orders are correct and correlate with tray cards and care plans to reflect current orders.
• Audits initiated for all residents who have behaviors of wandering and would be at risk to take food from other residents or areas that is not their ordered diet to ensure care plan is reflective of the behavior.
• Education initiated immediately for all staff to ensure understanding of timely removal of trays from the unit and not left unattended. All newly hired staff and or agency staff will receive the education prior to first shift worked.
• Educations was sent to all staff via CORV. Wet signatures will be obtained as staff report for duty on next scheduled shift.
• Education provided to all staff related to neglect.
• All newly hired staff and or agency staff will receive the education prior to their first shift worked.
• Administrative staff will be conducting audits of all units during meal times to ensure monitoring of all residents for safety during mealtime and to ensure that at the end of the meal or assisting residents with eating that the trays are removed timely and not left unattended and are returned to the tray cart and to the kitchen.
• Audits will be completed for every meal for the first 72 hours, then three times per week, then weekly, then monthly, then random thereafter.
• All audits and data will be reported to the QA committee for review, recommendation, and follow-up.

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 adequate supervision and safety for a resident, leading to a fatal incident. The resident, who had a therapeutic diet due to dysphagia and other medical conditions, consumed food from another resident's meal tray left unattended in the dining area. This occurred while the resident was unsupervised in the common area, and staff were occupied at the nurse's station. The resident, who had a history of wandering and cognitive impairment, was able to access and consume the food, which was not suitable for their dietary needs. The resident's medical history included diagnoses such as adult failure to thrive, protein calorie malnutrition, dementia, and dysphagia, among others. The resident was on a regular pureed diet with nectar thick liquids and received enteral feeding through a gastrostomy tube. Despite these dietary restrictions, the resident was able to access and consume a regular diet meal, which included solid foods that posed a choking hazard. The incident was captured on video footage, showing the resident eating from the tray and later slumping over on the couch, unnoticed by the staff until it was too late. The staff's inaction and lack of supervision contributed to the resident's death. The meal tray was left unattended in a common area, and the staff failed to monitor the resident, who was known to wander and had a history of putting things in their mouth. The staff at the nurse's station did not notice the resident's actions or their subsequent distress until after the resident had already consumed the food and was in distress. The nurse attempted the Heimlich maneuver and suctioning, but the resident was pronounced dead by EMS shortly after.

Removal Plan

• Statements were written by all staff on duty.
• Nurse on duty was interviewed via phone by RDCS and DON. She stated she noted him slumped over and bluish color to face and observed what she felt to be a possible obstruction to his airway, so she initiated the Heimlich and attempted to suction his airway until EMS arrived.
• Camera footage was observed by Administrator and DON to establish a timeline and confirm he had eaten food from a tray sitting in the common area.
• Education was initiated with all staff regarding picking up all trays timely and not leaving any food trays unattended on a unit.
• Audits were initiated of all residents who wander or have behaviors to ensure all are care planned for wandering and staff are aware of this behavior and risk for getting food that is not theirs.
• An audit was initiated for all residents on a mechanically altered diet to ensure orders are correct and tray cards and care plans also reflect correct diets as ordered.
• Standup/stand down initiated to track progress of the abatement plan.
• Audits initiated for all residents on a mechanically altered diet to ensure that orders are correct and correlate with tray cards and care plans to reflect current orders.
• Audits initiated for all residents who have behaviors of wandering and would be at risk to take food from other residents or areas that is not their ordered diet to ensure care plan is reflective of the behavior.
• Education initiated immediately for all staff to ensure understanding of timely removal of trays from the unit and not left unattended. All newly hired staff and or agency staff will receive the education prior to first shift worked.
• Education was sent to all staff via CORV. Wet signatures will be obtained as staff report for duty on next scheduled shift.
• Education provided to all staff related to neglect.
• All newly hired staff and or agency staff will receive the education prior to their first shift worked.
• Administrative staff will be conducting audits of all units during meal times to ensure monitoring of all residents for safety during mealtime and to ensure that at the end of the meal or assisting residents with eating that the trays are removed timely and not left unattended and are returned to the tray cart and to the kitchen.
• Audits will be completed for every meal for the first 72 hours, then three times per week, then weekly, then monthly, then random thereafter.
• All audits and data will be reported to the QA committee for review, recommendation, and follow-up.

Penalty

Inspection fine: $15,646

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 timely written notifications of emergent hospital transfers to residents, their representatives, and the Ombudsman for eight out of nine residents reviewed. This deficiency was identified through a review of records, interviews, and policy analysis. The facility's policy requires that residents and their representatives be notified of transfers, including the reason and location, and that the Ombudsman be informed when practicable. However, the facility did not adhere to these requirements, as evidenced by the lack of documentation in the residents' records and the absence of notifications to the Ombudsman. Several residents, including those with severe cognitive impairments and significant medical conditions, were transferred to the hospital without receiving the required written notifications. For instance, one resident with metabolic encephalopathy and severe cognitive impairment was transferred multiple times without proper documentation or notification to the Ombudsman. Another resident with a history of falls and severe cognitive impairment was also transferred without the necessary notifications. These omissions were confirmed through interviews with the Social Services Director and other staff members, who acknowledged the failure to notify the Ombudsman and provide written notifications to residents and their representatives. The facility's failure to provide written notifications was further highlighted by the lack of clarity regarding staff responsibilities for sending out transfer notifications. Interviews with the Administrator, Director of Nursing, and Medical Records staff revealed confusion about who was responsible for issuing these notifications. The Administrator believed that verbal communication with residents' representatives was sufficient, while the Medical Records staff was unsure of their role in the notification process. This lack of clarity and adherence to policy resulted in the deficiency identified by the surveyors.

Penalty

Inspection fine: $15,646

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 an accurate Minimum Data Set (MDS) assessment for one resident, identified as Resident 13, out of 28 sampled residents. This deficiency was identified through a review of records, staff interviews, and the Resident Assessment Instrument (RAI) Manual. The issue arose when the facility did not correctly code the MDS, which could lead to inaccurate assessment and care planning. Specifically, the resident's quarterly MDS indicated one fall with minor injury, but the subsequent annual MDS incorrectly showed no falls since the last assessment. This discrepancy was discovered during a review of the resident's electronic medical record (EMR), which documented a fall on 07/28/24, contradicting the annual MDS coding. Resident 13 had a medical history that included type II diabetes, dementia with agitation, degenerative disease of the nervous system, polyneuropathy, osteoporosis, anxiety disorder, and insomnia. The resident experienced a fall on 07/28/24, as noted in the EMR Progress Notes, where the resident was found on the floor due to cognitive impairment. During an interview, the MDS Coordinator acknowledged the incorrect coding of the annual MDS and confirmed that the facility uses the RAI Manual for MDS accuracy. The facility administrator expressed an expectation for accurate MDS assessments.

Penalty

Inspection fine: $15,646

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 update the care plan regarding resuscitation status for a resident, identified as R111, which could affect the appropriateness of care in the event of a respiratory or cardiac arrest. The resident's electronic medical record (EMR) indicated a Do Not Resuscitate (DNR) status, confirmed by a signed DNR order from the resident's representative and a physician's order. However, the care plan in the EMR inaccurately reflected a 'Full Code' status, indicating that the resident would receive cardiopulmonary resuscitation (CPR) if their heart or breathing stopped. The discrepancy was identified during a review of the resident's significant change of status assessment, which showed the resident had a terminal diagnosis and was receiving hospice services. Despite these updates, the care plan was not revised to reflect the resident's DNR status. The Director of Nursing (DON) acknowledged the inconsistency upon reviewing the EMR and stated that the care plan should have been updated to align with the resident's current resuscitation preferences.

Penalty

Inspection fine: $15,646

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 restorative nursing services to a resident, identified as R112, who was reviewed for such services. R112 had a history of acute osteomyelitis of the right tibia and fibula, generalized muscle weakness, abnormal posture, and multiple contractures, among other conditions. Despite these needs, the facility did not have a policy for restorative nursing, and there were no orders for range of motion (ROM) assistance in R112's clinical physician orders. The resident's care plan indicated a decline in activities of daily living and mobility, requiring assistance due to multiple fractures and contractures, but did not include specific interventions for ROM exercises. Interviews with staff revealed that the facility lacked a restorative nursing program, and there was no documentation of training or in-services provided to nursing staff for active or passive range of motion (AROM/PROM) exercises. The Director of Rehabilitation and other staff members confirmed that while therapy services had been provided to R112, there were no follow-up orders or documented training for nursing staff to continue ROM exercises after therapy discharge. The Director of Nursing acknowledged the absence of a restorative nursing program and the lack of communication between therapy and nursing departments regarding the continuation of ROM exercises. Observations and interviews with R112 indicated that the resident was not receiving the necessary ROM exercises, which were only performed during wound care or when repositioning was required. R112 expressed that his joints felt stiffer since the completion of therapy, and staff did not offer PROM. The lack of a structured restorative nursing program and the absence of documented orders or training for staff to provide ROM exercises contributed to the deficiency in care for R112, potentially leading to increased contractures and decreased mobility.

Penalty

Inspection fine: $15,646

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 recognize and thoroughly investigate an injury of unknown origin for a resident, identified as R52, which had the potential to place residents at risk of abuse. The facility's policy required all reports of resident abuse, including injuries of unknown origin, to be thoroughly investigated. However, the investigation into R52's injury was not conducted as an injury of unknown origin, despite the resident's severe cognitive impairment and inability to communicate effectively. R52 was admitted with medical diagnoses including a traumatic rupture of a ligament in the left wrist and was severely cognitively impaired, with a BIMS score of 00 out of 15. Progress notes indicated that R52 exhibited signs of pain and agitation, particularly in the right arm, which was later found to have a fracture. Despite these symptoms, the facility's investigation did not consider the possibility of an injury of unknown origin, and the investigation was limited to the resident's combative behavior and the assumption that the pain was related to this behavior. Interviews with staff, including the Administrator, revealed that the investigation was not as thorough as required for an injury of unknown origin. The Administrator admitted that the investigation did not involve the facility's physiatrist or the interdisciplinary team and was not conducted with the depth necessary for an abuse investigation. The facility's failure to conduct a comprehensive investigation into the fracture as an injury of unknown origin represents a deficiency in their handling of potential abuse cases.