Riverside Health And Rehab

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 cleaning of kitchen equipment, including the deep fryer, stove, and two ovens. During an initial tour of the main kitchen, the stove, deep fryer, and two ovens were observed with excessive grease and food residue buildup. The Kitchen Manager stated there was a cleaning log for the stove/grill, but no cleaning log or schedule for the ovens or deep fryer, and she did not know when those items had last been cleaned. She stated the ovens and deep fryer would be cleaned that day. The facility also failed to ensure kitchen staff had appropriate hair and facial hair restraints. A male kitchen staff member was observed plating meals with a beard but no beard cover, and he stated he was not required to wear one because he did not have hair. A female kitchen staff member was observed wearing a purple bonnet that did not fully cover approximately 5 inches of her hair, and she stated she believed any covering that touched her hair was sufficient. On another observation, a male cook with a beard was seen prepping meal trays without a beard cover and stated he did not have to wear one because he did not really have a beard. In addition, dietary staff did not correctly demonstrate thermometer calibration when taking food temperatures. One staff member was observed taking food temperatures without calibrating the thermometer and stated calibration was done by turning the thermometer off and on. Another staff member was observed entering the kitchen in a dirty uniform, scratching her face and neck, placing her hands in and out of her pockets, and handling food pans bare handed while only washing her hands once. The Kitchen Manager stated staff were expected to wear clean uniforms, hair restraints, and beard covers, and that thermometers should be calibrated after each food item is temped.

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 or obtain specialized rehabilitative services for one resident when Occupational Therapy was recommended but not approved. The resident was admitted with multiple diagnoses including spastic hemiplegia affecting the right dominant side, contractures, gait and mobility abnormalities, muscle wasting and atrophy, generalized weakness, and sequelae of cerebral infarction. The resident’s quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment, and the care plan identified impaired mobility and ADLs with a need for assistance related to cognitive and functional decline, right-sided hemiplegia, personal care needs, muscle wasting, and weakness. The quarterly Therapy Screening Form documented difficulty performing ADLs, including grooming, along with joint limitations and contractures. The Occupational Therapist noted difficulty completing grooming and hygiene tasks and a right digit contracture, and OT was recommended. A Rehabilitation Therapy Funding Information Form was completed and sent for administrator approval, but the administrator denied the request, documenting that it was not approved at that time. The Director of Rehabilitation stated that the resident was screened quarterly, that the last screening recommended continued OT services based on the resident’s right-hand contracture and decline in grooming and hygiene, and that if the funding form was not approved there was nothing more that could be done to assist with therapy services. During observation, the resident was sitting on the side of the bed looking distressed, with the fingers of the right hand contracted and the pinky finger digging into the palm. The resident stated that therapy had been helping, that the fingers had been straightening out, and that pain had improved, but therapy was stopped because the resident was told services were no longer approved. The Administrator stated he denied the funding form after his own review and said he did not see a reason to continue OT services, later acknowledging that the Therapy Screening Form contained the diagnosis and reason for services, including decline in grooming, hygiene, and right-hand contracture.

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

Surveyors observed multiple deficiencies in the facility's dietary services, including improper food storage, unclean equipment, and unsanitary practices. During kitchen tours, food items such as gravy, roast beef, opened cheese, and sliced sandwich meats were found in the refrigerator without labels or dates. Large bins containing sugar and flour had Styrofoam cups in direct contact with the food, rather than proper scoops. Additionally, dirty trays were stored on a rack in the prep area, and crumbs and scraps of paper were found on the floor. The oven's cooktop and sides were coated with thick grease and food debris, indicating a lack of regular cleaning. Interviews with dietary staff revealed a lack of awareness regarding the use of Styrofoam cups as scoops and confirmed that proper procedures for labeling, dating, and cleaning were not followed. The Dietary Manager acknowledged that staff should have labeled and dated food, that Styrofoam cups should not be used in dry food bins, and that the oven should have been cleaned. The facility was unable to provide a kitchen cleaning and service policy when requested by surveyors. These deficiencies had the potential to affect a significant number of residents who received meals prepared 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 implement occupational therapy (OT) recommendations for the use of hand splints for three residents with contractures. For one resident with cerebral palsy and quadriplegia, the OT discharge summary recommended use of a left hand splint for three hours daily to prevent worsening contractures. However, there were no corresponding orders or care plan updates in the electronic medical record (EMR), and the resident reported that after therapy services ended, no one assisted with applying the splint, which was observed unused in the room. Another resident with a right hand contracture had OT recommendations for continued use of a right hand splint, but the care plan did not address this intervention, and no orders or treatments were found in the EMR. Observations showed the resident's hand contracted and the splint not in use, with staff interviews confirming a lack of follow-through on therapy recommendations after discharge from rehabilitation services. The Director of Nursing (DON) and Rehabilitation Director acknowledged communication failures between nursing and therapy regarding the implementation of splinting orders. A third resident with a right hand contracture and severe cognitive impairment had a physician order and care plan interventions for daily splinting, but observations revealed the resident was not wearing a splint, and staff were unaware of the need. The occupational therapist confirmed the resident should have a palm guard, but it was not found in the room, and staff reported using a towel instead. Interviews with facility leadership confirmed gaps in documentation, communication, and implementation of splinting interventions as recommended by therapy.

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 promote residents' rights to dignity and privacy in two key areas. For 128 out of 147 residents, meals were served in Styrofoam containers during breakfast and lunch on two consecutive days. This occurred because the kitchen staff arrived to find dirty pots, pans, and dishes from the previous evening and did not have sufficient time to clean them before meal service. The Dietary Manager confirmed that serving meals in Styrofoam containers was not acceptable and that the kitchen should have been properly cleaned and prepared by the previous shift. The facility's policy on resident rights, which was undated, states that residents are to be protected and promoted in their rights, including privacy and dignity. Additionally, a resident with a history of congestive heart failure and neuromuscular dysfunction of the bladder, who was cognitively intact, did not have their right to physical privacy protected during medication administration. An LPN administered insulin and performed a suprapubic catheter irrigation with the resident's door left wide open and the privacy curtain not drawn, making the resident visible from the hallway. The LPN stated the door was left open to monitor an unlocked medication cart and laptop, but acknowledged that normally the privacy curtain would be used. Both the RN and DON confirmed that staff are expected to always provide privacy during patient care, with no exceptions.

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 assess residents' ability to self-administer medications and did not follow its own policy regarding medication administration. For one resident with diagnoses including end stage renal disease, diabetes, and hypertension, a medication cup containing eight medications was left unattended on the overbed table. The resident, who was cognitively intact per a recent BIMS assessment, stated she had fallen asleep and forgot to take the medications, and then proceeded to take them after being prompted. The LPN confirmed she had left the medications and had not observed the resident taking them, and also acknowledged that the resident had not been assessed for self-administration, which was not in line with facility policy. Another cognitively intact resident with a history of congestive heart failure was observed to have a medicine cup with 13 pills left on the bedside table by an LPN, who stated that the resident preferred to take medications with breakfast and that she would return to check if the medications were taken. The resident also had a bottle of Tums at the bedside, which he reported purchasing himself and using as needed, and stated that the physician had seen the bottle but had not commented. The LPN and RN both confirmed that there was no assessment for self-administration for this resident, and that facility policy did not allow medications to be left at the bedside. Facility policy required that residents may self-administer medications only after an assessment by the Interdisciplinary Care Team, but neither resident had such an assessment or order in place. Staff interviews confirmed that medications were not to be left unattended and that there were no residents currently assessed to self-administer medications. The facility also reported that some residents order their own over-the-counter medications, which staff monitor and remove as needed. These actions and inactions resulted in a failure to assess and authorize self-administration of medications, contrary to facility policy and regulatory requirements.

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

During an initial kitchen tour with the dietary cook, surveyors observed that the garbage container near the food preparation area was uncovered and overflowing, with additional garbage such as paper towels and gloves scattered on the floor. This unsanitary condition was directly observed in the kitchen, where meals are prepared for residents. In a subsequent interview, the Dietary Manager acknowledged that the situation was unacceptable and confirmed that garbage should be contained or emptied before reaching an overflowing state. The deficiency was limited to the improper disposal and containment of garbage in the kitchen area, as evidenced by the overflowing container and waste on the floor, with no mention of specific residents' medical histories or conditions at the time of the deficiency.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a Licensed Practical Nurse (LPN) failed to properly handle soiled linen after providing activities of daily living (ADL) care to a resident. The LPN exited the resident's room carrying a large bundle of unbagged soiled linen and placed it in the laundry cart located 60 to 75 feet away from the room. This action was in direct violation of the facility's policy, which requires soiled linen to be minimally handled and placed in a collection bag before being removed from a resident's room. The LPN confirmed during an interview that the linen was not bagged as required by facility procedures. The resident involved had been readmitted with diagnoses including a urinary tract infection (UTI) and dysphagia, and was on Enhanced Barrier Precautions due to an enteral feeding tube. Interviews with other staff, including a Certified Nurse Aide (CNA) and the Infection Preventionist (IP), confirmed that the facility's expectation and policy is for all soiled linen to be bagged prior to removal from a resident's room to prevent the spread of infection. The failure to follow this protocol was observed and acknowledged by staff.

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 post current nurse staffing information daily as required. On review of the 24-hour nurse staffing posting in the front lobby, the information displayed was dated three days prior to the date of review and did not reflect the current staffing levels. During interviews, both the Assistant Administrator and the Director of Nursing confirmed that the posting was outdated and acknowledged that the staffing data should be current, accurate, and updated daily.

Penalty

Inspection fine: $10,845

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 identify and acknowledge that a resident was missing, which led to a delay in implementing emergency protocols to locate the resident. The resident, who had moderate cognitive impairment and was at risk of elopement, was last seen sitting in his wheelchair on the front porch of the facility. Staff assumed the resident was visiting friends within the facility, and it was not until the resident missed his afternoon medications and dinner that staff realized he was missing. The facility did not report the resident as missing to the Administrator or the police within the required 30 minutes. Interviews with staff revealed a lack of communication and awareness regarding the resident's whereabouts. The Medical Records Clerk discovered that the transport company had mistakenly taken the resident instead of the intended individual, but this information was not promptly communicated to the facility's leadership. The Central Supply Clerk, who was covering the receptionist's lunch break, noticed transport vans but did not see anyone board them. The LPN on duty did not receive a report or notice anything unusual until a CNA mentioned the resident's untouched dinner tray. The Director of Nursing and Assistant Director of Nursing were unaware of the resident's absence until later in the day. The resident was eventually found at a local Waffle House, where he had informed workers that he wanted to go home. The police were contacted, and the resident was returned to the facility. Interviews with the Administrator and Social Services Director revealed confusion regarding the resident's decision-making capacity, as there was conflicting information in the medical records.

Removal Plan

• Resident #1 left facility via transport van without staff knowledge. Staff re-educated on physically checking on every resident at least every two hours. Resident #1 is without injury and elopement risk assessment repeated with interventions in place per plan of care. A resident count was conducted for all residents when Resident #1 returned to the facility. All residents were accounted for.
• Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch
• Re-education for staff on Abuse, Neglect, or Mistreatment
• Re-education for staff on physically checking on residents at least every two hours
• Continue a midnight census every night as a daily audit.
• Safe area (courtyard) provided for residents to socialize. Residents informed.
• Adhoc QAPI
• ADON/designee will audit midnight census five times weekly x4 weeks, then three x weekly for 4 weeks, then monthly x 1 until compliance is achieved.

Penalty

Inspection fine: $10,845

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 supervision for a resident, identified as R3, who successfully eloped from the facility. R3, who had been admitted with diagnoses including depression, cognitive communication deficit, and unspecified psychosis, had a BIMS score indicating moderate cognitive impairment. On the day of the incident, R3 was last seen sitting in his wheelchair on the front porch after lunch, which was his usual routine. However, R3 was not available for his afternoon medications or dinner, and staff assumed he was visiting friends within the facility. The facility did not report R3 as potentially missing to the Administrator or the Police within the required 30 minutes. Interviews with staff revealed a lack of communication and awareness regarding R3's whereabouts. The Medical Records Clerk noted a discrepancy with the transport company, which had mistakenly taken R3 instead of the intended resident. The Central Supply Clerk, covering the Receptionist's lunch break, observed transport vans but did not see anyone board them. LPN1, who was on duty, did not receive a report and was unaware of R3's absence until a CNA noted R3's untouched dinner tray. The DON confirmed that R3 left with transport instead of the intended resident, and a Code White was not initiated as it was not known that a resident was missing. The Administrator was not informed of the incident until the following day when R3 was returned to the facility by police after being found at a local Waffle House. The Administrator expressed that had she been aware of the situation, she would have initiated a lockdown and conducted a headcount. The SSD admitted to a lack of documentation regarding R3's decisional making capacity, contributing to the confusion in R3's medical record. The facility's failure to adhere to its elopement policy and ensure proper supervision and communication led to the resident's elopement.

Removal Plan

• Resident left facility via transport van without staff knowledge. Staff re-educated on physically checking on every resident at least every two hours. Resident is without injury and elopement risk assessment repeated with interventions in place per plan of care. A resident count was conducted for all residents when resident returned to the facility. All residents were accounted for.
• Elopement drill conducted.
• Check-in/Check-out (Porch Pass) process implemented for residents who desire to sit on the front porch.
• Re-education for staff on Elopement Policy and Process and Abuse, Neglect, or Mistreatment.
• Elopement risk assessments completed on residents who reside in the facility.
• A review of residents who are assessed as an elopement risk was completed and care plans updated as appropriate.
• Safe area (courtyard) provided for residents to socialize. Residents informed.
• Adhoc QAPI.
• Continue a midnight census every night as a daily audit.
• ADON/designee will audit for elopement assessments completed and accurate within 24 hours or admission/readmission five times weekly for 4 weeks, then three times weekly for 4 weeks, then monthly until compliance is achieved.
• ADON/designee will audit 24-hour report and new nurses' notes (facility activity report) for documentation of elopement risks five times weekly for 4 weeks, then three times weekly for 4 weeks, then monthly until compliance is achieved.
• Results of the monitoring will be presented to the Quality Assurance Performance Improvement (QAPI) Committee for a period or until substantial compliance is achieved and maintained. Any areas of concern identified will be addressed at time of discovery.

Penalty

Inspection fine: $16,943

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 conduct smoking assessments for 4 out of 10 residents who smoke and did not provide proper safety protocols for all 10 residents who smoke. During observations, it was noted that residents were smoking across the street from the facility without proper supervision or safety equipment. Interviews with residents revealed that they were crossing a busy street to smoke, expressing concerns about the lack of safety in doing so. Some residents mentioned keeping smoking materials on their person at all times, indicating a potential hazard. The facility's policy stated that smoking materials should be stored in assigned lockers, but this was not being enforced or monitored effectively. Review of individual residents' medical records highlighted specific risks and conditions that made smoking without proper supervision particularly hazardous. For example, Resident R80 had diagnoses including acute respiratory disease and COPD, while Resident R133 had chronic bronchitis and was identified as an unsafe smoker due to respiratory distress risk. These medical conditions, combined with the lack of proper smoking assessments and safety protocols, increased the potential for accidents and harm to these residents. The failure to address these risks in a timely manner contributed to the deficiency identified during the survey. Interviews with staff members revealed a lack of awareness regarding the smoking assessments and safety protocols for residents who smoke. Staff mentioned that residents were required to sign out to smoke but were not consistently monitored or supervised during this time. The facility's leadership acknowledged that they were not fully aware of the extent of residents smoking or the potential hazards associated with it. This lack of oversight and enforcement of smoking policies, combined with residents' behaviors and medical conditions, created an environment where accidents and safety risks were not adequately addressed.

Penalty

Inspection fine: $16,943

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 clean linen and washcloths to residents throughout the facility. This deficiency was identified through interviews, record reviews, and multiple observations. The Resident Council Meeting Minutes from September 2023 to February 2024 consistently revealed concerns about the lack of linens and washcloths. Observations on 03/12/24 and 03/13/24 showed that several rooms had stained, dirty, or soiled linens, and some beds had no linens at all. Residents were found lying directly on mattresses, and rooms had unpleasant odors, indicating a severe lapse in maintaining a clean and comfortable environment for the residents. During the Resident Council Meeting on 03/13/2024, residents expressed their frustration over the ongoing issue of linen shortages, stating that the problem had been discussed at every meeting without resolution. The Director of Nursing (DON) acknowledged the issue, attributing it to the outsourced laundry service, which was not providing timely and complete returns of laundered items. The DON mentioned that the contract with the outsourced company would be terminated at the end of the month, and all laundry services would be conducted in-house starting 04/01/24. However, the deficiency persisted at the time of the survey, affecting the residents' right to a safe, clean, and comfortable environment.

Penalty

Inspection fine: $16,943

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 sufficient Registered Nurse (RN) staffing on a 24-hour basis to ensure all residents receive adequate care. The facility's policy requires RN coverage for at least eight consecutive hours, seven days a week. However, the review of the Staffing Daily Posting revealed multiple days in December 2023, January 2023, and February 2023 where the facility did not meet this requirement. Specifically, there were six days in December, nine days in January, and thirteen days in February without the required RN coverage. This deficiency was confirmed through observations, interviews, and record reviews conducted by the surveyors. During interviews, staff members, including a Certified Nurse Assistant (CNA) and a Licensed Practical Nurse (LPN), reported challenges in providing adequate care due to insufficient staffing. The CNA mentioned that the number of residents they care for depends on the number of staff call-ins, and they often have to team up to provide care. The LPN stated that they communicate residents' concerns during huddles and inform the RN or Director of Nursing (DON) in case of emergencies. The DON acknowledged the staffing issues and mentioned that they or the Assistant Director of Nursing (ADON) would step in to assist when there is no RN on duty. Despite these efforts, the facility did not consistently meet the required RN staffing levels, leading to the identified deficiency.

Penalty

Inspection fine: $16,943

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 labeling and storage of medications and biologicals, as observed in multiple medication administration carts and storage rooms. Specifically, medications were found without open dates, loose pills were present in medication carts and narcotic lockboxes, and expired medications and biologicals were not removed from storage areas. For instance, in the medication storage room on Hall 300, items such as an open Luer Lock Disposable syringe and a bag of IV caps not in original packaging were found. Additionally, the refrigerator contained an unlabeled syringe and the floor was dirty with spills. In the treatment supply room on Hall 300, several items were improperly stored or expired, including hydrogen peroxide stored in a box labeled for non-woven drain sponges and a urological catheter strap in an open package. Similarly, the central supply room on Hall 200 contained expired suture removal trays and an open pack of cotton tip wood applicators. Loose pills and unlabeled medication pens were also found in medication carts on Halls 100 and 400, with some items lacking open dates, making it impossible to determine their expiration. Interviews with staff, including LPNs and the Central Supply Clerk, revealed a lack of awareness and adherence to proper medication storage protocols. The Director of Nursing (DON) indicated that medication storage rooms are managed by unit managers and the Central Supply Clerk, with monthly checks, while medication carts are managed by the nursing staff. However, the observations indicated that these checks were not effectively ensuring compliance with proper storage and labeling practices, leading to the deficiencies noted in the report.

Penalty

Inspection fine: $16,943

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 R30, was afforded the right to formulate an advance directive. The facility's policy on advance directives outlines specific procedures to be followed upon a resident's admission, including providing information about advance directives, obtaining signatures, and documenting any existing directives in the resident's medical and financial records. However, a review of R30's electronic medical record revealed no documentation of advance directives or any indication that R30 or his personal representative was given the opportunity to formulate one. This deficiency was confirmed during an interview with the Director of Nursing, who was unable to locate any advance directive for R30. R30 was admitted to the facility with multiple diagnoses, including osteomyelitis of the vertebra, sacral and sacrococcygeal region, multiple contracted muscles, opioid abuse, anxiety disorder, cerebrovascular accident with speech and language deficits, lack of coordination, convulsions, and stage four pressure ulcers. Despite these significant health issues, the facility did not follow its own policy to ensure that R30's rights regarding advance directives were upheld. This oversight indicates a failure in the facility's admission process and documentation practices, directly impacting the resident's right to make informed decisions about their care.

Penalty

Inspection fine: $16,943

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 or his personal representative received discharge notification in writing and in a language they could understand upon discharge to the hospital. Additionally, the facility did not ensure that the state Ombudsman received a copy of the notification in a timely manner. This deficiency was identified during a review of the facility's policy, record reviews, and interviews. The facility's policy requires that residents and their representatives be notified of transfers or discharges in writing and in a language they understand, and that a copy of the notice be sent to the state Ombudsman. However, the review of the resident's electronic medical record revealed no documentation to confirm that these notifications were made. The resident in question had multiple diagnoses, including osteomyelitis of the vertebra, sacral and sacrococcygeal region, multiple contracted muscles, opioid abuse, anxiety disorder, cerebrovascular accident with speech and language deficits, lack of coordination, convulsions, and stage four pressure ulcers. The resident was hospitalized from March 2 to March 6, 2024. During an interview, the Director of Nursing confirmed that the medical record did not contain a copy of the transfer paperwork given to the resident or the resident's representative. The documentation provided to the Ombudsman was also incomplete, lacking specific resident information such as names and dates of discharge.

Penalty

Inspection fine: $16,943

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 the interventions outlined in the care plan for Resident 53, who was at risk for falls due to multiple medical conditions including encephalopathy, seizures, and impaired mobility. The care plan specified the use of fall mats and ensuring the call light was within reach. However, during observations, the fall mats were found to be improperly positioned, with one mat diagonally under the bed and the other near the wall with a folding chair on top of it. This improper placement of fall mats was confirmed by both an LPN and the Director of Nursing (DON), who acknowledged that the mats should be beside the bed and the call light within reach to prevent falls. The DON also mentioned that Resident 53 sometimes places herself on the floor, which is noted in the care plan, but the expectation is that staff adhere to the care plan to keep the resident free from falls. The deficiency was identified through a review of the facility's policies and Resident 53's care plan, as well as direct observations and staff interviews. The facility's policies on care planning and fall management emphasize the need for individualized interventions and proper placement of assistive devices to prevent falls. Despite these policies, the facility did not ensure that the fall mats were correctly positioned, thereby failing to meet the professional standards of quality care as outlined in their own policies. This lapse in care was observed on multiple occasions, indicating a systemic issue in adhering to the care plan for Resident 53.

Penalty

Inspection fine: $16,943

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 nail care, maintain personal hygiene, and offer showers to a resident requiring extensive assistance with Activities of Daily Living (ADLs). The facility's policy mandates that necessary care be provided to all residents unable to perform ADLs independently. However, observations and interviews revealed that Resident 44, who has severe cognitive impairment and multiple medical conditions, did not receive proper nail care or regular showers. The resident's ADL Point of Care history indicated that he was only given a bath on eight out of twenty-nine days, with no option for a shower on seven of those days. Observations showed that the resident had long, dirty fingernails and significant facial hair, which he expressed dissatisfaction with during an interview. He also mentioned not being provided with a razor to shave his face and not being offered a shower. Interviews with staff members, including CNAs and LPNs, revealed inconsistencies in the provision and documentation of ADL care. CNA2 admitted to not providing any showers on the day of the interview and was unable to locate the documentation book for showers. CNA3 mentioned needing to ask a nurse before cutting the nails of diabetic residents, while LPN5 stated that personal hygiene tasks should be checked and addressed during morning care. The Director of Nursing (DON) confirmed that residents should be cleaned daily and that ADL care should include nail and personal hygiene. The DON also mentioned that showers should follow a schedule, but there was no documentation to indicate whether residents received a bed bath or a shower. Further interviews with other staff members, including CNA4 and LPN1, highlighted that personal hygiene care should be documented daily and that showers are typically provided between 8 am and 11 am. The Administrator confirmed that ADL care is provided throughout the day and that staff are educated on ADL care during orientation and ongoing training. However, the Administrator was only recently made aware that residents were not being offered showers according to their preferences. The lack of proper documentation and adherence to ADL care protocols led to the deficiency in providing adequate care for Resident 44.

Penalty

Inspection fine: $16,943

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 proper wound care procedures for a resident, identified as R85, who was admitted with diagnoses including osteomyelitis of the vertebra, sacral and sacrococcygeal region, protein-calorie malnutrition, and wound botulism. During an observation of wound care performed by an LPN with a CNA assisting, several procedural errors were noted. The LPN did not cleanse the wound in a circular motion as required, used the same gauze to blot both the wound bed and the surrounding tissue, and did not change gloves appropriately between tasks. Additionally, the soiled dressing was saturated and not dated or initialed, and the bed beneath the chux was also saturated and stained with drainage, indicating improper wound management and infection control practices. The LPN confirmed during an interview that she had not correctly performed the wound care, acknowledging the improper use of gauze and gloves. The facility's policy on wound care states that pressure ulcers should be treated in accordance with professional standards to promote healing and prevent infection. However, the observed actions did not align with these standards, potentially compromising the resident's wound healing process and increasing the risk of infection.

Penalty

Inspection fine: $16,943

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 medication administration error rate of less than 5 percent, resulting in an 8 percent error rate. Specifically, insulin administered via an insulin pen was primed incorrectly and administered incorrectly for Resident 100. The Licensed Practical Nurse (LPN) held the pen horizontally and did not confirm the insulin escaping the needle. Additionally, the LPN did not hold the pen in the resident's skin for the required 10 seconds after pressing the dose button, removing it within 3 to 4 seconds instead. During an interview, the LPN confirmed the incorrect priming method and claimed to have counted to 10 before removing the needle, which was not observed to be true. Another instance involved LPN3 preparing to administer insulin to Resident 14. LPN3 also primed the insulin pen incorrectly by holding it horizontally and could not confirm that insulin had escaped the needle before administration. These actions led to the facility failing to meet the required medication administration error rate, as the incorrect priming and administration of insulin were observed in 2 out of 25 opportunities for error.