Beech Tree Health And Rehabilitation

Penalty

Inspection fine: $138,802110 days payment denial

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

Summary

The facility failed to protect residents from abuse and did not identify resident-to-resident altercations as abuse, affecting six residents with cognitive impairments. Resident #91, with severe cognitive impairment, wandered into other residents' rooms without interventions to protect her. She sustained injuries from an altercation with Resident #40, who also had severe cognitive impairment and a history of aggressive behaviors. Despite the altercation resulting in scratches on Resident #91's face, no new interventions were implemented to prevent further incidents. Staff were observed not redirecting Resident #91 or offering meaningful activities, and the care plan lacked specific interventions for her wandering behavior. Resident #40, admitted with a history of aggressive behavior, was involved in multiple incidents of aggression, including the altercation with Resident #91. Despite her history and recent aggressive episodes, her care plan did not address her aggressive behavior, and staff were not adequately informed or prepared to manage her actions. The facility's policies on abuse prevention and intervention were not effectively implemented, as evidenced by the lack of appropriate care planning and staff training to handle aggressive residents. Additionally, Residents #24 and #73 were involved in an altercation resulting in injuries, yet their care plans were not updated to reflect the incident. The facility's failure to recognize and address these altercations as abuse, coupled with inadequate interventions and care planning, placed all residents at risk. The facility's policies on abuse prevention and reporting were not followed, leading to a situation of Immediate Jeopardy, which required immediate correction to ensure resident safety.

Penalty

Inspection fine: $138,802110 days payment denial

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 and investigate incidents of abuse and injuries of unknown origin for several residents, leading to a deficiency in compliance with regulatory requirements. Resident #39, who was severely cognitively impaired and non-ambulatory, sustained a left femur fracture with an undetermined cause. Despite the resident's complaints of pain and swelling in the right leg, the facility's documentation did not mention any issues with the left leg, and no thorough investigation was conducted to determine the cause of the fracture. The Director of Nursing (DON) and the Administrator did not consider the incident reportable, and no formal investigation or root cause analysis was performed. Additionally, the facility failed to report and investigate resident-to-resident altercations involving Residents #24, #73, #46, #44, #91, and #40. These residents, who were all cognitively impaired, were involved in physical altercations that resulted in injuries. The facility's staff witnessed these incidents but did not report them to the appropriate authorities, citing the residents' cognitive impairments as a reason for not considering the incidents as abuse. The facility's policies on abuse and unusual occurrences were not followed, and the incidents were not reported to state agencies, local law enforcement, or Adult Protective Services (APS). The facility's failure to identify and investigate potential abuse and injuries of unknown origin placed the residents in Immediate Jeopardy, a situation that could cause serious harm or death. The facility's policies required reporting of such incidents within specific timeframes, but these were not adhered to. The Administrator, who was also the facility's abuse coordinator, and the DON did not ensure that the facility's policies and federal regulations were followed, leading to a citation for Immediate Jeopardy at F-609 with a scope and severity of K, indicating substandard quality of care.

Penalty

Inspection fine: $138,802110 days payment denial

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 investigate an injury of unknown origin and multiple resident-to-resident altercations, which were potential indicators of abuse, for several residents. Resident #39, who was severely cognitively impaired and non-ambulatory, sustained a left femur fracture with an undetermined cause. Despite the resident's complaints of pain and swelling in the right leg, the facility's documentation did not reflect any investigation into the left leg injury, nor was an incident report completed. The Director of Nursing (DON) and the Administrator did not conduct a formal investigation or root cause analysis, and the incident was not reported as an injury of unknown origin. Additionally, the facility did not adequately investigate three separate resident-to-resident altercations. In one incident, two severely cognitively impaired residents, #73 and #24, were involved in a physical altercation, resulting in injuries to both. The facility's investigation was incomplete, lacking witness statements and resident interviews, and the care plans for the residents were not updated to reflect the altercation. In another incident, Resident #46 sustained injuries after an altercation with Resident #44, but there was no documentation of an incident report or investigation. The DON was informed of the incident but did not consider it abuse due to the residents' cognitive impairments. The facility's policies on abuse prohibition and investigation were not followed, as evidenced by the lack of thorough investigations and documentation for the incidents. The Administrator, who was responsible for abuse investigations, confirmed that the facility did not adhere to its policies or federal regulations. The failure to investigate these incidents placed the residents at risk and resulted in a citation for Immediate Jeopardy, indicating a situation that could cause serious harm to residents.

Removal Plan

• The facility provided an acceptable Removal Plan for F-610.
• The corrective actions were validated on site by the surveyor for F-610.

Penalty

Inspection fine: $138,802110 days payment denial

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 develop and implement comprehensive person-centered care plans for several residents, leading to multiple incidents of resident-to-resident altercations and injuries. Residents with histories of aggressive behaviors and cognitive impairments, such as dementia, were not provided with appropriate interventions to manage their behaviors. For instance, one resident with a history of aggressive behavior was involved in an altercation with another resident, resulting in scratches and injuries. Despite the incident, no new interventions were added to the care plans to prevent further occurrences. Additionally, the facility did not address the wandering behaviors of a resident with severe cognitive impairment, which led to altercations with other residents. The care plans lacked specific interventions to manage the resident's wandering and interactions with others, contributing to the potential for further incidents. The facility's failure to update care plans after incidents or to include person-centered activities and interventions for residents with behavioral issues was a significant deficiency. The facility's care planning process was inadequate, as evidenced by the lack of updates and revisions to care plans following incidents. The responsibility for creating and revising care plans was unclear, with the MDS Coordinator position vacant and no designated staff member taking charge of care plan updates. This lack of accountability and oversight in care planning contributed to the facility's inability to address and manage residents' needs effectively, leading to immediate jeopardy for the residents involved.

Penalty

Inspection fine: $138,802110 days payment denial

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's administration failed to provide effective leadership and oversight, resulting in a deficiency related to abuse prevention and reporting. The administration did not ensure that systems were in place to protect residents from abuse, investigate allegations, or report incidents to the appropriate authorities. This failure placed several residents in immediate jeopardy, as the facility did not recognize resident-to-resident altercations and injuries of unknown origin as potential abuse. The administration also failed to maintain an effective Quality Assurance Performance Improvement (QAPI) program, which is crucial for identifying and addressing such issues. Several incidents highlighted these deficiencies. Resident #39, with severe cognitive impairment, was found to have a left femur fracture, but the facility did not conduct a thorough investigation or report the injury as an injury of unknown origin. Similarly, altercations between residents, such as those involving Residents #91 and #40, and Residents #24 and #73, were not properly investigated or reported. The facility's staff, including the Director of Nursing (DON) and the Administrator, did not follow the facility's abuse policy, often dismissing incidents due to the residents' cognitive impairments. The facility's administration, including the Administrator and the DON, failed to recognize the seriousness of these incidents and did not conduct root cause analyses or report them as required. The facility's policies on abuse prevention and investigation were not followed, and the administration did not ensure that staff were adequately trained to identify and report abuse. This lack of compliance with federal, state, and local regulations resulted in a citation for immediate jeopardy, highlighting the administration's failure to protect residents and maintain an effective QAPI program.

Removal Plan

• The Administrator and DON received education on how to identify, investigate, and report future allegations of abuse and injury of unknown origin.
• Staff will receive education on how to identify abuse. Staff education will be conducted by the Risk Manager and the DON.
• The DON will be responsible for monitoring compliance.
• The Director of Reimbursement and Clinical Services will provide daily oversight of the facility.
• The Governing Body, facility leadership and members of the operations, compliance and QAPI corporate staff will determine if additional oversight is needed.
• Ad-Hoc QAPI meetings will be held with representatives of the Governing Body, members of the operation, compliance and QAPI corporate staff to review results of audits, rounds, patterns/trends identified through SOC meetings, and other compliance monitoring activities.
• The facility will continue to hold SEC calls to review and discuss events and incidents.
• QAPI meetings will be attended by the QAPI team and members of the Governing Body. Based on patterns/trends identified, an educational plan will be created for the facility.

Penalty

Inspection fine: $138,802110 days payment denial

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's Governing Body failed to provide effective leadership and oversight, resulting in a deficiency related to residents' rights to be free from abuse. The facility did not identify, investigate, or report resident-to-resident altercations and injuries of unknown origin as potential abuse cases. This failure affected four residents, including one with severe cognitive impairment and a history of maltreatment, who sustained a fracture that was not properly investigated or reported. Another resident with dementia and a history of wandering was involved in an altercation with another resident, resulting in injuries that were not reported or investigated as abuse. The facility's policies on abuse prevention and QAPI were not effectively implemented. The Administrator and DON did not complete thorough investigations or root cause analyses for incidents involving resident altercations and injuries of unknown origin. The facility's QAPI program was not effective in identifying and resolving issues related to abuse investigations and reporting. The Administrator admitted that incident reports were not being reviewed as they should be, and the facility's QAPI meetings did not address the incidents involving the affected residents. Interviews with facility staff, including the Administrator and the VP of Regulatory Compliance and QAPI Program Consultant, revealed a lack of recognition of abuse allegations and a failure to follow established policies. The facility did not conduct thorough investigations or report incidents to local and state authorities. The Administrator acknowledged that the facility's QAPI program had room for improvement, but believed it was effective despite the identified deficiencies.

Removal Plan

• The Administrator and DON received education on how to identify, investigate, and report future allegations of abuse and injuries of unknown origin.
• Staff will receive education on how to identify abuse, conducted by the Risk Manager and the DON.
• The DON will be responsible for monitoring compliance.
• The Director of Reimbursement and Clinical Services will provide daily oversight of the facility.
• The Governing Body, facility leadership, and members of the operations, compliance, and QAPI corporate staff will determine if additional oversight is needed.
• Ad-Hoc QAPI meetings will be held with representatives of the Governing Body, members of the operation, compliance, and QAPI corporate staff to review results of audits, rounds, patterns/trends identified through SOC meetings, and other compliance monitoring activities.
• The facility will continue to hold SEC calls to review and discuss events and incidents.
• QAPI meetings will be attended by the QAPI team and members of the Governing Body. Based on patterns/trends identified, an educational plan will be created for the facility.

Penalty

Inspection fine: $138,802110 days payment denial

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's Quality Assurance Performance Improvement (QAPI) program failed to identify and address quality deficiencies related to injuries of unknown origin and abuse for four residents. The program did not conduct thorough investigations, perform root cause analyses, or develop person-centered interventions. This failure resulted in an Immediate Jeopardy situation, indicating that the noncompliance had caused or was likely to cause serious harm to residents. The facility's policies on injury of unknown source and abuse prevention were not effectively implemented, leading to unreported and uninvestigated incidents. Resident #39 experienced a fracture that was not identified as an injury of unknown origin, and no incident report or thorough investigation was conducted. The resident had a witnessed fall, but the connection to the fracture was not made until much later. Similarly, resident-to-resident altercations involving residents #91, #40, #24, #73, #46, and #44 were not recognized as abuse due to the residents' cognitive impairments. These incidents were not reported to local and state authorities, and the facility failed to follow its abuse policy. The facility's QAPI meetings did not address these incidents, and the Administrator admitted that incident reports were not being reviewed as they should be. The QAPI program was deemed ineffective, with weaknesses in identifying and addressing abuse allegations. The facility's failure to maintain an effective QAPI program and to identify and report serious outcomes related to abuse had the potential to impact all residents.

Removal Plan

• The Administrator and DON received education on how to identify, investigate, and report future allegations of abuse and injury of unknown origin.
• The education included review of the Administrator and DON's responsibility to operate/manage the facility efficiently and effectively to ensure each resident maintains the highest practicable physical, mental, and psychosocial well-being.
• A review of the tools to be used for future allegations and interviews with the Administrator and DON confirmed they acknowledged their roles and responsibilities.
• Staff will receive education on how to identify abuse. Staff education will be conducted by the Risk Manager and the DON. The DON will be responsible for monitoring compliance.
• The Director of Reimbursement and Clinical Services will provide daily oversight of the facility. The Governing Body, facility leadership and members of the operations, compliance and QAPI corporate staff will determine if additional oversight is needed.
• Ad-Hoc QAPI meetings will be held with representatives of the Governing Body, members of the operation, compliance and QAPI corporate staff to review results of audits, rounds, patterns/trends identified through SOC (risk) meetings, and other compliance monitoring activities.
• The facility will continue to hold SEC calls to review and discuss events and incidents.
• QAPI meetings will be attended by the QAPI team and members of the Governing Body. Based on patterns/trends identified, an educational plan will be created for the facility.

Penalty

Inspection fine: $138,802110 days payment denial

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 quarterly financial statements for five residents with personal fund accounts, as required by their policy. The policy states that residents have the right to manage their financial affairs and should receive individual financial records through quarterly statements. However, the facility did not provide these statements to Residents #8, #27, #28, #34, and #78, all of whom had personal fund accounts managed by the facility. Interviews with the residents and their responsible parties confirmed that they did not receive the required quarterly statements. The Business Office Manager (BOM) acknowledged responsibility for managing resident trust accounts and stated that the company previously mailed the quarterly statements to the facility, which were then sent to the residents. However, the company stopped sending these statements nearly a year ago, and the BOM was unaware that the facility had access to print and send the statements themselves. As a result, the quarterly resident trust account statements had not been sent to the residents or their representatives for almost a year, leading to the deficiency.

Penalty

Inspection fine: $138,802110 days payment denial

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 accurate daily nurse staffing information for 7 out of 31 days reviewed. The facility's policy, titled Staffing Posting Guidelines, requires the posting of current staffing information, including the total number of hours worked by RNs, LPNs, and CNAs, in the lobby or entrance area. However, during an observation on April 1, 2024, the staffing information displayed was outdated, showing the schedule for March 28, 2024, instead of the current date. This discrepancy was confirmed by the Scheduler, who acknowledged that the correct staffing information had not been posted since March 28, 2024. Further review of the daily nurse staffing sheets compared to actual time punches from March 16, 2024, to March 29, 2024, revealed inconsistencies on six days. For instance, on March 17, 2024, six CNAs were scheduled, but only four actually worked. Similar discrepancies were noted on other dates, with fewer CNAs or LPNs working than scheduled. The Scheduler confirmed these inconsistencies and stated that it was her responsibility to post the daily staffing information. She also mentioned that any changes or call-ins were supposed to be manually updated by a floor nurse, which evidently did not occur, leading to inaccurate staffing postings.

Penalty

Inspection fine: $138,802110 days payment denial

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 accurately complete Minimum Data Set (MDS) assessments for four residents, leading to deficiencies in capturing their current health status. Resident #39, who was admitted with diagnoses including Dementia and a left femur fracture, had an MDS assessment that did not document the fracture, despite confirmation from the Regional Remote MDS Coordinator that the assessment was inaccurate. Similarly, Resident #78, diagnosed with Anxiety and receiving Buspirone for treatment, had MDS assessments that failed to include the anxiety diagnosis, as confirmed by the Director of Nursing. Resident #20, with diagnoses including Major Depressive Disorder and Anxiety Disorder, exhibited behaviors such as agitation and turning over furniture, which were not captured in the MDS assessment. The Social Service Director acknowledged the oversight, stating that the behaviors should have been documented. Additionally, Resident #46, who experienced hallucinations involving his deceased wife, had an MDS assessment that did not reflect these behaviors. The Director of Nursing confirmed that the hallucinations and delusions should have been included in the assessment. These deficiencies highlight a pattern of incomplete and inaccurate MDS assessments, which are crucial for generating an accurate picture of residents' health status. The failure to document significant diagnoses and behaviors in the MDS assessments indicates a lack of thorough review and communication among staff, as well as a failure to adhere to the guidelines outlined in the Resident Assessment Instrument Manual 3.0.

Penalty

Inspection fine: $138,802110 days payment denial

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 offer hand hygiene assistance to five residents before meals, as observed in one of two dining areas and two of three resident units during meal tray distribution. The facility's policy on hand hygiene, dated June 2023, mandates that staff assist residents with hand hygiene before meals to prevent the spread of infection. However, during observations on April 1, 2024, staff members, including LPN #9 and CNAs #9, #10, #11, and #12, did not offer hand hygiene assistance to residents before serving their meals. This was confirmed through interviews with the staff, who acknowledged their failure to comply with the facility's hand hygiene policy. The residents involved had various medical conditions and cognitive impairments. Resident #78, with dementia and mild neurocognitive disorder, was not offered hand hygiene assistance by LPN #9. Resident #203, with severe cognitive impairment, was similarly neglected by CNA #9. Resident #50, with Alzheimer's disease, and Resident #54, with severe cognitive impairment, were not assisted by CNAs #10 and #12, respectively. Resident #79, with moderate cognitive impairment, was also not offered hand hygiene by CNA #11. The Director of Nursing confirmed that it was expected for residents to be offered hand hygiene assistance prior to meals.

Penalty

Inspection fine: $138,802110 days payment denial

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 resubmit a Pre-Admission Screening and Resident Review (PASRR) in a timely manner after new mental health diagnoses were identified for two residents. Resident #27 was initially admitted with diagnoses including Dementia, Psychosis, Depression, PTSD, Agoraphobia, and Panic Disorder. A PASRR Level I Screen dated December 7, 2021, indicated no Level II condition, and the outcome was negative. However, a new diagnosis of Major Depressive Disorder (MDD) was added on September 19, 2022, which was not updated in the PASRR. The Director of Nursing (DON) confirmed that the PASRR should have been resubmitted to include the new diagnosis, as MDD is distinct from mild or situational depression. Similarly, Resident #78 was admitted with diagnoses including Dementia, Mild Neurocognitive Disorder, PTSD, Nightmare Disorder, Anxiety, and Depression. A Level I PASRR dated March 16, 2023, also showed a negative outcome. However, a new diagnosis of MDD was added on April 17, 2023, which was not reflected in a new PASRR submission. The DON acknowledged responsibility for PASRRs and confirmed that a new PASRR should have been submitted following the new diagnosis. These oversights indicate a failure to adhere to the facility's policy of promptly referring residents with new or serious mental disorders for a Level II resident review.

Penalty

Inspection fine: $138,802110 days payment denial

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 during Activities of Daily Living (ADL) for a resident diagnosed with Alzheimer's Disease and Cerebral Infarction. The facility's policy on ADL care, which includes routine cleaning and inspection of nails, was not adhered to for this resident. The resident, who was cognitively intact and required extensive assistance with personal hygiene due to a self-care performance deficit related to weakness and a left below the knee amputation, was observed multiple times with visibly dirty fingernails. Observations conducted over several days revealed that the resident's fingernails remained dirty, despite the facility's policy and the resident's expressed desire to have them cleaned. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed the oversight. The Director of Nursing acknowledged that the nursing staff was expected to maintain residents' nail hygiene during ADL care or showers, as per the facility's policy.

Penalty

Inspection fine: $138,802110 days payment denial

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 complete a fall investigation for a resident who was involved in an incident during a transfer. The resident, who had severe cognitive impairment and required substantial assistance with mobility, was reportedly lowered to the floor by two CNAs during a transfer to a shower chair. Despite the resident's complaints of pain and subsequent diagnosis of a left femur fracture, no incident report or investigation was conducted to determine the root cause of the injury. Interviews with staff revealed that the incident was not reported as a fall, and no formal investigation or root cause analysis was conducted. The CNAs involved in the transfer did not complete an incident report, and the LPN on duty at the time did not perceive the event as a fall, as the resident was only lowered to the floor. The DON and Administrator were aware of the fracture after the resident was sent to the hospital, but they did not consider the incident as reportable or conduct a thorough investigation. The facility's policies for identifying, investigating, and reporting falls or injuries of unknown origin were not followed. The Administrator, who was also the Abuse Coordinator, relied solely on staff interviews to determine the cause of the injury. The lack of a formal investigation and failure to report the incident as an injury of unknown origin contributed to the deficiency in the facility's handling of the resident's fall and subsequent injury.

Penalty

Inspection fine: $138,802110 days payment denial

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 develop a dementia care plan for a resident diagnosed with dementia, as required by their policy. The resident, who was admitted with diagnoses including dementia, lack of coordination, and bipolar disorder, had an active diagnosis of non-Alzheimer's dementia. Despite this, the comprehensive care plan did not include a dementia care plan. The resident was prescribed Aricept, a medication for dementia, indicating the need for a care plan addressing this condition. Observations over several days showed no concerns related to the resident's behaviors or dementia diagnosis. Interviews with the Director of Nursing and the Regional Remote MDS Coordinator confirmed the absence of a dementia care plan, acknowledging that the care plan should have included person-centered interventions for the resident's dementia. Staff interviews indicated awareness of non-pharmacological approaches for behaviors, but the deficiency remained in the lack of a formalized care plan.

Penalty

Inspection fine: $138,802110 days payment denial

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 physician or nurse practitioner acted upon a recommendation from the consultant pharmacist regarding a potentially inappropriate medication for a resident. The facility's policy requires a licensed pharmacist to perform a monthly drug regimen review and communicate any irregularities to the attending physician, Medical Director, and Director of Nursing. In this case, the consultant pharmacist identified Oxybutynin as potentially inappropriate for a resident over 65 due to increased sedation and anticholinergic effects, and recommended discontinuation. However, this recommendation was not acknowledged or acted upon by the physician or nurse practitioner. The resident involved had a history of osteoarthritis, dementia, psychosis, chronic kidney disease, renal insufficiency, and restless leg syndrome. Despite the pharmacist's recommendation, the medication regimen was not adjusted, and no rationale for rejecting the recommendation was documented. Interviews with the Director of Nursing and the nurse practitioner revealed that the recommendation was not addressed, as it was missed in the process of being placed in the nurse practitioner's inbox. The nurse practitioner stated she did not recall seeing the recommendation and would not have changed the medication if she had seen it.

Penalty

Inspection fine: $138,802110 days payment denial

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

Summary

The facility failed to maintain a medication error rate below 5%, resulting in a 7.69% error rate. This deficiency involved two residents. The first resident, with diagnoses including Diabetes Mellitus Type 2 and Acute Bronchitis, was administered Albuterol Sulfate incorrectly by an LPN. The LPN did not instruct the resident to inhale and exhale properly before administering the medication and failed to wait the required one minute between puffs, as per the manufacturer's guidelines and physician orders. The LPN acknowledged the mistake during an interview, and the Director of Nursing confirmed the error. The second resident, diagnosed with conditions such as Metabolic Encephalopathy and Heart Failure, received Potassium Chloride an hour late. The LPN responsible for administering the medication stated that she started her shift at 8:00 AM, which led to the delay in administering the 7:00 AM medication. The DON was aware of this scheduling issue and expected the unit manager to cover the administration of medications until the LPN arrived. The DON confirmed that the medication was administered late, contributing to the facility's medication error rate.