Avir At Woodlands

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 registered nurse (RN) was on duty for at least 8 consecutive hours a day, seven days a week, as required. Record review of the Direct Care Staff Daily Report for the specified quarter revealed that on seven separate days, there was no evidence of 8-hour RN coverage. Both the Director of Nursing (DON) and the Administrator (ADMN) confirmed during interviews that the expectation was to have RN coverage for 8 hours daily, but this was not achieved due to the inability to hire RNs, particularly for weekend shifts during the months of February and March. The DON stated she was available by phone and lived close to the facility, while the ADMN noted that support staff were available by phone as well. The ADMN was responsible for creating the staffing schedule and acknowledged that there was no policy in place for RN staffing. The lack of RN coverage was attributed to ongoing difficulties in hiring RNs, and there was no documentation to show that the required RN hours were met on the identified dates. The report does not mention any specific residents affected or provide details about their medical history or condition 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

The facility failed to employ a sufficient number of staff in the food and nutrition service department, resulting in repeated delays in meal preparation and service. Observations revealed that only one dietary manager, one other staff member, and one dishwasher were present in the kitchen during meal preparation, which was not adequate to meet the posted mealtimes. Meals, including hall trays and main dining room service, were consistently delivered late, sometimes up to one hour and twenty minutes past the scheduled time. Residents reported that meals were regularly 1-2 hours late, and grievances regarding late meals were documented over several months. Interviews with the dietary manager, DON, and administrator confirmed that the delays were due to understaffing and high turnover in the kitchen staff. The dietary manager stated that the kitchen should have had one cook, one dishwasher, and two dietary aides per meal, but this staffing level was not met. The delays in meal service affected residents' medication schedules and activities of daily living, as confirmed by both staff and resident interviews. Facility policy required meals to be served within 45 minutes of the scheduled time, but this standard was not met.

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 employ sufficient staff in the food and nutrition service department, resulting in meals not being served at the posted mealtimes. Observations over several days showed that meal trays for long-term care residents were consistently delivered late to both hallways and the main dining room, with some meals being served up to two hours after the scheduled time. Eight residents interviewed confirmed that meals were regularly late, which also caused delays in scheduled activities. The posted meal times were not adhered to, and grievances regarding late meals were filed by residents over several consecutive months. Interviews with the Dietary Manager (DM), Director of Nursing (DON), and Administrator (ADMN) confirmed that meal service was delayed due to understaffing and high turnover in the kitchen staff. The DM stated that the kitchen was operating with fewer staff than required, which directly impacted the timeliness of meal service. Both the DON and ADMN acknowledged that late meals affected residents' medication schedules and activities of daily living, such as showers and incontinent care. Facility policy required meals to be provided within 45 minutes of the scheduled time or resident request, but this standard was not met.

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 due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.

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 develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. The resident, an elderly female with a recent femur fracture, high blood pressure, atrial fibrillation, and muscle weakness, was admitted and assessed as cognitively intact. Despite facility policy requiring a baseline care plan to be completed within 48 hours to address immediate health and safety needs, the care plan was not initiated until after this timeframe had elapsed. Interviews with facility staff, including the Registered Nurse Coordinator (RNC), Director of Nursing (DON), and Administrator (ADMN), confirmed that the baseline care plan was not completed as required. Staff acknowledged the oversight and indicated that the charge nurse was responsible for initiating the care plan, with the DON responsible for monitoring completion. No specific reason for the failure was provided beyond staff oversight, and the deficiency was identified through record review and staff interviews.

Penalty

Inspection fine: $85,613

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 two residents from neglect during transportation to medical appointments in the facility van. One resident, a male with diabetes, flaccid hemiplegia, and moderate cognitive impairment, was not secured with a seatbelt while being transported in his wheelchair. Despite requesting the seatbelt, the transport aide did not secure him, stating she did not like the seatbelt. During the trip, the aide had to brake suddenly due to traffic, causing the resident to fall out of his wheelchair onto the floor of the van. The resident remained on the floor for approximately 30 minutes until returning to the facility, where it took four staff members to assist him out of the van. The resident reported feeling unsafe and stated the aide was aware of his need for a seatbelt but failed to provide it. Another resident, a female with cerebral infarction, bilateral above-knee amputation, diabetes, and end-stage renal disease, was also transported without being secured by a seatbelt. She reported asking the transport aide to use the seatbelt, but the aide claimed it did not work. During the trip, the aide braked suddenly, and the resident had to brace herself to avoid falling out of her wheelchair. The resident expressed feeling unsafe and unwilling to be transported by the same aide in the future. Both incidents involved the same transport aide, who had received training and return demonstrations on securing residents and using seatbelts but failed to follow procedures during actual transports. Interviews with facility staff and review of training records revealed that the transport aide had been trained and checked off on competencies related to securing wheelchairs and using seatbelts. However, the aide stated she was unsure how to secure residents with seatbelts and did not feel properly trained, despite documentation of completed training and return demonstrations. The facility's policies required staff to ensure residents were safely secured during transport, but these procedures were not followed, resulting in residents being placed at risk of injury. The facility identified these failures as neglect, as defined in their policy, due to the lack of necessary services to prevent physical harm and emotional distress.

Removal Plan

• Resident #10 was assessed by the charge nurse for injuries, physician was notified, orders for x-rays were obtained, and responsible party was notified.
• Residents with appointments requiring wheelchair transport were identified as affected by use of the current van.
• Safe Surveys were conducted with other residents transported by facility staff in wheelchairs and those not in wheelchairs.
• Van driver was retrained on facility safety procedures for strapping residents into the wheelchair using tie downs and seatbelts by another staff member.
• Nursing Home Administrator observed retraining of van driver by a more senior staff member with van experience.
• Facility van was removed from service for transporting residents in wheelchairs.
• Van will not be put back in service until the complete restraint system, including seatbelts for wheelchairs, is replaced.
• Facility purchased a new van; residents requiring wheelchair transport will be transported by sister facilities until all staff are checked off for operations of the new van.
• Administrator, surveyor, and two facility-approved drivers observed sister facility driver demonstrate wheelchair tie downs and seat belting prior to transporting a resident.
• One of the facility's van drivers accompanied the resident and the driver on the appointment.
• Administrator reviewed van driver competencies completed on the vehicle.
• Residents will not be transported in the existing van in a wheelchair until after the restraint system is updated and all drivers are checked off on securing the wheelchair with tie downs and seatbelt system.
• Both van drivers have been in-serviced not to use the wheelchair van until the system for securing wheelchairs is replaced and competencies with return demonstration are completed by the NHA/designee.
• Van driver was suspended pending investigation.
• Van was inspected by a company specializing in wheelchair transport vehicles; technician stated system is functioning but old and needs updating.
• NHA called and emailed to request the inspection report.
• NHA/designee in-serviced all staff on state provider letter regarding Abuse, Neglect, Exploitation, Misappropriation of resident property, and other incidents.
• All staff, including new hires and agency, are required to complete the in-service prior to starting their next scheduled shift.
• NHA/designee in-serviced all staff that drive the van on safety and emergency procedures with a post-test; staff who fail the post-test will be retrained and retested.
• Staff will not be allowed to operate the facility van until they have successfully passed the post-test.
• NHA/designee performed competencies and return demonstration on emergency procedures, operating the wheelchair lift, test driving, and reviewing a YouTube video for strapping the wheelchair and buckling the person in the wheelchair for all transport staff.
• Staff will be suspended from driving until competencies are passed; competencies with return demonstration will be completed on hire, annually, and as needed.
• NHA and Regional Nurse Consultant reviewed the Van Driver Orientation List and added instructions for emergency procedures, including procedures for if a resident falls out of seat or chair (pull over, call 911, notify NHA).
• NHA/designee will conduct audits with observation for proper securement of wheelchair and seatbelt use.
• NHA/designee will interview residents transported by facility staff using a set of safety-related questions.
• Ad-Hoc QAPI held with Medical Director, NHA, DON, ADON, Regional Nurse Consultant to review the alleged deficiency, policy and procedure, and the plan of removal of immediacy.
• NHA will be responsible for ensuring the plan is completed.
• RDO/designee will provide oversight by observation and record reviews to ensure the plan of removal items are reviewed and completed, continuing monitoring.

Penalty

Inspection fine: $85,613

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 and maintain a safe environment for three residents, resulting in multiple incidents of elopement and unsafe transport. One resident, with a history of traumatic brain injury, cardiac issues, and seizures, was care planned for exit-seeking and wandering behaviors. Despite being placed in a secure unit, this resident repeatedly attempted to leave the facility, including climbing over fences, pushing on exit doors, and ultimately eloping through an unlocked window. The facility was unaware of the resident's absence until after the elopement had occurred, and it was observed that several windows in the secure unit lacked proper locks, allowing the resident to exit undetected. Documentation revealed ongoing exit-seeking behaviors, aggressive outbursts, and multiple failed attempts by staff to redirect or supervise the resident adequately. Staffing on the secure unit was insufficient, with only one CNA present during critical times, making it impossible to provide the required level of supervision for residents at high risk of elopement. Interviews with staff and the DON confirmed that the secure unit should have had at least two staff members at all times, and that the lack of window locks directly contributed to the resident's ability to elope. The administrator acknowledged that maintenance had not installed the necessary window locks, and there was no follow-up to ensure this safety measure was completed. The resident's physician stated that the resident was not capable of making safe decisions independently and that the facility's proximity to a major highway posed a significant danger if the resident were to leave unsupervised. Additionally, the facility failed to ensure that two other residents were safely secured during van transportation to and from the facility. These failures resulted in the identification of Immediate Jeopardy, as residents were placed at risk of serious harm due to inadequate supervision and environmental hazards. The facility's own policies required identification of residents at risk for wandering and elopement, as well as implementation of strategies to maintain their safety, but these were not effectively followed or enforced.

Removal Plan

• Administrator notifies Medical Director of immediate jeopardy.
• Director of Nursing/Designee initiates in-service on adequate supervision to prevent a resident from leaving the facility, including policies on elopement/missing resident.
• Care plan team evaluates the need for 1:1 and/or alternate placement for residents exhibiting exit seeking behaviors not controlled by interventions, to be discussed during clinical morning meetings and care plan meetings for residents on the secure unit.
• All staff, including new hires and agency, to be in-serviced on this policy prior to beginning their next shift.
• All residents residing on the secure unit are assessed by IDT rounds, including Administrator, Director of Nursing, Regional Nurse Consultant, and direct care staff, with elopement risk assessments completed.
• Policies for one on one supervision created, including criteria for 1:1 and definition (resident within line of sight of staff), and interventions to be used prior to 1:1.
• Resident is discharged to a different facility with a more secure unit.
• Ad-Hoc QAPI meeting held with Medical Director, NHA, Regional Nurse Consultant, Director of Nursing, and Assistant Director of Nursing to review the deficiency, policy, and plan for removal.
• IDT (Administrator, Director of Nursing, Assistant Director of Nursing) reviews head count and checks windows to ensure they are secure with L bracket to prevent opening more than 6 inches in the secure unit daily Monday to Friday, and Manager on Duty Saturday and Sunday, then weekly thereafter.
• RDO or designee provides physical oversight at facility weekly, then monthly.
• Administrator/designee monitors compliance by physical plant rounds Monday through Friday; Manager on Duty monitors on weekends, with immediate action for any identified concerns and Ad-Hoc QAPI meeting if trends/patterns are identified.
• Administrator responsible for ensuring plan completion.
• RDO/Designee provides oversight of Administrator to ensure plan items are reviewed and completed.

Penalty

Inspection fine: $85,613

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 nursing staff to meet the needs of all residents, specifically on the secured locked unit, resulting in inadequate supervision for a resident with a known history of elopement and exit-seeking behaviors. This resident, a cognitively intact female with cardiac issues, seizures, and a traumatic brain injury, was admitted to the memory care unit due to her high risk for elopement. Despite care plan interventions requiring close supervision and 1:1 observation following an elopement incident, staff were not consistently present to provide the required supervision, and there was confusion among staff regarding the implementation of 1:1 supervision. Observations revealed that the resident was left alone in her room and in the hallway without staff in close proximity, even after being placed on 1:1 supervision. Interviews with CNAs and nursing staff indicated that they were not informed about the need for 1:1 supervision for this resident, nor were they provided with documentation tools or clear instructions. The DON and ADMN both stated that their expectation was for the resident to be within line of sight at all times, but acknowledged that staff were not always aware of or following this requirement. There was also no existing policy for 1:1 supervision at the time of the incident. The facility's failure to ensure adequate staffing and communication regarding supervision requirements led to repeated lapses in monitoring a resident at high risk for elopement. The medical director confirmed that the staffing levels on the secure unit were insufficient to meet the needs of all residents, particularly those requiring enhanced supervision. The deficiency was identified as Immediate Jeopardy due to the risk posed to resident safety and well-being.

Removal Plan

• Notify the Medical Director of the immediate jeopardy.
• Assess all residents residing on the secure unit for appropriate placement and complete elopement risk assessments.
• Create policies for one-on-one supervision, including criteria for 1:1, assignment of a third designated person not part of usual staffing, and required interventions prior to 1:1 placement.
• Discharge Resident #3 to a different facility with a more secure unit.
• Initiate in-service training for all staff (including new hires and agency) prior to working next scheduled shift, covering adequate supervision, secure unit staffing, and elopement protocols.
• Reassign staffing from other departments to work in the secure unit as needed for both day and night shifts to ensure two staff members are always present.
• Discuss residents’ change of condition with the care plan team during morning meetings, quarterly, and as needed, and evaluate the need for additional interventions.
• Hold an Ad-Hoc QAPI meeting with the Medical Director, NHA, Regional Nurse Consultant, DON, and ADON to review the deficiency, policy, and plan for removal.
• IDT (including Administrator, DON, and ADON) to review staffing schedules in the secure unit to ensure two staff are always present daily Monday to Friday, and Manager on Duty on weekends.
• Any negative findings for sufficient staffing to be immediately brought to the Administrator/Designee for further action, including sending additional staff as needed.
• RDO or designee to provide physical oversight at the facility weekly for 4 weeks, then monthly for 2 months.
• Administrator/designee to monitor compliance by reviewing staffing schedules and assignment sheets Monday through Friday; Weekend Manager on Duty to monitor on weekends.
• Any identified concerns to be addressed immediately, and if trends/patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss additional interventions for the next 2 months.
• Administrator responsible for ensuring completion of the plan.
• RDO/Designee to provide oversight of Administrator to ensure plan items are reviewed and completed.

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's drug regimen was free of unnecessary drugs, specifically concerning a male resident who was administered a female hormone replacement drug, Medroxyprogesterone, without proper review for continued necessity or adequate monitoring. This medication was prescribed to address inappropriate sexual behaviors, but there was no documented rationale for its benefit or monitoring from June 14, 2024, until the current date. The resident's diagnoses included depression, type II diabetes mellitus, mood disorder, generalized anxiety, sexual dysfunction, hypertension, and chronic obstructive pulmonary disease. The resident had a severe cognitive impairment and exhibited sexual behaviors directed toward others, occurring 4 to 6 days a week. Interviews revealed that the facility's staff failed to obtain the necessary consent for administering the medication. The Assistant Director of Nursing (ADON) acknowledged that the consent process was missed due to agency staff involvement, and the Director of Nursing (DON) admitted that only verbal consent was obtained from the resident's representative, who lived out of state. The representative was aware of the medication but had not signed any consent forms. The DON stated that there was no policy for obtaining consents, and the failure was attributed to a lack of communication and oversight during the admission process.

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 develop comprehensive person-centered care plans for two residents, which resulted in deficiencies in addressing their specific medical and psychosocial needs. Resident #41, a female with a moderately impaired cognitive status and multiple diagnoses including depression and dementia, did not have a care plan that accurately reflected her treatment needs. Despite her family's preference for a holistic approach, the care plan included interventions for medications that were not prescribed, such as antipsychotics, antianxiety, and antidepressants. This oversight in the care plan could lead to inadequate management of her delusions and mood fluctuations. Resident #315, a male with severe cognitive impairment and a history of sexually inappropriate behavior, also had a care plan that was not adequately tailored to his needs. Although he was prescribed medroxyprogesterone for managing his behavior, the care plan lacked specific interventions related to this medication. The plan included general approaches such as reviewing medications and monitoring behavior, but it did not provide measurable objectives or detailed strategies to address his inappropriate actions effectively. Interviews with the ADON and DON revealed that the care plans were not individualized or measurable, which could result in residents not receiving the necessary care and monitoring. The facility's policy emphasized the importance of creating personalized care plans with measurable objectives, but this was not reflected in the care plans for Residents #41 and #315. The lack of person-specific care plans was attributed to oversight by the facility's 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 maintain a safe environment free from accident hazards in two specific areas, Hall 300 and Hall 400. On Hall 300, an unlocked cabinet in the kitchen was found to contain hazardous items such as a spray bottle of grill and oven cleaner, a bottle of rubbing alcohol, a wire metal brush, and a steel wool cleaning pad. These items were accessible to residents, which posed a risk of injury. During an interview, an LVN acknowledged that cleaning items should not have been stored in the kitchen and that the kitchen staff were responsible for monitoring these items. The LVN confirmed that chemicals should have been stored in a manner that prevented resident access. On Hall 400, the shower room was found unlocked, containing various personal care items such as shampoo, body wash, deodorant, shaving cream, antifungal powder, zinc oxide paste, and body lotion, all accessible to residents. The ADON stated that these items should not have been stored where residents could access them, as ingestion could cause serious harm. The ADON and ADMN both indicated that the failure was due to staff not following established policies and procedures, which required hazardous items to be locked away and inaccessible to residents. The facility's policy on Environmental Services Safety Procedures emphasized the importance of storing equipment and chemicals securely to prevent resident access.

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 sufficient nursing staff to meet the needs of residents, as evidenced by a review of timesheets and interviews with residents and staff. On multiple dates, the facility did not meet the required direct care staff hours as per their PPD budget, which was set at a rate of 2.85. This shortfall in staffing was noted on seven out of ten days reviewed, with discrepancies ranging from a few hours to nearly thirty hours less than required. Interviews with residents revealed that the lack of adequate staffing led to delayed responses to call lights, with one resident reporting a two-hour wait for assistance after urinating on herself. Another resident mentioned having to call a family member for help due to the long wait times for staff assistance. These delays in care were attributed to the insufficient number of aides available to attend to the residents' needs. Staff interviews highlighted additional issues related to staffing shortages. A confidential interview and the housekeeping (HK) supervisor noted that CNAs were tasked with cleaning duties, which detracted from their ability to provide resident care. The HK supervisor confirmed that the MCU was not cleaned regularly due to a lack of HK staff, and CNAs were expected to clean the area, further impacting their primary caregiving responsibilities. The Director of Nursing (DON) and the Administrator (ADMN) acknowledged the staffing issues, citing retention and hiring difficulties as contributing factors to the failure to meet the PPD 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

The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week, on 15 specific days within a 91-day period. This deficiency was identified through a review of the facility's Direct Care Staff Daily Report and interviews with staff members. The absence of RN coverage on these days placed residents at risk, as decisions requiring an RN's expertise in managing healthcare needs and overseeing direct care staff were not guaranteed. Interviews revealed that the Human Resources (HR) personnel were initially responsible for scheduling nursing staff, but failed to ensure RN coverage when an RN took time off. The Director of Nursing (DON), who was hired in January 2024, later assumed responsibility for scheduling but also struggled to find RN coverage. The Administrator (ADMN), who started four weeks prior to the survey, acknowledged the lack of a system to track RN coverage and attributed the failure to staffing challenges. Despite the absence of RN coverage, the DON and Assistant Director of Nursing (ADON) were available on call, and the facility relied on Licensed Vocational Nurse (LVN) coverage.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents received food that was palatable, attractive, and served at a safe and appetizing temperature during a lunch meal. On the date of the observation, the temperature logbook for breakfast was not completed, and food temperatures were not checked before plating began. Specific food items, such as pureed broccoli rice and mechanical chicken, were served below the required temperature of 135 degrees. Interviews with dietary staff revealed that food temperatures were not taken due to being behind schedule, and there was a lack of documented training on temperature monitoring. The Dietary Manager (DM) acknowledged that the food temperatures were inadequate and should have been checked before serving. The Administrator (ADMN) confirmed that the failure to monitor food temperatures could lead to bacterial growth and potential foodborne illness. The facility's policy on food preparation and service emphasized the importance of maintaining food temperatures outside the danger zone of 41 F to 135 F to prevent the growth of pathogenic microorganisms. The deficiency was attributed to the dietary staff's haste and the lack of proper monitoring by the DM.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. Foods in the dry storage, refrigerator, and freezer were not properly sealed or labeled, with several items found to be expired. Specifically, dry oatmeal had a scoop left inside the container, and various food items such as oats, cereal, bread, and rolls were either unsealed or expired. In the refrigerator, items like lime juice, milk, and cheese were opened without being dated, and in the freezer, ice cream and frozen foods were similarly unsealed and undated. Additionally, the ice machine scoop was improperly stored on top of the unit, and an open trash receptacle was found in the cooking area. A dietary aide (DA) was observed not wearing a hair restraint on his beard, despite acknowledging the requirement and having received in-service training on the matter. The dietary manager (DM) admitted to not being aware of the expired products and acknowledged that all food items should have been labeled and dated. The DM also confirmed that hairnets should be worn on all exposed hair, including beards, and that the uncovered trashcan was unsanitary. The DM stated that the ice scoop should not have been stored on top of the ice machine, as it was unsanitary, and that the scoop should not be left inside the oatmeal bin to prevent cross-contamination. The DM admitted to not adequately monitoring staff compliance with food safety protocols, which she attributed to staff not following through with in-service training. The administrator (ADMN) also noted that she had not performed any follow-up on dietary staff since starting her position, attributing the failures to staff not adhering to in-service guidelines.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the Memory Care Unit (MCU), one of the four hallways reviewed. Observations revealed a persistent smell of urine, debris, and trash in the hallway and resident rooms, and an unpainted window frame with exposed wood and debris. Interviews with staff indicated that the housekeeping (HK) staff was insufficient, leading to inadequate cleaning of the MCU. The HK Supervisor confirmed that the MCU was designated to be cleaned only on Fridays, but due to low staffing, it was not always cleaned weekly. The responsibility for cleaning often fell on the Certified Nursing Assistants (CNAs), who were also tasked with resident care, leading to a conflict in duties and insufficient cleaning. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) further highlighted the staffing issues, with both acknowledging that the MCU should be prioritized for cleaning due to its high-touch nature and potential for spreading bacteria. The DON stated that the failure to maintain a clean environment was due to insufficient cleaning staff, while the ADMN admitted to being unaware of the dirty environment and emphasized the need for more staff to improve the situation. The facility's policy on providing a homelike environment was not adhered to, as the MCU did not meet the standards of cleanliness and order outlined in the policy.