Beltline Healthcare Center

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a nurse practitioner's order for a urinalysis (UA) was completed for a resident after the resident's responsible party expressed concerns about a possible urinary tract infection (UTI). The resident, an elderly female with diagnoses including dementia, congestive heart failure, chronic kidney disease, history of stroke, and breast cancer, was noted to have moderate cognitive impairment and required substantial assistance with activities of daily living. Her care plan included interventions for bladder incontinence and monitoring for signs and symptoms of UTI, with instructions to report such symptoms to the medical provider. On a specific date, the resident's family requested a UA due to the resident expressing discomfort during urination. The Assistant Director of Nursing (ADON) documented the family's request and notified the Director of Nursing (DON), who in turn sent a message to the medical provider. The medical provider's note confirmed that an order for a UA was approved by the nurse practitioner. However, review of the resident's electronic health record revealed that no order for a UA was entered or completed. Documentation in the facility's 24-hour nurse reports over subsequent days continued to reflect the family's ongoing concerns and requests for a UA, but no action was taken to complete the test. Interviews with facility staff revealed breakdowns in communication and follow-through. The DON acknowledged missing the message regarding the UA order and stated that the ADON should have entered the order and ensured its completion. Nursing staff reported documenting the family's concerns in the 24-hour report, which was supposed to be reviewed during daily meetings, but the DON admitted she did not always review these reports herself. The medical provider confirmed that a delayed UA could place the resident at risk, and the facility's policy emphasized the resident's right to receive services included in their care plan. Despite repeated documentation and family requests, the UA was never completed, constituting a failure to provide care in accordance with professional standards and the resident's care plan.

Penalty

Inspection fine: $32,006

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

Summary

The facility failed to provide necessary care and services for three residents reviewed for quality of care. For one resident with a seizure disorder, after experiencing a seizure, staff did not complete neurochecks, perform a thorough assessment, or conduct lab monitoring as required by the care plan and physician orders. There was no immediate notification to the resident's representative or physician regarding the seizure, and documentation of post-seizure monitoring was absent. Surveillance footage and interviews confirmed that staff did not intervene appropriately during or after the seizure, and the resident was later sent to the ER at the family's request due to concerns about a change in condition. Another resident who sustained a fall with a head strike and injury was not properly monitored upon return from the ER. The facility did not complete or document neurological checks as required by protocol for head injuries. Interviews with staff revealed a lack of clarity regarding the process for neurochecks and incident reporting, and the resident's hospital records were not initially available in the facility's chart. The resident was observed with a significant bruise and stitches above the eyebrow, but there was no evidence of the required post-fall neurological assessments being performed or documented. A third resident with dementia and bipolar disorder refused prescribed psychotropic and dementia medications since admission, but the facility failed to assess, intervene, or develop a plan of care in response to the ongoing medication refusal. This lack of intervention led to behavioral decompensation and ultimately required psychiatric hospitalization. The report details that these failures placed residents at risk for unmanaged medical and psychiatric conditions, with documentation and interviews confirming the lack of timely assessment, monitoring, and communication with medical providers and resident representatives.

Penalty

Inspection fine: $32,006

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 with bipolar disorder and dementia received necessary behavioral health care and services as required by their comprehensive assessment and care plan. The resident repeatedly refused prescribed psychotropic and dementia-related medications over an extended period, with documented refusals for multiple medications on numerous occasions. Despite these ongoing refusals, the facility did not assess, monitor, or implement appropriate behavioral health interventions, nor did they revise the resident's care plan to address the medication refusals. There was also a lack of timely initiation of psychological or psychiatric services in response to the refusals. The resident's behaviors escalated over time, including incidents of physical aggression towards staff and other residents, confusion, wandering, and taking other residents' belongings. Staff interviews revealed inconsistent practices regarding medication refusals, with some staff attempting multiple times to administer medications and others notifying physicians or family only after repeated refusals. Documentation showed that the resident's family was not informed about the consistent medication refusals, and the care plan did not include interventions to address these refusals or the resulting behavioral issues. The facility's interdisciplinary team did not effectively communicate or coordinate to address the resident's changing condition and behavioral health needs. As a result of these failures, the resident's behaviors escalated to the point of physical aggression towards another resident, leading to a transfer to an inpatient hospital for stabilization. The facility's lack of timely and appropriate response to the resident's medication refusals and behavioral health needs constituted a deficiency in providing necessary behavioral health care and services, as required by regulation.

Removal Plan

• All residents on dementia and psychotropic medications are reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse.
• The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication.
• All residents on psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions to address medication refusals and history of behaviors. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse.
• The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals. The medication administration report will also be reviewed during this process to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee. The care plan will be updated by the DON, ADON, or MDS Nurse.
• The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors.
• The medical director was notified of the immediate jeopardy citation by the administrator.
• An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal.
• The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors.

Penalty

Inspection fine: $32,006

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

Summary

The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, resulting in a deficiency. The resident, an elderly female with severe cognitive impairment, dementia with behavioral disturbance, bipolar disorder, major depressive disorder, and insomnia, was admitted to the facility and exhibited ongoing medication refusals for her prescribed dementia and psychotropic medications. Despite repeated refusals documented in the Medication Administration Record (MAR) and nursing notes, there was no evidence that the facility adequately addressed these refusals or implemented effective interventions. The care plan did not address the resident's medication refusals or provide individualized behavioral interventions related to her dementia diagnosis. Throughout her stay, the resident displayed escalating behaviors, including aggression towards staff and other residents, confusion, wandering, and taking other residents' belongings. Staff interviews revealed that medication refusals were a persistent issue, with some staff reporting that the resident had never taken medications from them and that her compliance was unpredictable. Although staff documented refusals and some behavioral incidents, there was a lack of timely notification to the physician and family, and no consistent follow-up or adjustment of interventions was documented. The resident's family was not informed of the ongoing medication refusals, and the psychiatric provider was not involved in a timely manner, with only one documented visit after admission and no clear evidence of ongoing psychiatric oversight. The resident's behaviors escalated to the point of physical aggression towards another resident, leading to her transfer to an inpatient psychiatric hospital for further evaluation. The facility's own policy required individualized, person-centered interventions and involvement of the interdisciplinary team and family in care planning, but these steps were not adequately followed. The deficiency was identified as Immediate Jeopardy due to the facility's failure to ensure the resident received necessary treatment and services to maintain her highest practicable well-being, as evidenced by untreated dementia symptoms, behavior escalation, and lack of appropriate care planning and communication.

Removal Plan

• All residents on dementia medications were reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse.
• The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication.
• All residents with a diagnosis of dementia and/or require psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions to address medication refusals and history of behaviors. Interventions will also include pharmacological and non-pharmacological approaches to care. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse.
• The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals. The medication administration report will also be reviewed during this process to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee immediately. The orders will include monitoring for any changes in condition after refusals. The care plan will be updated by DON, ADON, MDS or designee.
• The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director.
• Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days for dementia medications, increased or escalating behaviors.
• Dementia/Behavior Health Policy: Importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care.
• Care Plan Policy: All residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, dementia/behavioral health care services, pharmacological/non-pharmacological interventions, non-compliance with care, and behaviors.
• The medical director was notified of the immediate jeopardy citation by the administrator.
• An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal.
• In-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment.
• Monitoring the Plan of Removal implementation occurred through daily onsite visits. Facility monitoring activities included review of 24-hour reports, medication administration records, risk management logs and physician notification to verify that interventions for dementia medication refusal and escalating behaviors were implemented. Additionally, staff in-services were reviewed and verified they were conducted for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services.

Penalty

Inspection fine: $32,006

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

Summary

The facility failed to notify a resident's physician and responsible party of a significant change in condition following a witnessed seizure. The resident, an elderly female with multiple comorbidities including anemia, hyperlipidemia, major depressive disorder, insomnia, hypertensive heart disease, hemiplegia, acute respiratory failure, GERD, osteoarthritis, and muscle wasting, had no documented history of seizure disorder upon admission. Despite this, she was on anticonvulsant medication and had a care plan in place for seizure management. On the morning of the incident, staff observed the resident experiencing a seizure, including foaming at the mouth and shaking, but did not immediately notify the physician or the resident's responsible party as required by facility policy and federal regulations. Following the seizure, staff failed to initiate neurological checks, perform a thorough assessment, or obtain laboratory work as outlined in the resident's care plan. Documentation in the medical record did not reflect any neurochecks or post-seizure monitoring. The responsible party and physician were not informed of the event in a timely manner. The resident remained without clinical intervention until later in the day when the family, after observing concerning behavior on a room camera, requested a hospital transfer due to the unaddressed change in condition. Interviews with staff revealed that the charge nurse did not notify the physician or responsible party, citing workload and time constraints, and the ADON and DON were under the impression that notifications had been made when they had not. Video surveillance and interviews confirmed that the resident exhibited seizure activity and post-ictal symptoms, including foaming at the mouth and minimal responsiveness, for several hours without appropriate clinical response or notification. The responsible party only became aware of the situation after viewing the camera footage and contacting the facility, at which point the resident was transferred to the hospital. The facility's failure to follow established protocols for notification and post-seizure care resulted in a deficiency, as it did not ensure timely medical evaluation or involvement of the responsible party in care decisions.

Penalty

Inspection fine: $32,006

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 required physician visits were completed at least once every 30 days during the first 90 days of admission for two residents. For one resident, who had multiple complex diagnoses including anemia, heart disease, diabetes, and severe cognitive impairment, there was no documented evidence of a face-to-face physician visit at the 30-day and 60-day marks after admission. The only recorded physician visit was on the date of admission, with subsequent visits by physician extenders, but a gap of 41 days occurred without a documented visit by either the physician or extenders. During this period, the resident experienced a seizure and was sent to the emergency room, with no immediate notification to the responsible party or physician documented in the records. Another resident, also with severe cognitive impairment and multiple psychiatric and medical diagnoses, did not have documented face-to-face physician visits as required. The resident was seen by a nurse practitioner twice shortly after admission and by the physician once, but then there was a 43-day gap without a documented visit. During this time, the resident exhibited significant behavioral issues, including aggression, medication refusals, and was ultimately transferred to the hospital for behavioral decompensation and refusal of care. Medication administration records showed frequent refusals, and nursing notes documented escalating behavioral problems. Interviews with facility staff revealed a lack of clarity regarding the required frequency of physician visits in the first 90 days post-admission. Staff described that the physician and extenders visited weekly, but there was no consistent process to ensure that all required visits were completed and properly documented. Staff turnover and issues with uploading physician visit documentation into the electronic chart were also cited as contributing factors to the deficiency.

Penalty

Inspection fine: $32,006

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 pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident, specifically for two residents reviewed for medication administration. For one resident, there were twelve occasions in July when blood pressure was not obtained or documented prior to the administration of physician-ordered antihypertensive medication with specific parameters. The medication was either not administered or marked as not available, but no blood pressure readings or vitals were recorded on the Medication Administration Record (MAR) or in nursing progress notes for those times. Another resident experienced similar issues, with blood pressure not obtained or documented prior to the administration of physician-ordered antihypertensive medications twelve times in August and seven times in September. The MAR reflected that medications were not administered or marked as not available, but again, no blood pressure readings or vitals were recorded for those administration times. Nursing progress notes for these periods also lacked corresponding blood pressure readings when medications were held. Interviews with staff revealed that facility policy required blood pressure to be checked and documented prior to administering medications with parameters, and that reasons for withholding medications should be documented in the MAR and progress notes. Staff acknowledged that sometimes documentation was missed due to being busy, and that the electronic charting system did not always enforce entry of vitals when medications were skipped. The facility's policy also required notification of the physician when a dose was not given, but this was not consistently documented.

Penalty

Inspection fine: $32,006

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 oversight and ensure that systems were in place to protect resident health and safety during a period when the facility operated without an assigned administrator. During this time, three Immediate Jeopardy situations occurred involving three residents. The facility did not maintain administrative oversight or monitoring systems, resulting in failures to notify physicians and responsible parties of significant changes in resident conditions, to complete required neurological checks after a fall with head injury, and to address repeated refusals of psychotropic medications for a resident with dementia and bipolar disorder. One resident, an elderly female with multiple complex medical conditions including a seizure disorder, experienced a seizure in the morning. The facility failed to promptly notify her physician and family, only sending a message to the physician in the afternoon and not informing the family until later that evening. There was no documentation of neurological monitoring or post-seizure assessment, and no evidence of follow-up physician involvement. Another resident, newly admitted with diabetes and hyperlipidemia, sustained an unwitnessed fall with a head strike and required sutures. There was no documentation of the fall in nursing progress notes, no incident report, no ER records filed, and no evidence of neurological monitoring upon her return to the facility. A third resident with severe cognitive impairment, dementia, and bipolar disorder had ongoing refusals of dementia and psychiatric medications over approximately eight weeks. Despite repeated refusals, there was no evidence of physician notification, follow-up psychiatric evaluation, or care plan interventions addressing the refusals. The resident's untreated conditions escalated to behavioral crises, resulting in transfer to a psychiatric hospital. Interviews with staff and leadership revealed confusion about who was acting as administrator, lack of clear communication, and uncertainty about who was responsible for abuse/neglect reporting and administrative oversight during the period without an assigned administrator.

Penalty

Inspection fine: $32,006

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 complete and accurate clinical records for a newly admitted female resident with diagnoses of hyperlipidemia and diabetes, who experienced a fall resulting in a head injury and subsequent hospitalization. After the resident fell, struck her head, and was sent to the emergency room due to excessive bleeding, the facility did not complete an incident report at the time of the event. The initial care plan identified the resident as being at risk for falls, with interventions in place, but there was no immediate documentation of the fall, injury assessment, or actions taken in the clinical record. Nursing progress notes for the relevant period did not contain any documentation related to the fall, and the incident report form remained incomplete until several days later, only after surveyor inquiry. Upon the resident's return from the hospital, the facility failed to ensure that her clinical record included hospital documentation from the emergency room visit. Interviews with staff revealed confusion regarding responsibility for documentation and incident reporting, as well as a lack of clarity about protocols for post-fall neurological assessments. The charge nurse on duty did not document the resident's return from the hospital or complete required neurochecks, and the hospital discharge paperwork was not immediately obtained or filed in the resident's record. The Director of Nursing later retrieved the hospital records through an online portal, but this was not done at the time of the resident's return. Observations and interviews confirmed that the resident had visible injuries, including a large bruise and sutures above her eyebrow, and that staff were aware of the fall and subsequent hospitalization. However, the lack of timely and complete documentation, including incident reports, injury assessments, and hospital records, constituted a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. This deficiency was identified through interviews, record reviews, and direct observation.

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 safety and proper management of controlled substances, leading to the diversion of 44 tablets of Hydrocodone-Acetaminophen, a Schedule II-controlled substance, prescribed to a resident. The incident occurred when Medication Aide A, who had access to the medication cart, was the only individual with access during the time the tablets went missing. The discrepancy was discovered during a medication count conducted by Charge Nurse B, who confirmed the tablets were present at the beginning of the shift but missing by the end of the shift. The resident involved was an elderly female with a history of cognitive decline, colon cancer, and abdominal swelling. She was prescribed Hydrocodone-Acetaminophen for pain management, to be administered every six hours. The medication was delivered to the facility, and one tablet was administered by Charge Nurse B before the remaining tablets were reported missing. The absence of the medication could have left the resident at risk for unrelieved pain. The facility's investigation revealed that Medication Aide A failed a drug test, testing positive for substances she was not prescribed, leading to her termination. The facility's controlled substances policy required double-lock storage and shift-change audits, which were not effectively followed, allowing the diversion to occur. The missing tablets were never recovered, and the incident was reported to the police. The resident's hospice was notified, and alternative pain management was provided.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe environment free from accident hazards in four areas, including two shower rooms, an activity room, and a medical supply storage room. In the shower rooms, doors were found unlocked and ajar, with unsecured cabinets containing potentially hazardous items such as razors, mouthwash, and open bottles of cleansers. The lack of locks on these doors and cabinets posed a risk of residents accessing and potentially ingesting or injuring themselves with these items. In the activity room, both a mechanical lift and a sit-to-stand lift were observed to be unlocked and unsecured when not in use. This oversight was acknowledged by staff, who confirmed that these devices should have been locked to prevent residents from attempting to use them unsupervised, which could lead to injury. The staff admitted to being unaware of the unlocked state of these devices, despite having been trained on the importance of securing them. The medical supply storage room was also found with its door ajar and unlocked, allowing access to medical supplies such as syringes, lancets, and various medical liquids. The DON confirmed that all equipment and supplies should be locked and secured to prevent resident access, which could result in harm. Despite the facility's policies and staff training on safety, these deficiencies were observed, indicating lapses in adherence to safety protocols.

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 during a kitchen inspection. The inspection revealed multiple instances of improper food storage, including unlabeled and undated food items in the refrigerator. Specifically, there were clear plastic containers of watermelon, applesauce, grated cheese, and a yellow liquid substance that were not labeled or dated. Additionally, five pans of cheesecake were found unsealed and exposed to air, which could lead to contamination. Further inspection of the facility's dry storage pantry uncovered several expired food items and improperly stored goods. There were two dented cans of dark red kidney beans stored alongside other canned goods, which is against the facility's policy. The pantry also contained expired items such as Twist Lemonade packages, Hidden Valley Ranch packages, and V8 Vegetable Juice. Open packages of pasta, cornbread mix, shredded coconut, and cornstarch were found unsealed and exposed to air, increasing the risk of contamination. Interviews with staff, including the Dietary Manager and the Administrator, highlighted a lack of awareness and oversight regarding food safety practices. The Dietary Manager acknowledged his responsibility for ensuring proper labeling, dating, and storage of food items but admitted to lapses in routine checks. The Administrator expressed surprise at the findings, noting that a recent mock survey had not raised any concerns. Despite no reported illnesses from the food served, the presence of expired and improperly stored items poses a significant risk to residents' health.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection control program, as evidenced by the improper cleaning of medical equipment between resident uses. Specifically, RN B did not clean the glucometer after checking the blood sugar levels of multiple residents. After using the glucometer on Resident #24, RN B placed it on the medication cart without cleaning it and proceeded to use the same glucometer on Resident #5 and Resident #85 without disinfecting it between uses. RN B acknowledged forgetting to clean the glucometer and admitted to having received recent training on infection control. Similarly, LVN C did not disinfect the blood pressure cuff between resident uses. After checking the blood pressure of Resident #27, LVN C used the same equipment on Resident #8 and Resident #20 without cleaning it. LVN C believed that cleaning the blood pressure machine was only necessary during a COVID-19 outbreak. The Director of Nursing (DON) confirmed that staff were expected to clean shared equipment between uses to prevent cross-contamination, as outlined in the facility's infection control policy.

Penalty

No penalty information released

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

Summary

The facility failed to provide individualized and group activities for a resident, leading to a deficiency in meeting the resident's needs for physical, mental, and psychosocial well-being. The resident, a female with a BIMS score indicating no cognitive impairment, was observed spending all her time in bed watching television and expressed a desire to participate in group activities like bingo. Despite her interest, there was no documented evidence of an activities assessment or progress notes in her clinical chart from May to November 2024. Interviews with staff revealed a lack of communication and coordination regarding the resident's participation in activities. The CNA who provided care to the resident was unaware of the need for the resident to attend group activities, and the Activity Director had not engaged the resident in any activities, citing the resident's tendency to be asleep in the mornings. The Activity Director admitted to not having assessed the resident to determine the best time for in-room activities, which contributed to the resident's isolation. The Director of Nursing (DON) and other staff members acknowledged the importance of activities in preventing isolation and maintaining the resident's quality of life. However, there was a clear disconnect between the resident's expressed interests and the facility's actions to facilitate her participation in activities. The facility's policy on informing residents and staff about activity schedules was not effectively implemented, resulting in the resident's lack of engagement in both individual and group activities.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. Specifically, the facility did not ensure that the Licensed Vocational Nurse (LVN) flushed the resident's gastrostomy tube (G-Tube) with 30 cc of water prior to medication administration, as per the physician's orders. Additionally, the LVN did not flush the G-Tube with 10 cc of water between each medication, nor did she check the G-Tube placement and residual during medication administration. These actions were observed during medication administration, where the LVN mixed medications with 5-10 cc of water and administered them without the required flushing or checking for residuals. The resident involved was an elderly female with multiple diagnoses, including respiratory failure, dysphagia, and gastrostomy status. The facility's policy required checking the placement of the tube by aspiration or auscultation, flushing the tube with 30 ml of water or according to physician orders, and administering one medication at a time with a flush of 5-10 ml of water between each medication. The Director of Nursing (DON) acknowledged the mistakes made by the LVN and stated that the staff were expected to follow physician's orders and facility policy to prevent complications such as G-Tube clogging and aspiration.

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 written plan of care included the most recent hospice plan of care and a description of the services furnished by the LTC facility. This deficiency was identified for one resident who was reviewed for hospice services. The resident's care plan was not updated to reflect that she was on hospice, despite documentation in other records indicating that hospice services had begun. The resident, who had a history of dysphagia, dementia, behavioral disturbance, and other medical conditions, was receiving hospice services from a hospice company starting on a specified date. However, the care plan did not reflect this change, which was confirmed through interviews with the resident, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON). The DON acknowledged that the care plan update had been overlooked due to managing multiple residents' information. The facility's policy on comprehensive care planning emphasizes the importance of developing and implementing a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs. The policy also outlines the necessity of updating care plans to reflect any changes in the resident's condition or services received, such as hospice care. The failure to update the care plan could potentially affect the care provided by the facility staff, as the care plan drives the type of care and services a resident receives.

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 complete a discharge summary that included a reconciliation of all pre-discharge medications with the resident's post-discharge medications for a resident who was discharged home. This oversight was identified during a review of the resident's records and interviews with staff. The resident, who was cognitively intact and had a history of several medical conditions including hypertension and osteoarthritis, was discharged without a documented reconciliation of her medications, which included anticoagulant therapy. Interviews with staff revealed that the standard procedure for discharging a resident involved printing a medication list from the computer, reviewing it with the resident, and sending all medications home with them. However, in this case, the necessary documentation was not found in the resident's electronic clinical record. The resident reported not receiving her blood thinners upon discharge and had to address the issue with her physician afterward. Staff members, including the RN who discharged the resident, believed that all medications were provided, but no documentation could confirm this. The Director of Nursing (DON) and other staff members were unable to locate the medication reconciliation documentation in the resident's records. The facility's policy required a reconciliation of medications to be included in the discharge summary, but this was not completed. The absence of this documentation posed a risk to the resident's continuity of care and proper medication administration after discharge.