Brodie Ranch Nursing And Rehabilitation Center

Penalty

Inspection fine: $22,920

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 Resident #11 was protected from an unwitnessed fall that resulted in a head injury. Resident #11 was an elderly female with diagnoses including dementia, Alzheimer’s disease, unsteadiness on feet, lack of coordination, and heart disease. Her quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment, and she was dependent on staff for transfers and bed mobility. Her care plan identified her as at risk for falls due to poor safety awareness, impaired mobility, weakness, Alzheimer’s disease, and dementia, and included an intervention to ensure she was not left unsupervised in her wheelchair. On the day of the incident, staff found Resident #11 lying on the floor with her face on the left side and bleeding from the left side of her head. Her wheelchair was behind her. She was sent to the hospital, and the record documented a laceration to the left side of her face with skin glue, a side-of-head wound with 4 staples, bruising to the left arm, abrasion to the left lower leg, and swelling and bruising to the left eye. Staff interviews confirmed the fall was unwitnessed and that the resident could not explain what happened. The DON and ADM stated they believed she had fallen, but they also acknowledged they did not know how the incident occurred and did not report it as an injury of unknown origin. The facility also failed to complete smoking safety evaluations for two residents before survey entrance, and one resident’s care plan did not address smoking. Resident #73 had diagnoses including COPD, emphysema, muscle weakness, gait and mobility abnormalities, cognitive communication deficit, dementia, schizoaffective disorder, and PTSD. His care plan listed tobacco use and included education and support interventions, but nursing assessments showed no smoking safety evaluation until after survey entrance. Resident #103 had diagnoses including schizoaffective disorder bipolar type, major depressive disorder, COPD, epilepsy, diabetes, polyneuropathy, rheumatoid arthritis, anxiety disorder, repeated falls, muscle weakness, cognitive communication deficit, unsteadiness, lack of coordination, and gait abnormalities. Her care plan referenced smoking behavior, and a physician note identified her as a current smoker, but nursing assessments showed no smoking safety evaluation until after survey entrance. Observation showed both residents smoking in the designated area under staff supervision, and staff interviews confirmed the smoking safety evaluation process was expected but had not been consistently completed.

Penalty

Inspection fine: $22,920

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 residents were treated with respect and dignity by not consistently knocking before entering resident rooms and by not ensuring a resident was dressed in his own clothing. During observation, a housekeeper entered resident rooms without knocking, including the rooms of three residents who were reviewed for resident rights. The housekeeper stated she did not knock if no one was in the room, although she also stated staff were supposed to knock and notify residents before entering because residents could be receiving care and it was a privacy issue not to do so. The DON and ADM both stated staff should knock before entering resident rooms, even if no one appeared to be in the room. Record review showed that the care plans for the residents reviewed did not reflect anything about privacy or knocking on the resident's door. One resident had diagnoses including type 2 diabetes with neuropathy, COPD, and unspecified heart disease and did not have a BIMS score listed on the admission MDS. Two other residents had BIMS scores of 12, indicating moderate cognitive impairment, and one of those residents was legally blind and had diagnoses including type 2 diabetes and COPD. The observations and interviews documented that the housekeeper entered rooms without knocking, and the facility records did not show individualized care plan guidance related to privacy or knocking. The facility also failed to ensure a resident with severe cognitive impairment was dressed in his own clothing on multiple days. Record review showed the resident had diagnoses including depression, cognitive communication deficit, muscle weakness, PTSD, age-related physical debility, and chronic pain, and required substantial to maximal assistance with upper body dressing and was completely dependent for lower body dressing. Observations found him lying in bed wearing a hospital gown on multiple occasions, while his own shirts and pants were present in his room. The resident stated he wanted to wear his own shirt and pants and that staff had not offered to help him change. A CNA stated she could not remember whether she dressed him in his own clothes and was not sure if she had asked him if he wanted to get dressed in his own clothes, while OT documented assisting him with dressing as part of therapy.

Penalty

Inspection fine: $22,920

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 an injury of unknown origin to Health and Human Services after a resident had an unwitnessed fall with injury and could not explain what happened. The resident was an older female with diagnoses including severe dementia, Alzheimer’s disease, unsteadiness on feet, lack of coordination, and heart disease. Her quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment, and she was dependent on staff for transfers. On 04/15/2026, staff found the resident lying on the floor in her room with her face on the left side and bleeding from the left side of her head. Her wheelchair was behind her. She was able to move her extremities and speak in Spanish as usual, but she had a laceration to the left side of her face and left cheekbone, later documented with skin glue, four staples to the head, bruising to the left arm, an abrasion to the left lower leg, and swelling and bruising to the left eye. She was sent to the hospital after her son was notified. During interviews, the LPN said the resident had an unwitnessed fall and could not tell staff what happened, and that the DON was responsible for reporting the incident to HHS. The DON said the resident fell and hit her head, but stated the event was not reported because she and the ADM believed it was a fall and not an injury of unknown origin. The ADM also said he did not report it because he did not find it suspicious and did not consider it an injury of unknown origin, despite acknowledging that he was responsible for reporting incidents and that an injury of unknown origin should be reported within two hours. The facility policy stated that injuries of unknown source are possible indicators of abuse and that allegations must be reported to the appropriate agencies within applicable timeframes.

Penalty

Inspection fine: $22,920

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 refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for PASRR Level II review after significant changes in status. For Resident #113, the record showed a diagnosis of bipolar disorder newly identified on 08/25/25, but the only PASRR Level I screening in the chart was dated 10/08/2019 and indicated the resident was negative for mental illness. No subsequent PASRR assessment was found after the bipolar diagnosis was added to the resident's diagnoses. Resident #113's records also showed an annual MDS dated 03/13/26 with a BIMS score of 11, indicating moderately impaired cognition, and bipolar disorder and depression listed among active diagnoses. The care plan completed on 03/30/26 did not include a care plan for bipolar disorder or depression. During interview, the MDSN stated she was responsible for PASRR assessments but could not locate a PASRR screening after the new diagnosis and said she inadvertently missed the PASRR assessment. The NP stated she was not aware of the bipolar diagnosis and reported no current signs or symptoms consistent with bipolar disorder. For Resident #87, the face sheet listed paranoid personality disorder, generalized anxiety disorder, and dementia. The admission MDS dated 03/20/26 showed she could not participate in the BIMS assessment, indicating severe cognitive impairment, and documented verbal behaviors and rejection of care every day during the review period. The PASRR Level I evaluation dated 10/01/2025 reflected dementia as the primary diagnosis and no mental illness. During observation, the resident stated she knew someone was killing children and putting poison in their breakfast cereal, and she did not respond to redirection. The LG stated she had never thought about PASRR services for the resident, and the MDSN stated she had not reviewed the chart to determine whether a PASRR referral was needed.

Penalty

Inspection fine: $22,920

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 comprehensive person-centered care plan for Resident #73 that included measurable objectives and timeframes to meet his identified medical, nursing, mental, and psychosocial needs. Resident #73 was admitted with diagnoses including type 2 diabetes mellitus, COPD, emphysema, muscle weakness, gait and mobility abnormalities, lack of coordination, cognitive communication deficit, dementia, schizoaffective disorder, and PTSD. His admission MDS dated 12/29/2025 reflected a BIMS score of 10, indicating moderate cognitive impairment, and stated he did not use tobacco. However, the care plan dated 05/20/2026 included a focus that he uses tobacco with interventions to educate the resident/family on tobacco risks and provide support, despite the MDS indicating he did not use tobacco. Observation and interview on 05/19/2026 showed Resident #73 in bed stating he had only a few teeth and wanted dentures so he could eat better; he displayed only three visible teeth on the top row. Later that day, he was observed smoking in the outdoor smoking area without obvious hazard while supervised by four staff members. During interviews, staff stated smoking residents were supposed to have a smoking safety evaluation, but the MDS nurse said she did not think there was a process for a resident who entered as a nonsmoker but later started smoking. She also stated that dental problems should have been care planned under nutrition. The administrator stated a smoking safety assessment should be completed for all smokers within 72 hours of admission and that smoking observed after admission should prompt care plan updates, but he did not know how compliance was monitored. The care plan also included a nutrition focus dated 01/07/2026, but it did not address the resident’s compromised oral/dental status despite his report that he wanted dentures to eat better.

Penalty

Inspection fine: $22,920

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

Summary

The facility failed to provide or obtain routine dental services for Resident #73 and did not offer him dental services or refer him to a dentist. Resident #73 was a male admitted to the facility with diagnoses including type 2 diabetes mellitus, COPD, emphysema, muscle weakness, gait and mobility abnormalities, lack of coordination, cognitive communication deficit, dementia, schizoaffective disorder, and PTSD. His admission MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and documented abnormal mouth tissue, obvious or likely cavity or broken natural teeth, and inflamed or bleeding gums or loose natural teeth. The clinical record from December 2026 through 05/20/2026 contained nothing related to dental services. During observation, Resident #73 stated he only had a few teeth, wanted dentures so he could eat better, and said he wanted to see a dentist but had not seen one since admission. The ADM later confirmed that Resident #73 had not been referred for dental services and had not seen a dentist since arriving at the facility. The ADM also stated that attempts had been made to have the resident sign consent forms for dental treatment, but the resident was unavailable, and that the resident was entitled to be referred to the dentist.

Penalty

Inspection fine: $22,920

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 infection prevention and control program when CNA C and CNA D provided incontinent care to a resident with type 2 diabetes, chronic kidney disease, muscle weakness, lack of coordination, cognitive communication deficit, and major depressive disorder. The resident’s MDS reflected a BIMS score of 15, indicating intact cognition, and the care plan identified an ADL self-care performance deficit with required ADL care provided by staff. During observation, both CNAs entered the room, washed their hands, and donned disposable gloves before providing peri-care. CNA C removed the soiled brief and cleaned the resident’s front and back with wet wipes, but did not change gloves after direct contact with feces and handled the wet wipe packet with contaminated gloves. She then stored the contaminated packet, along with remaining wipes and other incontinent care items, in the drawer for future use. CNA D observed CNA C touching the wipe packet with contaminated gloves but did not intervene during the observation. The DON later stated that CNA C should not have handled the wipe packet with soiled gloves and that the contaminated packet should have been disposed of immediately rather than saved for future use.

Penalty

Inspection fine: $17,796

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 deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.

Removal Plan

• Notify Medical Director
• Notify Ombudsman
• Conduct ad hoc QAPI
• DON to provide education to trainers regarding abuse and neglect
• Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
• Provide in-service to all nurses involved with admissions process regarding bed rails
• Audit bed rails currently in use
• Inspect bed rails currently in use
• Verify consent on file for all bed rails in use
• Verify order and care plan for all bed rails
• Complete bed rail safety evaluation for all residents with bed rails
• Audit low air loss mattresses currently in use
• Verify order and care plan for all low air loss mattresses in use
• Complete fall risk assessment for all residents with low air loss mattress
• Provide staff education regarding use of enabler/bed rail
• Provide staff education regarding false safety
• Provide staff education regarding low air loss mattress
• Audit admissions for completion
• Audit low air loss mattresses and bedside rails
• Conduct ongoing monitoring for improvement to be reviewed at QAPI

Penalty

Inspection fine: $17,796

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 deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing the use of bed rails and the risk of entrapment for a resident with severe cognitive impairment. The resident was an elderly female with diagnoses including a left femoral neck fracture, severe dementia, repeated falls, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan, focused on ADL self-care performance deficit related to unspecified dementia, only specified staff assistance for bed mobility and encouragement to participate, and did not mention bed rails or any risk of entrapment. The facility obtained a signed bed rail consent form from the resident’s family member, which detailed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment between the rails and mattress or bed components. However, from the time of admission through the period reviewed, there was no documented assessment for bed rail safety, no physician order for bed rails, and no addition of bed rail use or entrapment risk to the resident’s care plan. Maintenance staff reported that bed rails were installed on the resident’s bed at the request of a charge nurse, without a documented work order date and under the assumption that all clinical steps had been completed. The facility’s policy required that alternatives be attempted first, that the IDT assess the resident for entrapment risk, obtain informed consent, verify equipment compatibility, and update the care plan, but these steps were not carried out for this resident prior to installation. The resident was later found unresponsive in the early morning hours, seated on the floor on the right side of the bed with her head and neck positioned between the side rail and the mattress. A CNA reported that the resident had been resting calmly during an earlier round and was later observed partially out of bed with her head pinned between the assist bar and the mattress. The LVN responding to the CNA’s report observed the resident in a sitting position off the mattress with her head resting between the side rail and mattress, and CPR was initiated before EMS arrived and pronounced her deceased. The county medical examiner reported bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress that, while initially leaving little space between the mattress and rails, could be compressed enough to create significant space between the mattress and rails.

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 immediately notify a resident's representative after the resident experienced an unwitnessed fall that resulted in injury and had the potential for requiring physician intervention. The resident, an elderly male with diagnoses including unspecified dementia, hypertension, congestive heart failure, and metastatic prostate cancer, had a history of falls and was assessed as having moderately impaired cognition. On the day of the incident, the resident was found on the floor of his restroom after standing up from the toilet and experiencing weakness in his legs, leading to a fall. The nurse on duty assessed the resident, noted multiple skin tears, and initiated fall protocol and neurochecks. The nurse notified the on-call nurse practitioner and the assistant director of nursing but did not notify the resident's family member or representative. The resident's family member, who was listed as the emergency contact, was not informed of the fall by the facility. Instead, the family member learned of the incident directly from the resident the following morning, who described the fall and his pain. When the family member contacted the facility, the nurse confirmed the fall had occurred the previous day. Interviews with facility staff, including the LVN, RN, DON, ADON, and administrator, revealed that the expectation was for the family or emergency contact to be notified of any significant change, such as a fall, regardless of the resident's status as their own responsible party. The staff member involved stated she did not notify the family because she believed the resident was his own responsible party. Review of facility policies and in-service training materials confirmed that both the provider and the resident's representative should be notified of a fall, with documentation of the date and time of notification. The failure to notify the resident's representative was inconsistent with facility policy and staff training, as well as the expectations of facility leadership.

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 staff consistently honored residents' rights to privacy and dignity by not knocking on residents' doors before entering their rooms. During observations, a CNA was seen entering the rooms of three residents without knocking. Interviews with two of these residents confirmed that staff did not always knock before entering, and both expressed irritation and a desire for staff to knock consistently, especially when their doors were closed or when they were changing. The residents involved had significant medical histories, including heart disease, cognitive communication deficits, dementia, muscle wasting, and other chronic conditions. Their cognitive abilities ranged from moderate to severe impairment, as indicated by their BIMS scores. Despite these challenges, the residents were aware of and affected by the lack of respect for their privacy. Interviews with the CNA, DON, and ADM revealed that all staff had been trained on the policy requiring staff to knock before entering residents' rooms, regardless of the residents' cognitive status, except in emergencies. The staff acknowledged the importance of this practice for maintaining residents' privacy and dignity, and management reported that compliance was monitored through rounds and in-service training. However, the deficiency occurred because the policy was not consistently followed, and staff could not explain why the required action was omitted.

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 prepare and serve food in a manner that conserved nutritive value, flavor, and appearance for the majority of its residents. Observations revealed that food, including vegetables for various diets, was prepared as early as 2 hours and 45 minutes before meal service and held in shallow, uncovered pans on the stove for extended periods. Test trays for both regular and pureed diets were found to be at low temperatures and described as bland in flavor. Pureed foods were served with visible lumps, requiring chewing, which is inconsistent with prescribed dietary guidelines. Food temperatures recorded during meal service were often below recommended serving temperatures, with some items as low as 88 to 99 degrees Fahrenheit. Multiple residents reported dissatisfaction with the food, citing issues such as cold temperatures, lack of flavor, and insufficient variety. Interviews with residents and a confidential group interview indicated that complaints about cold and unappetizing food were consistent and ongoing. Staff interviews confirmed that food preparation often began several hours before service, and that food was sometimes left sitting in hallways before being served, contributing to the temperature issues. Despite repeated complaints documented in Resident Council meeting minutes and grievance logs, the facility did not address the concerns effectively, and the same issues persisted over several months. The facility's own Diet and Nutrition Care Manual specified that pureed foods should not contain visible lumps and should not require chewing, yet observations and test trays contradicted these standards. Staff interviews revealed a lack of clear communication and follow-through regarding resident complaints, with dietary management unaware of the extent of dissatisfaction. The ongoing failure to prepare and serve food at safe and appetizing temperatures, with appropriate flavor and texture, was directly observed and corroborated by resident and staff interviews, as well as facility documentation.

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 medication cart located on the 200 hall, assigned to a medication aide (MA-A), was observed to be unattended and unlocked for approximately 10 minutes, making medications accessible to residents. Multiple staff members walked past the unlocked cart without securing it. The facility's policy requires medication carts to be locked at all times when unattended, and this was confirmed in interviews with the medication aide, a registered nurse (RN-C), the Director of Nursing (DON), and the administrator (ADM). Each staff member acknowledged the importance of keeping the cart locked to prevent unauthorized access to medications. The facility's policy, as reviewed, states that medications and biologicals must be stored safely, securely, and properly, with access limited to authorized personnel. The failure to lock the medication cart resulted in medications being accessible to residents and others, contrary to facility policy and accepted professional standards. No specific residents were identified as having accessed the medications during the incident.

Penalty

Inspection fine: $10,761

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 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The incident involved a male resident with a history of age-related physical debility, repeated falls, muscle wasting, and a history of stroke and heart attack. The resident was found on the ground in the dining room and remained there for over an hour and a half without being assessed by a nurse. There was no nursing documentation or incident report created by the responsible RN. The resident had a severely impaired cognition as indicated by a BIMS score of 00 and required substantial assistance with mobility. Despite being at risk for falls, the resident was not assessed after being found on the floor, and no vital signs or neuro checks were conducted. The resident's family members eventually arrived and assisted him to bed without any staff intervention or assessment. The RN claimed the resident was combative, which prevented an assessment, but this was contradicted by family members who stated the resident was not aggressive. The lack of assessment and documentation was a significant oversight, as the resident passed away approximately eight hours later. The facility's policies on fall management and incident reporting were not followed, as no physical assessment was completed, and no incident report was filed. This failure resulted in the identification of an Immediate Jeopardy situation, highlighting the risk of residents not receiving necessary medical care.

Penalty

Inspection fine: $10,761

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

Summary

The facility failed to ensure a safe environment for Resident #1, who was able to elope from the facility through an emergency exit door. This incident occurred after CNA C used the exit code to the emergency door, which was not supposed to be used except in emergencies. The door was not properly latched, allowing Resident #1 to leave the facility unnoticed. The resident was later found at a gas station by LVN B, who did not stay with him until assistance from the facility arrived. The resident was eventually taken to the hospital, where he tested positive for cocaine. Resident #1 was a male with multiple diagnoses, including type II diabetes, schizophrenia, and acute kidney failure. He had a moderate cognitive impairment and used a wheelchair. Despite being assessed as a low risk for elopement, he had expressed a desire to leave the facility on several occasions. His care plan included monitoring for behavior episodes, but there was no indication of exit-seeking behavior prior to the incident. The facility's failure to secure the emergency exit and provide adequate supervision placed Resident #1 at risk for unsafe elopement, dehydration, and hospitalization. The incident highlighted lapses in staff adherence to protocols regarding emergency exits and supervision of residents, particularly those with a history of leaving facilities against medical advice.

Penalty

No penalty information released

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

Summary

The facility failed to thoroughly investigate an alleged verbal abuse incident involving two residents. Resident #1 accused Resident #2 of making sexual comments, which led to Resident #1 throwing a cup of cold water on Resident #2. Despite the incident being documented by LVN A and reported as a resident-to-resident incident, the allegation of verbal abuse was not investigated as required by the facility's policy. Resident #1, who has a moderate cognitive impairment, reported the incident to LVN A, who documented it in the progress notes and completed an incident report. However, the Director of Nursing (DON) and the Administrator (ADM) were not informed of the nature of the incident, specifically the alleged verbal abuse. The DON was unaware of any aggressive behavior or sexual comments, and the ADM was not informed of the incident's details, which prevented the initiation of an investigation. The facility's policy mandates that all abuse, neglect, and exploitation (ANE) allegations be reported immediately to the Administrator. The failure to report and investigate the verbal abuse allegation could place residents at risk and prevent the facility from taking corrective actions to prevent further abuse, neglect, and exploitation. The incident was not discussed in the stand-up meeting, and the Psychologist noted that Resident #1 did not display signs of fear or recall the incident, attributing any paranoia to her dementia.

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 an effective discharge planning process for a resident, which focused on the resident's discharge goals and included regular re-evaluation to identify changes requiring modification of the discharge plan. The resident, a male with diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, aphasia following cerebral infarction, and depressive episodes, expressed a desire to move to a specific local nursing facility. Despite having a BIMS score indicating intact cognition and being his own responsible party, the facility did not have a discharge plan in place for him. The social worker (SW) was aware of the resident's wish to transfer but had not documented any efforts in the electronic medical record (EMR). Instead, she kept a notebook with notes on her attempts to contact the desired facility. The SW was under the impression that the resident's family, who were only listed as emergency contacts, might be involved in decision-making, although the resident was his own responsible party. The SW had not reached out to the family or sent any clinical documents to the other facility, as she was waiting for a response from them. The SW's caseload was not considered large, yet she had not documented her efforts or progress in the EMR. The Director of Nursing (DON) and the Administrator (ADM) were aware of the resident's desire to move, but the ADM was unsure about the resident's Medicaid status, which he thought might be delaying the referral process. The facility's policy required the discharge planning process to focus on the resident's goals and involve them as active partners, but this was not adhered to in this case. The lack of documentation and communication regarding the resident's discharge planning placed him at risk of not having a plan to address his post-discharge needs.

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 have the results of the most recent survey posted in a place readily available to residents, family members, and legal representatives. During an observation, a binder labeled 'Survey Results' was found on a table at the entrance of the facility. This binder contained survey results dating back to 2021 but did not include the results from the most recent full recertification survey conducted from 02/06/24 to 02/08/24. The binder did contain a Notice of Accepted Plan of Correction Form referencing the full recertification survey dated 02/08/24. This omission was confirmed during an interview with the administrator, who had recently started working at the facility and was unsure of the exact date he had requested the survey results. Confidential interviews with four residents revealed that they were interested in knowing the results of State Agency investigations. One resident expressed a desire to see the results before entering the facility to determine if it was a safe place to live. Another resident felt that knowing the survey results was important to understand what was happening in their home and to see if others were experiencing similar issues. The administrator acknowledged that making the survey results available was his responsibility and recognized that residents might be more outspoken about their problems if they could see that others had similar issues documented in the survey results.