Continuing Care At Highland Springs

Penalty

Inspection fine: $46,105

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 ensure a resident with significant behavioral health needs received necessary behavioral health care and services in accordance with her assessment and care plan. The resident was an older female with bipolar disorder, recurrent major depressive disorder with psychotic symptoms, vascular dementia with psychotic disturbance, anxiety disorder, and epilepsy. Her MDS showed a BIMS score of 14, indicating little to no cognitive impairment, and documented depressive symptoms several days in the prior two weeks. Her care plan identified depression related to a family member’s death, lack of closure, perceived lack of money, limited family visits, and feeling confined to her room, with signs including poor appetite, trouble sleeping at night, and sleeping in. The care plan also documented suicidal ideations and interventions such as listening, providing comfort, and communication to promote mental and psychological well-being, with the social worker identified as her mental health professional. The resident had a history of suicidal behavior and ideation while at the facility. Progress notes documented that on one occasion she wrapped a draw sheet around her neck, stated she wanted to die and join her deceased family member, and an order was obtained to keep a close eye on her every 15 minutes. On another occasion, she approached a nurse stating she was feeling suicidal, was looking for a bottle of pills to take, and did not care anymore; she also told police she would use a light bulb to cut herself, and she was transported to a hospital. The care plan reflected prior hospitalizations at behavioral health facilities, and interviews with the DON, Administrator, and family confirmed multiple inpatient behavioral health stays and a prior suicide attempt at the facility involving a bedsheet around her neck. Despite this history, record review of the electronic health record on the date of her death showed no evidence that she was receiving behavioral health services at the time of her suicide. In the period leading up to the fatal event, staff continued to observe depressive symptoms and suicidal ideations. A social worker note documented that the resident stated she wanted to die, felt she was a disappointment, did not want to do anything, and did not want to eat, though she denied a plan and said she would not harm herself; the physician was notified, and the resident had a private caregiver with her daily from 2:00 PM to 4:00 PM. An LVN reported that for months after the resident’s third behavioral health facility stay, the resident continued to express suicidal ideations, slept all day, and often said she was sad; the LVN stated she reported these ongoing suicidal ideations to the medical director and DON, but the resident was not sent back to a behavioral health center. The facility instead increased activities and relied on counseling by the social worker, although the social worker reported that for the last six months the resident refused to speak with her and was not seeing another therapist. On the day before the resident’s death, an LVN documented that the resident produced an unopened bottle of diphenhydramine (Benadryl) from her drawer, and the nurse locked it in the medication cabinet and administered a provider-ordered dose; the next morning the resident was found unresponsive with pink emesis and two diphenhydramine bottles at the bedside, one almost empty, and hospital records indicated concern for an intentional overdose. Interviews and record review confirmed that, at the time of this lethal ingestion, the resident was not receiving behavioral health services despite her ongoing suicidal ideations and documented history of depression and prior suicide attempts. The facility’s own suicide threats policy required immediate reporting of suicide threats to a licensed nurse, leadership, and campus dispatch, continuous staff presence with the resident until a licensed nurse or provider arrived, and interdisciplinary assessment and care plan revision after such incidents. While some prior suicidal episodes resulted in hospital transfers and temporary 1:1 sitters, the ongoing expressions of suicidal ideation over several months after the last behavioral health discharge were not accompanied by documented behavioral health services or further inpatient evaluation. Staff interviews revealed that personal sitters and CNAs were aware of the resident’s depression and sleep patterns but did not consistently report suicidal ideations to the social worker, who stated she was not informed of continued suicidal ideations. The combination of a known history of suicide attempts, repeated suicidal statements, refusal of counseling, and lack of active behavioral health services at the time of the event formed the basis of the deficiency, culminating in the resident’s ingestion of a lethal dose of diphenhydramine and subsequent death.

Removal Plan

• Staff initiated emergency response procedures when Resident #1 was found vomiting and convulsing with an almost empty bottle of Benadryl at bedside.
• Nursing staff completed a 100% room sweep of all skilled nursing residents' rooms to ensure no outside or unauthorized medications were present in residents' rooms.
• Send a communication to all family members of skilled nursing regarding the facility medication policy for outside medications and send monthly for the next three months.
• Add communication on the facility policy for outside medications to the admission packet for all new residents.
• Director of Nursing initiated interviews with all staff that cared for Resident #1 in the past week to confirm whether any signs or changes in resident mood or suicidal ideations were observed.
• Reinforce that suicide threats are to be taken seriously and immediately reported to the licensed nurse, clinical leaders, campus dispatch and/or administration.
• Staff must immediately report suicidal threats to the licensed nurse.
• The licensed nurse must immediately notify CC Leadership on Call and campus dispatch.
• Administration/nursing administration with the medical provider will determine appropriate interventions including potential 1:1 supervision and potential need for emergency/acute care evaluation/treatment.
• The interdisciplinary team will assess actions/expressions as soon as possible to determine needed interventions and revise care/service plans.
• Documentation must be recorded in the medical record and an incident report completed.
• Director of Nursing or designees will conduct wellness interviews of all interviewable residents using PHQ-9 questions #1, #2, and #9 to assess for immediate signs of depression, depression symptoms, and/or thoughts of self-harm.
• Residents with concerning responses will have appropriate interventions implemented immediately including provider notification and psychiatric referral.

Penalty

Inspection fine: $46,105

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 with measurable objectives and specific interventions to address a resident’s identified suicidal ideations and significant mental health history. The resident was an older female with bipolar disorder, recurrent major depressive disorder with psychotic symptoms, moderate vascular dementia with psychotic disturbance, anxiety disorder, and epilepsy. Her MDS showed a BIMS score of 14, indicating little to no cognitive impairment, and documented that she felt down, depressed, or hopeless on several days in the prior two weeks. The care plan noted prior behavioral health hospitalizations and that she would exhibit or express depression related to the death of a family member, lack of closure, financial concerns, limited family visits, and feeling confined to her room. Signs and symptoms of depression such as poor appetite and sleep disturbance were documented, and the care plan stated she would speak with the social worker if she needed counseling, identifying the social worker as her mental health professional. The resident’s care plan also documented that she had suicidal ideations, but the interventions listed were limited to listening and providing comfort when she was confused and agitated and communicating in a manner that promoted mental and psychological well-being. Despite multiple serious episodes indicating active suicidal ideation and behavior, the care plan was not revised to include more specific, measurable, and individualized interventions. Progress notes showed that on one occasion a CNA reported the resident had wrapped a draw sheet around her neck, stated she wanted to die and join her husband, and the MD ordered close observation every 15 minutes. On another occasion, the social worker documented that the resident stated she wanted to die, although she denied a plan and said she would not harm herself; the physician was notified and it was noted she had a caregiver with her for two hours daily. Later, the resident directly approached an LVN stating she was feeling suicidal, was looking for a bottle of pills to take, and did not care anymore; she also told police she would use a light bulb in her room to cut herself, leading to her being sent to the hospital. After these events, the care plan for suicidal ideation was not updated with detailed, resident-specific safety measures or clear, measurable objectives and timeframes. The DON stated that each department was responsible for its portion of the care plan, that the MDS coordinator was new and in training, and that there was no clinical manager for approximately two weeks, during which time he was responsible for care plans. The DON believed the existing interventions were appropriate and thought the resident was following them by attending activities and speaking with the social worker, so no additional interventions were added until after surveyor inquiry. The Administrator reported that the resident had been sent to behavioral health facilities multiple times and had previously been found with a bedsheet around her neck after a suicide pact with her husband, and that a 24-hour sitter had been reduced to two hours daily at the resident’s request. The Administrator and Medical Director both believed the resident had long-standing depression and had declined or refused some offered help, and the social worker reported that staff had not informed her of the resident’s continued suicidal ideations and that the resident had refused to speak with her for the last six months. Ultimately, EMS later found the resident unresponsive with an empty and a partially empty bottle of Benadryl at bedside, with multiple seizures en route to the hospital, and she was pronounced dead; family and EMS expressed concern that she may have intentionally overdosed, and surveyors determined that the facility had failed to develop and implement a comprehensive care plan with adequate, measurable interventions for her suicidal ideations.

Removal Plan

• Staff initiated emergency response procedures when Resident #1 was found vomiting and convulsing with an almost empty bottle of Benadryl at bedside.
• Director of Nursing initiated interviews with all staff who cared for Resident #1 to determine whether any signs or changes in mood or suicidal ideations were observed.
• Director of Nursing (or designee) will conduct wellness interviews of all interviewable residents using PHQ-9 questions #1, #2, and #9 to assess for depression symptoms and/or thoughts of self-harm; any concerning responses will trigger immediate interventions including provider notification, psychiatric referral, and care plan updates.
• Social worker (or designee) will visit residents with concerning PHQ-9 responses and reassess ongoing visit needs.
• Social worker/nursing will conduct wellness interviews of non-interviewable residents using PHQ-9 questions #1 and #2 (staff observation); any concerning responses will trigger immediate interventions including provider notification, psychiatric referral, and care plan updates.
• Regional Director of Clinical Operations completed a 100% audit of MDSs, confirming zero residents answered 'yes' to thoughts of being better off dead.
• Regional Director of Clinical Operations completed a 100% audit of MDSs with depressive symptoms.
• Director of Nursing (or designee) will conduct an audit of all current resident care plans to validate measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs identified in the comprehensive assessment; discrepancies will be corrected promptly.
• Director of Health Services Education and Training will train the Staff Development Coordinator (and/or designee) on the policy for comprehensive person-centered care plans with measurable objectives, timeframes, and interventions addressing mental health needs.
• Staff Development Coordinator (and/or designee) will educate all leadership and licensed nurses on the facility policy for comprehensive person-centered care plans with measurable objectives, timeframes, and interventions addressing mental health needs; training will be documented on a Management Training Roster maintained by NHA/HR; retraining will occur annually.
• Employees not trained due to absence, schedule rotation, or other factors will be removed from the schedule until required training is completed and documented.
• Standard operating procedures for handling unauthorized outside medications and required actions if noted in resident rooms will be incorporated into ongoing new-hire orientation for all licensed nurses and nurse managers.
• Identified at-risk residents will be reviewed during clinical meeting to assess for changes in depressive symptoms and/or suicidal ideations.
• Social worker (or designee) will perform wellness interviews using PHQ-9 questions #1, #2, and #9 with a randomized sample of residents; any identified concern will trigger immediate interventions including provider notification, psychiatric referral, care plan updates, and safety measures.
• Social worker will conduct wellness interviews of non-interviewable residents using staff-observation PHQ-9 questions #1 and #2.
• Director of Nursing (or designee) will conduct an audit of all newly admitted residents to confirm PHQ-9 assessments were completed and appropriate care plan interventions were implemented.
• Director of Nursing (or designee) will audit all current resident care plans to validate measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs; discrepancies will be corrected promptly.
• Director (or designee) will conduct an audit of all newly admitted residents to validate care plans include measurable objectives, timeframes, and interventions addressing mental health and psychosocial needs to prevent serious harm or death.
• Audit findings will be reviewed during QAPI meetings; additional audits and education will be determined based on findings.

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 comprehensive person-centered care plans with measurable objectives and timeframes for three residents whose assessments identified medical, nursing, mental health, and psychosocial needs. For Resident #5, the annual MDS reflected severely impaired cognitive function with diagnoses including Alzheimer’s Disease and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. Her mood assessment showed poor appetite or overeating and self-isolating, and she was receiving Sertraline 100 mg daily for depression, but her comprehensive care plan dated 06/07/2025 did not include goals or interventions related to depression, Alzheimer’s Disease, associated behaviors, or the psychotropic medication. Resident #7’s admission MDS reflected intact cognitive function with diagnoses of Major Depressive Disorder, recurrent, severe with psych symptoms, and anxiety disorder. Her mood self-assessment showed feeling down, depressed, or hopeless over the prior 2 weeks, and her active orders included Zoloft 25 mg daily for depression and Abilify 2 mg daily for depressive psychosis with delusion. Her comprehensive care plan dated 07/22/2025 did not reflect any goals or interventions related to depression, anxiety, or the use of Zoloft and Abilify. Resident #33’s quarterly MDS reflected mild cognitive impairment with a diagnosis of Major Depressive Disorder, Single Episode, Unspecified. Her mood self-assessment showed feeling down, depressed, or hopeless and self-isolating, and she was prescribed Lexapro 5 mg daily. Her care plan dated 05/22/2025 did not include goals or interventions related to depression or Lexapro. The Clinical Manager stated that the holistic admission assessment serves as the baseline care plan and that the comprehensive care plan should include items such as antipsychotics, antidepressants, insulin, anticoagulants, and psychotropics. The ADON stated that antidepressants and antipsychotics must be reflected in care plans so the team can monitor effectiveness and determine whether dosage adjustments may be needed.

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

Resident #27, who had diagnoses including hypertensive heart disease with heart failure, presence of a cardiac pacemaker, reduced mobility, peripheral vascular disease, and lymphedema, was assessed as cognitively intact with a BIMS score of 15. Her physician orders for September 2025 included Carvedilol, Potassium Chloride 20 mEq ER, Aspirin 81 mg ER, Chlorthalidone, Thera M-plus with iron, Systane eye drops, and Amlodipine. The care plan directed staff to administer medications per orders and monitor for side effects. During observation, LVN A crushed and administered together medications that included Potassium Chloride 20 mEq ER and Aspirin 81 mg ER, both marked not to crush. In interview, LVN A stated she had been in-serviced on medication administration and the five rights, and acknowledged she was not supposed to crush medications that were ER or labeled not to crush, stating she did not realize these medications were extended release. The DON stated the staff had been in-serviced on medication administration and confirmed that extended-release medications were not supposed to be crushed.

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. During observation of the freezer on 09/09/24 at 9:23 AM, surveyors found 1 tub of ice cream with the lid open and exposed to air, 1 box of pie crust shells open and exposed to air, and 1 box of biscuits open and exposed to air. In an interview on 09/09/2025 at 9:45 AM, the Chef stated she had been unaware that some boxes were open and exposing food to air. She said she did not know how to address the issue, had not realized it was a problem, and was new to the position, still in training, and unsure about the facility's procedures. The Dietary Manager stated on 9/10/2025 at 2:00 p.m. that she oversaw all kitchen operations and expected all frozen foods to be wrapped, covered, or sealed once opened, but nightly kitchen checks were not documented. Review of the facility policy titled Standard Operating Procedure for Food and non-food storage, dated 04/2024, showed the policy did not have guidelines for opened foods stored in the freezer.

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 residents and their representatives with information on their rights related to filing grievances or concerns. This deficiency was identified through observations, interviews, and record reviews, which revealed that the facility did not make information available to residents or their representatives about who the grievance official was, their contact information, how to file an anonymous grievance, or their right to obtain a written decision regarding their grievance. This lack of information was observed for three residents, who were unaware of the grievance procedures and had not been educated on the facility's policies. Resident #1, a female with chronic diastolic heart failure, scoliosis, major depressive disorder, and anxiety disorder, had a moderately impaired cognition with a BIMS score of 10. She expressed that she had concerns in the past but was unsure of whom to report them to, relying instead on a family member. Resident #2, with aphasia, major depressive disorder, and chronic kidney disease, had no cognitive impairment with a BIMS score of 15. She also did not know the grievance official or how to file a grievance anonymously. Resident #3, with major depressive disorder and aphasia, was similarly unaware of the grievance procedures and expressed frustration due to communication difficulties. Interviews with staff members, including a CNA, LVN, Unit Manager, DON, Social Worker, and Administrator, revealed inconsistencies in their understanding of the grievance process and the identity of the grievance official. The facility's admission agreement and grievance policy did not clearly identify the grievance official or provide detailed information on filing grievances anonymously. Observations of the facility confirmed the absence of postings related to grievance procedures, further contributing to 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 coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for four residents, as identified in the report. The deficiency was noted during interviews and record reviews, where it was found that the facility did not transcribe or submit the PASARR Level 1 Screenings (PL1s) to the LTC Online Portal for these residents. This oversight could potentially place residents eligible for PASARR services at risk of not receiving necessary services. The report details the medical conditions of the residents involved. For instance, one resident was admitted with diagnoses including Major Depressive Disorder, Legal Blindness, and Chronic Obstructive Pulmonary Disease, with a BIMS score indicating moderately impaired cognition. Another resident had diagnoses such as Major Depressive Disorder, Aphasia, and a history of Transient Ischemic Attack, with no cognitive impairment. Despite these conditions, the facility did not ensure the PL1 screenings were uploaded to the LTC Online Portal, which is a crucial step in coordinating necessary services. Interviews with facility staff, including the Director of Nursing (DON), MDS Nurse, and Administrator, revealed a lack of awareness and responsibility regarding the PASARR process. The DON and MDS Nurse acknowledged that the PL1 screenings were completed and placed in residents' hard charts but were not uploaded to the portal. The Administrator admitted to being unsure of the PASARR requirements and confirmed that the facility did not have a designated person to oversee the PASARR procedures. This lack of coordination and oversight contributed to the deficiency identified in the report.

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 accurately submit PASARR Level 1 (PL1) screenings for residents with diagnoses of mental illness, intellectual disability, or developmental disability. Specifically, the facility did not submit correct PL1 screenings for three residents upon admission, despite their active diagnoses of Major Depressive Disorder. Additionally, the facility did not submit a new PL1 screening for a resident who was diagnosed with Major Depressive Disorder during their stay. These failures were identified for four residents reviewed for PASARR screenings. The report details that Resident #5, Resident #7, and Resident #8 were admitted with active diagnoses of Major Depressive Disorder, yet their PL1 screenings incorrectly indicated no evidence of mental illness. Furthermore, the facility did not transcribe or submit these PL1 screenings to the LTC Online Portal, nor did they correct the PL1s to reflect the residents' actual diagnoses. Similarly, Resident #3, who was diagnosed with Major Depressive Disorder during their stay, did not have a new PL1 screening submitted, and their existing PL1 screening inaccurately indicated no evidence of mental illness. Interviews with facility staff revealed a lack of awareness and understanding of PASARR requirements and processes. The MDS nurse admitted to not uploading any PL1s to the LTC Online Portal and not auditing them for accuracy. The Administrator also expressed uncertainty about PASARR requirements and confirmed that the facility did not have a designated person overseeing PASARR procedures. The facility's policy stated that a positive Level 1 screen should lead to a Level 2 evaluation by the local mental health agency, but this process was not being followed due to the inaccuracies in the PL1 screenings.

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 units, Pod 1 and Pod 2. Observations revealed that mechanical lifts on both pods were left unlocked and unsecured when not in use, posing a risk of injury to residents and staff. Additionally, a wheelchair was found unlocked in the common area of Pod 1, and razors were discovered unsecured in a wheeled supply cart on Pod 2. These lapses in securing equipment and supplies were confirmed through interviews with various staff members, including LVNs, CNAs, the Unit Manager, the DON, and the Administrator, all of whom acknowledged the risks associated with improperly stored equipment. The staff interviews highlighted inconsistencies in the storage practices for mechanical lifts, wheelchairs, and razors. LVN B and LVN A indicated that mechanical lifts should be stored in the facility's Spa Room or at the end of hallways, while wheelchairs should be kept in residents' bathrooms or a separate room when not in use. Razors were supposed to be locked in the facility's storage room. The Unit Manager and DON reiterated the importance of locking and securing all equipment to prevent potential injuries. Despite these protocols, the facility did not provide a policy related to the storage of mechanical lifts, wheelchairs, or razors, indicating a lack of formalized procedures to ensure compliance with safety standards.

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 palatable food for residents during two of the four meals reviewed, specifically the lunch meal on 08/01/24. Observations revealed that the pureed lunch tray contained mashed potatoes and roast beef that were bland and had a thick texture, while the root vegetable soup was overly salty. The mechanical lunch tray included roast beef that was dry and resembled breadcrumbs, and carrots that were not properly chopped. Interviews with staff indicated that water was added to the puree recipe without proper training, which altered the taste and potentially the nutritional value of the meals. The facility did not have a specific recipe for puree diets, and the kitchen staff did not taste the food for palatability before serving. The Dietary Manager and Dietician confirmed the lack of flavor and inappropriate texture of the meals, and the Sous Chef mentioned limitations on using sodium-enhanced seasonings. The facility's policy on texture-modified diets was not followed, as the meals did not meet the expected consistency and flavor standards. The Administrator acknowledged the expectation for meals to be served warm and per diet orders but did not taste the food served on the day of the deficiency. The facility's failure to adhere to its own policies and ensure proper training and food preparation practices led to 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 adhere to professional standards for food service safety, as observed during an inspection of the kitchen. The inspection revealed several issues with food storage and labeling. Inside the large freezer, a silver pan of pink shrimp was found on a sheet pan, covered only with parchment paper and labeled with a fluorescent green label dated the same day as the inspection. Additionally, an open box of celery and green bell peppers was found on the bottom shelf, and an open container of unsealed fruit cups was in the refrigerator. Three large white containers on the floor, containing loose sugar, brown rice, and flour, were ajar, unlabeled, and had white measuring scoops inside them. The ice machine had dust on its side vents, and a stained towel was observed on the beverage dispenser grate. Interviews with the kitchen staff, including the Dietary Manager and the Sous Chef, highlighted a lack of awareness and adherence to proper food storage protocols. The Dietary Manager acknowledged the potential risk of food-borne illness due to improperly sealed, labeled, and dated food. The Sous Chef admitted to being unaware that vegetables should not be stored in open boxes and was instructed to discard the shrimp due to its planned use in an upcoming meal. The Sous Chef also recognized the potential harm to residents from consuming improperly stored food, which could lead to sickness and airborne illnesses. The facility's policies and procedures for food storage and sanitation were reviewed, revealing specific guidelines for storing perishable and non-perishable items, as well as cleaning protocols for dining venues and equipment. These policies emphasize the importance of maintaining sanitary conditions and proper labeling to prevent contamination. However, the observed practices in the kitchen did not align with these established standards, indicating a gap between policy and practice.

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 a resident with a suitable mobility device, which hindered her independence and participation in social activities. The resident, who had a history of chronic diastolic heart failure, scoliosis, major depressive disorder, and anxiety disorder, expressed discomfort with her current power wheelchair and two manual wheelchairs provided by the facility. Despite her requests and the facility's awareness of her discomfort, no alternative mobility devices were offered, leading to her isolation and inability to engage in activities she enjoyed. The resident's care plan emphasized her desire to maintain independence and participate in social activities, yet she was confined to her room due to the lack of a comfortable mobility device. Physical and occupational therapy evaluations noted her difficulties with wheelchair mobility and her preference to avoid prolonged bed rest. Despite these assessments, the facility did not take adequate steps to address her needs, resulting in her feeling confined and isolated. Interviews with facility staff, including the Therapy Manager, Social Worker, CNA, and DON, revealed a lack of communication and action regarding the resident's mobility needs. The Therapy Manager acknowledged the resident's discomfort with the power wheelchair but did not pursue alternative solutions. The Social Worker and DON were unaware of other available mobility devices, and the CNA did not report the resident's needs to the charge nurse. This lack of coordination and response contributed to the resident's continued isolation and unmet psychosocial 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 provide necessary assistance for a resident who was unable to perform activities of daily living, specifically in maintaining personal hygiene and dignity. The resident, a male with a history of heart failure, arthritis, and chronic kidney disease, required maximum assistance with toileting due to moderately impaired cognition. On a particular morning, the resident had to wait over an hour for assistance, resulting in him soiling himself. This incident occurred because the CNA assigned to him prioritized other tasks and did not check on him promptly. The resident expressed feelings of neglect and a lack of care from the staff. Interviews with staff revealed systemic issues in the facility's response to call lights and shift change procedures. The CNA admitted to not knowing if the resident had called for help and acknowledged that residents were not checked at shift changes. The Clinical Manager noted that the resident had pressed the call light multiple times with significant wait times, indicating a lack of timely response. The DON confirmed that residents should be checked every two hours and that call lights should be answered promptly. Despite these expectations, the facility's practices did not align, leading to the resident's loss of dignity and potential risk for falls.