Deerbrook Skilled Nursing And Rehab Center

Penalty

Inspection fine: $118,500

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 resident was free from neglect when wounds present on admission were not fully identified, reported, or treated for 12 days. The resident had severe cognitive impairment, was dependent on staff for all ADLs, and had multiple diagnoses including sepsis, malnutrition, dementia, legal blindness, COPD, anemia, muscle wasting, heart disease, acute kidney failure, and traumatic brain hemorrhage. The resident’s admission assessment documented a high risk for pressure ulcers, and the hospital record showed wounds present on original admission, including a pressure injury to the right posterior hip and a pressure injury to the left lateral foot. The record showed that only the left lateral foot wound had treatment orders early on, while there were no additional treatment orders for the other wounds until later. The facility’s admission progress note documented a DTI to the right hip and left outer foot, but the comprehensive skin assessment was not completed promptly after admission. The wound care nurse later documented additional wounds, including an unstageable DTI of the right medial heel, a stage 4 pressure wound of the left hip, a stage 3 pressure wound of the right sacrum, and an unstageable necrotic wound of the scrotum. The care plan did not include interventions for several of these wounds, and the weekly skin review initially lacked wound details such as type, stage, and measurements. Staff interviews showed breakdowns in communication and follow-through. The primary wound care nurse stated the weekend nurse should have completed a full skin assessment and contacted the physician for wound orders, but that did not happen. The admitting nurse stated she expected the weekend wound care nurse to assess the resident and obtain orders, while the weekend wound care nurse stated she did not recall receiving notification of the new admission and did not recall completing a comprehensive skin assessment. The DON stated the admitting nurse should have conducted the initial head-to-toe assessment and alerted the wound care nurse, and that the wound assessments should have been done as early as possible. The Administrator stated she was not aware of the resident’s wounds until the resident was sent to the hospital via 911 and acknowledged there was a communication failure and missing steps in the resident’s care.

Penalty

Inspection fine: $118,500

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 resident with multiple pressure injuries received timely wound assessment, treatment, and care planning after admission. The resident was admitted with severe cognitive impairment, dependence for all ADLs, malnutrition, anemia, dementia, COPD, heart disease, kidney failure, and sepsis related to suspected skin/soft tissue infection. Admission records noted pressure injuries on the right posterior hip and left lateral foot, and the resident’s Braden score was 12, indicating high risk for pressure ulcers. The admission progress note also documented a DTI to the right hip and a wound to the left outer foot. The record showed that a comprehensive skin assessment and treatment orders were not completed promptly for several wounds. The wound care nurse later documented multiple wounds, including an unstageable DTI of the left lateral foot, an unstageable DTI of the right medial heel, a stage 4 pressure wound of the left hip, a stage 3 pressure wound of the right sacrum, and an unstageable necrotic wound of the scrotum. Treatment orders for these wounds were not obtained until 03/25/26, about 12 days after admission, and additional wound orders for the left ischium and right distal lateral hip were not written until 04/15/26. The weekly skin review completed earlier in the stay documented wounds but did not include details such as wound type, stage, or measurements. The care plan also did not include interventions for several of the wounds that were later identified. Staff interviews showed that the initial full skin assessment was not completed soon after admission as expected. The primary wound care nurse stated the weekend nurse should have completed a full skin assessment the day after admission, but it was not done. The DON stated the admitting nurse should have completed the initial assessment and the weekend wound nurse should have completed the full skin assessment, and that the assessment was not done as early as expected. The wound care nurse, admitting nurse, weekend treatment nurse, MDS nurse, and other staff described gaps in communication and follow-through regarding new admissions, wound identification, and wound orders. The resident was later discharged to the emergency room due to abnormal vital signs, congestion, and blood in the urine. The facility also failed to turn and reposition another resident as required by the care plan. That resident was observed lying supine without repositioning for several hours, and the resident stated she had not been turned all morning and had not been asked to be turned. The CNA stated the resident did not like to be turned because it hurt her back, but the CNA had not told a nurse the resident refused. The nurse stated he was unaware the resident had not been turned and explained that staff were expected to encourage repositioning, document refusals, and notify the family and physician when refusals occurred.

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 appropriate communication and acceptance from the receiving health care institution prior to the transfer of a resident with severe cognitive impairment and aggressive behaviors. The resident, who had diagnoses including muscle wasting, gait abnormalities, muscle weakness, and dementia, was being considered for transfer due to aggressive actions such as kicking, biting, and threatening staff. The social worker submitted a referral to a behavioral hospital, but at the end of her shift, the resident had not yet been accepted. Despite this, the DON facilitated the resident's transfer to a medical center without confirmation of acceptance or proper communication regarding the resident's needs. Upon arrival at the medical center, staff there were unaware of the reason for the transfer and had not been informed of the resident's behavioral issues or need for psychiatric services. The resident was subsequently returned to the facility within a few hours. Interviews with facility staff, including the ADON and Clinical Services Director, confirmed that the transfer was not conducted according to policy, which requires prior acceptance and notification of the receiving facility. The administrator stated she was unaware the transfer occurred without acceptance and emphasized that the expectation is for acceptance to be obtained before any transfer.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including Parkinson's disease, type 2 diabetes, hypertension, anxiety disorder, muscle weakness, and lack of coordination. The resident had moderate cognitive impairment and required setup or clean-up assistance for eating, as indicated in the quarterly MDS assessment. Despite a primary care provider order instructing staff to attempt feeding assistance and elevate the head of the bed during meals, the care plan was not updated to reflect the resident's need for feeding assistance. Observations showed the resident struggling to feed himself, with food spilling and difficulty getting food onto utensils during meals. Interviews with staff revealed a lack of awareness of the provider's order and a breakdown in communication regarding the resident's change in self-feeding ability. The MDS Coordinator was unaware of the order and stated it was the nurses' responsibility to inform her of such changes. Nursing staff acknowledged the resident's need for assistance and the importance of reporting changes to the care team for care plan revision. The facility's policy required care plan updates when there is a significant change in a resident's condition, but this was not followed, resulting in the resident's care plan not reflecting his current 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

A resident with severe cognitive impairment and multiple diagnoses, including non-Alzheimer's dementia, cerebrovascular accident, hypertension, and muscle weakness, was identified as requiring assistance with activities of daily living (ADLs), including personal and oral hygiene. The resident's care plan specified the need for setup or clean-up assistance with oral hygiene and partial/moderate assistance with personal hygiene. During observation, the resident was found in bed with fingernails approximately 0.3 cm long and visibly dirty, containing a brown substance underneath. The resident expressed a preference for long nails but indicated a desire for them to be cleaned. Interviews with staff, including the CSD and the Administrator, confirmed that it was the responsibility of care staff to ensure residents' fingernails were cleaned and trimmed according to their preferences, with nurses responsible for trimming the nails of diabetic residents. The facility's policy required daily cleaning and regular trimming of nails to prevent infections and skin problems. Despite these policies and care plan interventions, the resident did not receive the necessary fingernail care, as evidenced by the observed condition of the nails and staff acknowledgment that care was 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

The facility failed to provide special eating equipment and utensils for a resident who required them, as well as appropriate assistance during meals. The resident, a male with diagnoses including Parkinson's Disease, muscle weakness, lack of coordination, and moderate cognitive impairment, was observed multiple times struggling to get food onto his spoon and experiencing food spillage while eating both in the dining area and in bed. Despite these difficulties, the resident was served meals on a regular plate without any adaptive devices such as a plate guard, and there was no evidence of referral to occupational or speech therapy for assessment of assistive devices. Interviews with staff confirmed that the resident needed assistance with meals and that adaptive equipment, such as a divided plate, would be beneficial. The facility's policy required that residents who could benefit from adaptive devices be provided with them, but this was not followed in the resident's case. The care plan and provider orders did not address the need for assistive devices, and staff acknowledged the risk of inadequate nutrition due to the lack of proper assistance and equipment.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a certified nursing assistant (CNA) failed to follow established infection prevention and control protocols during incontinent care for a resident on Enhanced Barrier Precautions (EBP). The CNA entered the resident's room, which had EBP signage and available personal protective equipment (PPE), and performed incontinent care wearing only gloves but not a gown as required. During the care, the CNA did not change gloves or perform hand hygiene when transitioning from a contaminated to a clean area, contrary to facility policy and the resident's care plan. The CNA later acknowledged understanding the requirements but stated she forgot to wear a gown and to change gloves due to nervousness. The resident involved was an older male with multiple comorbidities, including heart failure, hypertension, diabetes mellitus, and a history of cerebrovascular accident, and was completely dependent on staff for incontinent care. His care plan specified the use of gloves and gowns during high-contact care activities due to the presence of indwelling medical devices and wounds, and to reduce the risk of infection. Facility policies reviewed confirmed the necessity of donning both gown and gloves for such care and performing hand hygiene when moving from dirty to clean tasks. Interviews with facility leadership confirmed these expectations for staff.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all patient care equipment was in safe operating condition for one resident with multiple medical conditions, including Parkinson's disease, hypertension, type 2 diabetes, anxiety disorder, muscle weakness, and lack of coordination. The resident, who had moderate cognitive impairment, was found lying flat in bed and unable to use the bed remote control to elevate the head of the bed as ordered by his primary care provider. The resident reported being unable to eat or sleep since the previous evening due to the malfunctioning bed, and staff observations confirmed that the bed remote was not working. The bed was also noted to be in the highest position, and the resident refused care because of the broken bed. Staff interviews revealed that while the issue was reported by the midnight nurse and logged in the electronic maintenance system by the morning nurse, the Assistant Director of Nursing (ADON), Maintenance Director, and Clinical Services Director were not aware of the problem until the morning. The Maintenance Director stated that staff should have moved the resident to a functioning bed and reported the issue directly to him. The facility's policy required the interdisciplinary team to assess the resident's sleeping environment for safety and comfort, but this was not followed, resulting in the resident being left in an unsafe and uncomfortable position for an extended period.

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 working call system was available and within reach for residents in their rooms, specifically for two residents with significant cognitive and physical impairments. Observations revealed that the call light buttons for both residents were found on the floor under the head of their beds, making them inaccessible. Staff interviews confirmed that the call lights were not within reach, and staff acknowledged that this would prevent the residents from calling for help if needed. One resident, a male with moderate cognitive impairment, muscle weakness, and a history of falls, was observed lying in bed without access to his call light, which was on the floor. He was unaware of the location of his call light and expressed a desire to call for assistance. A staff member found the call light on the floor and placed it within his reach, noting that the resident would not have been able to call for help in case of an emergency or incontinence. Another resident, a female with severe cognitive impairment, muscle weakness, and a history of falls, was also found sleeping in bed with her call light on the floor and out of reach. A CNA entered the room, found the call light on the floor, and placed it within the resident's reach, stating that the resident would not have been able to call for help if needed. Facility leadership and policy confirmed the expectation that call lights should always be within reach of residents to allow them to request assistance.

Penalty

Inspection fine: $15,940

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

Summary

A deficiency occurred when a resident with a history of dementia, mood disorder, anxiety, and bilateral hearing loss was able to leave the facility unattended. The resident, who had moderate to severe cognitive impairment as evidenced by fluctuating BIMS scores and documented poor judgment, was not identified as an elopement risk on initial assessments. Despite a history of wandering at home and family reports of previous elopement behaviors, the resident was allowed to sit outside the facility unsupervised. On the day of the incident, the resident left the premises without staff knowledge and was later found approximately one mile away near a freeway by a staff member. Interviews and record reviews revealed that staff supervision protocols for residents sitting outside were inconsistent. There was no designated staff assigned to monitor residents on the patio, and staff relied on periodic checks or visual observation from inside the building. The resident was not signed out, and there was no documentation of his departure. Staff and family interviews confirmed that the resident was not capable of safely leaving the facility alone due to his cognitive impairment, and the area outside the facility included busy streets and a nearby freeway, increasing the risk of harm. Documentation of the incident was incomplete, with missing incident reports and inadequate nursing notes regarding the event. The facility's elopement policy required investigation, reporting, and documentation of missing residents, but these procedures were not fully followed. Staff interviews indicated confusion about supervision responsibilities and criteria for allowing residents to leave the building independently. The lack of adequate supervision and failure to implement appropriate safety measures for a cognitively impaired resident led to the resident's unsupervised departure from the facility.

Penalty

Inspection fine: $15,940

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 prevention and control program, as evidenced by multiple lapses in infection control practices observed among staff caring for three residents with significant medical needs. Certified Nursing Assistants (CNAs) did not consistently perform hand hygiene after providing perineal care or before exiting resident rooms. For example, one CNA failed to wash or sanitize hands after pericare for a resident with a history of urinary tract infections and pneumonia, and another CNA did not perform hand hygiene between glove changes or after pericare, instead proceeding to touch common surfaces and assist the resident in communal areas. Staff also failed to adhere to Enhanced Barrier Precautions (EBP) as required for residents with wounds, indwelling medical devices, or other infection risks. Several CNAs did not wear gowns during high-contact care activities, such as changing briefs or emptying urinary catheters, despite EBP signage and care plans indicating the need for these precautions. In addition, a mechanical lift used for resident transfers was not sanitized between uses for different residents, increasing the risk of cross-contamination. Interviews with staff revealed misunderstandings about the application of EBP and inconsistent knowledge of proper infection control procedures. The residents involved had complex medical histories, including chronic wounds, indwelling catheters, colostomies, and frequent incontinence, placing them at increased risk for infection. Care plans and facility policies outlined specific interventions and precautions, such as regular hand hygiene, use of gloves and gowns, and disinfection of equipment, but these were not consistently followed. Staff interviews confirmed lapses in practice, with some CNAs citing being rushed or unaware of available supplies, and others misunderstanding the requirements for EBP. These failures were directly observed and documented by surveyors during the review period.

Penalty

Inspection fine: $15,940

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. Specifically, the facility did not report to the appropriate authorities when a resident with dementia and moderate to severe cognitive impairment was found to have eloped from the facility. The resident, who had a history of wandering and cognitive deficits, left the facility unsupervised and was later found walking near a restaurant by a staff member who was off duty. The incident was not reported to the State Survey Agency as required by regulations. The resident involved had diagnoses including dementia, mood disorder, anxiety, and bilateral hearing loss, and had a fluctuating BIMS score indicating moderate to severe cognitive impairment. Prior to the incident, the resident was not assessed as being at risk for elopement, despite a history of wandering at home. On the day of the incident, the resident was last seen by staff approximately 30 minutes before being observed outside the facility. Staff initiated a search and located the resident about an hour later, walking back toward the facility. Interviews and documentation revealed that the resident was confused, had poor judgment, and was not safe to be outside alone, especially given the proximity to a busy street and freeway. Despite the clear risk and the requirement to report such incidents, the facility did not submit a self-report to the appropriate authorities. Interviews with staff and administration indicated confusion and disagreement about the resident's cognitive status and whether the incident met the criteria for reporting. Some staff believed the resident was able to make his own decisions, while others recognized the severity of his impairment and the danger posed by his elopement. The lack of timely reporting was confirmed by a review of the Texas Unified Licensure Information Portal, which showed no incident report for the event.

Penalty

Inspection fine: $15,940

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

Summary

A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate perineal care to a male resident who was frequently incontinent of bowel and bladder. During an observed care episode, the CNA did not cleanse the external urethral orifice of the penis as required by facility policy, which specifies that perineal care for male residents should begin with cleansing the urethra and then moving outward. The CNA used disposable wipes to clean the groin and penis but did not specifically clean the urethral opening. The resident was dependent on staff for all activities of daily living, including perineal hygiene, and had a care plan in place to address incontinence and prevent urinary tract infections (UTIs). The resident involved had multiple medical diagnoses, including chronic obstructive pulmonary disease (COPD), muscle weakness, mobility abnormalities, a history of stroke, anxiety, and depression. The resident was cognitively intact and required total assistance for personal hygiene. The care plan documented the need for regular checks and thorough cleaning to prevent skin breakdown and UTIs, with specific instructions to wash, rinse, and dry the perineum after episodes of incontinence. Despite these documented interventions, the observed care did not meet the established standards. Additionally, the CNA did not perform hand hygiene between glove changes or after completing perineal care, contrary to facility policy and infection control protocols. The CNA admitted to not sanitizing hands between glove changes and acknowledged that gloves were sometimes kept in her pocket due to glove size availability issues. The Director of Nursing confirmed that staff are expected to change gloves and perform hand hygiene to prevent infection, especially when moving from clean to dirty areas during care. The facility's perineal care policy, last revised in December 2011, outlines the steps for proper cleaning and hand hygiene, which were not followed during the observed incident.

Penalty

Inspection fine: $15,940

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

Summary

A deficiency occurred when a certified nursing assistant (CNA) who was not authorized to administer medications applied two Lidocaine patches to a resident during morning care. The medication aide (MA) provided the patches to the CNA, instructing her to apply them while the resident was receiving peri care, as the MA was occupied dispensing medications to another resident. The CNA applied one patch to the resident's right hip and a second patch to the left thigh, despite not being trained or authorized to administer medications. The MA later acknowledged that it was not facility policy for CNAs to apply medication patches and that only medication aides and nurses were responsible for this task. The physician's order for the resident specified the application of a Lidocaine patch to the hip once daily for pain, but did not clarify which hip. The MA and the Director of Nursing (DON) both noted the lack of clarity in the order, with the DON stating that the order should have been clarified and that only one patch was expected to be applied. The physician was also unsure whether the patch was intended for one or both hips and indicated the need to clarify the order. The MA did not report the discrepancy in the order at the time of the incident. The facility's policies and job descriptions specify that only authorized staff, such as medication aides and nurses, are permitted to administer medications, and that CNAs are not trained or authorized to do so. The DON confirmed that the CNA had not been trained in medication administration and would not have known the rights of administration. The incident was considered a medication error, as the administration of the Lidocaine patches was not in accordance with the provider's order or facility policy.

Penalty

Inspection fine: $17,345

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

Summary

A deficiency occurred when staff failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, two CNAs transferred a resident from her wheelchair to her bed without following the resident's plan of care or referencing the Kardex for transfer instructions. The resident, who had significant medical conditions including muscle weakness, end stage renal disease, reduced mobility, and cognitive impairment, was dependent on staff for all activities of daily living and was identified as requiring a mechanical lift for transfers due to her high fall risk and inability to assist. During the transfer, the resident's right leg became caught on an exposed, uncapped metal part of the bed frame, resulting in a severe laceration that required 15 sutures and 18 staples. The incident was witnessed by staff and confirmed by the resident, who reported that her leg was caught on the bed during the transfer. The bed was later inspected and found to have a grab bar with a pipe sticking out without a cap, creating a rough and hazardous surface. The facility did not have a specific policy on accidents and hazards, and the staff involved did not consult the resident's care plan or seek guidance from nursing staff prior to the transfer. Interviews with staff and the resident's family confirmed that the injury occurred during the transfer and not prior to the resident's arrival at the facility. The CNAs involved did not notice any blood or injury before the transfer, and the resident was alert and able to communicate her needs. The failure to follow established protocols for safe resident transfers and to maintain equipment in a safe condition directly led to the resident's injury.

Removal Plan

• CR#1 involved in alleged deficient practice was discharged to the hospital due to a laceration sustained during a transfer from the wheelchair to the bed.
• The incident involving CR#1 was reported to Health and Human Services.
• The Administrator initiated the investigation, and blood was noted on the side of the bed frame on the square opening area.
• CNA D was in-serviced on Referring to Resident POC for Transfer Instruction.
• CNA W was in-serviced on Referring to Resident POC for Transfer Instruction.
• The Maintenance Director conducted an inspection of all beds, and bed frames. Beds that were missing caps on the side of the bed frame were sealed with either a cap or tape. These open areas are generally utilized to attach side rails to the bed frame.
• The Maintenance Director placed a tab in the open area identified on CR#1 bed and then aides changed the bed out per family request.
• The Administrator notified the Medical Director of the alleged deficient practice.
• The Corporate Clinical Service Director reviewed facility policy regarding Safe Lifting and Movement of Residents and no revisions were deemed necessary.
• Resident CR#1 returned from the hospital with 18 staples and 8 sutures.
• An audit of past incidents was conducted. Two incidents were identified and previously reported to Health and Human Services.
• An in-service was initiated by the Administrator and the Assistant Director of Nursing with the aides on Safe Lifting and Movement of Residents, Referring to Resident POC for Transfer Instruction, and Resident Abuse and Neglect. The aides were not allowed to return to work until they received this in-service.
• The Director of Rehab and the Assistant Director of Nursing completed a 100% checkoff on Resident Transfers with the certified nursing aides. The aides were not allowed to return to work until they received this in-service.
• Newly hired nurses will be in-serviced by the Assistant Director of Nursing or designee on Safe Lifting and Movement of Residents, Referring to Resident POC for Transfer Instruction, and Resident Abuse and Neglect.
• Nursing staff were in-serviced by the Assistant Director of Nursing on Reporting Hazardous Equipment Immediately Including Removing Hazardous Equipment.
• The openings identified by Surveyor were covered and a facility wide audit conducted. Areas of concern addressed immediately. Tape was applied to two Assist Bars that had openings.
• Ambassador Rounding Sheet that was implemented to monitor bed frames was updated to include the monitoring of the Assist Bars. Ambassadors will also check vacant rooms.
• Nurses were in-serviced by the Director of Nursing on referencing Kardex prior to directing staff including C.N.A.s and staff from other departments on how to transfer residents. The Charge Nurse and Nurse Managers will update the Kardex upon admissions and readmissions with any change(s) in status.
• Nurses were in-serviced by Director of Nursing instructing Charge Nurses to assess new and readmitted residents to determine transfer status and to communicate findings to the C.N.A.(s) on duty.

Penalty

Inspection fine: $17,345

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 services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining nutrition, grooming, and personal and oral hygiene. Three residents were affected by this deficiency. One resident, a male with severe cognitive impairment and multiple health issues including osteomyelitis and diabetes, did not receive showers as per the facility's schedule. His records indicated he was supposed to receive substantial assistance with bathing, yet he reported not having a bath or shower since his admission. Another resident, a male with normal cognition but dependent on assistance for all ADLs due to conditions like acute respiratory failure and a stroke, also did not receive showers according to the schedule. His family filed a grievance about the lack of showers, and he confirmed not having received a shower in two weeks. The facility's staff had conflicting information about the shower schedule, and the resident's family had to intervene to address the issue. A third resident, a female with severe cognitive impairment and a right-hand contracture, did not receive proper fingernail care. Her nails were observed to be long and dirty, with a brown substance underneath. Staff interviews revealed that nail care supplies were available, but the resident's nails had not been clipped for one to two months. The facility's policy required regular nail care to prevent infections, but this was not adhered to, leading to concerns about potential injury and infection.

Penalty

Inspection fine: $17,345

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

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, a female with severe cognitive impairment and a history of falls, was supposed to have bilateral floor mats as an intervention to prevent falls. However, during observations and interviews, it was noted that the fall mats were not present at the bedside, contrary to the care plan. Interviews with the Director of Nursing (DON), the resident's assigned nurse, and certified nursing assistants (CNAs) revealed a lack of awareness and adherence to the care plan. The assigned nurse was unsure if the resident needed a fall mat and had not seen any in the room. Similarly, the CNAs confirmed the absence of fall mats and indicated that the resident had previously used them in a different room. The facility's policies on care planning and fall prevention were not followed, as the care plan interventions were not implemented, potentially placing the resident at risk of injury.

Penalty

Inspection fine: $17,345

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 prevention and control program, as evidenced by the actions of LVN B, who did not adhere to Enhanced Barrier Precautions (EBP) while administering IV antibiotics to a resident. The resident, a male with a history of sepsis, type 2 diabetes mellitus, acute prostatitis, and acute metabolic acidosis, was admitted with a PICC line and was on EBP due to the presence of an indwelling medical device. The care plan for the resident required the use of gloves and a gown during high-contact care activities to prevent the spread of infections, particularly multidrug-resistant organisms (MDROs). During an observation, LVN B was seen administering IV antibiotics to the resident without wearing a gown, although she did wear gloves. This was contrary to the facility's policy on EBP, which mandates the use of both gloves and a gown during high-contact activities involving residents with indwelling medical devices. LVN B acknowledged forgetting to wear a gown, which was necessary to protect both the resident and staff from potential cross-contamination. Interviews with the facility's administration and Director of Nursing confirmed the expectation for staff to follow EBP policies to prevent infection spread.

Penalty

Inspection fine: $13,822

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

Summary

A deficiency occurred when a resident who required continuous oxygen therapy was not provided with sufficient oxygen during transport to and attendance at a medical appointment outside the facility. The resident, who had a history of acute respiratory failure with hypoxia, heart failure, pleural effusion, dementia, chronic kidney disease, and fluid overload, was documented as needing continuous oxygen via nasal cannula per physician orders and care plan interventions. On the day of the incident, the resident was prepared for an outside appointment and was sent with a portable oxygen tank. The portable oxygen tank provided to the resident was not adequately checked to ensure it was full, nor was an extra tank sent for the duration of the appointment. Staff interviews revealed that the nurse responsible did not receive instruction on how to calculate the resident's oxygen needs for the outing, and she only glanced at the tank, noting it was less than full when the resident left. The resident was on the tank for approximately 1.5 hours before leaving the facility, and no arrangements were made to confirm oxygen availability at the medical office. Upon arrival at the medical office, the resident's oxygen saturation was found to be critically low, and the tank was discovered to be empty. The resident developed cyanosis and required emergency intervention, including a rapid switch to a new oxygen tank and subsequent transfer to the hospital for acute hypoxic respiratory failure. Interviews with staff and documentation confirmed that the facility failed to ensure the resident had an adequate supply of oxygen for the duration of the appointment, consistent with professional standards of practice and the resident's care plan.

Penalty

Inspection fine: $31,304

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 timely treatment and care to a resident who experienced a sudden change in condition, including mental status and neurological deficits. The resident, who had a history of severe cognitive impairment and atrial fibrillation, showed signs of altered mental status and difficulty swallowing on the day of the incident. Despite these symptoms, the resident was not transported to the emergency room until approximately four hours after the initial change in condition was noted. Interviews with staff revealed that there was a lack of urgency in responding to the resident's condition. Nurse B, who was responsible for the resident at the time, did not suspect a stroke and opted for regular transport instead of calling 911, despite the resident's altered mental status and non-verbal behavior. The nurse communicated with the transportation company and was informed of a delay, but did not take further action to expedite the resident's transfer to the hospital. The Director of Nursing and other staff members were not adequately informed or involved in monitoring the resident's condition during the delay. The facility's policy on changes in a resident's condition did not clearly differentiate between situations requiring emergency versus regular transport, contributing to the delay in care. The resident was eventually transported to the hospital, where she was diagnosed with a suspected stroke and later passed away.

Removal Plan

• Resident CR#1 involved in alleged deficient practice was discharged to the hospital.
• Administrator notified the Medical Director of the alleged deficient practice.
• Nurse Managers completed a 100% assessment of all residents residing in the facility for changes in condition, and none were identified.
• LVN B was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the emergency room.
• The facility audited the change in conditions for the last 3 days for altered mental status concerns, monitoring of residents, and notification to the physician, no concerns were identified.
• LVN C was in-serviced on Recognizing a Change in Condition & Monitoring While Awaiting Transport to the emergency room.
• The Corporate Clinical Service Director reviewed facility policy regarding change in condition and no revisions were deemed necessary.
• An in-service was completed by the Corporate Clinical Service Director with the Director of Nursing on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation.
• The Director of Nursing completed an in-service with the licensed nursing staff on residents with changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Licensed nurses will not be allowed to return to work until they receive this in-service.
• Newly hired nurses will be in-serviced by the Director of Nursing or designee on changes in condition must be monitored closely to ensure that documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation.
• The Director of Nursing or designee completed an in-service with the licensed nursing on when to send a resident to the hospital when there is a change in condition that cannot be managed in the facility. Licensed nurses will not be allowed to return to work until they receive this in-service.
• Use non-emergency transport for stable residents requiring evaluation or treatment for non-urgent conditions, such as worsening chronic symptoms or mild infections.
• Call 911 for life-threatening emergencies or rapidly deteriorating conditions, such as chest pain, severe respiratory distress, unresponsiveness, or suspected trauma. Always assess vital signs, consult facility protocols or providers as needed, and document the decision-making process thoroughly to ensure appropriate and timely care.
• CNA's received in-services on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed. CNAs will not be able to work until they have completed this in-service.
• Newly hired CNA's will be in-serviced by the Director of Nursing or designee on Changes in Condition and Their Signs and Symptoms/Who to Notify When a Change in Condition is Observed.
• The 24-hour report will be reviewed daily by the Director of Nursing or designee to audit nurse documentation in progress notes of change in conditions and the documentation reflects the completion of required assessments, physician notification, on-going documented monitoring of resident status, and transported to the hospital in a timely manner based on resident assessment and physician recommendation. Discrepancies noted during reviews will be immediately corrected by contacting the attending physician of the change of condition and completing documentation in the patient's progress note.