Kemp Care Center

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, for three residents who were unable to perform these tasks independently. For one resident with moderate cognitive impairment and multiple diagnoses, documentation showed missed scheduled showers, with the resident and staff interviews confirming that showers were often delayed or not provided as scheduled. The care plan for this resident included specific interventions for negotiating ADL times and reattempting care after refusals, but these were not consistently followed, and the resident reported only receiving a shower about once a week despite being scheduled for three times weekly. Another resident, who was cognitively intact but required moderate assistance with showering, also did not receive scheduled showers or bed baths on several occasions. This resident expressed feeling unclean and dissatisfied with the infrequency of bathing, stating a desire to receive showers at least three times a week as scheduled. Documentation confirmed multiple missed showers, and the care plan required staff assistance with personal hygiene and bathing, which was not consistently provided. A third resident with moderate cognitive impairment and significant physical limitations received only one documented bath in a month, despite being scheduled for multiple showers per week. Observations noted the resident wearing soiled clothing, and both the resident and staff interviews indicated that showers were frequently missed due to time constraints and staffing issues. Staff reported that missed showers were communicated to supervisors, but no changes were made, and there was a lack of clarity and follow-through regarding responsibility for completing showers on different shifts. The facility's policy required bathing according to the resident-centered plan of care, but this was not adhered to for these residents.

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

Surveyors identified that the facility failed to provide food that was palatable and served at an appetizing temperature for several residents. Multiple residents reported that their food was often cold, not seasoned, or, at times, too hot to eat. Resident grievances and council meeting minutes documented complaints about cold food and beverages. During interviews, residents consistently described dissatisfaction with the temperature and taste of their meals, with some stating the food was lukewarm, unseasoned, or had an unappealing texture. A sampled lunch tray reviewed by the Dietary Manager, Area Director of Operations, and surveyors revealed that the meatloaf had red-tinged areas and the potato wedges were lukewarm, further supporting resident complaints. Despite these findings, facility staff, including the Dietary Manager and Area Director of Operations, maintained that there were no issues with the food, citing proper cooking temperatures and a lack of direct complaints to them. The facility's policy on menu approval and honoring resident preferences did not address requirements for food palatability or serving temperature. The deficiency was substantiated through resident interviews, review of grievances and council minutes, and direct observation of meal service.

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 assessments accurately reflected a resident's status for one resident reviewed for MDS assessment accuracy. Specifically, the discharge MDS assessment for a male resident with chronic combined heart failure was incorrectly coded as 'return not anticipated' instead of 'return anticipated.' The resident was readmitted to the facility from the hospital within the required timeframe, which should have prompted a 'return anticipated' discharge assessment rather than a new admission assessment. The MDS Coordinator, who was responsible for completing the assessment, acknowledged after reviewing the resident's records that the incorrect assessment type was selected and that it should have been modified to reflect the correct status. Interviews with facility staff, including the MDS Coordinator, Regional Reimbursement Nurse, and Administrator, confirmed that the correct assessment was not completed and that there was no specific policy or procedure in place regarding MDS assessment accuracy, with staff relying on the RAI manual for guidance. The error was identified through record review and staff interviews, and it was noted that the correct assessment is important for ensuring continuity of care and an accurate plan of care upon the resident's return.

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 (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who required oxygen therapy. Record review showed that the resident, an older adult female with diagnoses including abnormal lung findings, neuromuscular bladder dysfunction, stroke, and diabetes, had a physician's order for oxygen at 2-3 liters per minute via nasal cannula every shift for hypoxia. The resident's quarterly MDS assessment indicated she used oxygen and had moderately impaired cognition. However, her care plan, as of the most recent revision, did not include any information or interventions related to oxygen therapy. Observations confirmed that the resident had oxygen equipment in her room and an oxygen sign outside her door, but she was not observed using oxygen during multiple checks. Interviews with facility staff, including the MDS Coordinator, DON, and Administrator, revealed that the omission of an oxygen care plan was not recognized until brought to their attention. The facility's policy requires a comprehensive care plan to address all identified needs, including measurable objectives and timeframes, but this was not followed for the resident's oxygen therapy.

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 the facility failed to ensure that a resident receiving enteral nutrition via a feeding tube was administered the correct rate of formula as ordered by the physician. The resident, who had severe protein-calorie malnutrition and required a feeding tube for nutrition, had a physician order for Isosource 1.5 calorie formula to be administered continuously at 53 ml/hr. However, multiple observations revealed that the feeding pump was set at 55 ml/hr instead of the prescribed rate. Nursing staff, including an LVN, acknowledged the discrepancy and stated that charge nurses were responsible for verifying orders each shift and each time the feeding was administered. The resident's care plan included interventions to check tube placement and gastric residuals per protocol, and the facility's policy required that enteral feedings be administered as ordered by the physician. Despite these protocols, the incorrect rate was administered on more than one occasion, and the error was confirmed by both nursing staff and facility leadership during interviews. The DON and Administrator both stated that nurses were expected to follow physician orders and that monitoring was their responsibility, but the error was not identified or corrected in a timely manner.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a resident with chronic obstructive pulmonary disease, who required the use of a CPAP device at bedtime, did not have her CPAP mask stored according to professional standards of practice. During observation, the CPAP mask was found placed on top of a bubble gum container on the resident's nightstand, exposed and not stored in a bag as required. The resident, who had intact cognition but required staff assistance for personal care and was unable to reach the mask herself, stated that staff typically left the mask in this manner and did not store it in a bag. Interviews with facility staff, including the ADON, DON, Administrator, and an RN, confirmed that the CPAP mask should have been stored in a bag when not in use to maintain cleanliness and prevent contamination. Staff acknowledged responsibility for ensuring proper storage, with specific mention of daily rounds and assigned duties for checking respiratory equipment. However, the facility's policy on oxygen administration did not address CPAP mask storage, and the mask was not stored as required at the time of the survey.

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 nurse (ADON) failed to administer a resident's prescribed Magdelay (magnesium chloride supplement) as ordered. The resident, an elderly female with diagnoses including dementia, hypertension, muscle weakness, and osteoporosis, had an active order for Magdelay 64mg once daily. On the observed date, the ADON prepared and administered a tablet of sloMg instead of the ordered Magdelay. The sloMg bottle had different active ingredient amounts and was not the correct medication or dosage as prescribed. The ADON relied on a handwritten note on the bottle and did not verify the medication or clarify the order with the physician before administration. Interviews with the ADON, DON, and Administrator confirmed that the medication was not administered as ordered and that the nurse was responsible for ensuring accuracy and clarifying any discrepancies. The facility's policy required medications to be administered as prescribed and in accordance with regulations. The error was identified through observation, record review, and staff interviews, which revealed that the resident received an incorrect medication and dosage due to failure to follow proper medication administration procedures.

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 drugs and biologicals were stored in locked compartments accessible only to authorized personnel, as required by regulation. During an observation, a bottle of Ayr Nasal Solution and biotene dry mouth moisturizing spray were found on the bedside table of a male resident with a diagnosis of diastolic (congestive) heart failure. The resident's care plan indicated he was unable to safely self-medicate and required 24-hour nursing care, and there was no order or assessment in place for self-administration of medications. The resident's cognition was intact, but he had a communication problem related to unclear speech. Interviews with the DON and ADON confirmed that the resident had not been evaluated for self-administration of medications and that no residents in the building were permitted to self-medicate. Both the DON and ADON acknowledged that medications should not be left at the bedside and should be stored in the nurse's cart. The facility's policy required medication rooms, carts, and supplies to be locked or attended by authorized personnel. The presence of medications at the resident's bedside was not detected by staff prior to the surveyor's observation.

Penalty

No penalty information released

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

Summary

The facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs. This deficiency indicates that residents did not consistently receive meals that were adequate in nutrition, taste, or tailored to their individual dietary requirements as required by regulation.

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

Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen. During an initial kitchen tour, ham was found in the refrigerator past its use by date, and potatoes were stored in a container without a label or date. The Dietary Manager confirmed that the ham was one day out of date and acknowledged that it should have been discarded on the expiration date. She also explained that the potatoes had been labeled and dated, but the label became unreadable due to moisture and was not replaced. The Dietary Manager stated that both she and the cooks were responsible for ensuring proper labeling and removal of expired food, and that daily checks of the fridge were conducted, but she was unsure how the expired ham was missed. Further interviews with dietary staff confirmed that the fridges were checked daily for expired food and that all food items should be labeled and dated when prepared. The Administrator stated that all food items were expected to be labeled, dated, and discarded upon expiration, with the Dietary Manager responsible for oversight. Review of the facility's food storage policy indicated that open packages of food should be stored in closed containers, labeled, and dated, and that perishable refrigerated items should be dated once opened and used within seven days.

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 proper infection prevention and control procedures while providing incontinent care to a female resident with neuromuscular bladder dysfunction, a history of stroke, and diabetes. The resident, who had moderately impaired cognition and required assistance with multiple activities of daily living, was observed receiving care during which the CNA wiped the resident's front and back areas without changing gloves or performing hand hygiene. The CNA then handled clean items, including a brief, barrier cream, linen, and a gown, all while wearing the same contaminated gloves. Hand hygiene was only performed after leaving the resident's room and removing the gloves. Interviews with the CNA revealed a lack of awareness regarding the missed hand hygiene and glove change, despite acknowledging the risk of cross-contamination. The Director of Nursing (DON) and the Administrator both stated that staff are expected to change gloves and perform hand hygiene between dirty and clean tasks, and that training on these procedures is provided at least annually. Facility policies reviewed indicated that hand hygiene is required after contact with body fluids, soiled linens, and before and after personal care or toileting, but these procedures were not followed during the observed incident.

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 report the results of an abuse investigation to the administrator or designated representative and to the state survey agency within the required 5 working days. Specifically, after a resident reported that a PASRR representative placed an item on a store checkout belt and the resident paid for it, the facility initiated an investigation. The incident was reported to the state survey agency, and the local health authority was notified that the representative would no longer be allowed in the facility. The investigation ultimately concluded that the allegation was unconfirmed, and there were no witnesses to the incident. Despite these actions, the facility did not submit the required provider investigation report to the state survey agency within the mandated timeframe. Record review of the TULIP website confirmed that the 5-day report had not been turned in. During interviews, facility leadership was unable to provide proof that the report was submitted, and attempts to contact the previous administrator responsible for the report were unsuccessful. The facility's own policy required that such reports be sent to the state agency within five working days using the designated form, but this was not done in this case.

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 implement its written policies and procedures to prevent abuse, neglect, and misappropriation of resident property, specifically concerning a resident who was allegedly exploited by a Community Support Advocate. The facility's policy requires all allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property to be reported to the facility administrator, who is responsible for further reporting to the Health and Human Services Commission (HHSC) within specified timeframes. However, in this case, the facility did not adhere to these procedures, as the incident involving the resident's money being used by the Community Support Advocate was not reported to the administrator or the state as required. The resident involved was a cognitively intact male with a BIMS score of 15, indicating full cognitive function. He had several medical diagnoses, including GERD, congestive heart failure, osteoarthritis, muscle weakness, and hypertension. The resident reported that the Community Support Advocate frequently used his money to purchase drinks and exerted undue influence over him during shopping trips. Despite these allegations, the facility staff, including an LVN, did not report the incident to the administrator, assuming that the discussion in a morning meeting was sufficient notification. Interviews with facility staff and the administrator revealed a lack of communication and adherence to the facility's abuse and neglect policy. The administrator, who was also the abuse coordinator, was unaware of the incident until it was too late to report within the required timeframe. The failure to report and investigate the allegations of misappropriation of resident property placed the resident at increased risk for exploitation and highlighted a significant deficiency in the facility's implementation of its abuse prevention policies.

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 report an alleged misappropriation of property involving a resident within the required 24-hour timeframe. The incident involved a community support advocate allegedly using the resident's money to purchase a candy bar. The allegation was not reported to the state agency as required by the facility's policy and state guidelines. This oversight was due to the facility's staff not informing the administrator about the incident, which resulted in a failure to investigate and report the allegation. The resident involved was a cognitively intact male with a history of GERD, congestive heart failure, osteoarthritis, muscle weakness, and hypertension. The resident reported that the community support advocate frequently used his money to buy drinks and claimed authority over him. Despite these claims, the facility did not take immediate action to report or investigate the allegations, as the staff assumed the issue was known to all after a morning meeting discussion. Interviews with the facility's staff, including the LVN and the administrator, revealed a lack of communication and understanding of the reporting procedures. The LVN did not report the incident to the administrator, believing it was already known, and the administrator was unaware of the situation until later. This lack of reporting and investigation could potentially place residents at risk for abuse, as the facility did not adhere to its own policies and state regulations regarding the timely reporting of such incidents.

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 allegations of abuse, neglect, or mistreatment were thoroughly investigated and reported in accordance with state law. Specifically, the facility did not investigate an allegation of misappropriation of property involving a resident and a Community Support Advocate. The incident involved the alleged use of the resident's money by the advocate to purchase personal items, which was not reported to the facility administrator or the state agency within the required timeframe. The resident involved was a cognitively intact male with a history of GERD, heart failure, osteoarthritis, muscle weakness, and hypertension. He reported that the Community Support Advocate frequently used his money to buy drinks and exerted undue influence over his shopping activities. Despite these allegations, the facility's LVN did not report the incident to the administrator, assuming that the discussion in a morning meeting was sufficient notification. The facility's administrator, who was also the abuse coordinator, was unaware of the incident until it was too late to comply with the reporting requirements. The administrator acknowledged the importance of investigating and reporting such incidents to protect residents from abuse and exploitation. The failure to investigate and report the incident as per the facility's policy and state guidelines placed residents at risk for abuse, neglect, and exploitation.

Penalty

Inspection fine: $92,814

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

Summary

The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the facility did not perform weekly ulcer assessments and obtain measurements for several residents' pressure injuries. This included a stage 4 pressure injury on a resident's left outer ankle, pressure injuries on another resident's buttocks, and a stage 3 pressure injury on a resident's left buttock. Additionally, wound care treatments were not performed as ordered for multiple residents, and treatment orders did not indicate the correct location of pressure injuries for some residents, leading to further complications and worsening of wounds. The facility also lacked a system to ensure that skin assessments and treatments were completed as ordered. Skin assessments were not performed accurately, and there was a failure to prevent the worsening of moisture-associated skin damage in one resident. The facility did not follow its Skin Integrity Management policy, and the Director of Nursing (DON) failed to provide adequate oversight for wound care management and assessments. This resulted in an Immediate Jeopardy situation, which was identified and later removed, but the facility remained out of compliance due to the need for in-service training and evaluation of corrective systems. Observations and interviews revealed that residents were not receiving timely and appropriate wound care. For instance, one resident's wound vac dressing was not changed as scheduled, and another resident's left ankle wound was not offloaded as required. The treatment nurse admitted to not measuring wounds and not completing ulcer assessments due to staffing issues and lack of training. The DON and other staff members were often unaware of the residents' wound conditions, indicating a significant communication breakdown and lack of proper documentation and follow-up on wound care treatments.

Penalty

Inspection fine: $92,814

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

Summary

The facility failed to ensure the resident environment remained free from accident hazards, leading to several incidents involving four residents. Resident #42 received a first-degree burn from hot coffee due to inadequate safety measures. Despite the incident, the facility did not update the resident's care plan or implement new safety protocols immediately. The dietary manager and nursing staff were unaware of the proper procedures for handling hot liquids, and the coffee temperature logs were inconsistently maintained. The resident's care plan was only updated after surveyor intervention, and the facility's policy on hot liquid spills was not followed effectively. Resident #165 was observed smoking without supervision, contrary to his care plan, which required staff supervision due to safety concerns. The DON and other staff members were unaware of how the resident obtained his cigarettes and lighter, indicating a lapse in the facility's smoking policy enforcement. The administrator acknowledged the need for better smoking process management to prevent safety hazards. Residents #58 and #115 were found to have cigarettes and lighters in their possession, which was against the facility's smoking policy. Both residents were observed smoking unsupervised, posing a significant fire hazard. The DON and other staff members admitted to challenges in enforcing the smoking policy, including difficulties in confiscating smoking materials from residents. The facility's failure to adhere to its smoking policy placed residents at risk of burns and fire hazards.

Removal Plan

• Resident's #42 care plan was updated to include at risk for coffee burn and specialized cup with a lid to help prevent coffee spills by the DON.
• Resident's #42 hot liquid assessment was completed by the DON.
• Hot liquid Assessments were updated on all residents in the facility by the DON.
• Residents at high risk for coffee burns were assessed for the need of assistive devices if consuming hot liquids. Care plans were updated by the DON/Regional Compliance Nurse.
• The medical director was notified of the situation by the administrator.
• An off cycle QAPI meeting was completed with the IDT team and medical director to discuss the immediate jeopardy and plan of removal.
• The ADO will in-service the Administrator and Dietary Manager 1:1 on the following topics.
• All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees.
• Coffee will not be served over 140 degrees. All brewed coffee will have the temperature logged before serving.
• Hot liquid Spills Policy
• Guidelines on serving coffee in a nursing facility policy
• The following in-services were initiated by Administrator, DON, ADON for all staff. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced.
• All new hires will be in-serviced in orientation. All agency staff will be in-serviced prior to assuming shift.
• All brewed coffee will have cups of ice added until the internal temp reaches 135-140 degrees.
• Coffee will not be served over 140 degrees. All brewed coffee will have the temperature logged before serving.
• Hot liquid Spills Policy
• Guidelines on serving coffee in a nursing facility policy
• The administrator will be responsible daily for ensuring the coffee temperature will be checked and logged prior to serving / making coffee available to residents. Coffee will not be served until the temperature is between 135-140 degrees.

Penalty

Inspection fine: $92,814

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 sufficient staff to provide nursing-related services to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not provide prompt and proper incontinent care for two residents. The record review of time sheets indicated that the number of CNAs working was insufficient to meet the required 110 hours in a 24-hour period based on the facility's assessment. This staffing shortage was confirmed by multiple staff interviews, which highlighted the challenges in providing adequate care due to understaffing, including missed showers and delayed incontinent care. Resident #219, an elderly female with multiple diagnoses including cerebral infarction, type 2 diabetes, and vascular dementia, was observed in a room with a strong urine odor. The resident had not been changed for an extended period, resulting in a wet and stained mattress. The CNAs providing care did not follow proper hygiene protocols, such as changing gloves and using clean wipes for each stroke. Interviews with the CNAs and the LVN confirmed that the resident was not checked on as frequently as required, and proper incontinent care procedures were not followed due to being sidetracked by other duties and nervousness. Resident #54, an elderly female with diagnoses including dementia, stroke, and diabetes, was also found to have received improper incontinent care. The CNA providing care did not clean the entire buttock area, failed to perform hand hygiene after removing soiled gloves, and did not change gloves when moving from dirty to clean areas. The CNA admitted to being in a hurry and nervous, which led to improper care. Interviews with the DON and the Administrator confirmed that the facility was aware of the staffing issues and the potential for infection due to improper incontinent care. The facility's management acknowledged the staffing shortages and the impact on resident care but had not received approval to use agency staff to fill the gaps.

Penalty

Inspection fine: $92,814

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, leading to multiple deficiencies in care practices. Several staff members, including CNAs and nurses, did not follow proper hand hygiene and glove-changing protocols while providing perineal care, dressing changes, and other resident care activities. For instance, a CNA did not wash or sanitize hands when changing gloves between dirty and clean tasks while providing perineal care for a resident, and another CNA placed used wipes and barrier cream on a clean linen cart, contaminating it. Additionally, a treatment nurse failed to use personal protective equipment (PPE) as required by enhanced barrier precautions while completing a dressing change for another resident. The facility also failed to ensure proper cleaning and disinfection of medical equipment between residents. An LVN did not clean a glucometer between checking the blood sugar levels of two residents, increasing the risk of cross-contamination. Furthermore, several staff members did not follow enhanced barrier precautions, such as wearing gowns and gloves, when providing care to residents with specific medical conditions that required such precautions. This included activities like linen changes, resident hygiene, and wound care. In addition to these lapses, the facility did not maintain clean linen carts properly. Observations revealed that clean linen carts were left uncovered, exposing the linens to potential contamination from the environment. Interviews with staff confirmed that they were aware of the requirement to keep linen carts covered but failed to do so consistently. These deficiencies collectively placed residents and staff at risk for cross-contamination and the spread of infections.

Penalty

Inspection fine: $92,814

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 consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life. Specifically, the facility did not document their efforts to resolve concerns collected at the resident council meetings held on multiple dates. The recurring issue of call lights not being answered timely was raised in each meeting, but there was no documentation of any actions taken to address these concerns. This failure was confirmed through interviews with the resident group, the Social Worker, the Activities Director, the DON, and the Administrator, all of whom acknowledged the issue but did not provide evidence of any follow-up actions or resolutions. The resident group consistently reported that call lights were not being answered timely, with instances of residents waiting for hours to receive assistance. Despite these repeated complaints, the facility did not file grievances or document any steps taken to address the issues. The Social Worker, who was responsible for grievances, and the Activities Director, who communicated the concerns to the DON and Administrator, both indicated a lack of knowledge or action regarding the proper grievance process. The Administrator, who had only been at the facility for one month, admitted that the concerns should have been brought to him and distributed to department heads for resolution. The Corporate Nurse was unable to provide the policy regarding grievances when requested.

Penalty

Inspection fine: $92,814

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 necessary services to maintain grooming and personal hygiene for three residents. Resident #14, a male with unspecified dementia and hemiplegia, was not routinely showered or bathed. Despite being scheduled for baths on Monday, Wednesday, and Friday, only one bed bath was documented for the entire month of April. Observations revealed that Resident #14's hair appeared greasy, his shirt was stained, and his skin was dry and flaky. Interviews with staff indicated confusion and lack of communication regarding who was responsible for giving Resident #14 his baths, leading to missed showers and unchanged clothes. Resident #31, a male with heart disease, congestive heart failure, and moderately impaired cognition, also did not receive his scheduled baths. He was supposed to be bathed on Monday, Wednesday, and Friday during the 2 PM-10 PM shift but only received 2 out of 13 scheduled baths in April. Interviews with staff revealed that there had been changes in the shower schedule and a lack of clarity on who was responsible for ensuring the baths were given. The Administrator confirmed that the failure to provide regular baths could lead to poor hygiene and skin breakdown. Resident #16, a male with Down Syndrome and severe cognitive impairment, had long, broken, and uneven fingernails with a brown material under them. Despite requiring extensive assistance for personal hygiene, observations over several days showed that his nails remained untrimmed and dirty. Interviews with staff indicated that CNAs were responsible for nail care on shower days or when needed, but this was not consistently done. The DON and Administrator acknowledged the importance of keeping nails clean to prevent infection and scratching but noted that the responsibility was not clearly assigned or monitored.

Penalty

Inspection fine: $92,814

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

Summary

The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for five of six residents reviewed for pharmacy services. Specifically, Resident #26 did not receive timely administration of buspirone, gabapentin, duloxetine, and metoprolol succinate. The medication administration audit report indicated multiple instances where these medications were administered late, beyond the 1-hour grace period, potentially affecting the resident's treatment for anxiety, pain, depression, and blood pressure management. Resident #26's care plan and medication orders were not followed as prescribed, leading to significant delays in medication administration on several occasions. Resident #218 also experienced delays in the administration of spironolactone, metoprolol, venlafaxine hydrochloride, and pregabalin. The medication administration audit report showed that these medications were consistently administered late, beyond the 1-hour grace period. The resident's care plan did not address the use of these medications, and the MDS assessment was still in progress. The delays in medication administration could have impacted the resident's treatment for fluid buildup, high blood pressure, depression, and nerve pain. Additionally, Resident #165 did not receive timely administration of aspirin, omeprazole, Lyrica, and carisoprodol. The medication administration record revealed that these medications were either not given or administered late. RN A admitted to not giving the prescribed medications due to being in a hurry and not reading the MAR correctly. The DON was unaware of the late medications and stated that staff had not informed her of the issue. The facility's medication administration procedures were not followed, leading to potential adverse effects on the residents' health.

Penalty

Inspection fine: $92,814

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 all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for two of five medication carts and one of twenty-two residents reviewed for pharmacy services. Specifically, Resident #36 had prescribed and over-the-counter medications at her bedside, which were not authorized. The resident had a history of hemiplegia following cerebral infarction, chronic pain, hypertension, cognitive communication deficit, and major depression. The resident's care plan indicated that the facility was responsible for administering her medications, and she was not permitted to self-administer. However, during an observation, the resident was found with a bottle of Tums, a box of stomach relief tablets, and a tube of silver sulfadiazine cream on her bedside table, none of which were ordered for her use at the time. The Director of Nursing (DON) confirmed that the resident should not have had these medications in her room and that no residents were allowed to self-administer medications. Additionally, the treatment nurse left the medication cart used for treatments unlocked while attending to a resident in another room. The cart remained unattended and unlocked for approximately 19 minutes. The treatment nurse admitted to being nervous and forgetting to lock the cart, acknowledging that anyone could have accessed the medications and treatments. Furthermore, an LVN was observed sitting at the nurse's station while the medication cart on Hall 200 was left unlocked. The LVN was unaware that the cart was open and acknowledged that it posed a potential hazard for residents. Both the DON and the Administrator confirmed that all medication carts should be locked when unattended to prevent unauthorized access and potential misuse of medications. The facility's policies on medication administration and medication carts clearly state that medication carts must be locked when not in use or under direct supervision. The failure to adhere to these policies was confirmed through interviews with the DON, LVN, and the Administrator, who all acknowledged the risks associated with leaving medication carts unlocked and medications at residents' bedsides. The Administrator emphasized that no resident could self-administer medications and that all medications should be kept in medication carts or the medication storage area to ensure safety and proper monitoring.

Penalty

Inspection fine: $92,814

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 residents had the right to a safe, clean, comfortable, and homelike environment, specifically in the case of one resident's room. Resident #4, a [AGE] year-old female with diagnoses including seizures, Pseudobulbar affect, high blood pressure, and dementia, was observed in a room that smelled of urine and bowel. The resident required total assistance with toileting and was always incontinent of bowel and bladder. Despite the care plan indicating that staff should check for incontinent episodes every 2 hours and assist as needed, the room was repeatedly found to have a strong odor of urine and bowel during the survey period from 04/28/24 to 05/02/24. Multiple observations and interviews confirmed the persistent odor issue. On 04/28/24, Resident #4 was found in bed with no clothes on, and the room smelled of urine and bowel. On 04/29/24, the room continued to smell of urine during different times of the day. The treatment nurse and housekeeper both acknowledged the odor, with the housekeeper noting that she cleaned the mattress and fall mats daily but still noticed the smell. The administrator also confirmed the urine odor and identified soiled clothes in the resident's closet as a potential source. The roommate of Resident #4 also mentioned the urine smell but did not report it, thinking it could have been her own issue.

Penalty

Inspection fine: $92,814

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 Resident #54, who had multiple diagnoses including insomnia, high blood pressure, dementia, stroke, and diabetes. The resident's quarterly MDS assessment indicated severe cognitive impairment and extensive assistance required for daily activities. Despite having a physician's order for Trazodone to manage insomnia and mood, the medication use was not included in the resident's care plan. This omission was confirmed during an observation and interview with the MDS nurse, who acknowledged that the care plan should have included the medication and related interventions. The Director of Nursing (DON) and the Administrator both confirmed that the MDS nurse was responsible for completing the care plans, and the DON was the overseer. They admitted that the care plan should have been complete and accurate to ensure the resident received appropriate care. The deficiency was identified during a state survey, and it was noted that the care plan was updated only after the surveyor's intervention to include the use of Trazodone and related interventions. The facility's policy on comprehensive care planning mandates the development and implementation of a person-centered care plan that includes measurable objectives and timeframes to meet the resident's needs, which was not adhered to in this case.

Penalty

Inspection fine: $92,814

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 who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Resident #219, an elderly female with diagnoses including cerebral infarction, type 2 diabetes mellitus, and vascular dementia, was not provided prompt and proper incontinent care. During an observation, it was noted that Resident #219 had a strong urine odor in her room and had not been changed for an extended period. CNA G and SNA H provided incontinent care but failed to follow proper hygiene protocols, such as changing gloves and using clean wipes for each stroke. The mattress was found to be wet, and the resident had a dark brown stain extending up her buttocks, indicating prolonged exposure to urine and feces. Both CNAs admitted to not following proper procedures due to being sidetracked and nervousness, respectively. The DON and Administrator acknowledged the importance of proper incontinent care but noted lapses in oversight and adherence to protocols by the staff. Additionally, the facility failed to ensure CNA C properly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #54. Resident #54, an elderly female with severe cognitive impairment and a history of UTI, was observed receiving inadequate incontinent care. CNA C did not clean the entire buttock area, failed to change gloves appropriately, and did not perform hand hygiene after removing soiled gloves. CNA C admitted to knowing the correct procedures but did not follow them due to being in a hurry. The DON and Administrator reiterated the importance of proper incontinent care and hand hygiene to prevent infections but acknowledged the need for better oversight and adherence to protocols. The facility's policy on perineal care emphasizes the importance of maintaining resident dignity, preventing infections, and following proper hygiene protocols. However, the observations and interviews revealed significant lapses in following these procedures, putting residents at risk for infections and decreased quality of life. The DON and Administrator recognized the deficiencies and the need for improved oversight and adherence to established protocols to ensure residents receive appropriate care.

Penalty

Inspection fine: $92,814

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 respiratory care was provided consistent with professional standards of practice for two residents. For Resident #19, the handheld nebulizer was observed lying at the bedside and not stored in a bag, exposing it to the air and surroundings. Interviews with the LVN and DON confirmed that handheld nebulizers should be stored in a bag to prevent infection, and it was the responsibility of the nursing staff to ensure proper storage. The resident's medical history included chronic obstructive pulmonary disease, and the care plan indicated the use of aerosol or bronchodilators as ordered. However, the nebulizer was not stored correctly, posing a risk of respiratory infections or complications for the resident. The DON acknowledged the oversight and emphasized the importance of proper storage for infection control. The LVN admitted to not noticing the improper storage and reiterated the risk of infection due to exposure to germs. The facility's policy on oxygen administration was reviewed, which stated that tubing and equipment should be changed or cleaned when visibly contaminated. However, the policy was not followed in this instance, leading to the deficiency. For Resident #8, the nasal cannula was observed on the floor, and the oxygen concentrator filter was covered in gray fuzzy material. The resident's medical history included dementia and acute respiratory failure with hypoxia, and the care plan indicated the use of oxygen therapy. Interviews with the LVN and DON confirmed that it was the nurse's responsibility to ensure the nasal cannula was properly stored and the oxygen concentrator was cleaned. The LVN admitted to not ensuring the proper storage and cleaning, and the DON emphasized the importance of these actions to prevent infection. The facility's policy on oxygen administration was reviewed, which stated that tubing and equipment should be changed or cleaned when visibly contaminated. However, the policy was not followed in this instance, leading to the deficiency.

Penalty

Inspection fine: $92,814

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 was given psychotropic medication to treat a specific diagnosis. The resident, a [AGE] year-old female with a history of vascular dementia, anxiety disorder, chronic obstructive pulmonary disease, hypertension, and cerebral infarction, was administered Seroquel (Quetiapine Fumarate) without an appropriate diagnosis to support its use. The resident's significant change MDS assessment indicated moderate cognitive impairment, but there was no diagnosis to justify the use of the antipsychotic medication. Despite this, the resident received Seroquel on a routine basis, and the pharmacy consultant did not make any recommendations regarding its use for dementia. Interviews with facility staff revealed a lack of awareness and understanding regarding the appropriate diagnoses for Seroquel use. An LVN acknowledged that Seroquel should not be given to residents with dementia and expressed concerns about the potential risks and side effects. The DON confirmed that dementia was not an approved diagnosis for Seroquel and stated that the resident had been taking the medication for a while without proper justification. The Administrator admitted to not being familiar with antipsychotic medications and their indications. The facility's policy indicated that unnecessary drugs should not be used without adequate indications, highlighting a failure in adhering to this policy.

Penalty

Inspection fine: $92,814

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 it was free of medication error rates of 5 percent or greater, resulting in a medication error rate of 10.0%. This was based on 4 errors out of 40 opportunities, involving two residents. One resident did not receive the correct dose of Aspirin 81 MG and Omeprazole 40 MG, and was also not administered Lyrica 75 MG as ordered. Another resident was given the wrong type of Aspirin 81 MG, receiving an enteric-coated tablet instead of the prescribed chewable form. These errors were observed during medication administration by RN A. The first resident, a male with a history of fracture, diabetes, coronary artery disease, and hypertension, did not receive his prescribed Lyrica and was given incorrect doses of Aspirin and Omeprazole. The second resident, a female with diabetes, high blood pressure, and congestive heart failure, received the wrong type of Aspirin. The Director of Nursing (DON) acknowledged the errors and attributed them to staffing issues, while the Administrator emphasized the importance of administering medications as ordered. The facility's policy requires immediate reporting of medication errors to the physician and the DON, along with a medication error report to prevent recurrence.

Penalty

Inspection fine: $92,814

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 the necessary incontinent care, resulting in neglect. The resident, an elderly female with a history of cerebral infarction, type 2 diabetes mellitus, and vascular dementia, was found in a room with a strong urine odor and wet, brown stains on her sheets and mattress. The care plan for the resident indicated that she required assistance with personal hygiene and had a potential for pressure ulcer development, necessitating incontinent care after each episode and the application of a moisture barrier. However, the resident had not been changed for an extended period, leading to the observed conditions. During an observation and interview, it was revealed that the resident had not been changed since around 12:30 PM, despite the requirement for checks every two hours. CNA G admitted to not checking on the resident as frequently as needed due to other duties, while SNA H confirmed that the last change was before breakfast. Both aides acknowledged the importance of frequent incontinent care to prevent infections and skin breakdown. The LVN and DON also confirmed that the lack of prompt incontinent care could lead to pressure injuries and infections, and the DON noted that the incident could be considered neglect. The Administrator confirmed the incident, stating that the resident had not been changed and that it could be considered neglect. The facility's policy on abuse and neglect emphasized the resident's right to be free from neglect, defined as the failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. The failure to provide timely incontinent care for the resident was a clear violation of this policy, as confirmed by multiple staff members and the facility's administration.

Penalty

Inspection fine: $92,814

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 implement their written policies and procedures to prohibit neglect and abuse for one resident reviewed for abuse and one staff member reviewed for abuse training. The Social Worker did not immediately report Resident #11's allegation of verbal abuse by Resident #219 to the Administrator, as required by the facility's policy. Resident #11, who had intact cognition and a history of anxiety disorder, reported that her roommate, Resident #219, had threatened to kill her. The Social Worker, who had been employed for three months, did not consider the threat as abuse initially and planned to report it the next day, which was against the facility's policy of immediate reporting of abuse allegations. Additionally, the facility failed to ensure that LVN K completed abuse training upon hire. LVN K was hired on 03/05/24 but did not complete the required abuse prevention training until 03/25/24, which was 20 days late. The Human Resource Coordinator acknowledged that the training should have been completed within 3-5 days of hire and was responsible for ensuring its timely completion. The delay in training meant that LVN K was not adequately prepared to identify and report abuse during the initial period of employment. The facility's policy on abuse and neglect, revised on 03/29/18, mandates immediate reporting of any suspected abuse, neglect, exploitation, or mistreatment to the facility administrator. The policy also requires new employee orientation to include training on abuse prevention. The failure to adhere to these policies could place residents at risk of abuse, neglect, and decreased quality of life.

Penalty

Inspection fine: $92,814

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 were reported immediately, as required. Specifically, the Social Worker did not report Resident #11's allegation of verbal abuse and a death threat by her roommate, Resident #219, to the Administrator immediately. Resident #11, who had intact cognition and a history of anxiety disorder, reported that Resident #219 had cussed at her and threatened to kill her with a gun. The Social Worker, who had been employed at the facility for only three months, did not believe Resident #219 was capable of carrying out the threat and decided to wait until the next morning meeting to report the incident, which was against the facility's policy for immediate reporting of abuse allegations. Resident #11's care plan indicated she had difficulty coping with her roommate, and the Social Worker and staff were supposed to monitor the situation. Despite this, the Social Worker did not take immediate action when Resident #11 reported the threat. During an interview, the Social Worker admitted that he did not initially consider the threat as abuse but rather as a grievance, and he acknowledged that he should have reported it immediately to the abuse coordinator. The facility's policy on abuse and neglect, revised in 2018, clearly stated that any suspected abuse, neglect, exploitation, or mistreatment should be reported immediately to the Abuse Preventionist or designee. The Administrator confirmed that any threats or resident-to-resident altercations should be reported immediately. The failure to report the incident promptly could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.