Liberty Health Care Center

Penalty

Inspection fine: $24,845

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

Summary

The deficiency involves the facility’s failure to ensure a resident received timely assessment and care in accordance with professional standards of practice and the resident’s care plan after a reported change in condition. The resident was an elderly female with Alzheimer’s disease, dementia, prior cerebral infarction, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers, requiring a two-person Hoyer lift transfer at all times. Her care plan and Kardex both identified her as non–weight bearing and requiring Hoyer lift with two staff. On the afternoon of the day before the incident, documentation by an LVN indicated no edema or injuries, and a late-night note by another LVN documented edema but did not specify location, grade, or associated pain. During the night shift, a CNA transferred the resident from wheelchair to bed using a Hoyer lift alone, despite knowing the resident required a two-person Hoyer transfer and acknowledging awareness that Hoyer lifts required two staff. The CNA reported not being trained on the Hoyer lift at the facility and not checking the Kardex due to lack of access to the electronic system. After the transfer, while providing incontinence care, the CNA noticed bruising on the resident’s left leg and skin tears on her arms near the wrists. The CNA stated she informed a CNA supervisor, who allegedly said the leg had always been like that and did not check it, and that she also informed the night-shift LVN that the resident appeared to be in pain and asked the LVN to look at the leg. The LVN reportedly responded that the resident would be screaming if she was in pain and later, when shown the resident’s left foot with edema around 5:10–5:15 a.m., told the CNA to elevate the leg and then continued providing care to other residents without immediately assessing the resident. The LVN who had worked the prior day shift and returned for the morning shift stated that the resident had no bruises, edema, or skin tears when she left the previous evening. After receiving morning report, this LVN was asked by the night LVN to assess the resident at approximately 6:40 a.m. Upon pulling back the covers, she observed extensive new findings: discoloration and bruising to both arms and the right thigh, left lower extremity swelling and discoloration, multiple skin tears with missing top skin and no flaps, a knot on the right forearm, a scratch on the forehead, a large bruise on the back, fresh blood on the gown and blankets, and significant pain responses (grimacing, moaning, and frowning) when the resident was touched or moved. The resident was unable to articulate what had happened and denied falling or being harmed when questioned. Hospital evaluation documented a forehead abrasion, obvious deformity of the left lower extremity, severe hematoma of the right upper extremity, bilateral upper extremity contusions with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling, with concern for elder abuse noted. The facility’s investigation found no reported falls or incidents that could explain the injuries, confirmed that the night LVN had been notified of leg changes but did not promptly assess the resident, and classified the situation as an Immediate Jeopardy related to failure to assess and respond to a change in condition and to follow safe transfer requirements.

Removal Plan

• Suspended CNA A and LVN C immediately pending investigation
• Terminated LVN C for failure to assess and document a resident after being notified of a change in condition
• Completed facility-wide skin assessments with no new or abnormal findings
• Conducted environmental and safety rounds with no hazards or abnormal findings identified
• Conducted resident safe surveys with residents reporting they feel safe in the facility environment
• Provided staff education on abuse, neglect, and exploitation policies
• Completed mechanical lift (Hoyer) competencies with nursing staff
• Conducted targeted staff interviews with employees who had direct contact with the resident within the previous 72 hours regarding observed abnormalities and reporting
• Re-educated staff regarding the role of the Facility Abuse Coordinator, incident and accident reporting, documentation requirements, and charting expectations
• Reviewed electronic records of residents for assessment issues; no issues identified
• Held an AD HOC QAPI meeting with the interdisciplinary team to review the incident and identify system improvements
• Implemented staff training and competency testing/demonstration on abuse/neglect/reporting, documentation, transfers, resident assessment, and pain assessment
• Conducted in-services for all direct care staff; staff not present were not permitted to work their assignment until in-serviced
• In-serviced all new hires during facility orientation
• In-serviced all agency staff prior to working their floor assignment
• Completed in-service training on falls, documentation, Stop and Watch alert tool in PCC, and reporting abuse/neglect immediately to the Abuse Coordinator; 100% of staff trained
• Completed nursing staff training and competencies on skin assessments and pain assessments; 100% of nursing staff trained
• Conducted impromptu observations and skills/knowledge checks of Hoyer lift transfers and resident assessments
• Conducted daily reviews of resident records for assessments via daily 24-hour report review
• Monitored staff daily and conducted impromptu knowledge checks
• Reviewed 24-hour reports daily and reviewed resident charts for required charting

Penalty

Inspection fine: $24,845

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

Summary

The deficiency involves the facility’s failure to ensure safe transfers and adequate supervision during a mechanical lift transfer for one resident, resulting in serious injuries. The resident was an elderly female with Alzheimer’s disease, dementia, prior stroke, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers. Her care plan and Kardex specified that she was non–weight bearing and required a Hoyer lift with two staff for all transfers. Earlier on the day in question, she had been seen by facility physicians and nursing staff, and had received a shower and Hoyer transfer with two staff, with no bruises, skin tears, edema, or leg injury documented or observed. On the evening and night shift, a CNA assigned to the resident’s hall was instructed to put the resident to bed. The CNA reported that she took a Hoyer lift she had used on another resident and transferred this resident from wheelchair to bed by herself, despite knowing that Hoyer transfers required two staff and that the resident was a two-person Hoyer transfer. She stated she did not ask for help and acknowledged she had been trained that Hoyer lifts required two staff, although she also claimed she had not been trained on the Hoyer at this facility and said she did not check the Kardex because she did not have access. Another CNA confirmed that all Hoyer transfers were supposed to be done with two staff and that the resident’s requirements were available in the Kardex. The facility’s written Safe Resident Handling/Transfers policy required two staff for mechanical lift transfers and mandated that transfers be performed according to the resident’s plan of care. After the single-staff Hoyer transfer, the CNA and another aide assisted with repositioning the resident in bed. During this time, skin tears and bruising on the resident’s arms were observed. The assisting CNA reported that the skin tears appeared bloody and asked what had happened; she was told by the primary CNA that the injuries were old and that the nurse was aware. The primary CNA stated she informed the nurse that the resident appeared in pain, but the nurse allegedly responded that the resident would be screaming if she were in pain. The CNA also reported noticing bruising on the resident’s left leg and said she told her supervisor and the nurse, and was told the leg was always like that or that it was edema and to elevate it. The nurse on duty acknowledged being notified around early morning that the resident’s leg appeared bruised or swollen but did not immediately assess the resident, instead instructing that the leg be elevated while she continued care for another resident. By the following morning, when the day-shift LVN assessed the resident at the request of the night nurse, extensive injuries were found. The assessment revealed bilateral bruising to both arms, multiple skin tears with missing top layers of skin and no flaps, a large bruise on the back, a scratch on the forehead, and swelling, discoloration, and obvious deformity of the left lower extremity. The resident grimaced and moaned with touch or movement. Hospital evaluation documented a forehead abrasion, severe hematoma and contusions of the upper extremities with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling. Police photographs showed purple and red bruising on both hands with fresh and dried blood on the sheets, and the left leg bruised, purple, inflamed, and turned in an abnormal direction. There were no documented falls or incidents that could explain these injuries, and staff interviews did not identify any reported event, leaving the single-staff Hoyer transfer and subsequent lack of timely assessment after reported changes in condition as the central actions and inactions leading to the deficiency. The facility’s internal investigation confirmed that there were no abnormal findings on the resident earlier that day, including during a shower and physician visits, and that no staff reported any fall or incident during the night. The CNA who performed the transfer admitted using the Hoyer lift alone for this dependent, non–weight-bearing resident, contrary to the care plan, Kardex, and facility policy. The night nurse acknowledged failing to assess the resident after being notified of a change in her leg’s condition. The day nurse, who had last seen the resident without injuries the prior evening, found extensive new bruising, skin tears, and leg deformity the next morning. The combination of a one-person mechanical lift transfer for a resident care-planned for two-person Hoyer use, failure to follow the safe transfer policy and plan of care, and failure to promptly assess and document a reported change in condition led to the identified deficiency in ensuring the environment was free from accident hazards and that residents received adequate supervision and assistance to prevent accidents.

Removal Plan

• Completed facility-wide skin assessments with no new or abnormal findings identified.
• Conducted environmental and safety rounds with no hazards or abnormal findings identified.
• Conducted resident safe surveys; residents reported they felt safe in the facility environment.
• Provided staff education on abuse, neglect, and exploitation policies.
• Completed mechanical lift competencies with nursing staff.
• Reviewed electronic records of residents; no issues identified with assessments.
• Held an AD HOC QAPI meeting with the interdisciplinary team and involved police notification, social work, and the Regional Nurse; implemented ongoing daily monitoring of residents.
• Implemented staff training and competency testing/demonstration covering abuse, neglect, reporting, documentation, transfers, resident assessment, and pain assessment.
• Conducted in-services for all direct care staff (in person and/or via phone); staff not present were not permitted to work their assignment until in-serviced; new hires to be in-serviced during orientation; agency staff to be in-serviced prior to working their floor assignment.
• Completed in-service training on falls, documentation, Stop and Watch alert tool in PCC, abuse coordinator identification, and immediate reporting of abuse/neglect with 100% staff trained.
• Completed nursing staff training and competencies for skin assessment and pain assessments with 100% nursing staff trained.

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 a deficiency in medication storage and administration when a resident’s morning medications were found unsecured on her bedside table. The resident, a female with delusional disorder and schizophrenia, had an intact BIMS score of 14 and was independent in functional abilities. Her care plan contained no evidence that she was permitted to self-administer medications or keep medications in her room. Record review of her Medication Administration Record showed that four different medications (six tablets) were documented as given that morning, although exact administration times were not listed. At 10:02 AM, surveyors observed a small medication cup with medications at the resident’s bedside; the resident stated the medications had not been there long, that she needed to take them, and then immediately took them herself, explaining she must have been asleep and staff were not able to wake her. Interviews with nursing staff and the DON confirmed that the facility’s established process required nurses or medication aides to verify the MAR, identify the correct resident, and remain with the resident to observe consumption of medications, and that medications were never to be left in a resident’s room. RN and LVN staff both stated they would not leave medications with residents and described this as a clear rule. The facility’s written Medication Administration policy required observation of resident consumption of medication, and the Medication Storage policy required all drugs and biologicals to be stored in locked compartments, with medications under the direct observation of the person administering them or locked in the storage area/cart during a medication pass. Despite these policies and staff statements, the resident’s medications were left unattended at the bedside, unsecured and not under direct observation, constituting a failure to follow facility policy and regulatory requirements for medication storage and administration.

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 protect multiple residents from misappropriation of property and exploitation by a former Business Office Associate (BOA). The BOA accepted cash payments for a resident's monthly fees and a Social Security overpayment, but only a portion of the funds was deposited into the facility account, leaving a significant amount unaccounted for. Payment receipts were provided to the resident's family, but the funds were not properly deposited, and the discrepancy was only discovered after the family received a collection notice and reported the issue to the facility. The BOA later admitted to depositing some of the funds after her termination and could not account for the missing amount. In addition, the BOA created and cashed checks from the personal funds of three other residents for supposed purchases of personal need items, such as furniture, without authorization from the residents or their representatives. The residents did not receive the items, and in some cases, signatures were forged on withdrawal records. Interviews with residents, responsible parties, and staff confirmed that the purchases were not authorized, and the items were not delivered. The facility's audit revealed that the invoices used for these purchases were fabricated, with false information and templates found on the BOA's work computer. Another incident involved the BOA instructing a resident's family member to provide blank money orders for payment, one of which the BOA made out to herself and deposited into her personal account without authorization. The BOA admitted to this action, citing personal financial difficulties. The facility's policies required proper authorization and documentation for handling resident funds, but these procedures were not followed, resulting in the misappropriation and exploitation of resident property.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive, person-centered care plans to address all identified needs for two residents. For one resident with diagnoses including cerebral palsy and muscle wasting, who was dependent for all activities of daily living and receiving hospice care, the care plan did not include any reference to hospice services, despite a physician order for hospice admission. The omission was confirmed by both the DON and the Administrator, who acknowledged that the care plan for hospice was overlooked during a period when the facility was without an MDS Nurse and care plan responsibilities were being managed by the DON and ADON. For another resident with chronic diastolic heart failure and type 2 diabetes, who was dependent for most ADLs and had an indwelling urinary catheter due to urinary retention, the care plan did not address the presence of the catheter or required catheter care. This was confirmed through record review and interviews with the DON and Administrator, who both stated that the care plan for the catheter was missing. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes for all identified needs, but this was not followed in these cases.

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 regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.

Penalty

Inspection fine: $200,929

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 and enforce written policies and procedures to prohibit and prevent abuse of residents, as evidenced by an incident involving a verbally aggressive altercation between a staff member and a resident. During the incident, a staff member engaged in a loud and angry argument with a resident over cigarettes, escalating to the point where the staff member challenged the resident in a threatening manner. Witnesses reported that the staff member used a mean tone and made statements that upset the resident, causing her to cry and shake. The resident, who had a history of dementia, major depressive disorder, anxiety, and hemiplegia, was left emotionally distressed by the encounter. The facility also failed to ensure that allegations of abuse were reported to the Abuse Coordinator immediately, as required by policy. The staff member who witnessed the incident completed a concern form but did not report the incident directly to the Abuse Coordinator, Administrator, or supervisor. The concern form was left in a mailbox and not discovered until two days later, resulting in a delay in the facility's awareness and response to the abuse allegation. The staff member expressed fear of retaliation and uncertainty about the reporting process, despite having received training on abuse and reporting requirements. Additionally, the facility did not report the abuse allegation to the state agency within the mandated two-hour timeframe after being notified. The Administrator delayed reporting the incident while working on the investigation and could not provide a logical reason for the delay. Furthermore, the facility failed to implement immediate protective measures for the resident during the investigation, as the staff member accused of abuse continued to work several shifts before being suspended. Interviews with staff and residents confirmed these lapses in policy implementation, reporting, and resident protection.

Removal Plan

• Housekeeping Staff A Terminated.
• Housekeeping Staff B was in-serviced and educated on timely reporting by Administrator.
• Safe surveys on 10 residents completed. All residents were presented with a safe survey with no concerns.
• Notification to the Medical Director and Ombudsman occurred. Notification provided by Administrator.
• Resident #2 was assessed for psychological needs by MD and was stable. Resident #2 reassessed for psychological needs and was stable per MD.
• Monitoring for emotional distress will be performed each shift and documented in resident's electronic medical record.
• Resident assessed with PHQ9 and no depression identified.
• All department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI. Education Performed by: Regional Nurse.
• The administrator was in-serviced on reporting Abuse within an 2 hour period of learning of the allegation. Reviewed the latest provider letter.
• Ad Hoc QAPI performed.
• All facility staff, including nursing, therapy, dietary, housekeeping, and administration, will receive training on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person) training provided via online training portal or in person by DON or designee. The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods for doing so-either by directly notifying the Abuse Coordinator in person or via phone.
• Abuse coordinator phone number is posted around the facility.
• A post-training exam with a required 100% passing score is required. Staff unable to attend the in-service will not be permitted to work until training is completed. All staff in serviced via care feed or in person.
• The Abuse Coordinator started completing daily audits of all incident/concern reports for timely response and follow-up.
• A weekly leadership team huddle (Administrator, DON, ADON, Social Worker) was implemented to review all allegations of abuse and ensure prompt interventions.
• A retrospective review of all abuse allegations from the past 30 days was initiated, no abuse allegations reported, confirm compliance and identified any gaps. Audit will be completed by: Administrator.
• Abuse Coordinator who failed to act or report in a timely manner have been counseled and educated on policy requirements by corporate staff. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise.
• Disciplinary procedures for involved parties have been initiated per HR guidelines.
• Ongoing Monthly Abuse Training: Scheduled for the second week of each month, beginning in May for three months.
• The Administrator and DON, or designee, will review all reportable 3 times a week for 30 days, then once a week for 60 days to ensure appropriate reporting procedure was followed, and appropriate interventions were initiated.
• Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings.

Penalty

Inspection fine: $200,929

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 following a significant mental health event. The resident, who had a history of major depressive disorder, anxiety, mood disorders, and previous suicide attempts, expressed suicidal ideation by asking staff for helium to end her life. Despite this clear expression of intent, the care plan was not updated to address suicide prevention or self-harm after the incident. The existing care plan only included general interventions related to antidepressant medication and monitoring for risk of harm, but did not specifically address the acute suicidal ideation or the subsequent self-harm event. On the day of the incident, the resident repeatedly asked for helium and stated her desire to kill herself due to family issues and feelings of hopelessness. Staff placed her on 15-minute checks as per facility policy at the time, but did not conduct a room sweep for potentially dangerous objects. During one of these checks, a nurse found the resident had cut her wrist with a microblade razor, which she had obtained independently. The staff intervened, provided first aid, and removed additional sharp objects from the room. The resident was then placed on one-on-one supervision and later transferred to the hospital for evaluation. Interviews with staff revealed gaps in training and awareness regarding suicide prevention protocols and care plan updates. The Director of Nursing, social worker, and other staff members acknowledged that the care plan should have been updated to reflect the resident's behaviors and risk for self-harm following the incident. Documentation showed that the interdisciplinary team did not revise the care plan or document a team meeting to address the resident's change in status, as required by facility policy. This failure to update the care plan after a significant change in the resident's condition constituted the deficiency identified by surveyors.

Removal Plan

• Resident #1's care plan was updated to reflect resident centered behavioral health status, including the initiation of a psychiatric virtual visit and ongoing behavioral observations.
• A 100% audit of current residents using the PHQ-9 screening tool began.
• Care plans are being updated, if warranted by the PHQ-9 screening tool, to reflect PHQ-9 results and ensure individualized, resident-centered care.
• Nursing administration staff received in-service training on care plan update protocols, provided by the regional compliance nurse.
• An ad-hoc QAPI meeting was held with the Medical Director, Administrator, Director of Nursing, and the interdisciplinary team to evaluate current systems related to care planning and suicide prevention. Local ombudsmen notified.
• QAPI will continue to review care plan compliance and quality monthly.
• The Director of Nursing or designee will monitor the 24-hour report (generated through Point Click Care based on progress notes entered into the residents chart) and PHQ-9 completion daily for any depression or suicidal thoughts and care plans will be updated as needed.
• Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings.

Penalty

Inspection fine: $200,929

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 provide adequate supervision and implement appropriate interventions for a resident who expressed suicidal ideation. The resident, who had a history of major depressive disorder, anxiety, bipolar disorder, and previous suicide attempts, verbally expressed a desire to end her life and specifically asked staff if the facility had helium, stating she wanted to kill herself. Despite this clear expression of suicidal intent, the resident was only placed on 15-minute monitoring checks, and a room search for potentially harmful objects was not conducted. The resident subsequently attempted to cut her right wrist with a microblade razor between the 15-minute checks, resulting in superficial wounds. The resident's care plan did not address her major depressive disorder, suicidal thoughts, or self-harm risk, despite her psychiatric history and recent statements. Staff interviews revealed that the facility's policy at the time was to initiate 15-minute checks if a resident did not have a specific plan for self-harm, and 1:1 supervision only if a plan was present. However, the resident's statements and actions indicated a significant risk, and the lack of a room search allowed her access to a razor, which she used in her suicide attempt. Additionally, staff involved in the incident could not recall receiving training on updated suicide prevention policies, and documentation of such training was not available. Further interviews with staff and review of facility policies confirmed that the resident was not provided with 1:1 supervision or an immediate room search following her suicidal statements. The facility's suicide prevention policy required that residents expressing suicidal ideation not be left alone and receive 1:1 care until emergency psychiatric care could be arranged. The failure to follow these protocols, update the care plan, and ensure staff training contributed to the resident's opportunity to attempt self-harm while under the facility's care.

Penalty

Inspection fine: $200,929

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 staff member (HSK A) engaged in a verbally aggressive argument with a resident over cigarettes. The resident, who had diagnoses including dementia, major depressive disorder, anxiety, and hemiplegia, was able to make herself understood but had moderate cognitive impairment. During the incident, HSK A became loud and angry, and after the resident told her to "shut up," HSK A got up from her chair and challenged the resident to make her shut up. Witnesses reported that the exchange escalated, with HSK A using a mean tone and making further aggressive remarks, which caused the resident to cry and become visibly upset. The facility's records show that the incident was not reported immediately as required by policy. The witness to the event, another staff member, placed a note under the HR door but did not notify the administrator or designated abuse coordinator right away. The incident was reported to the administrator several days later, and the staff member involved continued to work in the facility during that time. The facility's policy requires immediate reporting and intervention in cases of alleged abuse, but this protocol was not followed in this instance. Interviews with the resident and other witnesses confirmed that the staff member's behavior was verbally abusive and outside the norm for interactions between staff and residents. The resident expressed feeling sad and upset at the time of the incident, and other residents present described the staff member as disrespectful and angry. The facility's own investigation confirmed the occurrence of verbal abuse, and the failure to follow established abuse prevention and reporting policies contributed to the deficiency.

Penalty

Inspection fine: $200,929

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, but not later than two hours after the allegation was made, as required by regulation. Specifically, an incident occurred in which a staff member was verbally aggressive toward a resident during a dispute over cigarettes. The incident was witnessed by another staff member, who documented the event on a concern form and left it in a mailbox outside the HR door, rather than reporting it directly and immediately to the abuse coordinator or administrator as required by facility policy. The administrator did not become aware of the incident until two days later and did not report the allegation to the state agency within the mandated two-hour timeframe. The resident involved had a history of dementia, major depressive disorder, anxiety, and hemiplegia following a stroke. The resident was able to make herself understood and had moderate cognitive impairment. During the incident, the staff member raised her voice and made threatening remarks, causing the resident to become upset, cry, and shake. The resident later reported feeling sad and upset at the time of the incident, though she and the staff member later reconciled. The staff member continued to work scheduled shifts after the incident until the administrator was notified and suspended her pending investigation. Interviews and record reviews revealed that the staff member who witnessed the incident did not immediately report it due to fear of retaliation, despite being trained on abuse reporting. The administrator acknowledged the delay in reporting and could not provide a logical reason for not reporting the incident promptly. Other staff and residents confirmed the details of the incident and the delay in reporting. The facility's failure to follow its own abuse prevention and reporting policies resulted in a delay in protecting the resident and in notifying the appropriate authorities.

Removal Plan

• Housekeeping Staff A terminated.
• Housekeeping Staff B was in-serviced and educated on timely reporting by Administrator.
• Safe surveys on residents completed. All residents were presented with a safe survey with no concerns.
• Notification to the Medical Director and Ombudsman occurred. Notification provided by Administrator.
• Resident assessed for psychological needs by MD and was stable. Resident reassessed for psychological needs and was stable per MD.
• Monitoring for emotional distress will be performed each shift and documented in resident's electronic medical record.
• Resident assessed with PHQ9 and no depression identified.
• All department heads were re-educated on the abuse prevention policy, immediate reporting expectations, and responsibilities of supervisors in escalating concerns during ad hoc QAPI. Education performed by Regional Nurse.
• The administrator was in-serviced on reporting Abuse within a 2 hour period of learning of the allegation. Reviewed the latest provider letter.
• Ad Hoc QAPI performed.
• All facility staff, including nursing, therapy, dietary, housekeeping, and administration, will receive training on Abuse, Neglect, Exploitation, Timely Reporting of Abuse to the Abuse Coordinator (by calling or in person) training provided via online training portal or in person by DON or designee. The in-service included detailed instruction on recognizing signs of abuse/neglect, the importance of immediate reporting, and specific methods for doing so-either by directly notifying the Abuse Coordinator in person or via phone.
• Abuse coordinator phone number is posted around the facility.
• A post-training exam with a required 100% passing score is required. Staff unable to attend the in-service will not be permitted to work until training is completed. All staff in serviced via care feed or in person.
• Abuse Coordinator started completing daily audits of all incident/concern reports for timely response and follow-up.
• A weekly leadership team huddle (Administrator, DON, ADON, Social Worker) was implemented to review all allegations of abuse and ensure prompt interventions.
• A retrospective review of all abuse allegations from the past 30 days was initiated, no abuse allegations reported, confirm compliance and identified any gaps. Audit will be completed by Administrator.
• Abuse Coordinator who failed to act or report in a timely manner have been counseled and educated on policy requirements by corporate staff. Counseling included a review of F607 policy requirements: mandatory reporting timelines, how and when to escalate abuse concerns, documentation expectations, and suspension protocol when allegations arise.
• Disciplinary procedures for involved parties have been initiated per HR guidelines.
• Ongoing monthly abuse training scheduled for three months.
• The Administrator and DON, or designee, will review all reportable three times a week for 30 days, then once a week for 60 days to ensure appropriate reporting procedure was followed, and appropriate interventions were initiated.
• Any discrepancies will be addressed immediately and reviewed during weekly clinical stand-ups and monthly QAPI meetings.

Penalty

Inspection fine: $200,929

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

Summary

The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with dementia, major depressive disorder, anxiety, hemiplegia, and hemiparesis. The incident occurred during a dispute over cigarettes between a housekeeper and the resident, where the housekeeper became verbally aggressive, raised her voice, and made threatening remarks. The resident became visibly upset, cried, and expressed a desire to retaliate, indicating significant emotional distress. The facility's investigation into the incident was incomplete. While the housekeeper was suspended and some interviews were conducted, the investigation did not include interviews with all residents who witnessed the event. Specifically, two other residents who were present during the altercation were not interviewed by the administrator, and the safe surveys conducted did not address the issue of verbal abuse by staff. Additionally, the reporting of the incident was delayed, as the initial witness did not immediately report the event to the administrator as required by facility policy. Documentation and interviews revealed inconsistencies and gaps in the investigation process. The administrator assumed that the social worker had interviewed all relevant residents, but this was not the case. The social worker was unsure if interviews with all witnesses were documented, and one resident confirmed he was not interviewed about the incident. The facility's own policy requires thorough investigation of abuse allegations, but this was not followed, resulting in a lack of evidence that the incident was fully investigated to prevent further abuse.

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 proper pharmacy procedures for accounting controlled drugs, as evidenced by missing signatures on the Controlled Drugs - Count Record forms for two medication carts. Specifically, the 300 Hall Nurse Cart and the 200/500 Halls Medication Aide Cart had numerous instances where staff did not sign the forms at shift changes, indicating that narcotic counts were not conducted. This lack of documentation was observed on various dates in June 2024, with both nurses and medication aides failing to sign off on the count sheets. The absence of signatures suggests that the required reconciliation of controlled drugs was not performed, which could lead to unaccounted medications. Interviews with staff, including medication aides and the Director of Nursing (DON), revealed a lack of training and awareness regarding the cart count sheet process. The DON acknowledged the potential for drug diversion if narcotic counts were not completed. Additionally, the Pharmacy Consultant, who was responsible for reviewing the medication carts, failed to identify the missing signatures during her review. The facility's Controlled Substances policy mandates that controlled medications be counted at the end of each shift by both the incoming and outgoing staff, a procedure that was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the secure storage of medications, specifically clonidine and a Fentanyl patch, which were left unattended at the nurse station. During an observation, these medications were found on the desk, accessible to staff, residents, and visitors, without supervision by a nurse or medication aide. This oversight was acknowledged by the Administrator, who confirmed that medications should not be left unattended as they could be removed by anyone passing by. Interviews with staff revealed that LVN B had left the medications on the desk while attending to other tasks, acknowledging that this was against protocol. The Director of Nursing (DON) was aware of the incident and confirmed that medications should not be left in areas where they could be accessed by unauthorized individuals. A review of the facility's Controlled Substance policy indicated that controlled substances must be stored in a locked container within the medication room, separate from non-controlled medications, and access should be recorded and remain locked at all times.

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 a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's needs as identified in the comprehensive assessment. Specifically, the facility did not apply a hand splint as ordered by the physician for a resident with muscle wasting, atrophy, and cerebral infarction. The physician's orders required the application of a resting hand splint to the resident's right upper extremity to prevent contracture, with instructions for the splint to be removed every night. However, observations on multiple occasions revealed that the resident did not have the splint applied, and the resident's hand was clenched tightly, although she could open it when asked. Interviews with the Director of Nursing (DON) and a Certified Nursing Assistant (CNA) revealed a lack of awareness and communication regarding the application of the splint. The DON acknowledged that the splint was not applied as ordered and stated it was the CNA's responsibility to ensure its application. The CNA admitted she was unaware of the requirement to apply the splint and had not been informed of this responsibility. Despite seeing the instruction on the aide assignment sheet, she did not apply the splint because she had never seen it. This oversight could potentially lead to the resident's hand becoming contracted, as noted by both the DON and the CNA.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident receiving enteral feeding received appropriate care and services to prevent complications. Specifically, LVN A did not verify the placement of the resident's G-tube before administering water flushes and medications. The resident, a male with dysphagia, was admitted with orders to receive all feedings and medications via G-tube, with placement verification required before each use. However, during an observation, LVN A administered the flushes and medications using the plunger of a syringe instead of allowing them to flow by gravity, contrary to the facility's policy. The Director of Nursing (DON) confirmed that the staff should follow the policy for gastrostomy tube placement checks and that flushes and medications should be administered via gravity. The facility's policy, revised in November 2018, outlines the steps for confirming tube placement and administering medications through an enteral tube, emphasizing the importance of gravity flow to prevent injury. The failure to adhere to these procedures could place residents at increased risk of complications such as improper nutrition, infection, aspiration, and possible injury.