Paradigm At First Colony

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 safe and appropriate respiratory care for a resident who was admitted with diagnoses including aortocoronary bypass graft, atherosclerotic heart disease, atrial fibrillation, and heart failure. The resident’s baseline care plan stated that she had oxygen via nasal cannula to maintain adequate oxygen saturation and respiratory comfort and directed staff to follow physician orders for oxygen therapy delivery. However, the resident’s orders did not include an oxygen order, and the hospital transfer paperwork listed an oxygen flow rate of 1.5 to 4 L/min via nasal cannula. A review of the record showed that oxygen was administered to the resident without a physician order from the time of admission through the date identified in the report. A LVN stated she saw the resident on oxygen during her initial round, assumed there was an order because oxygen was already in place, and did not verify whether an oxygen order existed before administering it. Another LVN stated she relied on the hospital discharge paperwork and believed the NP had said to continue all orders from the hospital discharge list, even though no oxygen order was present in the hospital discharge summary. She also documented oxygen administration at 3 liters per minute for anxiety based on the transfer paperwork. The NP stated she did not tell staff that the resident needed oxygen or had oxygen on the discharge orders, and said oxygen could be started in a respiratory emergency and then an order obtained afterward. The DON and ADON both stated there was no oxygen order on the hospital discharge summary and acknowledged that the oxygen order was not transcribed into the computer. The DON also stated the facility did not have a policy to administer oxygen for anxiety, and the ADON said if there was no emergency, the resident should have had an oxygen order before oxygen was applied.

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 deficiency involves the facility’s failure to provide timely and adequate assistance with activities of daily living and incontinence care, resulting in a resident being left in soiled conditions on two separate occasions. The resident was an elderly male with dementia, dysphagia, esophageal obstruction, colostomy status, ileus, and intestinal obstruction, who was dependent on staff for toileting and incontinent care and had both an indwelling catheter and an ostomy. His care plan and orders required staff to monitor and manage his colostomy and feeding tube, provide extensive assistance with ADLs, and assist with incontinent care and repositioning. On one evening, a family member reported that after visiting the resident, cleaning him, changing his bed sheets, and cleaning his floor, she left and returned about an hour later to find him covered in feces. A photo from that date showed the resident lying in a light brown liquid substance on his colostomy bag, stomach, adult brief, bedsheets, and clothing. The family member brought the Unit Manager and an RN to the room and requested that the resident be showered. The Unit Manager and RN later confirmed that they recalled the incident, described the colostomy bag as leaking, and stated that they did not know how long the resident had been in that condition. On another occasion, the same family member reported that when she visited and removed the sheet from the resident, his adult brief was open underneath him and the bed was soaked with urine and tube-feeding formula. A photo from that date showed an open adult brief with light tan stains and bed sheets soaked with a light tan substance. The family member called an LVN to the room and showed him the condition. Staff interviews, including with the Unit Manager, RN, DON, Administrator, and LVN, acknowledged that the resident’s colostomy and feeding tube frequently leaked, that residents were supposed to be checked every two hours or more frequently as needed, and that the resident would need to be checked more often due to frequent leakage. The facility’s ADL policy stated that necessary assistance and supervision would be provided when residents were unable to perform ADLs independently.

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 honor a resident's right to have her designated Power of Attorney (POA) exercise her rights, as required by state law. The POA, who was a friend and neighbor of the resident, provided a notarized Texas Durable Power of Attorney document to the facility. Despite the document being properly signed and notarized, the facility Administrator determined it was invalid, citing the resident's cognitive impairment and questioning the legitimacy of the notary. The Administrator instructed staff not to provide the requested clinical records to the POA and referred to the POA documentation as a 'trash piece of paper.' The resident in question was an elderly female with a history of altered mental status, muscle weakness, anxiety, and mood disturbance. Upon admission, her cognitive status was assessed as moderately impaired, but subsequent evaluations indicated she was alert, oriented, and had adequate judgment. The resident confirmed she knew her POA, trusted her, and was not coerced into signing the POA document. She also expressed willingness to move to another facility to be closer to her POA. Staff interviews revealed that the facility's decision to deny the POA's rights was influenced by a previously open Adult Protective Services (APS) case, although APS confirmed the case was closed with no allegations against the POA. The Social Worker and Administrator both cited concerns about the POA's validity due to the APS involvement and the resident's cognitive status, despite documentation and statements from both APS and the resident supporting the POA's legitimacy. The facility's actions resulted in the POA being denied access to the resident's clinical records and the ability to assist in her care decisions.

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 two residents had their call lights within reach, as required by their care plans and facility policy. For one resident, who had diagnoses including non-Alzheimer's dementia, stroke, spinal stenosis, and muscle weakness, the call light was observed hanging behind the right side of the bed, out of reach, while the bed controls were accessible. The resident reported that staff sometimes did not return the call light to her reach after providing assistance, and she would wave at staff passing by to get help if she could not reach the call light. Her care plan specifically required that the call light and bed controls be within reach at all times to mitigate her risk for falls and injuries. Another resident, with severe cognitive impairment and multiple medical conditions such as heart failure, neurogenic bladder, and respiratory failure, was found with his call light behind the bed and nightstand, tangled among other cords and not accessible. He stated he often had to yell for help because the call light was not on his bed. Staff interviews confirmed that it was the nurses' responsibility to ensure call lights were within reach and that all staff were expected to check call light placement. The facility's policy required call lights to be accessible and within reach of the resident's bed or sitting area, but this was not followed for these two 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

The facility failed to provide evidence that all alleged violations of abuse, neglect, and exploitation were thoroughly investigated and that the results of these investigations were reported to the State Survey Agency within five working days, as required. This deficiency was identified for six out of eight residents reviewed for abuse, neglect, and exploitation. Specific incidents included allegations of rough care during activities of daily living (ADL) assistance, rough care during medication pass, failure to provide essential care, resident-to-resident physical altercation, and concerns of possible sexual assault and unsanitary conditions. In each case, the facility did not submit the required five-day investigation findings via the TULIP database, and no additional information related to the incidents was found in the system. For example, two residents with self-care deficits and intact cognition reported that a CNA was rough during ADL care, but the facility did not identify the CNA in documentation, nor did it submit a five-day investigation report. Another resident's family member alleged rough care during medication administration, but again, no five-day investigation findings were submitted, and documentation was lacking regarding the incident details and staff training at the time. In a separate case, a resident's responsible party alleged that a CNA failed to provide essential care, but the facility did not submit the required investigation findings, and the CNA could not recall the details of the incident. Additional incidents included a resident hitting another resident, with both residents having behavioral health diagnoses and care plans addressing aggression and psychotropic medication management. Despite assessments and interventions being documented in the clinical record, the facility did not submit the required five-day investigation findings. Another case involved an allegation of possible sexual assault, lack of catheter dressing, and unsanitary room conditions, reported by an insurance provider, but again, no five-day investigation findings were submitted. Staff interviews confirmed awareness of abuse and neglect training, but the required documentation and reporting of thorough investigations were not completed or retained as required by facility policy and 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

The facility failed to provide proper pharmaceutical services in the administration of eye drops to a resident with glaucoma and other significant medical conditions. During a medication pass, a medication aide did not pull down the lower eyelid before instilling the prescribed Latanoprost eye drops, contrary to facility policy and standard procedure. Additionally, the aide placed the medication cap with the inside facing down on an unclean nightstand surface, which was not disinfected prior to the procedure, and then replaced the cap onto the bottle after administration. The resident involved was an elderly female with a history of heart failure, fainting, glaucoma, and elevated blood pressure. She had severe cognitive impairment and required varying levels of staff assistance for activities of daily living. The resident's care plan noted impaired visual functioning and risk for decreased ADLs due to glaucoma, but did not specify interventions for medication administration as ordered by the physician. Observation revealed that the medication aide instilled the eye drops without forming a pouch by pulling down the lower eyelid, and the resident did not always receive the correct number of drops as ordered. The aide also failed to maintain the cleanliness of the medication cap, potentially contaminating the dropper. These actions were inconsistent with both the facility's policy and the aide's documented competency checklist, which required proper technique for eye drop administration.

Penalty

Inspection fine: $19,838

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

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. The deficiency involved a resident who was on anticoagulant therapy with Eliquis and experienced an unwitnessed fall with a head injury. Despite the resident's condition, the facility delayed sending the resident to a higher level of care, opting for regular EMS transport instead of 911, which was against the facility's policy for such incidents. The resident, who had a history of muscle weakness, unsteadiness on feet, vascular dementia, end-stage renal disease, and osteoporosis, was found sitting on the floor with swelling to the right cheek. The resident's vital signs were stable, and she denied any pain, but her speech was slurred, which was not immediately acted upon as a potential sign of a serious condition. The nurse on duty, RN A, used her judgment to send the resident to the hospital via regular EMS, despite knowing the resident was on blood thinners and the facility's policy required 911 transport for unwitnessed falls with head injuries. Interviews revealed that the facility did not have a specific policy for unwitnessed falls with head injuries for residents on anticoagulants, and the DON was not aware of the resident's medication regimen. The facility's failure to follow proper procedures and the lack of immediate action in response to the resident's condition led to the identification of an Immediate Jeopardy situation, as the resident was later diagnosed with an acute subdural hematoma and required emergency medical intervention.

Removal Plan

• CR #1 was transferred to hospital.
• The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting to review the IJ template and Plan of Removal.
• RN A was suspended pending investigation.
• The Director of Nursing and Assistant Director of Nursing assessed residents who had unwitnessed fall for any signs or symptoms of headache, vomiting, or abnormal findings to the scalp/head with no adverse findings.
• The Director of Nursing initiated an in-service with licensed nurses. Topics included: Fall Procedures, specifically on activating the emergency response system (911) for any residents who has a fall with a visible head injury. 911 should be activated upon identification and notification to Physician and the DON would be secondary. Licensed nurses will be educated before starting their next shift. Education will be included in orientation.
• The Director of Nursing provided 1:1 education with RN A. Education included Fall Procedures and activating the emergency response system (911) for any resident who has a fall with a visible head injury. 911 should be activated upon identification of the abnormal findings and notification to Physician and DON would be secondary; and completing through assessments post-fall with consideration for residents on anticoagulants.
• The Regional Nurse Consultant provided 1:1 education with the DON. Education included Fall Procedures and activating the emergency response system (911) for any resident who has a fall with a visible head injury ' 911 should be activated upon identification and notification to Physician and DON secondary; and completing through assessments post-fall with considerations for resident on anticoagulants.
• Fall documentation will be reviewed each weekday in morning meeting on weekends, holidays, and after hours by DON/designee to ensure completed and appropriate actions are taken and documented.
• The Administrator and DON reviewed the policy on Fall Management and Changes of Condition no changes noted.

Penalty

Inspection fine: $19,838

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 adequate supervision and assistance devices to prevent accidents for a resident who was on anticoagulant medication. This resident, who had a history of falls and was diagnosed with conditions such as muscle weakness, unsteadiness on feet, vascular dementia, end-stage renal disease, and osteoporosis, experienced multiple unwitnessed falls within a short period. Despite being care planned for fall risks, the interventions in place were insufficient to prevent these incidents, leading to a severe head injury and hospitalization. The resident's care plan included interventions such as anticipating needs, providing prompt assistance, ensuring adequate lighting, and encouraging the resident to ask for help. However, these measures were not effective, as the resident continued to fall, with incidents occurring on several dates in November. The resident's cognitive impairment, indicated by a BIMS score of 7, contributed to her inability to remember to use the call light for assistance, further complicating the situation. Interviews with facility staff revealed that the resident was often placed in the common area near the nurse station for supervision, but she was mobile in her wheelchair and could move freely, which increased the risk of falls. The facility acknowledged the challenges posed by the resident's dementia and mobility but did not have the staffing resources to provide one-on-one supervision. The repeated falls and the facility's inability to implement effective interventions led to the identification of an Immediate Jeopardy situation, highlighting the need for a more robust fall prevention strategy.

Removal Plan

• The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting to review the IJ template and Plan of Removal.
• CR #1's care plan was reviewed and fall interventions updated by MDS Coordinator after each fall.
• The Regional Nurse did 1:1 in-service with MDS on fall management and developing individualized fall prevention plans.
• Residents who experience a fall event are reviewed during the daily clinical morning meeting by the Interdisciplinary Team (IDT).
• The facility will identify residents who are on anticoagulants by Physician Orders, Anticoagulant Care Plans, and side effect monitoring on the EMAR.
• Residents are assessed for risk for falls by the charge nurse on admission, quarterly, with significant change and fall events.
• The Director of Nursing initiated an in-service with licensed nurses on fall management, change of condition, and Kardex.
• The Director of Nursing provided education with staff members that provide direct care to residents.
• The Regional Nurse Consultant provided 1:1 education with the DON on fall management and developing individualized fall prevention plans.
• The Administrator and DON reviewed the policy on Fall Management with no changes required.
• Fall trends are brought to QAPI and reviewed monthly with the Medical Director.
• The Administrator reviewed the facility assessment, staffing on the memory care unit (supervision), and residents who are at risk for falls with no adverse findings identified.

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 privacy of residents' personal and medical records for seven out of ten residents reviewed. During an observation, a laptop on the nurse's cart was left open and unattended, displaying the full names and room numbers of seven residents. This occurred while CMA A was in a resident's room administering medication, leaving the laptop accessible to unauthorized individuals, including a housekeeping staff member who was in direct sight of the screen. Interviews with CMA A and RN A confirmed that the staff was aware of the requirement to lock computer screens to protect resident information, as per HIPAA regulations. CMA A admitted to forgetting to lock the screen, acknowledging it as a violation of privacy protocols. The facility's policies on resident rights and HIPAA compliance emphasize the importance of safeguarding resident information from improper use and disclosure, which was not adhered to 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 that the daily nursing staffing information was posted and readily accessible for review from November 14 to November 19, 2024. During an observation on November 19, 2024, at 9:09 a.m., it was noted that the staffing information displayed at the receptionist desk was outdated, showing the date of November 13, 2024. An interview with the Staffing Coordinator revealed that she was responsible for updating the daily nursing staff information but had forgotten to do so for the past few days. The Administrator confirmed that the Staffing Coordinator was tasked with this responsibility and acknowledged that the daily staffing information should be posted at the front of the facility each day. Additionally, the Administrator mentioned that the facility did not have a staffing posting policy in place.

Penalty

Inspection fine: $44,721

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 safe and appropriate administration of intravenous (IV) fluids for a resident, specifically in the management of a peripherally inserted central catheter (PICC) line. The resident, who was readmitted from the hospital with a PICC line, did not have physician orders or a care plan in place for monitoring and dressing changes of the PICC line. This oversight persisted from the time of the resident's readmission until the PICC line was ordered to be discontinued by a nurse practitioner. The resident's PICC line was not removed after the completion of IV antibiotics, and the dressing was not changed according to the facility's policies, which require changes every 5 to 7 days. Observations revealed that the resident's PICC line had two tape dressings, one of which was dated from the hospital stay, and both dressings appeared brownish in color, indicating they had not been changed as required. Interviews with various staff members, including the Director of Nursing (DON), Licensed Vocational Nurses (LVNs), and the Nurse Practitioner (NP), highlighted a lack of communication and adherence to protocols. The NP admitted to not placing orders for the PICC line's discontinuation or dressing changes, and the nursing staff failed to notify the physician upon completion of the antibiotic therapy. The deficiency was identified as an immediate jeopardy situation, posing a risk of infection and sepsis due to the prolonged presence of the PICC line and lack of proper dressing changes. The facility's staff, including the DON and Administrator, acknowledged the failure to follow physician orders and the potential infection control concerns. The lack of documentation and communication among the nursing staff and the NP contributed to the oversight, resulting in the resident's PICC line being left in place longer than necessary without appropriate monitoring and care.

Removal Plan

• Resident #37's PICC line was assessed by the Director of Nursing with no adverse effects or signs or symptoms of infection noted.
• A physician's order was obtained for the removal of the PICC line, and PICC line was discontinued without adverse effects.
• The Physician ordered lab work and results were noted with no adverse findings.
• All other residents with central lines were assessed by the Director of Nursing to ensure an up-to-date dressing, active order sets to include monitoring, flushes, dressing changes, orders to obtain central lines after IV therapy is completed, and central line specific care plans.
• The Administrator and DON informed the Medical Director of the Immediate Jeopardy situation through an AD Hoc QAPI meeting.
• The Regional Nurse Consultant provided 1:1 education with the DON on providing oversight with residents with central lines and ensuring compliance with central line policies and procedures.
• The Director of Nursing initiated in-services with licensed nurses on ensuring compliance with central line policies and procedures.
• The Director of Nursing conducted 100% rounds on residents with central lines and compliance was noted with policies and procedures.
• The Administrator reviewed the Central Line Policies and Procedures and no changes were required.
• The charge nurse will input and complete orders for residents who obtain or admit with a central line and will be validated in clinical morning meeting by nurse leadership.
• The clinical morning meeting will include reviewing high risk residents to include residents with central lines and ensuring compliance with central line policies and procedures.

Penalty

Inspection fine: $44,721

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

Summary

The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed in the kitchen. During an inspection, it was noted that multiple food items in the walk-in refrigerator were not labeled with dates of opening or preparation, contrary to the facility's policy requiring such labeling and disposal after 72 hours. Additionally, cases of canned food were found stored directly on the floor in the storage room, which poses a risk of cross-contamination. Further observations revealed significant issues with the kitchen's infrastructure, including a wet floor near the dish machine and three-sink compartment, and improper air gaps in the ice machine and dish machine, which are necessary to prevent backflow. There were also holes in the ceiling and walls near the Dietary Food Service Manager's office, which could allow pest entry. A drain water backup was observed on the kitchen floor, and it was discovered that the facility had not self-reported this issue to the local Department of Health, as required by city ordinance. Interviews with the Dietary Food Service Manager and other staff revealed a lack of immediate action and reporting regarding the drain water backup and air gap issues. The facility continued operations despite the presence of these hazards, and it was only after a Health Department Inspector's visit that the kitchen was ordered to cease operations. The facility's failure to maintain proper food safety standards and infrastructure, along with inadequate reporting and response to the sewage backup, led to the closure of the kitchen until necessary repairs and sanitation were completed.

Penalty

Inspection fine: $44,721

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 #88, who has a history of chronic obstructive pulmonary disease (COPD) and other medical conditions. Despite having physician orders for oxygen therapy, the care plan did not address Resident #88's behavior of removing her oxygen cannula and not storing it properly, which poses a risk of infection and fire hazard. Observations revealed that the cannula was left on the bed, and interviews with staff indicated that there was no consistent monitoring or cleaning of the oxygen equipment, despite the resident's noncompliance with keeping the oxygen on. Resident #43, who has cerebrovascular disease and is always incontinent of bladder and frequently incontinent of bowel, also lacked a comprehensive care plan addressing potential skin issues. The resident's admission records and assessments indicated a need for skin care planning due to incontinence, but this was not included in the care plan. Interviews with the Director of Nursing and MDS Coordinators revealed that the omission was an oversight, and the potential negative outcomes of not addressing skin issues were acknowledged. The facility's failure to include these critical aspects in the care plans for Residents #88 and #43 could lead to unmet medical, functional, and psychosocial needs, potentially causing a decline in their health. The facility's care planning policies require comprehensive care plans to be developed within seven days of the comprehensive assessment, but this was not adhered to in these cases.

Penalty

Inspection fine: $44,721

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 proper pharmaceutical services, resulting in a medication error rate of 15%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed in the administration of medications to two residents by two staff members, MA A and RN A. Specifically, MA A did not follow physician orders when administering Pantoprazole granules mixed with yogurt instead of apple juice or applesauce, and incorrectly gave Ferrous Gluconate instead of Ferrous Sulfate to a resident. Similarly, RN A failed to administer medications correctly by not shaking Megestrol oral suspension as required, administering the wrong iron supplement, and giving Latanoprost eye drops at the wrong time of day. The residents involved had complex medical histories, including conditions such as sepsis, schizophrenia, hypertension, heart failure, and respiratory distress. One resident required total care assistance with activities of daily living and had moderately impaired cognition, as indicated by their BIMS score. The errors in medication administration could potentially impact the therapeutic outcomes and health of these residents, as the medications were not given as prescribed by their physicians. Interviews with the staff involved revealed a lack of proper training and oversight in medication administration. MA A admitted to not having received medication training since starting at the facility and acknowledged the errors made. RN A also expressed regret for the mistakes and noted the absence of in-service training on medication administration. The Director of Nursing, who had recently started at the facility, confirmed that the staff had been trained according to the facility's policy, but additional training would be provided. However, the facility's policy did not adequately address the timely and correct administration of medications.

Penalty

Inspection fine: $44,721

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

Summary

The facility failed to develop a person-centered baseline admission care plan for a resident within 48 hours of admission. The resident, a cognitively intact male with cerebrovascular disease and hemiplegia following a stroke, was admitted to the facility. The resident's admission records indicated impairments in upper and lower extremities and incontinence issues. However, the baseline care plan did not address the resident's potential for skin issues related to incontinence, which was a significant oversight given the resident's condition. Interviews with the Director of Nursing (DON) and MDS Coordinators revealed that the resident should have had a care plan addressing skin issues due to his incontinence and time spent in bed. The MDS Coordinators acknowledged the oversight and the potential negative outcomes, such as skin irritation and breakdown, that could result from not having a care plan in place. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident, leading to the deficiency.

Penalty

Inspection fine: $44,721

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 treatment and services for residents with pressure ulcers, as observed in two cases. One resident, a male with a history of pressure ulcers and other medical conditions, was not provided with an air mattress as ordered by the physician upon readmission. Despite having a stage 4 sacral wound and being at risk for further skin breakdown, the resident was left on a regular mattress until the order was placed for an air mattress. This oversight persisted despite multiple progress notes indicating the need for a Group-2 mattress to aid in wound healing and pressure reduction. In another case, a resident with multiple stage 4 pressure ulcers did not receive proper wound care as per physician orders. The wound care nurse failed to clean the wounds with normal saline and pat them dry before applying dressings, as was required. This lapse occurred during a wound care session observed by a wound care doctor, who measured the ulcers but did not ensure the wounds were cleaned before dressing. The nurse misunderstood the doctor's instructions, leading to incomplete wound care, which could potentially hinder healing and increase the risk of infection. Both cases highlight significant lapses in following physician orders and providing appropriate care for residents with pressure ulcers. The facility's failure to ensure the use of prescribed equipment and adherence to wound care protocols directly contributed to the deficiencies observed. These actions and inactions could place residents at risk for worsening of existing wounds or the development of new pressure ulcers.

Penalty

Inspection fine: $44,721

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 appropriate care for a resident with an indwelling Foley catheter, which is crucial for preventing urinary tract infections and maintaining continence. The resident, a male with multiple complex medical conditions including paraplegia, stage 4 pressure ulcers, and an indwelling catheter, was observed during a pressure ulcer treatment session. During this session, the Foley catheter was improperly placed on the bed with approximately 350 cc of urine in the bag, contrary to the facility's policy that requires the catheter bag to be positioned below the bladder level to ensure proper drainage and prevent urine reflux. The resident's medical records indicated a lack of documented evidence for Foley catheter care, monitoring, and output from the specified period. An interview with the LVN involved revealed uncertainty about who placed the catheter on the bed, despite acknowledging that such placement could lead to urinary tract infections. The facility's policy on catheter care, revised in February 2024, clearly outlines the need for proper catheter management, which was not adhered to in this instance.

Penalty

Inspection fine: $44,721

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 appropriate respiratory care for a resident requiring tracheotomy care and suctioning, as observed during a survey. Specifically, RN G did not use sterile technique during tracheotomy care and suctioning for a resident with a tracheostomy. The resident, a male with acute respiratory failure and other significant health issues, was observed in bed with audible moist breath sounds. RN G performed tracheotomy care without washing hands or using hand sanitizer between glove changes, and did not maintain sterile technique while handling the tracheostomy equipment. During interviews, RN G admitted to not using sterile technique and acknowledged the risk of infection posed by her actions. The Director of Nursing (DON) confirmed that RN G had not been in-serviced on tracheostomy care and had only started working at the facility three days prior. The facility's policy requires aseptic technique during tracheostomy care, which was not followed in this instance, potentially placing the resident at risk for respiratory infections.

Penalty

Inspection fine: $44,721

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, specifically in the handling of a resident's oxygen cannula. The deficiency was identified when the oxygen cannula of a resident with chronic obstructive pulmonary disease (COPD) was found underneath two bedsheets and a blanket on her bed. The resident, who was cognitively intact and independent in most self-care activities, had a physician's order for oxygen to maintain her oxygen saturation levels. However, the facility did not ensure that the cannula was properly disinfected before being placed in a plastic bag by a registered nurse (RN). Interviews with the RN and the facility's Administrator revealed a lack of consistent infection control practices regarding the handling of the oxygen cannula. The RN acknowledged the risk of infection control issues, while the Administrator noted that the resident's behavior of leaving the cannula on the bed was care-planned. Despite this, the facility's Infection Control Program emphasized the importance of evidence-based policies to reduce infection risks, yet no specific oxygen policy was provided upon request. This oversight in infection control practices could potentially place residents at risk of cross-contamination and infection.

Penalty

Inspection fine: $44,721

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 residents' right to respect and dignity, as evidenced by the actions of CNA M and MA J during an incident involving three residents. Resident #73, who has a history of altered mental status and moderate cognitive impairment, entered the room of Resident #78 and began pulling her hair and t-shirt. Resident #78, who has intact cognition but limited mobility due to an amputation, was frightened and screamed for help. Staff members, including CNA M and MA J, responded to the situation by laughing and referring to Resident #73 as 'crazy,' which was perceived as disrespectful and dismissive by the affected residents. Resident #78 expressed feeling unsafe and emotionally distressed by the incident, stating that the staff's reaction made her feel bad and that the facility did not take the situation seriously. She described the facility as a 'madhouse' and expressed a desire to leave for a more peaceful environment. Resident #70, who witnessed the incident from her bed, corroborated Resident #78's account, noting that the staff's laughter and comments about Resident #73 being 'crazy' were unprofessional and made her feel bad for Resident #78. Interviews with staff members revealed a lack of awareness or acknowledgment of the inappropriate behavior. CNA M and MA J denied laughing or making derogatory comments, and the facility's administration stated that they were unaware of any staff misconduct. Despite this, the residents' accounts and the facility's policy on resident rights highlight a failure to maintain a respectful and dignified environment, contributing to the deficiency noted in the report.

Penalty

Inspection fine: $44,721

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 were reported immediately to the Administrator, as required by their policy. This deficiency was identified in the case of a resident who was reported to have been slapped by an unknown CNA. The resident, who had severe cognitive impairment and multiple medical diagnoses including dementia and Alzheimer's disease, was unable to recall the incident clearly or provide specific details about the alleged perpetrator. Despite the report from the resident's family member to a manager on duty, the allegations were not communicated to the Director of Nursing or the designated abuse coordinator, and no report was made to the State Health Department within the required 24-hour timeframe. The incident was documented in the resident's progress notes by an LVN, who noted that the family had reported the alleged abuse. However, the LVN did not ensure that the report was escalated to the appropriate authorities within the facility. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of communication and follow-through on the abuse allegations. The facility's policy on abuse, neglect, and exploitation, which mandates immediate reporting to the state, was not adhered to, resulting in a failure to protect the resident and potentially placing other residents at risk for abuse or neglect.

Penalty

Inspection fine: $44,721

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 allegations of abuse involving a resident who claimed to have been slapped by a CNA. The resident, who has severe cognitive impairment due to dementia and other medical conditions, reported the incident to a family member. The family member then informed the facility staff, but the allegations were not reported to the State Survey Agency as required by the facility's policy. The resident's medical history includes chronic obstructive pulmonary disease, dementia, schizophrenia, and Alzheimer's disease, which contribute to her cognitive challenges. The incident was first reported by the resident to her family member, who then communicated it to the facility's LVN. The LVN conducted a physical assessment and found no physical evidence of abuse, such as bruising or redness. Despite the lack of physical evidence and the resident's inconsistent recollection of the event, the facility's policy mandates that such allegations be reported to the appropriate authorities. However, the report was not made, and the facility's abuse coordinator was not informed of the incident. Interviews with facility staff revealed a breakdown in communication and reporting procedures. The Director of Nursing and the interim administrator were unaware of the allegations, and the abuse coordinator did not receive any communication regarding the incident. The facility's policy requires that allegations of abuse be reported within 24 hours, but this was not adhered to, resulting in a failure to comply with state regulations and potentially placing residents at risk for further abuse.

Penalty

Inspection fine: $44,721

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 properly dispose of garbage and refuse by not ensuring that the dumpster door was closed at all times when not in use. This deficiency was observed during a survey on September 30, 2024, at 8:15 am, when the dumpster area behind the dietary department was found with a commercial-size dumpster that was three-quarters full of garbage and had its door open. During an interview at 8:45 am on the same day, the Dietary Food Service Manager confirmed that the dumpster door should be closed when not in use to prevent vermin, pests, and insects from accessing the dumpster and potentially entering the facility. The responsibility for keeping the dumpster doors closed was shared among staff from dietary, nursing, and housekeeping departments. A review of the facility's Policies and Procedures on waste disposal, dated June 2019, indicated that waste containers should be covered and the dumpster should be closed at all times. This failure to adhere to the policy could place residents at risk of infection from improperly disposed garbage.

Penalty

No penalty information released

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

Summary

The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically regarding the documentation of a resident's pain level. The resident, a male with multiple diagnoses including atherosclerotic heart disease, type 2 diabetes, and a lower extremity amputation, was admitted to the facility and had a care plan that included managing pain related to a skin condition. However, the pain assessment log showed inconsistent documentation of the resident's pain levels, with a significant pain level of 8 recorded at one point, but no corresponding documentation in the nurse's progress notes when pain medication was ordered. Interviews revealed that the Director of Nursing acknowledged the lack of documentation, stating that if it was not documented, it was not done. The LVN involved admitted to forgetting to document the resident's pain complaint and the subsequent call to the doctor for pain medication. The doctor confirmed that he was informed of the resident's pain and ordered Norco, but there was no documentation of the resident's pain level at that time. This lack of documentation could potentially affect the care and treatment of residents, as accurate records are crucial for managing their health needs.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate and complete clinical records for two residents, which is a violation of accepted professional standards. Specifically, the facility did not correctly document the race of one resident on his Facesheet and psychiatric subsequent assessment (PSA), leading to a misidentification. Additionally, the facility did not document a resident-to-resident altercation in the incident and accident report, which is crucial for tracking and managing such incidents. Resident #2, a cognitively intact African-American male with multiple health issues, was incorrectly noted as a White male on his Facesheet and as an African-American female on his PSA. This misidentification could lead to inappropriate care and treatment. Furthermore, the facility failed to document a resident-to-resident altercation involving Resident #2 and Resident #3 in the incident and accident report, which is essential for ensuring accurate records and appropriate follow-up care. The facility's failure to document the altercation and update the care plans for both residents involved in the incident highlights a lack of proper communication and documentation procedures. The charge nurse on duty at the time of the incident only documented the resident who received the hit, not the aggressor, which is against the facility's policy. This oversight could lead to inadequate monitoring and management of residents' behaviors, potentially putting them at risk.

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's call light was functioning properly, which put residents at risk of not being able to call for assistance when needed. The resident, a female with multiple diagnoses including diabetes mellitus, end-stage renal disease, and legal blindness, was unable to use her call light due to a missing button. Despite having a BIMS score indicating moderate impaired cognition, the resident was aware of the issue and reported that she had been unable to use the call light for months, often having to call out for help instead. During observations and interviews, it was revealed that the nursing staff, including an RN and a CNA, were aware that the call light was within reach but did not check its functionality. The RN admitted to not assessing the call light during rounds, and the CNA, who worked PRN, was unaware of how long the call light had been non-functional. Both staff members acknowledged that the resident would not receive timely care without a working call light, and the maintenance director was not informed of the issue. The facility's policy required that call lights be accessible, functional, and routinely monitored for functionality. However, interviews with the Unit Manager, ADON, and DON indicated a lack of clarity and responsibility among staff regarding who should ensure the call light's functionality. The Administrator expected the call light to be functional and within reach, but the deficiency persisted, leaving the resident unable to call for assistance when needed.