Park Valley Inn Health Center

Penalty

No penalty information released

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

Summary

The facility failed to ensure treatment and care were provided according to orders, resident preferences, and goals for a resident with traumatic subarachnoid hemorrhage, difficulty walking, muscle weakness, and severe cognitive impairment. After two head injury incidents on 6/11/26, the resident developed worsening hematomas and facial swelling over the next several days. The record and interviews reflected that the nurse practitioner was not notified from 6/12/26 through 6/14/26 about the worsening condition, even though the resident’s bruising and edema increased and she remained under neuro checks at the facility. The resident was sent to the hospital on 6/15/26 because of increased orbital edema. Hospital records showed CT findings of minimal subarachnoid hemorrhage in the left high cerebral region with scalp trauma, and she required ICU care. The nurse practitioner stated the resident’s worsening hematoma and increased eye edema were significant injuries and that staff should have notified him sooner. The physician also stated he expected staff to notify him and the NP whenever a resident had a fall and to send the resident out for a CT scan if the resident could not stay still during evaluation after a fall. The facility also failed to follow the hospital discharge order to stop ticagrelor when the resident returned on 6/18/26. The medication administration record showed ticagrelor continued to be administered after the discharge instruction. On 6/23/26, the resident fell again while attempting to transfer from a couch to her wheelchair and struck her head on an electric piano, causing a forehead laceration with bleeding that staff could not stop. She was sent to the hospital, received stitches, and returned to the facility the same day. Interviews with the DON, ADM, nurses, and the resident’s representative confirmed the sequence of events and the lack of timely notification and order follow-through.

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, appropriate pain management for one resident who required pain services and had severe cognitive impairment. The resident was admitted with traumatic subarachnoid hemorrhage, difficulty walking, lack of coordination, muscle weakness, and Alzheimer’s disease. Her quarterly MDS reflected a BIMS of 3, and her care plan identified her as at risk for pain and as rarely or never understanding in her ability to express ideas and wants. The order summary directed staff to assess pain every shift using non-verbal/noncognitive signs of pain because her pain intensity score could not be verbalized and she had a cognizant deficit. Review of the pain summary showed that on several dates staff assessed the resident’s pain using a numerical pain scale, while the remainder of the assessments from the same period were completed using PAINAD. During interview, the resident’s RP stated the resident had severe dementia, severe cognitive impairment, and diminished mental capacity, and was unable to verbalize or express pain levels. During observation, the resident was sitting in a wheelchair at the memory care unit nurse’s station and had a dark red laceration on the left side of her forehead with stitches; she was unable to answer questions when the surveyor attempted to interview her. The NP, DON, ADM, and nursing staff all stated they expected PAINAD or another nonverbal pain assessment tool to be used for this resident because she could not reliably report a numerical pain score. The DON and ADM were not aware that staff had used a numerical pain scale instead of PAINAD. The facility’s pain management policy stated that staff would observe for nonverbal indicators of pain and use a pain assessment tool appropriate for the resident’s cognitive status.

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 administer itself in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 13 of 19 staff reviewed for in-services. The deficiency involved staff assigned to the memory care unit who were not in-serviced on abuse, neglect and exploitation, incidents and accidents, and resident rights on 6/11/26. The report states this failure could place residents at risk of repeat safety failures, escalating neglect, and sustaining avoidable injuries. Review of the facility’s in-service records from 6/1/26 through 6/26/26 showed the Unit Manager trained staff on Abuse, Neglect and Exploitation, Incidents and Accidents, and Resident Rights on 6/11/26. However, the in-service roster for resident rights and accidents and incidents was photocopied from the abuse, neglect and exploitation in-service, and there were no other in-services given to staff in June 2026. Review of staff schedules showed multiple staff assigned to the memory care unit on both day and night shifts who were not in-serviced, including CNA N, RN E, RA, ADON, RN R, MDS coordinator, Staffing Coordinator, DON, Treatment Nurse, CNA O, CNA P, CNA Q, and LVN G. During interviews, several staff members gave inconsistent accounts of when and by whom they were in-serviced, and some could not recall the in-services at all. RN D said RN R in-serviced him within the last week on abuse and neglect, while RN E said she was in-serviced on abuse and neglect on 6/25/26 but could not recall who provided it. CNA L could not remember who, what, or when she was most recently in-serviced. CNA H and CNA S said the Unit Manager in-serviced them on abuse and neglect within the week, but RN D, CNA H, and CNA L later could not recall how many in-services they signed or signing three in-services on 6/11/26. The DON stated she asked the Unit Manager to reeducate memory care staff on resident rights, abuse and neglect, and incidents and accidents, and said she was present when the Unit Manager in-serviced staff on 6/11/26, but was not aware the roster had been photocopied. The ADM said he was not aware the Unit Manager made photocopies of the in-service roster and stated that in-services were important so staff knew the procedures and how to act.

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 an alleged injury of unknown origin was reported to the proper authorities within the required timeframe. R#1, who had diagnoses including traumatic subarachnoid hemorrhage, difficulty walking, lack of coordination, muscle weakness, and Alzheimer’s disease, also had severe cognitive impairment with a BIMS score of 3. On 6/11/26, staff identified a hematoma/bruise to the left eyebrow/forehead area during the morning, and the injury was documented in multiple notes and an injury investigation as an injury of unknown origin because the source was not observed and could not be explained by the resident. The record shows that LVN A documented the injury, the NP was notified, a facial x-ray was ordered, and neuro checks were started. The physician note stated the resident was seen for a hematoma to the right forehead, that no recent trauma was reported, and that the resident was a poor historian due to dementia. The facility’s injury investigation stated the injury was discovered at 9:30 a.m., that the source was not observed by anyone, and that the source could not be explained by R#1. The incident log also described the bruise as occurring when the resident ambulated without assistance and bumped into furniture, while other documentation and interviews reflected that staff did not know the cause of the injury. During interviews, the ADM stated there were no facility-reported incidents submitted to the SSA related to injuries of unknown origin for that period, and later said he conducted an internal investigation and did not believe the event warranted a report to the SSA. The DON stated the ADM was responsible for submitting injury of unknown origin reports to the SSA within 2 hours and said she did not believe the ADM self-reported the first incident. Other staff interviews reflected differing understandings about whether such injuries were reported and the required timeframe. The facility policy and provider letter both stated that suspicious injuries of unknown source must be reported immediately, but not later than 2 hours after the incident occurs or is suspected.

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 timely review and revise A resident’s comprehensive care plan after multiple incidents involving falls and head injuries. The resident had diagnoses including traumatic subarachnoid hemorrhage, difficulty walking, lack of coordination, muscle weakness, and Alzheimer’s disease, and her quarterly MDS reflected a BIMS score of 3, indicating severe cognitive impairment. Her care plan, revised on 6/26/26, identified her as being at risk for falls related to an unsteady gait and a history of falling and getting herself back up. Progress notes showed that the resident had a witnessed fall with a hematoma to the eyebrow/forehead area, followed by ongoing neuro checks and monitoring. Notes documented bilateral forehead hematomas, swelling, bruising, and later increased orbital edema to the right eye. She was transported to a medical center on 6/15/26 for increased right eye orbital edema and returned to the facility on 6/18/26. The physician later documented that she had been sent to the ED due to worsening hematoma, that CT of the head showed minimal SAH in the left high cerebral region, and that Brilinta was discontinued. The resident then had another fall on 6/23/26 while attempting to transfer from a couch to her wheelchair in the common area. She lost her balance, fell into the lower portion of an electric piano, and sustained a skin tear/abrasion to the left temple with bleeding that required pressure dressing and EMS transport. She returned from the hospital the same evening with a laceration to the left forehead and stitches. During interview, the administrator stated the IDT was expected to meet after each incident to discuss interventions and implement them, and that care plans should be revised as soon as possible. The record and interviews showed the resident’s care plan was not reviewed and revised in a timely manner after the incidents on 6/11/26 and 6/23/26.

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 who was unable to perform activities of daily living received necessary nail care to maintain good grooming and personal care. Resident #1 was admitted with diagnoses including dementia, hypertension, insomnia, lack of coordination, muscle weakness, and cognitive communication deficit. His MDS indicated that BIMS could not be completed because he was rarely or never understood, and he was fully dependent for self-care. His care plan identified that he required assistance with ADLs due to muscle weakness and included checking nail length and trimming and cleaning nails on bath day and as necessary. During observation, the resident’s fingernails were appropriately trimmed, but his toenails on both feet were approximately half an inch long, thick, dirty, yellow in color, and had a yellow substance underneath. RN A stated she had not paid attention to his feet and said the toenails needed to be trimmed as soon as possible, but she was concerned about performing the task because it appeared more complicated and required specialized expertise. The ADON stated that staff had not reported the condition of the toenails to her, and the DON stated the toenails had become overgrown and required evaluation by a podiatrist. Record review showed the request for podiatry service was made after the observation, and the facility policy stated that nail care should be provided according to resident condition and that certain residents require nail care by a physician or practitioner.

Penalty

Inspection fine: $35,550

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

Summary

The facility failed to ensure a resident with Alzheimer’s disease, generalized anxiety, diabetes, impaired mobility, and dependence on staff for ADL care received treatment and care in accordance with orders and the person-centered care plan. The resident had physician orders for Geri-sleeves to be applied every shift to both upper extremities to help prevent skin breakdown, but during observation she was sitting in her wheelchair without the Geri-sleeves in place and had visible bruising on both arms and skin tears on her lower extremities. Her care plan addressed dementia, ADL deficits, and fall risk, but did not address skin tears and related interventions. The resident developed a skin tear on the left lateral lower leg after an incident in which staff documented that she was transferred in her wheelchair without removal of the footrests, causing her shin to bump against the footrest. Three days later, she was documented with another skin tear on the right posterior lower leg while being pushed in her wheelchair. Staff interviews reflected that the resident’s lower-extremity injuries were believed to be related to the wheelchair footrest or metal parts of the wheelchair, and the resident was described as no longer able to ambulate and dependent on staff for movement and transfers. The resident’s wheelchair was observed with the footrest removed and the pointed metal attachment area aligned with the location of the skin tears. The facility also failed to ensure wound care was completed as ordered when dressings were off. At observation, the resident’s lower-extremity skin tears were open and no dressing was present. The wound care nurse stated the wounds should have been covered and that charge nurses were expected to perform wound care when the dressing came off, without waiting for the wound care nurse. The DON and ADON stated the wounds needed to be covered to prevent infection and that the assigned nurse should have replaced the dressing when it was removed. The facility policy stated wound treatments were to be provided according to physician orders and that dressing changes could be done when a dressing had dislodged.

Penalty

Inspection fine: $35,550

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

Summary

The facility failed to ensure a resident’s environment remained as free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent accidents during a transfer. On 05/19/2026, while Resident #1 was being moved from a wheelchair to a bed for a skin assessment, RN A and CNA B held onto the resident’s pants and used the pants to transfer her without using a gait belt. RN A stated they were trying to give the resident a boost and hoped she would stand during the transfer, and later acknowledged that using a resident’s pants for transfer was a dignity issue. Resident #1 was a [AGE]-year-old female with diagnoses including Alzheimer’s Disease, generalized anxiety, type 2 diabetes mellitus without complication, difficulty walking, and other abnormalities of gait and mobility. Her care plan reflected ADL self-care performance deficit related to Alzheimer’s, impaired cognitive function/dementia, and risk for falls related to muscle weakness and poor safety awareness. The quarterly MDS reflected she was unable to complete the interview, had both long- and short-term memory problems, used a wheelchair, and required substantial/maximal assistance for sit-to-stand and chair/bed-to-chair transfers. During the observation, Resident #1 was sitting in her wheelchair in the living area with no geri sleeves on and visible bruising and a skin tear at the left lateral lower extremity with no dressing present. CNA B stated staff were supposed to use a gait belt when transferring the resident from the wheelchair to the bed and were not supposed to transfer her using her pants. The ADON and DON both stated staff should not grab residents by their clothes to assist with transfers, and the DON stated Resident #1 needed a gait belt for transfers.

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 residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. During the survey, Resident #43, Resident #80, and Resident #114 were observed with unwanted facial hair on their chins, indicating they were not groomed as expected. The deficiency was identified through observation, interview, and record review for 3 of 10 residents reviewed for ADL care. Resident #43 was a female with diagnoses including dementia, type 2 diabetes mellitus with unspecified complications, hyperlipidemia, muscle weakness, lack of coordination, and depression. Her MDS showed a BIMS score of 0 and need for supervision or touching assistance, and her care plan addressed ADL self-care deficits related to dementia. She was observed walking in the hall with facial hair on her chin on two separate occasions, and her RP stated she shaved every day and would be embarrassed if she were cognitively aware of the hair. Resident #80 had diagnoses including dementia, major depressive disorder, anxiety, muscle weakness, anemia, and weakness. Her MDS showed a BIMS score of 2 and substantial/maximal assistance for personal hygiene, and her care plan noted an ADL self-care performance deficit related to dementia with personal hygiene/oral care interventions. She was observed lying in bed with hair on her chin and was unable to answer questions about it.

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 each resident's bedside, toilet, and bathing areas were adequately equipped with a working call system that would allow residents to call for staff assistance. Survey observations, interviews, and record review showed that 3 of 8 residents reviewed for the resident call system did not have their call lights within reach: Resident #16, Resident #22, and Resident #81. Resident #16 was a female with diagnoses including chronic respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, hypertensive heart disease with heart failure, lack of coordination, and muscle weakness. Her MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and that she required assistance from two or more helpers for activities of daily living, bed mobility, and transfers and used a wheelchair for mobility. Her care plan directed staff to keep her call light within reach and to encourage use of it for assistance as needed. During observation on 03/10/26, her call light was wound around the upper right bedframe and was not within reach. Resident #22 was a male with diagnoses including senile degeneration of the brain, vascular dementia, and adjustment disorder with anxiety. His MDS reflected a BIMS score of 02, indicating severe cognitive impairment, and that he was dependent on staff for activities of daily living, bed mobility, and transfers, requiring assistance from two or more helpers. His care plan also directed staff to keep his call light within reach and to encourage use of it for assistance as needed. During observations on 03/09/26, 03/10/26, and 03/11/26, his call light was observed twisted around or tied to the bed frame and hanging off the bed, not within his reach. Resident #81 was a female with diagnoses including acute respiratory failure with hypoxia, gastrostomy status, and furuncle of the buttock. Her MDS reflected a BIMS score of 0, indicating severe cognitive impairment, and that she was dependent on staff for all activities of daily living, bed mobility, and transfers and used a wheelchair for mobility. Her care plan directed staff to keep her call light within reach and to encourage use of it for assistance as needed. During observation and interview on 03/09/26, she could not verbally communicate her needs and her call light was not within reach; it was observed hanging off the bed and tied to the bed frame.

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 controlled medication reconciliation for Medication Cart #1 involving a resident with hemiplegia, pain, and type 2 diabetes mellitus. The resident had an order for Hydrocodone-Acetaminophen 5-325 mg, one tablet every six hours as needed for chronic back pain and right hip pain, and the resident’s MDS indicated a BIMS score of 13 with intact cognition. During survey observation, the controlled medication blister pack for this resident showed 34 tablets remaining while the narcotic log reflected a count of 35 tablets. LVN D stated he administered one PRN dose around noon but forgot to sign the controlled log, and he and LVN E counted controlled medications at shift change without noticing the discrepancy. LVN E later stated she knew about the discrepancy during the count and that the nurse responsible for the cart was accountable when accepting the cart key. The resident’s MAR for the day showed Hydrocodone-Acetaminophen was received, but the controlled medication administration log did not document the dose at the time it was given. The resident’s care plan included PRN pain medication interventions, including screening for pain, assessing pain, and documenting pain assessments. Facility staff interviews indicated that controlled medications were to be signed immediately after administration and counted at shift change, but the documentation and reconciliation for this resident’s narcotic were not completed accurately during the observed shift change process. The facility also failed to remove expired medications from a medication room refrigerator used for multiple halls. Surveyors found eight vials of Heparin Sodium injection 5000/ML expired on 03/09/2026 and two boxes of Bisacodyl 10 mg expired in 04/2025. The ADON and DON stated that nursing staff were trained on medication administration, controlled medication, and medication storage, and that ADONs and the DON were responsible for auditing med rooms and med carts. The facility’s medication storage policy stated that medication rooms were routinely inspected for outdated medications, but the expired Heparin and Bisacodyl remained in the refrigerator during the observation.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 of 23 residents reviewed for infection control. During wound care for a resident with Alzheimer’s disease, type 2 DM, severe cognitive impairment, and a stage 4 pressure ulcer of the right heel, an LVN completed the wound care, removed biohazardous trash from the room, and did not sanitize her hands after removing gloves before touching clean supplies on her treatment cart. The resident’s record showed a wound care order for the right heel pressure injury and a care plan addressing the pressure ulcer and MDRO reduction with Enhanced Barrier Precautions. During blood sugar check and insulin administration for another resident with type 2 DM, legal blindness, and chronic kidney disease stage 4, an LVN did not remove his gloves after completing the blood sugar check and exiting the resident’s room. He then used the same gloves to open the nursing cart, removed the insulin storage box for multiple residents on 700 Hall and supplies for the resident’s insulin administration, and walked back into the resident’s room to administer insulin without changing gloves or sanitizing his hands. The resident did not appear in distress and did not voice any complaints during the observation. Interviews with the LVNs, ADON, DON, and ADM confirmed the facility’s hand hygiene expectations, including hand hygiene before resident care, between dirty and clean tasks, after removing gloves, and before exiting the room. The LVNs stated they had recent infection control and hand hygiene in-services and acknowledged they did not follow proper hand hygiene steps during the observed care. The ADON and DON stated charge nurses, ADONs, and the DON were responsible for monitoring staff hand hygiene and infection control practices, and the DON stated the facility policy required hand hygiene before entering the room, between dirty and clean areas, between glove changes, and before coming out of the room.

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 immediately consult with a resident’s physician and notify the resident’s representative after a change in condition related to new skin injuries. The resident was an elderly male with Parkinsonism, unspecified dementia with severe cognitive impairment (BIMS score 3/15), atherosclerosis, and heart disease, who required staff assistance with ADLs and had a care plan identifying fall risk and use of assist rails and a low bed. On the early morning in question, a CNA reported finding the resident with his forearms or hands tangled between the bed rail and mattress, noting skin tears on both elbows and bruising on the hands and forearms, and stated he immediately reported this to the male charge nurse (LVN B). The CNA documented that the resident was found between the bed rail and mattress and that he put the resident back in bed and reported it to the nurse. LVN B stated that around the same early morning time, the CNA only told him about bruises on the resident’s arms and did not report that the resident had been tangled or had a fall. LVN B reported that he assessed the resident and saw only bruises, applied moisturizer, and contacted the NP, who advised monitoring and did not order x‑rays because there was no reported fall. LVN B’s progress note documenting discolored areas to both arms and notification of the resident’s representative and NP was entered as a late entry approximately eight hours after he was first notified of the incident. The DON later stated that his expectation was that staff immediately report any incidents or changes to the NP and that LVN B did not enter progress notes in a timely manner. Subsequent observations and interviews showed that other staff became aware of the bruising later that morning. The UD learned of the bruises from the day‑shift charge nurse (LVN C), confirmed with the CNA that the resident had been found tangled in the assist rail, and observed unusual bruising on the resident’s hands while he was in the dining room. LVN C reported that when she came on duty and checked the electronic record, there were no night‑shift notes about the bruising, and she observed bruises worse than usual and reported them to administration. A wound assessment completed that afternoon by the treatment nurse documented two new non‑pressure skin tears/abrasions on the right hand and right elbow with an onset date matching the incident date, and notifications to the resident, representative, and physician were recorded at that time. The facility’s incident/accident policy and federal regulation at 42 CFR §483.10(g)(14)(i)(A) require immediate assessment and practitioner and representative notification after an accident involving injury with potential need for physician intervention, which was not done promptly in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two residents received care in accordance with professional standards of practice, their person-centered care plans, and their expressed choices. One resident, a woman with a history of cerebral infarction, insomnia, and generalized anxiety disorder, was care planned to require assistance from one staff member for toileting due to fluctuating weakness and fatigue. Despite being cognitively intact, she reported that after activating her call light for bathroom assistance, a CNA responded by questioning why she did not get up herself, then left without providing help. The CNA returned approximately 30 minutes later without speaking or assisting, leaving the resident feeling bad about asking for help. Another resident, a male with hemiplegia and hemiparesis following cerebral infarction, type II diabetes with nephropathy, and end stage renal disease, also required partial to moderate assistance for toileting due to generalized weakness and amputation. He reported that during the night shift, the same CNA turned away and left when he needed to be cleaned up, despite his occasional dizziness and need for restroom assistance. He stated that he reported the incident to the administrator and that the experience made him feel like he was not receiving the care he needed. Interviews with staff confirmed awareness of the CNA's behavior, with one LVN noting gossip about the CNA not treating residents fairly. The administrator confirmed being made aware of the incidents, including a written letter from the female resident describing the unkind treatment. The facility's policy on dignity emphasizes care that promotes residents' well-being, satisfaction, and self-worth, supporting their rights and preferences in daily living activities. The events described represent a failure to provide care in a kind and dignified manner as required by both 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 ensure that a resident was free from abuse when another resident physically assaulted her. On the date of the incident, a resident with a history of schizoaffective disorder, anxiety, and depression, who was known to have potential for physical aggression, pushed another resident to the ground after becoming angry about the other resident entering her room. The assaulted resident, who had moderate cognitive impairment and multiple medical conditions including diabetes, heart failure, and chronic pain, sustained a skin tear on her left elbow as a result of the fall. The incident was witnessed by staff who responded to a scream and found the injured resident on the floor. Interviews and record reviews revealed that the aggressive resident had a documented care plan addressing her potential for physical aggression, with interventions such as staff intervening before agitation escalates and guiding her away from sources of distress. Despite these interventions, the resident became agitated and physically pushed the other resident, resulting in injury. The injured resident reported the assault to staff and requested that the police be called. Staff and other residents described the aggressive resident as a loner who could become impulsive and aggressive when triggered, while the injured resident was described as calm and helpful. The facility's failure to prevent the assault and injury constituted noncompliance with regulations requiring residents to be free from abuse, neglect, and mistreatment. The incident was reported to the appropriate authorities, and the facility's own investigation confirmed that the aggressive resident had pushed the other resident, causing her to fall and sustain an injury. The deficiency was identified as past noncompliance, with the noncompliance period beginning on the date of the incident and ending a few days later.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to meet the needs of a resident who required assistance with eating. The resident, an older adult male admitted with fractures to the nasal bone and spine, had an initial care plan indicating a need for one staff member's assistance during meals. However, on one occasion, the resident's dinner tray was left untouched, and he did not receive the required assistance with eating as outlined in his care plan. Interviews revealed that the CNA responsible for the resident's care delivered the meal tray but did not provide feeding assistance, believing the resident could feed himself and not checking the care plan or Kardex for specific instructions. The DON confirmed that the care plan is intended to guide staff in providing appropriate care and that not following it could result in harm. The facility's policy requires a comprehensive care plan for each resident, but in this instance, the intervention for feeding assistance was not implemented.

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 for several residents, specifically neglecting to include measurable objectives and timeframes to address their medical, nursing, and psychosocial needs. For one resident with severe cognitive impairment and multiple diagnoses, the care plan addressing dehydration risk was incomplete, lacking individualized details and a specific timeframe for the goal. The interventions listed, such as offering additional fluids, were not sufficiently tailored or updated to reflect the resident's current condition. Additionally, the facility did not ensure that care plan interventions for diversional activity deficits, such as 1:1 and in-room activities, were implemented and documented for multiple residents with severe cognitive impairment and various mental health diagnoses. Review of activity logs over several weeks showed that these residents were repeatedly not provided with the required 1:1 or in-room activities as outlined in their care plans. Interviews with staff confirmed that not all residents received these interventions, and documentation was inconsistent or missing for significant periods. Staff interviews revealed a lack of clarity and consistency regarding responsibility for implementing and documenting activities. The activity director and assistant acknowledged gaps in providing and recording 1:1 activities, and the interdisciplinary team members described expectations for care plan updates and monitoring that were not met in practice. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and regular updates, but these standards were not upheld, resulting in unmet resident needs.

Penalty

Inspection fine: $88,205

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

Summary

The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for several residents. Specifically, the facility did not test all residents who exhibited flu-like symptoms and failed to implement quarantine or droplet precautions when indicated. This oversight was observed in multiple residents, including those with acute upper respiratory infections, dementia, and other chronic conditions, who were at risk of respiratory distress and other complications. Observations revealed that staff, including CNAs and LVNs, did not adhere to Enhanced Barrier Precautions, such as donning gowns when required during resident care activities. For instance, a CNA was seen passing out trays without proper PPE, and an LVN administered medication via a gastrostomy tube without wearing a gown. Additionally, there was a lack of proper signage for PPE and airborne precautions outside the rooms of residents suspected of having the flu. Interviews with staff indicated a lack of communication and proper protocol adherence. The RN and CNA mentioned that they did not focus on PPE signage, assuming it was the responsibility of the DON or ADON. The facility's Infection Control Policy and quick reference for isolation precautions were not followed, contributing to the spread of infection among residents. The facility's failure to promptly notify medical providers and implement necessary precautions exacerbated the situation, leading to an outbreak of influenza within the facility.

Removal Plan

• The Director of Nursing and Administrator will be inserviced by the Regional Director of Clinical Services on Influenza Outbreak Management in Long Term Care.
• The Medical Director and patients assigned providers were updated on all patients with flu symptoms and on all patients that were positive by the DON.
• All licensed staff to be inserviced on notifying providers of changes in condition to include a pre/post test by the Regional Director of Clinical Services and/or Director of Nursing Services.
• All staff to be educated on Influenza and Outbreak Management in long term care to include a pre/posttest by the Regional Director of Clinical Services and/or Director of Nursing. Inservice will include signs and symptoms, precautions to take, prevention measures, isolation and outbreak management.
• All licensed staff will be inserviced on Proactive Healthcheck orders by the Regional Director of Clinical Services and/or Director of Nursing. The licensed nurse will enter this order for all patients to capture any flu signs and symptoms. The Proactive Healthcheck will be utilized through the remaining of the flu season.
• The Regional Director of Clinical Services completed a 100% chart audit, identifying all residents with flu symptoms to ensure the providers were notified. All providers were notified by the Director of Nursing Services of all patients with symptoms.
• An audit was conducted by the Regional Director of Clinical Services identifying all patients with active flu and flu symptoms to ensure they were isolated according to the CDC guidelines. All patients verified to have the correct precautions in place.
• Facility is utilizing the PHC Proactive Health Check daily -EHR tool which monitors for abnormal symptoms that may indicate a condition change and other possible illnesses in the residents. The symptoms monitored include-abdominal pain, chills or repeated shaking with chills, diarrhea or other GI upset, headache, loss of smell, loss of taste, muscle pain, nausea, Oxygen saturation, red shadowed eyes or pink eyes, shortness of breath, sore throat, and tingling sensation in face or hands. The PHC dashboard will be reviewed daily during stand up by the DON and/or ED.
• The Director of Nursing Services and/or designee (ADON, UM, ED) will review the 24 hour report (nursing documentation) daily during the clinical stand up meeting with staff monitoring for patient change of conditions and ensuring notification to providers was done. This process will be ongoing.
• The Sr. Regional Director of Clinical Services will review the 24 hour report (nursing documentation) weekly for four weeks to monitor for patient change of conditions and ensure notification to providers was done.
• The DON and/or designee (ADON and/or IP) will perform a minimum audit of 3 random audits on different hallways daily for 1 week, then bi-weekly for 4 weeks to monitor for PPE compliance.
• Compliance concerns to be addressed immediately by the DON and/or designee.
• Results of audits and reviews will be reported to and reviewed by QAPI committee monthly for three months.

Penalty

Inspection fine: $88,205

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

Summary

The facility failed to ensure a safe environment for residents requiring mechanical lifts for transfers, leading to an incident involving a resident who suffered a lumbar fracture and hemorrhage. The mechanical lift used for the resident's transfer was not in working order, and another lift that was out of order was not removed from the floor. This resulted in the lift falling on the resident, causing her to fall to the floor and sustain injuries. The resident involved was a female with a history of a wedge compression fracture, memory deficit following cerebral infarction, traumatic subarachnoid hemorrhage, and multiple sclerosis. She was dependent on staff for transfers and required a mechanical lift. On the day of the incident, two CNAs attempted to transfer her using a mechanical lift that had not been properly inspected or maintained, leading to the equipment failure and subsequent injury. Interviews with staff revealed a lack of communication and proper procedures for identifying and removing faulty equipment. The maintenance director did not document weekly inspections, and there was no formalized process for routine maintenance. Additionally, staff were not adequately trained to identify and report equipment issues, contributing to the unsafe use of the mechanical lift.

Penalty

Inspection fine: $88,205

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

Summary

The facility failed to adhere to professional standards for food service safety, as observed during a survey. On multiple occasions, a staff member, referred to as [NAME] I, did not wear a hair restraint that fully covered her hair while preparing food. Additionally, she was observed wearing a surgical mask around her neck, with hair falling out from the hair net. Other staff members, such as DA K and NSS L, were also observed not wearing masks in the kitchen, which is against the facility's policy for maintaining hygiene and preventing contamination. The report highlights several instances where [NAME] I did not perform hand hygiene while preparing food. She was observed removing gloves and putting on new ones without washing her hands multiple times. This included handling food directly, such as mixing puree bread and preparing macaroni, with torn gloves or without changing gloves after touching different surfaces. These actions were contrary to the facility's policy, which requires hand hygiene before putting on gloves and after touching any contaminated surfaces. Interviews with various staff members, including DA K, NSS L, NSS M, and [NAME] J, confirmed that the facility's expectations for hand hygiene and the use of hair restraints were not met. They acknowledged that failing to perform hand hygiene and not wearing proper hair restraints could lead to cross-contamination and potential health risks for residents. The facility's policies on the use of gloves and hand washing, dated November 3, 2004, were reviewed and indicated that hands should be washed when entering the kitchen and before putting on gloves, as well as after removing gloves or touching contaminated surfaces.

Penalty

Inspection fine: $88,205

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 accommodate the needs and preferences of five residents by not ensuring that their call lights were within reach while they were lying in bed. This deficiency was observed in multiple instances for each resident, indicating a pattern of neglect in providing necessary access to call lights, which are crucial for residents to request assistance. The lack of accessible call lights was noted during various times of the day, and in some cases, residents were observed in distress or unable to call for help due to the call lights being out of reach. Resident #39, a female with intact cognition, reported that her call light often fell out of reach, making it difficult to receive timely care. She recounted an incident where she was sick and unable to call for help for two hours because her call light was not accessible. Similarly, Resident #159, who has severe cognitive impairment and is completely dependent for activities of daily living, was observed with her call light out of reach on multiple occasions, raising concerns about her ability to call for help if needed. Other residents, such as Resident #80, who has mild to moderate cognitive impairment, and Resident #94, who has severe cognitive impairment, were also found without accessible call lights. Resident #80 was observed crying in bed without her call light and reported a fall during the night when she could not find it. Resident #94, who requires total assistance, was found with her call light on the floor, and an interview attempt revealed she was unresponsive. Resident #17, who is totally dependent on staff, was observed with her call light tucked behind her mattress, making it inaccessible. Interviews with staff, including the DON and Administrator, confirmed that call lights should always be within reach, yet this standard was not consistently met, leading to the deficiency.

Penalty

Inspection fine: $88,205

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 for three residents, which included measurable objectives and time frames to meet their mental and psychosocial needs. Specifically, the care plans for Resident #3, Resident #73, and Resident #97 were not adequately updated or developed. Resident #3 did not have a care plan in place within 21 days of admission, while Resident #73 and Resident #97's care plans lacked updates on activity preferences and dental status after their quarterly assessments. Resident #73, an elderly female with Alzheimer's disease, generalized anxiety disorder, and cognitive communication deficit, had no documented preferences for activities or information regarding her dental status in her care plan. Observations and interviews revealed that her dentures were loose, and she did not wear her top denture. Despite these issues, her care plan was not updated to reflect her current needs and preferences. Similarly, Resident #97, who had cerebral infarction, unspecified dementia, and bipolar disorder, did not have her activity preferences updated in her care plan, despite her participation in various activities like coloring and dancing. The facility's policy requires that a comprehensive, person-centered care plan be developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission. However, interviews with staff, including the MDS coordinator and the Director of Nursing, revealed a lack of clarity and responsibility regarding who should update the care plans. This lack of coordination and communication among staff members contributed to the deficiencies in the care planning process, potentially placing residents at risk of not receiving necessary care and services.

Penalty

Inspection fine: $88,205

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

Summary

The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the lack of daily clothing changes for several residents. Resident #3, Resident #59, and Resident #97 were observed wearing the same clothing over multiple days, from January 14 to January 17, 2025. Despite the residents' varying levels of assistance required for dressing, there were no documented attempts to assist them with changing clothes during this period. Interviews with staff revealed that while some residents, like Resident #59, had a history of refusing care, there was no consistent documentation or care planning to address these refusals effectively. Additionally, the facility failed to maintain a clean and odor-free environment for Resident #15. On January 14, 2025, Resident #15's room was observed to have a strong odor of urine, which persisted until it was reported and addressed later in the day. Staff interviews indicated that residents are supposed to be checked every two hours, and any odors should be promptly addressed to prevent potential health issues such as UTIs or skin breakdown. However, the initial failure to address the odor in Resident #15's room suggests a lapse in the facility's adherence to its hygiene and care protocols. The facility's policies and staff interviews highlight the expectation that residents' clothing should be changed daily and that any refusals of care should be documented and addressed through care planning. However, the lack of documentation and care planning for residents who refuse care, as well as the failure to maintain a clean environment for Resident #15, indicate deficiencies in the facility's implementation of these policies. These deficiencies potentially compromised the residents' dignity and quality of life.

Penalty

Inspection fine: $88,205

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

Summary

The facility failed to ensure that a resident was free from the use of physical restraints, which is a violation of their right to be treated with respect and dignity. The resident, a female with Alzheimer's and a history of wandering, was observed on multiple occasions in a wheelchair with the wheels locked, positioned against a desk or table, which prevented her from getting out. This situation was identified as a restraint, as it restricted the resident's movement and posed a risk of injury. Despite the facility's claim that the locked wheels served as a reminder for the resident not to stand, the resident was observed attempting to stand and nearly fell on several occasions. Interviews with facility staff, including a CNA, a nurse, the DON, and the ADM, revealed a lack of awareness and training regarding the use of restraints. The CNA and nurse both stated that residents should not be restrained and acknowledged the potential for injury if restraints were used. The DON and ADM also recognized that locking a resident in a wheelchair against a desk or table constituted a restraint, yet there was no restraint policy or training in place at the facility. This deficiency affected one resident directly and had the potential to impact other residents by contributing to restricted movement and psychological distress.

Penalty

Inspection fine: $88,205

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

Summary

The facility failed to implement its written policies and procedures regarding the prevention of abuse and neglect, as evidenced by an incident involving two residents. Resident #95, a man with severe cognitive impairment and a history of peripheral vascular dementia, was slapped on the shoulder by Resident #97, a woman with mild cognitive impairment and a history of bipolar disorder. The incident occurred after Resident #97 entered Resident #95's room, despite previous attempts to prevent such occurrences by providing a safety device to Resident #95. The incident was observed by a surveyor, but LVN T, who was notified of the incident, failed to follow the facility's incident procedures. Interviews with various staff members, including CNAs and LVNs, revealed inconsistencies in the understanding and implementation of the facility's abuse and neglect policies. While some staff members stated they would report such incidents immediately, others were unsure of the frequency of their training or the exact procedures to follow. The Director of Nursing (DON) and the Administrator (ADM) also provided insights into the facility's expectations and procedures, indicating that altercations should be reported immediately and investigated to determine if they are reportable to the Health and Human Services Commission (HHSC). The facility's policy on accidents and incidents, dated May 2016, requires immediate completion of an incident report upon staff awareness of an occurrence involving a patient. The policy also mandates a psychosocial well-being assessment for patients with potential psychosocial changes resulting from an incident. Despite these policies, the failure to report and properly address the incident between Resident #95 and Resident #97 highlights a deficiency in the facility's implementation of its abuse and neglect prevention protocols.

Penalty

Inspection fine: $88,205

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 acceptable parameters of nutritional status for a resident, leading to significant weight loss and potential health risks. The resident, an elderly female with multiple health conditions including congestive heart failure and severe cognitive impairment, was not consistently weighed, and her care plan was not updated to reflect her nutritional needs. Despite being on a regular ground diet, there were no orders for regular weight monitoring, and her food intake was not accurately recorded, contributing to her weight loss. Observations and interviews revealed that the resident was not receiving adequate assistance with meals, which was crucial given her dependence on others for activities of daily living. Staff members, including a certified medication aide and a speech-language pathologist, acknowledged the resident's poor meal intake and weight loss but failed to take appropriate actions or communicate effectively with the healthcare team. The resident's dietitian had not seen her in person and was unaware of the extent of her weight loss, while the director of nursing was not informed of the lack of weight monitoring or the resident's significant weight loss. The facility's failure to provide necessary oversight and intervention for the resident's nutritional needs resulted in a decline in her health condition. The resident's responsible party noted the lack of assistance with meals and incorrect meal trays, which further exacerbated the situation. The facility's inaction and lack of communication among staff members contributed to the resident's deteriorating condition, highlighting deficiencies in the care provided to maintain her nutritional status.

Penalty

Inspection fine: $88,205

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 pharmaceutical services for two residents, leading to medication errors and discrepancies. For Resident #31, a male with end-stage Alzheimer's disease and other complex medical conditions, the facility did not remove discontinued controlled medications from the medication cart. Despite a hospice order to discontinue Klonopin due to a recent fall, the medication remained in the cart with 21 pills left, indicating a failure to follow proper procedures for medication discontinuation and disposal. Similarly, for Resident #35, a female with multiple diagnoses including dementia and a recent femur fracture, the facility did not properly reconcile controlled medications. Although Tramadol was discontinued, the medication cart still contained 26 pills, and the last administration was recorded months prior. This discrepancy was not addressed, and the medication was not disposed of as required. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of communication and adherence to facility policies regarding controlled medication management. The DON was unaware of the missing medications and expected to be notified of such discrepancies immediately. The facility's policy required immediate reporting and investigation of medication discrepancies, which was not followed, leaving the residents vulnerable to medication errors.

Penalty

Inspection fine: $8,827

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 treatment and care for a resident, leading to a deficiency in quality of care. The resident, a female with dementia, pain, muscle weakness, and generalized anxiety disorder, experienced an unwitnessed fall. Despite being found on the floor multiple times, the necessary assessments and documentation were not completed by the nursing staff. LVN A did not document the fall, conduct neurological checks, or inform the oncoming nurse, which delayed the recognition of the resident's condition. The resident was found sitting on the floor on several occasions, and although aides and nurses were aware of her pain and difficulty standing, she was not sent to the emergency room until the following evening. The resident was diagnosed with a hip fracture at the hospital. The lack of documentation and communication among the staff contributed to the delay in providing necessary medical care. Interviews with staff revealed inconsistencies in reporting and documenting incidents, as well as a lack of adherence to the facility's policies on accidents, incidents, and changes in condition. The failure to follow professional standards of practice and the comprehensive person-centered care plan resulted in the resident not receiving timely and appropriate care.

Removal Plan

• Identify all patients with accident/incident reports
• Ensure accident/incident process is opened and have nurse open before returning to the floor
• Accidents and incidents discussed at stand up and stand down
• Ensure accident/incident process is opened, reports are completed, treatments are documented, process for unwitnessed falls have neuro checks initiated, and investigations are completed accordingly
• Audit accident/incident reports for completion
• In-services: Accidents/Incidents, Change of Condition, Pain, and MD notification
• Education: Pre/Post test on Accidents/Incidents, Pain, and Change of Condition

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 a resident from physical and emotional abuse by a CNA during breakfast time. The incident involved a CNA who, out of frustration, threw an empty juice cup that landed on the resident's lap. The resident, who has a severely impaired cognition with a BIMS score of 05, was unable to recall specific details of the incident but remembered experiencing pain. The CNA admitted to throwing the cup out of frustration due to the resident's behavior of taking another resident's juice, which she perceived as a risk of cross-contamination. Witnesses, including another CNA and the AD, confirmed the incident, noting that the resident screamed in pain when the cup hit his hand. The CNA who witnessed the event reported it to the DON, who then interviewed the involved CNA. The DON found the CNA's actions unacceptable and against the facility's abuse policy, leading to her suspension. The facility's policy emphasizes the residents' right to be free from abuse and outlines a commitment to protecting residents from such incidents. The resident involved in the incident has multiple diagnoses, including dementia, anxiety disorder, and schizophrenia, which contribute to his cognitive and physical vulnerabilities. Despite the incident, a subsequent assessment by an RN found no physical injuries on the resident. The psychology consultant also reported that the resident did not express any stress or reference the incident during a visit the following day.

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 safe and appropriate respiratory care for two residents who required nebulizer treatments. Observations revealed that the nebulizing masks and tubing for these residents were not stored in protective bags when not in use, contrary to the facility's policy. The masks were found to be exposed to the environment, foggy, and dirty, which could potentially lead to respiratory infections. The Licensed Vocational Nurse (LVN) confirmed that the equipment should have been sanitized and stored properly to prevent infections. Resident #2, a male with multiple diagnoses including hypertension, dementia, and heart failure, was receiving Albuterol sulfate via nebulization as needed. However, his care plan did not indicate any respiratory issues or the need for nebulizer medication. Resident #3, a male with chronic respiratory failure and COPD, was on oxygen therapy and received Budesonide and AR formoterol via nebulization. His care plan included interventions for oxygen therapy but did not address nebulizer use. The Director of Nursing (DON) acknowledged that staff were expected to comply with the facility's policy for nebulizer use and storage, and recognized the potential risk for respiratory infections due to this oversight.

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 hospice services were included in the care planning process, which is a violation of the resident's rights to participate in their care planning. The resident, an elderly male with severe cognitive impairment due to senile dementia, was receiving hospice services. Despite this, the facility did not invite or notify the hospice service provider to participate in the interdisciplinary team (IDT) meetings held to discuss the resident's behaviors and potential alternative placement. Interviews with various staff members, including the administrator (ADM) and social worker (SW), revealed a lack of communication and coordination with the hospice service provider. The SW admitted to not inviting the hospice social worker to the IDT meeting, believing it was unnecessary. The hospice service provider was responsible for the resident's care, medications, and services, yet they were not involved in the care planning meetings, which could affect the resident's health and well-being. The facility's policies and agreements with hospice services clearly outlined the need for collaboration and communication with hospice representatives in care planning. However, the facility did not adhere to these policies, as evidenced by the lack of documentation of hospice involvement in the resident's care plan. The facility's failure to include the hospice service provider in the care planning process was acknowledged by the ADM, who admitted that the hospice should have been included in the IDT meeting.

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 collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified through interviews and record reviews, which revealed that the facility did not immediately notify the hospice service provider (HSP) about the resident's increase in aggressive behaviors and the need to transfer the resident due to these behaviors. The resident, an elderly male with severe cognitive impairment and diagnoses including senile degeneration of the brain and unspecified dementia, exhibited physical and verbal behavioral symptoms directed at others, which were not effectively communicated to the hospice team. The resident's care plan required staff to report any changes or declines in condition to the hospice service provider, but there were no notes indicating that the hospice was notified of the resident's behaviors or involved in care planning meetings. Interviews with facility staff and hospice representatives revealed a lack of communication and coordination between the facility and hospice services. Hospice nurses and social workers were not informed of the resident's incidents or invited to interdisciplinary team (IDT) meetings, which discussed the resident's behaviors and alternative placement. The facility's policy required immediate notification of the hospice about significant changes in the resident's status and collaboration with hospice representatives in the care planning process. However, the facility did not adhere to these policies, as evidenced by the lack of documentation and communication with the hospice team. This failure to involve hospice services in the care planning process could potentially place residents at risk of not receiving appropriate interventions, treatments, and care.