Peach Tree Place

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes based on the comprehensive assessments for two residents. For one resident, an older female with Alzheimer’s disease, dementia, chronic kidney disease stage 3, depression, and anxiety, the MDS and CAA summary indicated that falls was a triggered care area and that it was addressed in the care plan. However, review of her undated comprehensive care plan showed no evidence that falls were addressed, despite documentation of a fall without injury in an event nurse’s note. Her comprehensive care plan also lacked any documented discharge plans or discharge assessment, contrary to what the facility’s policy required. For the second resident, an older male with acute kidney failure, Wernicke’s encephalopathy, severe protein-calorie malnutrition, hypertensive heart and chronic kidney disease with heart failure, depression, anxiety, dementia, GERD, gallstones, and carotid artery occlusion/stenosis, the MDS showed a BIMS score of 15, indicating he was cognitively intact. His MDS CAA summary indicated that communication, ADL functional/rehabilitation potential, nutritional status, dental care, and pressure ulcer were triggered areas and that these were addressed in the care plan. In contrast, review of his undated comprehensive care plan revealed no evidence that any of these triggered areas were actually addressed, and there was no documented discharge plan or discharge assessment, even though progress notes showed he had a scheduled dental appointment and documented dietary preferences. Interviews with facility staff confirmed that the MDS nurse (MDS-A) was responsible for completing the MDS assessments and initial comprehensive care plans, and that department heads relied on this nurse to update care plans. The ADON stated she was unsure who was responsible for including discharge planning information in the care plan and acknowledged that not having fall risk in the care plan could prevent falls from being addressed. The MDS nurse reported she was not aware that the care plans for the two residents were missing CAA-triggered areas and acknowledged that missing information could mean residents’ needs would not be person-centered or met. The DON and administrator both confirmed that MDS-A was responsible for the care plans and acknowledged that the resident identified as a fall risk should have had this addressed in the care plan, and that failure to address CAA triggers in the care plan could negatively affect communication and resident outcomes. The facility’s written policy required that CAA-triggered areas be further assessed and, when care planning was pursued, that the IDT develop and implement a comprehensive person-centered care plan addressing goals, preferences, strengths, weaknesses, needs, and discharge planning, which was not done for these residents.

Penalty

Inspection fine: $229,570

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's right to be free from abuse and neglect when four staff members, including licensed nurses, a nursing assistant, and a laundry staff member, physically restrained and forcibly carried a resident by his extremities, dragging him on the floor to his room. Once inside, the staff placed the resident in his room and held the door closed, preventing him from leaving. This action was taken in response to the resident exhibiting aggressive behaviors, including attempting to strike staff and other residents, and swinging a call light cord. The staff did not attempt de-escalation techniques or remove other residents from the area, and instead chose to physically restrain and seclude the resident without a physician's order or proper assessment. The resident involved had a history of major depressive disorder, anxiety disorder, and unspecified dementia with severe cognitive impairment, as indicated by a BIMS score of 5. He was admitted to a secure unit due to a history of elopement and was also under hospice care. Prior to the incident, the resident had documented skin tears on his fingers and upper arm, and his care plan included interventions for behavioral issues, such as positive interaction, de-escalation, and involving family when confusion or combativeness increased. However, the care plan did not include the use of physical restraints or involuntary seclusion, and there was no physician order for such interventions at the time of the incident. Interviews and video evidence confirmed that staff did not follow established protocols for managing aggressive behaviors, such as using de-escalation techniques or ensuring the safety of other residents by removing them from the area. Instead, staff physically restrained the resident, carried him by his arms and legs, and held him in his room against his will. The Director of Nursing and Administrator were not fully informed of the severity of the incident until after reviewing video footage. The resident's power of attorney was also not promptly notified of the incident or the use of restraints and medication. The facility's actions constituted abuse and neglect, as defined by their own policies and federal regulations.

Penalty

Inspection fine: $229,570

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

Facility staff failed to protect a resident's right to be free from involuntary seclusion. The incident involved a male resident with severe cognitive impairment, major depressive disorder, anxiety disorder, unspecified dementia, and Alzheimer's disease. The resident had a history of elopement and was admitted to a secure unit. On the day of the incident, the resident exhibited behaviors such as wandering into other residents' rooms, taking items, and becoming agitated when items were removed from him. He escalated to physically aggressive behaviors, including pushing a bedside table into a nurse, swinging a call light cord with a metal prong, and chasing staff down the hallway. Staff responded by physically restraining the resident, carrying him by his extremities without supporting his back or midsection, and placing him in his room. They then held the door closed, preventing him from leaving, while he struggled to get out. During the incident, staff did not attempt de-escalation techniques or remove other residents from the area as outlined in the resident's care plan. Instead, they focused on isolating the resident in his room and physically restraining him. The staff took turns holding the door closed, and the resident was left unsupervised inside the room, where he continued to display agitation, including breaking a window. The police and EMS were eventually called, and the resident was further restrained by law enforcement and administered medication by a hospice nurse. Interviews with staff revealed that the decision to seclude and restrain the resident was made collectively, and some staff expressed discomfort with the way the situation was handled. The facility's policies prohibit the use of unauthorized restraints and involuntary seclusion. However, staff actions during the incident did not align with these policies. The Director of Nursing and Administrator were not fully informed of the severity of the incident until after reviewing video footage. The resident's power of attorney was not notified in a timely manner, and there was no documentation of consent for the use of restraints or medication. The incident resulted in skin tears to the resident's finger and arm, and the resident was unable to recall the event during subsequent assessment.

Removal Plan

• Staff members LVN A, RN and NA were immediately suspended by the administrator. All three staff members remain suspended.
• Resident #1 had a head-to-toe assessment completed by the charge nurse. The skin tears to resident #1's finger and upper arm are being treated according to physician orders.
• Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts.
• The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents.
• Safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted.
• Head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses.
• Staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility.
• The medical director was notified of the immediate jeopardy by the Administrator.
• An ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal.
• The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe; De-escalate the behavior by giving the resident space; Monitor the residents from a safe distance; Provide 1:1 monitoring until further directed by the abuse coordinator; Staff will not restrain a resident or seclude a resident involuntarily.
• The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; All allegations of possible abuse must be investigated immediately by the Administrator or designee to ensure the proper measures are implemented to keep residents safe and from abuse; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe; De-escalate the behavior by giving the resident space; Monitor the residents from a safe distance; Provide 1:1 monitoring until further directed by the abuse coordinator; Staff will not restrain a resident or seclude a resident involuntarily.

Penalty

Inspection fine: $229,570

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

Facility staff failed to protect a resident's right to be free from physical restraints not required for medical treatment. On the day of the incident, the resident, who had diagnoses including major depressive disorder, anxiety disorder, unspecified dementia, and Alzheimer's disease, exhibited behaviors such as wandering, taking items from other residents' rooms, and becoming agitated when items were removed from his possession. The situation escalated when the resident became physically aggressive, swinging a call light cord and striking staff with a bedside table. In response, four staff members, including nursing and non-nursing personnel, physically restrained the resident by grabbing his arms and legs, dragging him across the floor, and carrying him by his extremities to his room without supporting his back or midsection. Once in the room, staff held the door closed, preventing the resident from leaving. The resident's care plan included interventions for aggressive behavior, such as removing him from situations, using calm communication, and providing diversions, but did not authorize the use of physical restraints. There was no physician order for restraints, and the only relevant medication order was a one-time administration of Haldol after the incident. Staff interviews revealed that the decision to physically restrain and seclude the resident was made collectively for staff convenience and safety, rather than as a last resort after all other interventions had failed. The Director of Nursing and Administrator were not fully informed of the severity of the incident until after reviewing video footage, and both expressed that staff actions did not align with facility expectations or policies. Facility policies reviewed by surveyors clearly prohibited the use of physical restraints for discipline or convenience and required thorough assessment, physician orders, and consent for any restraint use. The policies also defined physical and mental abuse, including unreasonable confinement and involuntary seclusion. The staff's actions in restraining and secluding the resident were not in accordance with these policies, and there was a lack of immediate notification to the resident's power of attorney and primary physician regarding the incident. The deficiency was identified as Immediate Jeopardy due to the failure to protect the resident's rights and the risk of physical and psychological harm.

Removal Plan

• Staff members LVN A, RN and NA were immediately suspended by the administrator. All three staff members remain suspended.
• Resident #1 had a head-to-toe assessment completed by the charge nurse. No further injuries were noted. The skin tears to resident #1's finger and upper arm are being treated according to physician orders.
• Trauma informed care assessments were completed by the DON/ADON and Social Worker on all residents including resident #1 and documented in the charts. No new findings were assessed. Resident #1 was at his baseline. No behaviors or emotional distress were noted.
• The Administrator, DON, ADON completed rounds on every resident in the facility to ensure that no additional unauthorized restraints or involuntary seclusion were in use on any residents.
• Safe surveys were completed for all residents who are able to be interviewed by the Administrator, DON, ADON and Social Worker. No additional unauthorized restraints or signs of involuntary seclusion were noted.
• Head-to-toe skin assessments were completed on all residents by the DON/ADON and nurses. No signs of abuse or new injuries were discovered.
• Staff interviews were conducted by the Administrator and DON to determine if any restraints or involuntary seclusion have been observed or used on any other residents in the facility. No additional findings were noted.
• The medical director was notified of the immediate jeopardy by the Administrator.
• An ADHOC QAPI meeting was completed with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal.
• The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics and policies: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include the use of unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma or re-traumatization to a resident; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily.
• The following in-services were initiated by Regional Compliance Nurse, DON, ADON for all staff. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will in serviced prior to assuming their next assignment. Topics: Abuse and Neglect Policy to include restraints, involuntary seclusion, and unreasonable confinement; Restraint Policy to include restraints are not to be used without reasonable rationale, assessment, physician orders, and consent; Resident Rights to include that it is a resident's right to be free from abuse such as unauthorized restraints, involuntary seclusion, and unnecessary confinement; Trauma informed Care to include unauthorized restraints seclusion, and unreasonable confinement can cause unnecessary trauma; Behavior management to include how to manage behaviors and de-escalate aggressive residents. If a resident is demonstrating aggressive behavior, remove all residents from the immediate area to keep them safe. De-escalate the behavior by giving the resident space. Monitor the residents from a safe distance. Provide 1:1 monitoring until further directed by the abuse coordinator. Staff will not restrain a resident or seclude a resident involuntarily.

Penalty

Inspection fine: $229,570

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 policies and procedures for the immediate reporting of suspected abuse, neglect, or theft, as required by both facility policy and state law. On the date of the incident, four staff members, including two nurses, a nursing assistant, and a laundry attendant, forcibly carried a resident by his extremities to his room and held the door closed, preventing the resident from leaving. This action was not reported to the facility administrator or the State Survey Agency immediately, as required. Instead, the administrator was not notified of the abuse until two days after the incident, despite the policy mandating immediate reporting of all suspected cases of abuse to the administrator and appropriate authorities. The resident involved was an elderly male with diagnoses including major depressive disorder, anxiety disorder, and unspecified dementia with severe cognitive impairment, as evidenced by a BIMS score of 5. At the time of the incident, the resident exhibited behaviors such as wandering, taking items from other residents' rooms, and becoming agitated. Staff responded by physically restraining the resident, carrying him to his room without supporting his back or midsection, and holding the door closed to prevent his exit. The incident was only fully discovered when the DON reviewed video footage two days later, revealing the extent of the staff's actions. Interviews with staff indicated that the decision to forcibly carry and seclude the resident was made collectively, and that the DON and administrator were not fully informed of the severity of the incident at the time it occurred. Staff members demonstrated varying levels of understanding regarding what constitutes abuse, restraint, and seclusion, and some expressed discomfort with how the situation was handled. The delay in reporting and the lack of immediate notification to the administrator and state authorities constituted a failure to follow established abuse reporting protocols, resulting in the identification of Immediate Jeopardy.

Penalty

Inspection fine: $229,570

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and multiple mental health diagnoses, including major depressive disorder, anxiety disorder, and dementia. The resident's care plan identified a history of trauma and behavioral issues, such as aggression and wandering, and included interventions like positive interaction, de-escalation techniques, and contacting family during episodes of increased confusion or combativeness. However, the care plan lacked specific de-escalation techniques for staff to implement, and staff did not follow the existing interventions during a behavioral incident. On the day of the incident, the resident exhibited behaviors such as wandering into other residents' rooms, taking items, and becoming agitated when an item was removed from his possession. The situation escalated when the resident pushed a bedside table into a nurse, chased staff with a call light cord, and fell to the floor. Instead of following the care plan interventions, four staff members forcibly carried the resident by his extremities to his room and held the door closed, effectively restraining and isolating him without attempting de-escalation or removing other residents from the area as outlined in the care plan. Interviews with facility leadership and staff revealed that the staff did not attempt any de-escalation techniques and chose to restrain and seclude the resident because they believed it was easier than removing other residents from the area. The Director of Nursing and Administrator both stated that staff failed to follow the care plan and did not notify the resident's family as required. The resident's power of attorney was not informed of the incident or the use of restraint and seclusion until after the fact, and expressed that she should have been contacted earlier to help de-escalate the situation.

Penalty

Inspection fine: $229,570

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, implement, and maintain an effective training program for all new and existing staff, including those providing services under contract and volunteers, as required. Specifically, two employees, an LVN and an RN, did not have documentation of annual dementia and restraint reduction training in their files. The LVN's file showed dementia training shortly after hire but lacked evidence of restraint reduction training, aside from a signed policy. The RN's file included an ungraded dementia test and no documentation of restraint training. Interviews with both staff members revealed uncertainty about when or if they had received the required training, with one stating that in-person training was cancelled and that training is now conducted online, often verbally, with signatures at the end. The RN did not recall any training on dealing with behaviors or restraints. The interim administrator confirmed that staff are responsible for completing their own online training and acknowledged recent changes in the training program, which made tracking employee progress more difficult. The facility was also without an HR person at the time, and the administrator was unable to provide a training policy during the survey. These actions and inactions led to the deficiency in staff training documentation and compliance.

Penalty

Inspection fine: $229,570

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 immediately inform residents, their representatives, and physicians of significant changes in residents' physical, mental, or psychosocial status, as required by policy. In one case, a male resident with severe cognitive impairment, major depressive disorder, anxiety disorder, unspecified dementia, and Alzheimer's disease exhibited combative behavior, broke a window, and required intervention from police, EMS, and hospice staff. Despite these significant behavioral changes and the administration of Haldol, the resident's primary physician and power of attorney (POA) were not promptly notified by facility staff. The POA was only informed after the incident by a hospice nurse, and the primary physician was not notified until days later by the DON. Documentation and interviews confirmed that the facility staff did not follow the care plan interventions for notification and failed to communicate the events in a timely manner. In another instance, a male resident with severe cognitive impairment, dementia, and multiple cancer diagnoses developed a Stage 3 pressure ulcer. Nursing staff identified the wound and notified wound care, but failed to notify the resident's primary physician and POA of the significant change in health status. The nurse responsible admitted to being too busy to make the notifications and did not document any attempt to contact the responsible party. The primary physician and wound care physician both confirmed they were not informed of the pressure ulcer until after the fact, and the responsible party was not reached or left a message. Facility policy requires immediate notification of the resident, physician, and representative in the event of significant changes, injuries, or the need to alter treatment. Record review and interviews revealed that these requirements were not met in the cases reviewed, resulting in a lack of timely communication regarding significant changes in residents' conditions and treatment regimens. The failure to notify could have prevented residents from receiving timely and needed treatment, as acknowledged by staff during interviews.

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 three residents, as required. Specifically, one resident receiving hospice services did not have a care plan addressing hospice care, another resident with a seizure disorder did not have a care plan related to seizure management, and a third resident with a Do Not Resuscitate (DNR) order did not have a care plan reflecting their DNR status. These omissions were identified through interviews and record reviews, which showed that the care plans lacked measurable objectives and time frames to meet the residents' needs. For the resident on hospice, records indicated a diagnosis of cerebral infarction and severe cognitive impairment, with hospice services ordered and initiated, but no corresponding care plan entry. The resident with a seizure disorder had a diagnosis of metabolic encephalopathy and dementia, was receiving anticonvulsant medication, and had physician orders for seizure management, yet there was no care plan addressing this condition. The resident with a DNR order had multiple chronic conditions and a signed DNR form in the record, but the care plan did not reflect this advanced directive. Interviews with facility staff, including the LVN, DON, MDS Coordinator, and Administrator, revealed inconsistent understanding and implementation of care planning processes. Staff described various methods for verifying code status and updating care plans, but acknowledged gaps in ensuring that all relevant diagnoses and directives were consistently reflected in the care plans. The facility's care plan policy was requested but not provided to the survey team during the survey.

Penalty

No penalty information released

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

Summary

Surveyors observed that the facility failed to maintain proper sanitation and cleanliness in the kitchen, specifically regarding the food fryer and the bottom shelf of a food preparation table. The fryer was found in an unsanitary condition, with food crumbs dried onto the fryer baskets and inside the fryer walls, and had not been cleaned after its last use. Additionally, the bottom shelf of the food prep table was not clean, with food crumbs present on the shelf and on the lids of containers holding flour, sugar, and powdered milk. These observations were confirmed during interviews with the Dietary Manager, who acknowledged that the fryer and baskets should have been cleaned after use and that the prep table and container lids should be cleaned daily. The Dietary Manager also stated that there was a cleaning schedule in place, and that equipment should be cleaned and sanitized after each use to prevent foodborne illness, with the kitchen cleaned daily to avoid attracting pests. The Administrator confirmed the expectation that the kitchen be cleaned daily and that food particles should not be left on containers or shelves. Review of facility policy and the FDA Food Code further supported the requirement for regular cleaning of equipment and surfaces to prevent accumulation of food residue and debris.

Penalty

No penalty information released

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

Summary

A deficiency was identified when a Licensed Vocational Nurse (LVN A) failed to adhere to infection prevention and control protocols during medication administration and vital sign monitoring for three residents. Observations revealed that LVN A did not perform hand hygiene before or after preparing and administering medications to the residents. Additionally, LVN A did not sanitize a reusable electronic wrist blood pressure cuff before or after use between residents. These lapses were observed during multiple medication passes and vital sign checks. During interviews, LVN A acknowledged not performing hand hygiene between resident interactions and not sanitizing the blood pressure cuff between uses. LVN A attributed the failure to not having alcohol-based hand rub (ABHR) readily available on the medication cart or in his pocket, despite the facility having an ample supply. He also demonstrated knowledge of the expectation to use sanitizer wipes for equipment but did not follow this practice during the observed medication administration and vital sign checks. Further interviews with the Registered Charge Nurse (RCRN) and Director of Nursing (DON) confirmed that facility expectations required hand hygiene before and after medication administration and equipment sanitization between each resident use. Review of facility policy supported these requirements, specifying hand hygiene after contact with residents or their equipment. LVN A's personnel file showed he had received infection control training during orientation.

Penalty

No penalty information released

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

Summary

The facility failed to implement written policies and procedures to prohibit and prevent abuse and neglect, as evidenced by the lack of timely background screenings for several staff members. Specifically, the facility did not conduct criminal history checks and checks of the EMR/NAR prior to the employment of an LVN, a cook, and two CNAs. This oversight was identified during interviews and record reviews, revealing that the background checks were conducted months after the staff members were hired, contrary to the facility's policy which mandates these checks within 72 hours of employment. Interviews with the Administrator and Human Resources staff highlighted a breakdown in the process, with the Administrator noting that the responsibility for conducting these checks initially lay with Human Resources. However, a change in procedure in mid-January led to the Administrator monitoring and signing off on audits. Despite this, an audit revealed that the necessary checks were not completed, and the corporate office had not yet conducted a promised audit of the EMR/NAR checks. The failure to perform these checks as required could potentially place residents at risk of abuse and neglect, as acknowledged by both the Administrator and Human Resources staff.

Penalty

No penalty information released

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

Summary

The facility failed to implement Enhanced Barrier Precautions for a resident who required feedings via a gastrostomy tube. During an observation of perineal care, it was noted that two CNAs did not follow the necessary precautions by donning a gown, despite a sign indicating the need for such precautions on the resident's door. The resident, who was unable to respond verbally, was observed to follow movements with his eyes. The CNAs involved acknowledged their failure to adhere to the precautions, with one citing forgetfulness and the other being new to the facility and unaware of the location of personal protective equipment (PPE). The Director of Nursing, who also serves as the Infection Preventionist, confirmed that Enhanced Barrier Precautions should have been implemented for the resident's gastrostomy tube. The facility's policy on Enhanced Barrier Precautions, dated April 1, 2024, outlines the need for targeted gown and glove use during high-contact resident care activities to reduce the transmission of multi-drug resistant organisms. The failure to adhere to these precautions could potentially lead to the spread of infection, as noted by the DON.