Alleghany Health And Rehab

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

Facility staff failed to notify a resident or their representative of a room change, as required by facility policy and regulatory standards. The resident was moved to a new room without being provided a room change consent form, and no signature was obtained to document agreement to the move. Interviews with the resident revealed initial confusion and reluctance about the move, which was later explained by staff as necessary for safety reasons. However, there was no documentation in the clinical record or facility paperwork to show that the resident or their representative was notified or that consent was obtained prior to the room change. Further review of facility documentation and interviews with staff, including the Social Worker Director, Administrator, and DON, confirmed that the standard process for room changes was not followed in this instance. The facility's own policy requires notification of the resident's legal representative at least twenty-four hours in advance, documentation of the reason for the change, and the resident's and roommate's reactions, none of which were completed. The only documentation found was a note indicating the resident's belongings had been moved, with no evidence of notification or consent.

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

Facility staff failed to conduct accurate and thorough investigations into allegations of inappropriate touching between two residents. In the first incident, a resident reported that another resident touched her thigh in the hallway while she was writing a letter. The administrator, who was present at the time of the report, dismissed the possibility of the incident based on her own observations of the physical setup and the alleged perpetrator's routine. The investigation lacked written witness statements from both the staff member who reported the incident and the residents involved, as required by facility policy. In a second incident, the same resident reported being inappropriately touched by the same alleged perpetrator while in the weight room. Staff immediately separated the residents and provided follow-up care, including psychological services and changes to room assignments to ensure safety. However, the investigation into this incident was also incomplete. It did not include statements from the residents involved or from a Certified Nursing Assistant who witnessed the event, although the CNA's statement was later provided. Additionally, the investigation inaccurately documented the details of the incident and omitted relevant information from the nurse practitioner who followed up with the resident. Facility documentation reviews revealed that the required procedures for investigating abuse allegations were not followed. The facility's policies mandate obtaining written statements from all involved parties and witnesses, as well as accurate and detailed reporting of the events. In both incidents, these requirements were not met, resulting in incomplete and inaccurate investigations of the alleged violations.

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

Facility staff failed to follow professional standards of care for two residents. For one resident with a history of inappropriate sexual behaviors, the nurse practitioner recommended interventions such as providing visual aid materials and allowing private time to help manage the behaviors. However, these recommendations were not implemented, and the care plan was not updated to reflect these interventions. The nurse practitioner was not informed that her recommendations had not been carried out, and the care plan only included 15-minute checks and instructions to notify the physician if behaviors continued, omitting the suggested behavioral interventions. Facility policy required that care plans be updated and that staff notify clinical leadership if interventions could not be implemented, but this was not done. For another resident who experienced an unwitnessed fall, staff failed to complete and document all required neurological checks following the incident. The facility's fall management procedure required consistent neuro checks after a fall, but documentation showed that these checks were missing on some days. The Director of Nursing confirmed the absence of neuro check documentation, indicating that the facility did not follow its own procedures for post-fall assessment and monitoring.

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

Facility staff failed to implement fall prevention interventions for two residents following documented falls. For one resident, clinical record review showed a fall occurred, but no new interventions were added to the care plan as required. The Director of Nursing (DON) confirmed that interventions should be added to the care plan but was unable to provide evidence that this was done. The facility's own policy, which requires immediate team meetings and updating care plans with new interventions after a fall, was not followed. Another resident experienced multiple falls over several months, yet the care plan was not updated with new interventions after any of these incidents. The DON again acknowledged the requirement but could not show that interventions were implemented. Facility documentation reviewed confirmed that staff are required to establish and implement new interventions on the care plan after a fall, but this procedure was not followed for either resident.

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

Facility staff failed to maintain a sanitary environment on two of three units, as evidenced by direct observations and interviews. In one instance, a bathroom in room B6 was found with dried brownish material consistent with feces on the base of the commode, the floor around the commode, and down the side of the commode. The housekeeper responsible for cleaning the area acknowledged the presence of feces and expressed concerns about inadequate cleaning tools and the inability to thoroughly clean due to restrictions on handling personal belongings. She also indicated that sometimes the rooms are not cleaned as thoroughly as they should be. In another instance, a resident's room on A wing (room A6) was observed to have puckered and moist wallpaper, accompanied by an odor resembling cat urine. The resident reported difficulty sleeping due to the odor and stated that staff attributed the issue to a possible roof leak or an animal or person urinating in the corner. The Maintenance Director confirmed the wallpaper was puckered and moist but did not detect an odor at the time. The DON and RDCS, upon entering the room, confirmed the presence of the odor and the moist wall. No formal policy for room sanitation and cleanliness was provided, only a form titled "Job to be done. Complete room cleaning."

Penalty

Inspection fine: $87,878

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 staff failed to protect residents from abuse and neglect, resulting in psychosocial harm for two residents. On two of the three nursing units, residents were subjected to a hostile environment due to the ongoing aggressive and sexually inappropriate behavior of a resident. This resident made verbal threats of physical harm and death, as well as sexual comments, which affected other residents. Despite numerous documented incidents of aggressive behavior, including threats to blow up the building and harm others, the facility did not implement adequate safeguards to protect the residents. The staff was aware of the resident's behaviors, yet interventions were insufficient, and the resident continued to have unrestricted access to other residents. One resident, who had a history of trauma and mental health issues, reported feeling unsafe and was observed to be visibly distressed by the aggressive resident's behavior. The facility's documentation revealed a pattern of the aggressive resident's behavior, including making sexual comments and threats, which were not effectively addressed by the staff. The facility's social worker and other staff members were aware of the situation but failed to implement effective interventions to prevent further harm. Additionally, another resident reported an allegation of verbal abuse and neglect by a CNA, which was not appropriately identified or addressed as an abuse allegation by the facility. The resident expressed distress over the incident and hesitated to use the call light due to fear of further negative interactions. The facility administrator treated the incident as a customer service issue rather than an abuse allegation, and the CNA involved continued to work without any suspension or restriction.

Penalty

Inspection fine: $87,878

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 staff failed to implement abuse policies and procedures to protect residents from aggressive behaviors, report instances of abuse, conduct thorough investigations, and implement appropriate safeguards. Resident #16, known for aggressive behaviors, verbally abused Resident #8, causing psychosocial harm. Despite staff awareness of Resident #16's behaviors, interventions were inadequate, and 15-minute checks were discontinued prematurely. Resident #16's history of aggression and threats was documented, yet no effective measures were taken to protect other residents, including Resident #8, from ongoing abuse. In another incident, the facility staff failed to protect Resident #17 from verbal abuse and neglect by a CNA. The resident reported the incident, but the facility administrator treated it as a grievance rather than an abuse allegation, failing to report or investigate it. The CNA continued to work without suspension, having access to Resident #17 and other residents. The facility's response to the incident was inadequate, as the administrator considered it a customer service issue rather than abuse. Additionally, the facility staff failed to obtain a criminal background check for the interim administrator, who also served as the abuse coordinator, within 30 days of employment. This oversight was discovered during a survey, and the administrator was suspended until a background check was completed. The facility's hiring policy requires background checks before employment, but this was not followed, leading to noncompliance with regulatory requirements.

Removal Plan

• Resident #16 was placed on 1:1 supervision to protect residents #2, #8, and #18. Resident #16 medications reviewed, and changes made to psychotropic dosing.
• FRI submitted and investigation initiated based on Resident #17 allegation identified by surveyor. The alleged employee was immediately suspended protecting Resident #17 and investigation initiated.
• Education will be completed with all current staff in the facility on the Abuse Policy which includes reporting and completing a thorough investigation. Staff not currently in the facility will not be able to work until education is completed.
• NHA conducting interviews with employees and residents related to resident #16 FRI.
• Current residents on A wing and B wing will be interviewed by the Regional President of Operations & Regional Clinical Director and other IDT members to determine if they had experienced any type of abuse, mental and/or sexually inappropriate, or lewd, aggressive, hostile or threatening comments that have been made toward them or others resulting in fear or feelings of being unsafe from either staff, residents or other visitors. Residents who are not interviewable will have a head-to-toe assessment.
• Medical Director notified.

Penalty

Inspection fine: $87,878

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 staff failed to provide appropriate treatment and services to two residents with mental disorders and a history of trauma, leading to deficiencies in their care. Resident #8, who had a known history of trauma, did not receive trauma-informed care to attain her highest practicable mental and psychosocial well-being. Despite having a care plan that included interventions such as psychiatric services and medication management, there was no evidence of identification of her triggers or interventions regarding another resident's repeated abusive behaviors towards her. Resident #8 reported feeling threatened and unsafe due to the actions of Resident #16, which exacerbated her anxiety and fear. Resident #16, who had a long-standing mental health history, was not being seen routinely by a psychiatric provider, and his care plan was not adequately updated to address his behaviors. Despite staff being aware of his inappropriate and aggressive behaviors, including making targeted sexual comments to Resident #8, the facility failed to implement effective interventions to manage his behaviors. The facility's response to his behaviors was limited to 15-minute checks and offering snacks, without any non-pharmacological safeguards to prevent further abusive behaviors. The facility's failure to ensure residents with mental disorders and a history of trauma received appropriate treatment and services resulted in an Immediate Jeopardy situation. The survey team identified that the facility did not have a consistent psychiatric provider on-site, and there was a lack of timely psychiatric services for residents like Resident #16. The facility's inaction and inadequate care planning contributed to the ongoing distress and safety concerns for Resident #8, highlighting significant deficiencies in the facility's approach to managing residents with complex mental health needs.

Removal Plan

• Psychosocial assessments were completed for Resident #8 and psych services were on-site to see the resident.
• Psychiatric services were onsite to see Resident #16. Completed review of Resident #16 medications and changes made to psychotropic dosing. Resident has been placed on 1-1 to provide diversion if behaviors are exhibited.
• Identify residents that have exhibited behaviors, residents with the diagnosis of PTSD, residents with a history of trauma and/or a mental disorder. The care plans of those residents identified will be reviewed to ensure they have the appropriate interventions and updated as indicated. They will also refer to psych services as indicated.
• All current residents will be reviewed to ensure they have received a trauma screening to identify triggers and care plans updated as indicated.
• Medical Director notified.

Penalty

Inspection fine: $87,878

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 staff failed to post daily staffing information, which is required for residents and visitors to view. During a walkthrough, the surveyor observed that the staffing postings in the lobby and time clock area were outdated, with dates from several days prior. The Director of Nursing (DON) confirmed the absence of current postings and acknowledged that the human resource director was responsible for updating them. The regional vice president of clinical mentioned that due to system issues, the human resource director was instructed to handwrite the daily postings, but this was not done effectively.

Penalty

Inspection fine: $87,878

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 staff failed to effectively administer the facility to ensure residents were free from abuse and did not fully implement their abuse policy, affecting residents on two of three nursing units. Resident #8, who had a history of trauma and abuse, was subjected to verbal and mental abuse by Resident #16, who exhibited ongoing aggressive and inappropriate behaviors. Despite being aware of these behaviors, the facility administrator and staff did not implement effective corrective measures to protect Resident #8 and other residents sharing common areas with Resident #16. The facility's documentation and interviews revealed that staff were aware of Resident #16's behaviors, yet interventions were inadequate, and the facility failed to conduct thorough investigations or implement necessary safeguards. Resident #16's chart documented numerous incidents of aggressive behavior, including threats and physical altercations with other residents. Despite these documented incidents, the facility did not take appropriate action to protect residents or investigate the incidents as required by their abuse policy. The facility administrator and staff were not fully aware of the severity of Resident #16's behaviors, and there was no evidence of psychiatric follow-up or appropriate medication management for Resident #16. The facility's failure to address these issues resulted in ongoing abuse and fear among residents, particularly Resident #8, who expressed feeling unsafe and traumatized by Resident #16's actions. Additionally, Resident #17 reported an allegation of verbal abuse and neglect by a certified nursing assistant, which resulted in psychosocial harm. The facility administrator reviewed and signed off on the grievance without effectively responding to the allegations, treating it as a customer service issue rather than an abuse allegation. The facility's abuse policy required immediate reporting and investigation of such allegations, but the administrator failed to follow these procedures. As a result, the certified nursing assistant continued to work without suspension or restriction, and the facility did not implement measures to protect residents from further abuse.

Penalty

Inspection fine: $87,878

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 staff failed to provide credible evidence that the facility assessment was reviewed at least annually and did not ensure the involvement of appropriate participants in the assessment process. This deficiency was identified during a review conducted on January 27, 2025, which revealed a lack of documentation indicating when the facility assessment was last reviewed and who participated in the process. The data within the assessment included outdated Quality Measure reports from December 2018 to February 2019 and more recent reports from August 2023 to October 2023. However, there was no evidence of active involvement from direct care staff, residents, resident representatives, or family members in the development or review of the facility assessment. The facility's Administrator and Regional Vice President of Operations were unable to provide further information regarding the review process or the participants involved. They assumed the assessment was discussed around July 2024, when it was uploaded online, but lacked evidence to support this claim. A meeting with the facility administrator, Director of Nursing, and corporate management staff confirmed the absence of credible evidence of involvement from key stakeholders in the assessment process. The facility's policy on facility assessment outlined the need for annual review and involvement of the governing body, but no additional information was provided to demonstrate compliance with these requirements.

Penalty

Inspection fine: $87,878

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 staff failed to maintain an active transfer agreement with a hospital, which is a requirement under federal regulation F843. This deficiency was identified during a survey conducted on January 27, 2025, when the facility administrator was unable to provide a current transfer agreement upon request. The survey team sought clarification from the administrator and corporate staff regarding the necessity of the transfer agreement, which is crucial for ensuring that residents can be moved quickly to a hospital when they require medical care. The facility's assessment indicated a resident population with significant medical needs, including 66 residents with dementia, 9 with sundowners, and 32 with behavioral health diagnoses. Despite these needs, the facility did not have an active transfer agreement with any hospital for psychiatric or emergency medical services. The administrator later submitted outdated agreements from 2009 and 2006, which were not valid under the current ownership, further highlighting the lack of compliance with the required regulations.

Penalty

Inspection fine: $87,878

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 staff failed to provide an ongoing activity program to meet the needs of residents on the memory care unit. Interviews with staff and residents revealed that activities were not conducted daily, and the activity calendar was not consistently followed. A Licensed Practical Nurse (LPN) noted the absence of a January activity calendar and mentioned that the activity director did not visit the unit daily, leading to residents feeling bored and neglected. The activity director assistant confirmed that activities were only conducted three to four times a week, not daily, as expected. Residents expressed dissatisfaction with the lack of activities, stating that scheduled activities like devotions were not conducted as planned. A review of the activity participation records for the 27 residents on the memory care unit showed that only two residents participated in activities in January, while the rest had no recorded participation. The activity calendar for January showed only three to four activities per week, with several days lacking scheduled activities. Previous months had more frequent activities, but staff reported that some scheduled activities never took place. The facility's grievance log contained several complaints about the lack of activities and failure to adhere to the calendar. The facility's policy stated that activities should meet various resident needs and be scheduled daily, but this was not being followed, leading to the deficiency.

Penalty

Inspection fine: $87,878

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 staff failed to conduct annual performance reviews for a certified nursing assistant (CNA #14) as required. CNA #14 was hired on June 12, 2022, and the first evaluation in her record was completed on January 27, 2025, which was after the surveyor had requested the employee files. This indicates that the annual evaluation was not conducted in a timely manner. During an interview, the Director of Nursing (DON) acknowledged that the purpose of the annual evaluations was to monitor the employee's performance and discuss areas needing improvement. The facility's policy on performance evaluations states that these evaluations provide a formal opportunity for supervisors and employees to discuss work performance and developmental areas related to the job description. The deficiency was discussed with the administrator, regional vice president of operations, and the DON during an end-of-day meeting.

Penalty

Inspection fine: $87,878

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 staff failed to utilize outside resources to ensure ongoing psychiatric services were available to residents needing such services. This deficiency affected residents across all three nursing units. The facility did not have a routine psychiatric provider from October 2024 until January 23, 2025. During this period, only one telehealth psychiatric visit was conducted, and mental health issues were managed by the medical providers on-site. The lack of a consistent psychiatric provider was confirmed during an interview with the medical nurse practitioner, who stated that there had been no on-site psychiatric provider since their tenure began. The facility's assessment indicated that there were 66 residents with dementia, 9 with sundowners, and 32 with a behavioral health diagnosis, with 32 residents being seen by behavioral health services. Despite this, the facility did not have a psychiatric provider available on-site or through telehealth consistently during the specified period. The facility administrator and Regional Vice President of Operations reported that routine psychiatric services were available until the provider resigned in mid-October 2024, and a new provider only began visiting the facility on January 24, 2025.

Penalty

Inspection fine: $87,878

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 staff failed to implement policies and procedures for reporting reasonable suspicion of abuse, resulting in the failure to protect residents from further potential abuse. Resident #8 was a victim of abuse by another resident, Resident #16, on multiple occasions. Despite being cognitively intact and reporting incidents of verbal and physical threats, the facility did not report these occurrences to the state survey agency or other authorities as required. The clinical records of both residents documented several instances of aggressive behavior by Resident #16, including threats to harm Resident #8, but these were not reported as abuse. Resident #16 exhibited ongoing behavioral outbursts that adversely affected other residents. The facility documentation revealed multiple instances of abusive behavior by Resident #16, including making obscene sexual comments, threatening staff and residents, and physical aggression. Despite these documented behaviors, the facility staff failed to report these incidents to the appropriate agencies. The facility administration was unaware of the severity of Resident #16's behaviors until informed by the survey team. Resident #17 reported an allegation of verbal abuse and neglect by a certified nursing assistant, which resulted in psychosocial harm. The facility staff did not identify the incident as an allegation of abuse and failed to report it as required. The resident expressed emotional distress and hesitance to use the call light due to the staff member's behavior. The facility's social worker believed the incident rose to the level of abuse and neglect, but the administrator treated it as a grievance rather than an abuse allegation. The facility's abuse policy outlines the procedure for reporting abuse, but it was not followed in this case.

Penalty

Inspection fine: $87,878

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 staff failed to conduct a thorough investigation into allegations of abuse and neglect involving two residents. For Resident #8, who reported being verbally abused by another resident, the facility's investigation was inadequate. The incident reportedly occurred in a common area with other residents present, yet the investigation only included interviews with the involved residents and one other resident, omitting interviews with staff or other potential witnesses. Additionally, another resident had previously expressed concerns about the alleged perpetrator's behavior, which was not considered in the investigation. For Resident #17, who alleged verbal abuse and neglect by a certified nursing assistant (CNA), the facility did not initiate an investigation. The resident reported that the CNA was rude and refused to provide a requested shower, leading to emotional distress. Despite the social worker's belief that the incident constituted abuse and neglect, the facility administrator treated it as a customer service issue and did not report or investigate the allegations. The CNA continued to work without any restrictions following the report. The facility's failure to investigate these allegations is contrary to their abuse policy, which requires all reported events to be investigated by the Director of Nursing and forwarded to the administrator for further action. The administrator's decision to dismiss the allegations as poor customer service resulted in a lack of appropriate response to potential abuse and neglect.

Penalty

Inspection fine: $87,878

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 staff failed to review and revise the care plans for two residents, Resident #8 (R8) and Resident #16 (R16), following multiple incidents of aggressive behavior and inappropriate sexual comments by R16 towards R8. R8, who was cognitively intact, reported feeling threatened and uncomfortable due to R16's behavior, which included threats of physical harm, inappropriate sexual comments, and physical aggression. Despite these ongoing issues, R8's care plan, which initially noted discomfort from other residents' comments, had not been updated since May 2024 to address the specific threats and inappropriate behavior from R16. R16's care plan, last revised in April and May 2024, identified behaviors such as foul language and verbal threats but did not include any updates or interventions following the reported incidents involving R8. Staff interviews revealed that multiple staff members were aware of R16's long-standing behaviors, including making sexual comments and threats, yet no revisions were made to either resident's care plan to address these issues. The facility's internal investigation into R16's behavior towards R8 began in January 2025, but the care plans remained unchanged. The care plan coordinator, RN #4, acknowledged that care plans should be reviewed quarterly and revised as needed, especially following incidents. However, she was unable to explain why the care plans for R8 and R16 were not updated. The facility's policy required the interdisciplinary team to review and update care plans at least every 90 days and after significant changes, but this was not adhered to in the case of R8 and R16. The survey team discussed these deficiencies with the facility's administration, but no additional information was provided.

Penalty

Inspection fine: $87,878

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

Summary

The facility failed to provide necessary behavioral health services to two residents, R8 and R16, as identified during a survey. R8, a trauma survivor with multiple psychiatric conditions, reported feeling threatened by another resident, R16, and expressed concerns about her safety. Despite having a care plan that included psychiatric services and medication management, R8 had not been seen by a mental health professional since September 2024, leading to a gap in her behavioral health care. R8's history of trauma and her current experiences with R16 were not adequately addressed by the facility, contributing to her ongoing distress. R16, who also had a long-standing history of mental health issues, was not receiving regular psychiatric care. His clinical record indicated diagnoses such as schizoaffective disorder and major depressive disorder. After a hospitalization in December 2024 due to threatening behaviors, R16 had not been seen by a psychiatric provider since his readmission to the facility. The facility's lack of consistent psychiatric services for R16, despite his known behavioral issues, further exemplified the deficiency in providing necessary behavioral health care. The facility's interim administrator and Regional Vice President of Operations acknowledged the absence of an on-site psychiatric provider since mid-October 2024, which contributed to the lack of regular psychiatric care for both residents. Although telehealth services were utilized for acute needs, the facility's plan for psychiatric services was not effectively implemented, resulting in inadequate behavioral health support for R8 and R16. This deficiency highlights the facility's failure to meet the behavioral health needs of its residents, as required by regulations.

Penalty

Inspection fine: $87,878

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 staff failed to provide meals at an appetizing temperature for residents on one of three units. During a lunchtime meal observation, the surveyor noted that the hot foods served, specifically a cheeseburger and mashed potatoes, did not reach the appropriate temperatures to be considered appetizing. The cheeseburger was recorded at 90 degrees, and the mashed potatoes at 120 degrees, both below the required temperature to ensure palatability. The regional dietary manager, present during the observation, confirmed that the meal was not appetizing in appearance, taste, or temperature, as evidenced by the unmelted cheese on the burger. Interviews with residents further corroborated the issue, with one resident describing the food as "lousy and lukewarm" and another stating that the food is often cold and menus are not followed. Facility documentation reviewed during the survey indicated that food should be served at proper temperatures, outside the danger zone, which was not adhered to in this instance. The deficiency was discussed in an end-of-day meeting with the facility's administration, but no additional information was provided before the exit conference.

Penalty

Inspection fine: $87,878

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 staff failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training for the director of nursing, as identified during a survey of 10 employee records. The surveyor requested the employee files on January 27, 2025, and upon review on January 28, 2025, it was found that the director of nursing had not completed the required QAPI training for the year 2024. The training was only completed on the morning of January 28, 2025, after the surveyor had requested the training records. This deficiency was communicated to the regional vice president of operations, the administrator, and the director of nursing during a meeting on January 28, 2025.

Penalty

Inspection fine: $87,878

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 staff failed to provide the required annual infection control training for the director of nursing, who also served as the infection preventionist. During a survey, the surveyor requested and reviewed 10 employee files for training compliance. It was discovered that the director of nursing had not completed her annual infection control training for the year 2024, although she was able to provide proof of completion for the year 2023. An interview with the director of nursing confirmed her belief that she had completed the training annually, but no documentation for 2024 was available. A meeting with the regional vice president of operations, the administrator, and the director of nursing was held to discuss the issue, but no additional information was provided before the exit conference.