Mulder Health Care Facility

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 protect cognitively intact residents from misappropriation of their money by a staff member, CNA1. One resident reported waking from sleep to find CNA1 in her room taking money from her wallet. This resident had diagnoses including adult failure to thrive and heart disease and had a Brief Interview for Mental Status (BIMS) score of 15/15, indicating she was cognitively intact. Her electronic medical record, including progress notes from early August through mid-December, contained no documentation of her allegation of misappropriation of property. During the facility’s investigation into this initial allegation, three additional cognitively intact residents reported missing money and identified CNA1 as the suspected individual. One resident with morbid obesity and heart disease stated that $55 to $75 was taken from her wallet within the first few weeks after admission; her progress notes over several months contained no entries related to this allegation. Another resident with congestive heart failure and chronic kidney disease reported that $50 to $65 had been stolen from her in May, and she stated that “that lady” (CNA1) stole her money; again, her progress notes over many months did not reflect this allegation. A fourth resident with a history of stroke reported that money had gone missing “a while ago,” believed CNA1 took it, and later stated the money had been taken almost a year earlier; her progress notes similarly contained no documentation of the misappropriation allegation. The Administrator and DON confirmed to surveyors that the facility’s investigation into the reports from these four residents led them to conclude that CNA1 likely stole the residents’ money. The facility’s Abuse Prevention Program Policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of residents’ belongings or money without consent, and stated that each resident has the right to be free from abuse, neglect, and misappropriation, and that the facility would provide a safe environment and protect residents from abuse. The policy also stated that training on abuse prohibition alone does not relieve the facility of responsibility to assure residents are free from abuse and that the facility would provide ongoing oversight and supervision of staff to ensure policies are implemented as written. Despite these policy provisions, multiple residents reported missing money associated with CNA1, and their records lacked documentation of these allegations in the progress notes.

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 follow its planned menus and ensure meals met residents’ nutritional needs and preferences as written and approved. Surveyors reviewed the facility’s week three menus and observed multiple meals where items listed on the menu were not served. For one dinner, the posted menu included minestrone soup, grilled cheese, French fries, lettuce, tomato, onion, apple slices, ketchup, margarine, and 2% milk and/or coffee, but residents actually received minestrone soup, grilled cheese, canned pears, and a choice of 2% milk, coffee, or juice, with no French fries, lettuce, tomato, onion, or apples provided. For a lunch meal, the menu listed chili with beans, baked potato, sweet potato cornbread, red grapes, sour cream and chives, margarine, and 2% milk, coffee, or tea, but residents received chili with beans, baby baked potatoes, sweet potato cornbread or a dinner roll, red grapes, and beverages, with no sour cream and chives served. For a supper meal, the menu listed corn dogs, creamy coleslaw, banana, margarine, and beverages, but residents received corn dogs, tater tots, coleslaw, sugar cookies, and beverages, with no banana served. Staff interviews confirmed that menus were routinely altered without adherence to the written, dietician-approved menu and without appropriate substitutions being reviewed. A cook reported that the facility did not usually order regular baking potatoes because of their size and instead used baby baked potatoes, and that sour cream and chives were usually not included. The Administrator stated that the facility relied on a whiteboard as the working menu and that it was labeled as subject to change. The Dietary Manager stated that menu items varied based on supply and ordering issues and acknowledged being unaware that a registered dietician needed to approve menu adjustments to ensure residents received appropriate amounts and types of food within the same food groups. Residents in a group interview reported they were not provided with the actual facility menu, only what was written on the dry erase board, and that alternates were not posted. They stated they were unaware that French fries and lettuce, tomato, onion, and ketchup were supposed to be part of a prior dinner meal, expressed that they liked French fries and would have wanted them, and noted that pears were served frequently and that no alternate fruit was offered when they did not like pears. The deficiency also included failure to provide an individual resident with meals consistent with her ordered diet texture, care plan, and preferences. One resident with dementia, chronic and acute kidney disease, cellulitis, and a severely impaired BIMS score was care planned as being at risk for significant weight loss and ordered a regular chopped diet with thin liquids, with all foods to be served in bite-sized pieces and requiring setup/cleanup assistance and indirect supervision during meals. Her tray card indicated a soft and bite-sized regular diet with no recorded dislikes. During a lunch observation, the posted whiteboard menu listed chili with beans, baby baked potato, cornbread/dinner roll, and grapes. The resident was served chili, a whole bread roll, and whole grapes; after refusing chili, she was given chicken noodle soup but did not receive any potatoes. She ate the whole roll and whole grapes quickly and independently without staff interaction. In a subsequent interview, the Dietary Manager, DON, and Administrator agreed that the roll should have been cut into bite-sized pieces, the resident should have received bananas instead of grapes, and potatoes should have been served, and confirmed that the facility was expected to provide a diet meeting the resident’s needs and that dislikes or allergies should be documented on the tray card.

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 failure of dietary staff to prevent contamination of food containers and lids during meal preparation and service for all 78 residents. During a midday observation, a cook was seen taking temperatures of chili with beans, mashed potatoes, and pureed mixed vegetables and, while doing so, repeatedly touched the inside of each food container with her bare hand. In a separate observation, a dietary aide was seen touching the inside of the lids with bare hands while placing the lids on bowls of chili with beans and then placing these bowls on resident trays. When interviewed, the cook acknowledged she was not supposed to touch the inside of food containers with her hand when taking food temperatures, and the dietary aide stated she did not know whether she was supposed to touch the inside of the lids. The dietary manager later confirmed that kitchen staff were not supposed to touch the inside of food containers or lids with bare hands when taking food temperatures or placing lids on bowls of chili. The report states this failure had the potential to increase the risk of foodborne illness for all 78 residents in the facility.

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 consistently and comprehensively manage nutritional services for a resident identified as being at risk for significant weight loss. The resident was admitted with dementia, chronic and acute kidney disease, and cellulitis of the left lower limb, and had a BIMS score indicating severe cognitive impairment. The admission MDS showed no significant weight loss prior to admission. Physician’s orders directed that the resident receive a regular chopped diet with thin liquids, be weighed weekly on shower days, be offered a bedtime snack each evening, and receive ProStat 30 mL twice daily to support wound healing. The care plan, revised shortly after admission, identified the resident as at risk for significant weight loss and directed that all foods be served as a regular diet cut into bite-sized pieces, that intake be monitored, and that the resident receive diet as ordered. The diet/tray card used by staff showed a soft and bite-sized regular diet and no recorded food or fluid dislikes. Review of the weight record showed weights of 118 lbs, 113.8 lbs, 114.0 lbs, and 110.0 lbs over several days, with no recorded weights after the last entry despite orders for weekly weights. The vitals report showed that meal intake was not documented for 10 of 46 meals since admission, contrary to the care plan and the facility’s Monitoring Nutrient Intake Policy, which required nursing to document percentage of each meal consumed and substitutions. The initial nutritional assessment documented that the resident was underweight and at risk for significant weight loss, with a plan to monitor for need of additional high-calorie supplements based on intake, skin, and weight trends, and for the RD to update the plan of care as needed. There was no documentation of facility follow-up related to the resident’s weight loss since admission, no evidence of efforts to ensure accurate meal intake documentation, and no evidence that weights were obtained as ordered. The DON and Administrator confirmed that no weights were documented after the last recorded date and that meal intake had not been consistently documented, despite the facility’s policies requiring monthly weights or more frequent monitoring as ordered, and recording of all obtained weights in the EMR.

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 protective measures following an allegation of abuse involving a certified nursing assistant (CNA) and a resident. According to the facility's Abuse Prevention Program policy, staff members accused of abuse are to be immediately removed from resident care duties and suspended pending the outcome of an investigation. However, after an incident in which a CNA was alleged to have acted aggressively, spoken in a condescending manner, and physically grabbed a resident's wrist despite the resident's objections, the CNA was allowed to continue working both during the remainder of the shift and on subsequent days while the investigation was ongoing. The resident involved was alert, oriented, and had a history of conditions including gastroenteritis, rheumatoid arthritis, osteoarthritis, weakness, and anxiety disorder. The resident reported feeling that the CNA was abusive, describing the CNA as haughty, condescending, and physically forceful, including grabbing her wrist tightly and yelling in her face. Witnesses, including another CNA and an LPN, corroborated the resident's account, noting the CNA's aggressive behavior, refusal to leave when asked, and the resident's visible distress, including trembling and watering eyes. The LPN observed redness on the resident's wrist and reported the incident to the Director of Nursing promptly. Despite these observations and the facility's policy, the CNA continued to work with residents, including on other shifts and in areas where she could have contact with additional residents. The failure to remove the CNA from resident care duties during the investigation represented a lack of immediate protective action as required by the facility's own procedures, potentially affecting the safety and well-being of other residents.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident, who was alert, oriented, and able to communicate her needs, was subjected to abusive behavior by a Certified Nursing Assistant (CNA). The resident reported that the CNA spoke to her in a haughty, condescending, and dictatorial manner, insisted she move her own belongings, and threatened to leave if she did not comply. During care, the CNA grabbed the resident's wrist twice, did not release her grip when asked, and yelled in the resident's face from a close distance. The resident expressed feeling a little afraid during the incident and described the CNA's behavior as escalating. Although no marks were left, the resident stated the grip was tight and confirmed she felt the CNA was abusive. Other staff present corroborated the resident's account. Another CNA described the situation as a "power trip" and confirmed the CNA's condescending tone and refusal to let go of the resident's wrist. A Licensed Practical Nurse (LPN) who entered the room observed the resident visibly trembling and with watery eyes, and noted the CNA was speaking aggressively and inappropriately close to the resident's face. The LPN also observed slight redness near the resident's wrist and reported that the resident calmed after the CNA left. The incident was reported to the Director of Nursing, and statements were gathered for investigation.

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the appropriate authorities within the required timeframe. According to the facility's Abuse Prevention Program policy, allegations involving abuse or serious bodily injury must be reported immediately, but not later than two hours after the allegation is made, and all other allegations must be reported within 24 hours. In this incident, a resident with intact cognitive function reported that a CNA spoke to her in a condescending and aggressive manner, grabbed her wrist tightly despite her requests to let go, and refused to leave the room when asked multiple times. The resident described the interaction as abusive and stated she felt afraid during the incident. Multiple staff members, including another CNA and an LPN, witnessed the event and corroborated the resident's account. The LPN observed the resident visibly upset, with watery eyes and trembling, and noted slight redness on the resident's wrist. The LPN also reported that the CNA continued to work the remainder of the shift after the incident. The LPN promptly reported the incident to the Director of Nursing and began gathering witness statements for an investigation. Despite the prompt internal reporting, the facility did not report the incident to the State Survey Agency within the required 24-hour period. The self-report to the state was made three days after the incident occurred, which is not in compliance with the facility's policy or federal regulations. This delay in external reporting constitutes the deficiency identified by the surveyors.

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 occurred when a resident with right-sided hemiplegia, impaired mobility, hypertensive intracerebral hemorrhage, chronic pain, and osteoarthritis was being transferred to the bathroom using an EZ stand. During the transfer, the resident's right arm was bumped against the door frame by CNA staff. The incident was not reported to the charge nurse or documented in the medical record as required by the facility's Resident Incident/Accident Reporting Protocol, which mandates immediate reporting and documentation of all incidents and accidents, regardless of severity. The resident later reported severe pain in the right arm to a registered nurse during a medication pass, prompting the facility to gather witness statements from the involved CNAs. Both CNAs confirmed the incident, noting that the resident's arm was hit during the transfer and that the resident declined an ice pack. The Director of Nursing confirmed that the incident was not reported to the nurse on duty, the charge nurse, or the oncoming shift, in violation of facility policy.

Penalty

Inspection fine: $186,261

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

Summary

A deficiency occurred when the facility failed to ensure a resident received adequate fluid intake to maintain acceptable hydration. The resident, who had multiple diagnoses including multiple sclerosis, chronic kidney disease, weakness, and dysphagia, was consistently not meeting the recommended daily fluid intake of greater than 1,400 ml. Despite the facility collecting intake data, staff did not total or assess daily fluid intake, and there was no ongoing assessment for signs and symptoms of dehydration. The resident experienced significant weight loss and was hospitalized twice within a short period for conditions related to dehydration and aspiration pneumonia, both times requiring intravenous fluids. The facility's own policies required assessment and care planning for dehydration risk, including monitoring fluid intake, weighing residents weekly, and updating care plans as needed. However, the facility failed to weigh the resident upon readmission after hospitalization, did not weigh the resident weekly as ordered, and did not update or revise care plan interventions to address the ongoing risk of dehydration and weight loss. There was also a failure to timely communicate significant weight changes to the provider. Interviews with staff revealed confusion about who was responsible for totaling daily fluid intakes, and it was confirmed that no one was consistently performing this task. Documentation showed that the resident's fluid intake was regularly below the recommended amount, and there was no evidence of dehydration assessments being performed. The resident's care plan included approaches to encourage fluid intake and monitor for signs of fluid imbalance, but these interventions were not effectively implemented or updated in response to the resident's declining condition. The lack of daily monitoring and assessment contributed to the resident's repeated hospitalizations and significant weight loss.

Penalty

Inspection fine: $186,261

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

Summary

A deficiency occurred when a resident who required extensive assistance for toileting was not provided timely care after requesting to use the bathroom. The resident, who had a history of orthopedic aftercare following surgical amputation, was non-weight bearing on the right leg, and required the use of a Hoyer lift with assistance from two staff members, asked a CNA for help to use the bathroom. The CNA informed the resident that she was on a two-hour toileting schedule and would need to wait, despite the resident not being on such a schedule according to her care plan. The resident waited approximately 1 hour and 20 minutes before being assisted to the bathroom. During this period, staff communication and follow-through were lacking. The CNA who received the request prioritized other residents and did not seek immediate assistance from other staff, even though the Director of Nursing later clarified that staff are expected to respond to such requests as soon as possible. Another CNA, who was supposed to assist, was on break and did not check in with the resident upon returning. The resident was observed participating in an activity during this time, and no staff approached her to ask if she needed to use the bathroom, despite her earlier request. The facility's policy emphasizes person-centered care and the importance of honoring resident preferences and needs, including timely assistance with toileting. The resident expressed discomfort and concern about potentially having an accident due to the delay. Interviews with staff revealed confusion about the resident's toileting schedule and a lack of clear communication regarding her care plan, which contributed to the delay in providing necessary assistance for activities of daily living.

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 immediately consult with a resident's physician when the resident experienced a significant change in condition. The resident, who had a history of coronary artery disease, diabetes mellitus type 2, chronic heart failure, and other conditions, was admitted to the facility after hospitalization for acute hyperkalemia. On the day of admission, the resident's oxygen saturation fell to 71%, and their pulse dropped below 50, which required immediate notification to the physician according to the facility's policy and the INTERACT change of condition reporting tool. Despite the critical changes in the resident's condition, there was no documentation indicating that the physician was notified. The facility's policy required immediate notification of the physician in such cases, but the staff failed to follow this protocol. The resident's condition was initially addressed by administering oxygen, which temporarily improved their oxygen saturation levels. However, the lack of communication with the physician meant that the resident's overall care and potential treatment adjustments were not adequately managed. Interviews with various staff members, including the MDS nurse, LPNs, and the Regional Clinical Director, revealed inconsistencies in the communication process. The Director of Nursing claimed to have notified the physician via email, but this was not documented in the resident's medical record, and the physician did not respond until two days later. The facility's failure to document and properly communicate the resident's change of condition to the physician resulted in a deficiency in the standard of care provided to the resident.

Penalty

Inspection fine: $14,433

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

Summary

The facility failed to provide adequate supervision and assistance during meals, leading to a resident suffering second-degree burns from hot soup. The incident occurred when the resident, who required supervision during meals, was left unsupervised in the dining room. The soup temperature was recorded at 177 degrees Fahrenheit, significantly higher than the facility's policy of serving hot liquids at a maximum of 135 degrees Fahrenheit. This lack of supervision and failure to adhere to temperature guidelines resulted in immediate jeopardy. The resident involved had a history of cerebral infarction, aphasia, weakness, dysphagia, diabetes mellitus type 2, and hemiplegia affecting the right side. The resident's care plan indicated a need for supervision and assistance during meals, including the use of a clothing protector and lidded cups to prevent spills. Despite these documented needs, the resident was not provided with the necessary supervision or protective measures during the meal when the incident occurred. Interviews with staff revealed inconsistencies in the understanding and implementation of supervision requirements. Staff members were unclear about who was responsible for supervising residents in the dining room, and there was a lack of adherence to the facility's policy on serving temperatures. The dietary manager and staff were not adequately educated on the correct serving temperatures, and there was no consistent monitoring of food temperatures at the point of service, contributing to the incident.

Removal Plan

• All residents have been assessed and care plans have been updated to the level of supervision during meals.
• Temperatures have been taken in the kitchen every 15 minutes on the serving steam table tray line due to a need for a part replacement.
• Test trays are done at the point of service for all residents in the dining room and one on each hall tray carts to be checked prior to beginning of service to verify food temp is 135-150 degrees.
• Residents that have a risk of hot liquid injury have cups with lids that snap on and are more difficult to remove and also have staff supervision per their care plan approach as agreed upon by IDT and therapy.
• Dietary staff have had direct supervision at meals and assist taking temperatures of foods prior to service.
• Dietary staff is being educated on the correct temperatures of service of food to be between 135-150 degrees at the point of service to the residents.
• Policies have been changed to reflect this change.
• Nursing staff is being educated on the definition of supervision that is expected in the dining room with the residents that require supervision. This is being audited at every meal to monitor compliance with every meal that residents at risk are having the correct level of supervision that is required to maintain safety with hot liquids/foods.
• Maintenance checked the steam table and parts were ordered and expedited. Replaced prior to the start of service.
• Facility will continue with weekly checks of the steam table for proper function. Due to faulty parts the temps on the food in the steam table were checked every 15 minutes to maintain safe temps.
• QAPI meeting held related to PIP started in relation to the changes that need to be completed.
• Staff education started with temperature changes in the dietary dept.
• Education to nursing staff related to the definition of supervision: 1:1, direct, and direct.
• Care plans related to the level of supervision that is required for residents at risk with hot liquids updated and educated to nursing staff.
• All education is ongoing with this being completed prior to the start of the next working shift.
• Both tray audits and the supervision audits are being completed at all 3 meals 7 days per week to maintain the safe environment for the residents at meal time.
• Resident council meeting held for the update of the residents to the recent changes and the updates to dining service.
• At this time all staff that have worked in the facility have been educated to the changes in policy and the level of supervision that is to be provided in the dining room at all meals.

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 a thorough investigation of an incident involving potential abuse between two residents. Resident 6, who has severe cognitive impairment and a history of dementia with mood disturbances, was involved in an altercation where they hit Resident 5 on the chest. The incident was witnessed by staff, and immediate actions were taken to separate the residents and provide supervision for Resident 6. However, the facility did not conduct interviews with other residents to determine if there were additional instances of abuse, as required by their Abuse Prevention Program Policy. The facility's policy mandates that all involved persons, including potential witnesses, should be interviewed during an investigation of resident-to-resident altercations. Despite this, the Nursing Home Administrator and Assistant Director of Nursing decided not to interview other residents, considering the incident isolated to Residents 5 and 6. This decision was made after consultation with the facility's regional director, which led to a deficiency in the investigation process as it did not fully comply with the facility's established procedures for handling potential abuse cases.