Citations in Arkansas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Arkansas.
Statistics for Arkansas (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Arkansas
- Provided comprehensive in-service training for all staff on abuse-reporting procedures to the Administrator, DON, and Office of Long-Term Care (L - F0610 - AR)
- Appointed the DON as Abuse and Neglect Coordinator to monitor, investigate, and report all allegations (L - F0610 - AR)
- Implemented a monitoring tool for ongoing documentation and reporting of abuse allegations (L - F0610 - AR)
Failure to Investigate and Report Alleged Abuse and Protect Residents
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of abuse involving a resident who required assistance with transfers and had intact cognition. In both cases, there was no evidence that a resident statement, accused staff statement, assessment of the resident, bedside staff interviews, or a police report were completed. The facility also did not document a body audit or a nurse assessment in the medical record following the allegations. The incidents were not reported to the appropriate authorities or the State Agency/Office of Long Term Care (OLTC) as required by facility policy and state regulations. When the first allegation was made that a staff member was rough with the resident, the staff member was simply reassigned to another hallway and allowed to continue working with other residents. The incident was reported to the Assistant Director of Nursing (ADON), but no formal investigation or documentation was completed at that time. The ADON did not conduct a body audit or assessment and did not know if the allegation was investigated further. The Certified Nursing Assistant (CNA) Supervisor also failed to report a separate incident involving another staff member and did not complete any write-up or formal report, only moving the accused staff member to a different hall. The Administrator later provided a minimal two-page investigation that lacked essential elements such as resident and staff interviews, body audits, and proper documentation. The Administrator admitted that the incident was not reported to mandatory authorities and that the documentation provided was the entirety of the investigation. The facility did not have an abuse coordinator at the time, and the highest-ranking person present was responsible for investigations. The Director of Nursing (DON) confirmed that the accused staff should have been separated from residents and that the incident should have been reported and investigated immediately.
Removal Plan
- Provide in-service training for all staff on reporting abuse and neglect to the Administrator, the DON, and Office of Long-Term Care.
- Report all incidents properly.
- Ensure resident safety.
- Interview residents regarding abuse and conduct body audits for residents unable to verbalize abuse.
- Appoint the DON to monitor, investigate, and report allegations of abuse.
- Implement a monitoring tool for documenting and reporting allegations of abuse.
- Appoint the DON as the Abuse and Neglect Coordinator.
- Ensure all staff complete training on reporting of abuse before returning to work.
Administrative Failures Result in Multiple Immediate Jeopardy Deficiencies
Penalty
Summary
The facility's administration failed to implement and enforce policies necessary for the effective management and operation of the facility, resulting in multiple deficiencies. There was no full-time RN working eight consecutive hours per day, and the facility lacked a Director of Nursing (DON) for an extended period. The responsibilities of the DON, including care planning, fall assessments, and MDS completion, were not being fulfilled, as confirmed by staff interviews. The Assistant Director of Nursing (ADON) was unable to assume these duties due to other responsibilities, and the Med Records Nurse had been working as a bedside nurse for six months, leaving medical records unattended. Employee files for former DONs showed no signed job descriptions, and there was no evidence of staff orientation or training programs as required by facility policy. The facility also failed to ensure that LPNs managing peripherally inserted central catheters (PICC) were properly certified or trained. The Administrator admitted to not tracking which LPNs were IV certified and confirmed there was no IV training provided in the facility. Bed rails were installed on most beds without proper assessments, consent, or documentation. The Housekeeping/Maintenance Supervisor, responsible for installing and maintaining bed rails, had not read manufacturer guidelines and did not keep logs or forms related to bed rail safety. Staff interviews revealed a lack of knowledge about bed rail assessments and documentation, and the process for determining bed rail use was informal and based on resident preference rather than clinical assessment. Residents who experienced falls did not receive fall assessments or updated care plans, and interventions to prevent further falls were not identified or implemented. A newly admitted resident was not assessed for mobility function, and necessary interventions and equipment to maintain independence were not provided. The facility was unable to provide a policy for Activities of Daily Living/Mobility when requested. These failures in administration and oversight led to Immediate Jeopardy findings for multiple federal regulations, with the potential to cause serious harm to all residents in the facility.
Removal Plan
- In-service/meeting given via phone by regional director to governing body members (Manager, medical director) and in person to administrator.
- Administrator in-serviced management staff (DON, COM, SS, HR, MOS) regarding the following: Responsibility of the Governing Body (facility oversight, operations and policy/procedure), Survey findings and Plan of Removal to correct: Fall Clinical Protocol, Registered Nurse requirement, Competent staff, Mobility, Bed rail usage and Supervision to prevent accidents, Plan moving forward to improve findings.
- In-service provided to Administrator by Regional Director.
- In-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required.
- Consent forms for residents with bed rails obtained.
- Bed rail assessments for residents with bed rails completed.
- Assessments and consents obtained for six residents identified as having bed rails with no assessments/consents.
- Monitoring sheets completed by Administrator and Director of Nursing (DON), by Housekeeping Supervisor and by Administrator and DON, for bed rail assessment and consents.
- File containing manufacturer guidelines for bed rails provided.
- Housekeeping Supervisor in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed.
- Staff in-serviced on bed rails and enhanced barrier precautions.
- Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.
Failure to Maintain Full-Time DON and RN Coverage Resulting in Lapses in Resident Care
Penalty
Summary
The facility failed to ensure the employment of a full-time Director of Nursing (DON) and did not provide registered nurse (RN) coverage for at least 8 consecutive hours per day, as required. Review of employee files and timecard reports revealed that the facility was without 8 consecutive hours of RN coverage on 53 out of 65 days, and there were periods when the DON position was vacant or filled by staff who did not fulfill the required duties. The lack of RN oversight and management led to significant lapses in care planning, assessment, and intervention for multiple residents. Several residents were directly affected by these deficiencies. One resident with severe cognitive impairment and a history of falls suffered two major falls with injuries, including fractures to both arms, without appropriate updates or escalation of interventions in their care plan. Another resident with a peripherally inserted central catheter (PICC) line did not receive RN assessment or care of the line for 18 days, and intravenous medications were administered by LPNs, some of whom were not verified as IV certified. Additional residents were admitted without timely completion of Minimum Data Set (MDS) assessments or comprehensive care plans, resulting in a lack of documented interventions for their care needs for extended periods. Interviews with staff confirmed that in the absence of an RN or DON, LPNs and CNAs were left to make assessments and update care plans, often without proper oversight or knowledge of the requirements. The Assistant Director of Nursing (ADON) did not assume DON responsibilities and was unaware that MDS assessments and care plans had not been completed. The facility's own documentation and staff statements indicated a lack of clear processes for ensuring RN coverage, verifying LPN IV certification, and maintaining compliance with federal and state regulations regarding nursing services.
Removal Plan
- Hire Interim Registered Nurse/Director of Nursing. Provide Registered Nurse weekend coverage and replace Director of Nurses in event of a call in. Update schedule to reflect Registered Nurse Coverage. Ensure Registered nurse coverage is 8 consecutive hours daily.
- In-service Administrator by Regional Director on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week.
- Remove Resident #33 peripherally inserted central catheter (PICC) Line. Review and update care plan as needed.
- In-service bedside LPN 1:1 by administrator about scope of practice regarding PICC line and site care.
- In-service all LPNs/RNs by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care.
- In-service all staff by administrator and/or director of nursing in person or by phone on ESP and infection control.
Failure to Ensure Competent Nursing Staff for IV Therapy and PICC Line Management
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies to care for every resident in a manner that maximized their well-being. Specifically, the facility did not ensure that LPNs with IV certification were the only staff accessing and managing a resident's PICC line, including administering IV antibiotics, performing IV flushes, and assessing the line's condition. Documentation revealed that multiple LPNs, some without documented IV certification, administered IV medications and performed assessments that were outside their scope of practice according to state regulations. The facility's own policies required consultation of state laws regarding scope of practice, but there was no evidence that the facility verified or tracked IV certification for LPNs, nor did it provide IV training to its staff. A review of the facility's staffing assessment and policies showed a lack of clear guidelines for RN coverage and no self-assessed staffing standards. The facility's job descriptions and interviews with staff indicated that LPNs were expected to perform assessments and interventions that should have been conducted by an RN, particularly for residents with complex needs such as those with a PICC line. The Arkansas Board of Nursing regulations specify that LPNs must work under the direction of an RN for tasks requiring substantial specialized judgment and skill, such as IV therapy and PICC line management. However, the facility did not ensure RN oversight or presence for these tasks, and staff interviews confirmed that LPNs were performing assessments and interventions independently. The deficiency was identified after a review of records for several residents, including one who was admitted with a PICC line for IV antibiotics and wound care. There were multiple days when no RN assessment or care of the line was documented, and IV antibiotics were administered by LPNs without verification of their IV certification. The facility's failure to ensure appropriate staffing, competency verification, and adherence to scope of practice requirements resulted in non-compliance with federal and state regulations, creating a situation that was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents.
Removal Plan
- Hire Interim Registered Nurse/Director of Nursing. Provide Registered Nurse weekend coverage and replace Director of Nurses in event of a call in. Update schedule to reflect Registered Nurse Coverage. Ensure Registered nurse coverage is 8 consecutive hours daily.
- In-service Administrator by Regional Director on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week.
- Remove Resident #33 peripherally inserted central catheter (PICC) Line. Review and update care plan as needed.
- In-service bedside LPN 1:1 by administrator about scope of practice regarding PICC line and site care.
- In-service all LPNs/RNs by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care.
- Provide in-services by the Administrator and/or Director of nursing to licensed nursing staff regarding: Care plans-Baseline, comprehensive, and closet care plans completed timely; MDS Timeliness; RN Assessments and interventions; Fall Documentation; Enhanced Barrier Precautions (EBP)/INFECTION CONTROL.
- Regional Director to provide in-service via phone to Administrator regarding LPN Administration of IV medication. Administrator to in-service DON and Human Resource Coordinator on tracking IV certifications of LPNs in event of another PICC line admission.
Failure to Assess, Obtain Consent, and Ensure Safe Installation of Bed Rails
Penalty
Summary
The facility failed to ensure that proper assessments, informed consents, and compatibility checks were completed prior to the installation and use of bed rails for two residents. Observations revealed that bed rails were in use on both sides of the beds for these residents, but there was no documentation of bed rail assessments, informed consent from the residents or their representatives, or evidence that the bed rails were compatible with the beds according to manufacturer guidelines. Staff interviews confirmed a lack of understanding and inconsistent practices regarding bed rail assessments, installation, and documentation, with some staff unaware of the requirements or the process for determining bed rail use. For one resident with a history of falls, dementia, and chronic ischemic heart disease, bed rails were observed in the up position on multiple occasions. However, neither the care plan nor the closet care plan indicated the use of bed rails, and staff were unsure if the resident was supposed to have them. The spouse of this resident reported never being informed about the bed rails or asked for consent. Maintenance staff responsible for installing bed rails admitted to not measuring beds for compatibility, not reading manufacturer guidelines, and not keeping records of maintenance or safety checks, despite acknowledging that loose bed rails could be unsafe. For another resident with multiple diagnoses including dementia and insomnia, bed rails were also observed in use, but the care plan and MDS did not reflect this. Staff interviews indicated that bed rails were already installed upon admission and that housekeeping, not nursing, installed them. The resident's family confirmed they were not informed about the bed rails, the risks involved, or asked for consent. There was also evidence of gaps between the mattress and bed rails, raising concerns about entrapment, and no documentation was found to support the safe and appropriate use of bed rails for either resident.
Removal Plan
- Provide in-service to Administrator by Regional Director regarding bed rails and assessing, getting signed consent and order prior to use.
- Administrator to provide in-service to nursing staff in person and via phone regarding policy and procedure of bed rails, assessing, consent to use and physician order requirement.
- Review records to be completed by nurse manager to identify other residents with bed rails.
- Identified residents will be assessed by nurse and consent obtained.
- Administrator and DON will monitor care areas weekly to ensure bed rails are assessed and consent obtained and in the record.
- Care plan and MDS will be updated by LPN Nurse consultant.
- IDT team will work with environmental services supervisor to ensure bed frame and bed rails are compatible for the provided bed per manufacturers guidelines and recommendations.
- Provide in-service by administrator to environmental service supervisor regarding bed rails, bed maintenance and ensuring bedrails and bedframe are compatible to prevent entrapment zones.
Failure to Update Fall Interventions and Care Plans After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls received proper assessments and interventions to prevent further accidents. The resident, who had severe cognitive impairment and required substantial assistance for mobility, experienced multiple falls within a short period. Despite documented incidents, including unwitnessed falls resulting in significant injuries such as fractures to both arms, the facility did not update the resident's care plan or implement new interventions after each event. The care plan remained unchanged even after the resident returned from the hospital with a cast, which the resident repeatedly removed, leading to additional falls and injuries. Staff interviews revealed that after each fall, assessments and incident reports were completed, but immediate interventions were not consistently documented or added to the care plan. The process for updating care plans and communicating new interventions to staff was not followed, particularly in the absence of a Director of Nursing (DON). The Assistant Director of Nursing (ADON) acknowledged that fall assessments and care plan updates were not being completed due to the lack of a DON, and that there was confusion among staff regarding their responsibilities in monitoring and preventing falls. The facility's policy required staff to identify and implement pertinent interventions after each fall, but this was not adhered to. The lack of timely and appropriate interventions, failure to update care plans, and insufficient staff training and oversight contributed to repeated falls and serious injuries for the resident. These actions and omissions resulted in non-compliance with federal requirements for quality of care and accident prevention.
Removal Plan
- Fall assessments and interventions reviewed and updated as needed for Residents #15 and #25 by facility nurse.
- In-service by administrator, regional director and nurse consultant for Nursing staff (RN, LPN, CNA) present and via phone for those not in facility regarding the following: Assessing, monitoring and intervening in falls to prevent injury and/or reduce falls; Proper interventions for falls; Care plans related to falls; Notification of PCP, DON, family and administrator.
- DON/Administrator in-serviced by regional director in regards to monitoring of incident and accident (I&A), fall records and daily nurse documentation to identify and address any concerns immediately.
Failure to Secure Exit Doors Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that exit doors were secured and functioning properly, resulting in a resident with severe cognitive impairment and a known history of elopement being able to exit the building without staff knowledge. The resident, who had diagnoses including alcohol-induced persisting dementia, major depressive disorder, anxiety disorder, and altered mental status, was identified as an elopement risk and had a care plan reflecting this risk. Despite this, the resident was able to leave the facility through the front entrance door after a nurse had entered, and staff only became aware of the elopement when the resident was not found in their usual locations during rounds. Staff interviews and record reviews revealed that the front door's locking mechanism was unreliable, particularly during high winds, which could prevent the door from latching and cause alarms to malfunction. Maintenance staff and nursing personnel acknowledged that the issue with the door not latching due to wind was a known problem, and a note had been posted at the door to remind staff to ensure it was closed during high winds. Additionally, staff reported that the alarms at the front and side doors were not working at the time of the incident, and the door could be opened after a short delay even when it was supposed to be locked. The resident was eventually found by law enforcement in a field behind the facility and returned safely. The incident was documented, and staff interviews confirmed that the resident was more confused when off the secure unit. The facility's failure to maintain secure exit doors and ensure proper functioning of door alarms directly contributed to the resident's ability to elope, despite the resident's documented risk and history of similar behaviors.
Removal Plan
- Place resident in secured unit for safety and monitor by staff and nurse manager/designee.
- Re-inservice all staff on abuse prevention program and facility elopement policy.
- Assess all residents for elopement risk using elopement and wandering assessment, review care plans, and update care plans for residents at risk for elopement.
- Update elopement binder with resident pictures and demographics and inservice staff on use of elopement binder.
- Complete body audit, incident, accident and elopement form when resident is found and returned to building, including documentation of last seen, when resident was found, and notification of family and doctor.
- Recheck all doors by maintenance for working locking mechanisms.
- Contact door company to check all doors for proper working condition.
Failure to Prevent Elopement Due to Inadequate Supervision and Unsecured Exit Codes
Penalty
Summary
The facility failed to adequately monitor and supervise a severely cognitively impaired resident, resulting in the resident exiting the facility without staff knowledge. The resident, who had a history of traumatic brain injury and a BIMS score indicating severe cognitive impairment, was able to access and use an exit door code that had been provided to certain residents by staff. This allowed the resident to leave the facility unsupervised and travel approximately 250 feet away, where they were found by a community member. At the time of the incident, the resident was observed in the lobby near the front door and subsequently exited the building using the code. Staff were unaware of the resident's departure until notified by an individual who saw the resident outside her home. The resident was outside for approximately 30 minutes in hot weather conditions before being returned to the facility by staff. Interviews with staff indicated that residents not considered at risk for elopement had access to the exit code, and the resident in question was not previously identified as having exit-seeking behaviors. The facility's elopement policy required identification and monitoring of residents at risk for unsafe wandering, but the failure to secure exit codes and supervise the resident led to the elopement event. Documentation and interviews confirmed that the resident was not injured during the incident, but the lack of adequate supervision and unsecured exit codes constituted non-compliance with requirements to prevent accidents and ensure resident safety.
Removal Plan
- Resident #46 was placed on the secured unit following their return to the facility.
- Elopement assessments were completed for all residents including Resident #46. The care plan for each resident identified at high risk of elopement was reviewed and updated as necessary.
- The administrator/designee initiated an in-service for staff on elopement and/or wandering. All staff have/will be in-serviced prior to working their next shift. The in-service was completed.
- Exit door codes were changed, and continue to be changed monthly or as needed.
- Staff was ordered to monitor behaviors and triggers for Resident #46.
- Window stoppers were placed on the windows of the secured unit to prevent residents from opening the windows and removing screens to leave the facility.
Failure to Assess and Support Resident Mobility and Independence
Penalty
Summary
The facility failed to assess and address the mobility needs of a resident with multiple complex medical diagnoses, including respiratory failure, diabetes mellitus, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and Raynaud's syndrome. Upon admission, the resident was documented as requiring assistance for most activities of daily living (ADLs) and was using a wheelchair for mobility. However, the initial evaluation was not a comprehensive assessment, and a required admission MDS was not completed by the deadline. The resident did not have a comprehensive, individualized care plan in place until well after admission, and the only care plan available was a generic, undated document with limited information. Observations and interviews revealed that the resident became totally dependent on staff for mobility and ADLs, resulting in a significant decline in functional status and psychosocial well-being. The resident reported feeling imprisoned, totally dependent, and expressed distress over the loss of independence. The resident was unable to maneuver the manual wheelchair due to multiple finger amputations and blackened fingertips, and staff did not provide or assess for appropriate adaptive equipment to promote independence. The resident's own mobility aids from home were not supplemented or replaced by the facility, and staff did not inquire about or provide interventions to support the resident's independence until prompted by surveyors. Staff interviews confirmed that care planning responsibilities were neglected due to the absence of a Director of Nursing, and no one had assumed those duties. The resident's psychosocial harm was compounded by missed opportunities to participate in activities due to lack of assistance and appropriate equipment. The facility also failed to communicate with the resident and their representative regarding available tools and interventions to improve mobility and independence, only reaching out after surveyor involvement. The lack of assessment, individualized care planning, and provision of necessary equipment led to a preventable decline in the resident's mobility and psychosocial health.
Removal Plan
- Provide in-service to Administrator by Nurse Consultant regarding preventing decline in residents' level of activities of daily living (ADL) functions, including providing necessary equipment appropriate for resident and facility.
- Administrator to provide in-service to DON regarding preventing decline in resident ADL functions, including providing necessary equipment and assessing for appropriate interventions to prevent declines.
- Administrator and Nurse Consultant to in-service nursing staff to identify and respond appropriately to a resident's decline in ADL functions, including assessing, monitoring and providing interventions. Nurses will be responsible for assessing and providing appropriate interventions.
- Contact Resident #184 family to bring specialized equipment (special belt for foot movement and trapeze bar) from home that is being requested by resident to facility so it can be used to assist with his independent transfer and repositioning.
- Administrator and DON to monitor care areas routinely to ensure equipment is in place.
- Notify Primary Care Physician of Resident #184 of mental health concerns and request further direction/orders. Contact family to bring personal items from home, notify Physician for any new orders and contact pharmacy for medication consult.
- Complete care plan and MDS for Resident #184.
Latest Citations in Arkansas
Surveyors found that the ice machine was not maintained in a clean and sanitary condition, with visible dirt and discoloration present on internal surfaces despite regular cleaning schedules. Staff confirmed the presence of dirt and described the cleaning procedures, but contamination was still observed during the inspection.
Staff failed to follow infection control practices, including not performing hand hygiene during incontinent care for a resident, not cleaning a glucometer after use by an LPN, and improper wound care technique by a wound care nurse who used contaminated gloves and uncleaned scissors while handling dressings.
Dietary staff did not consistently wash their hands between handling dirty and clean items during meal service. Staff were observed contaminating their hands with items like shakes and condiments, then immediately handling clean glasses and plates without hand hygiene, contrary to facility policy.
A resident with a history of urinary tract infections and chronic kidney disease had an indwelling urinary catheter bag placed on a trash can containing trash, with the bag touching the floor and no barrier underneath. Multiple staff, including LPNs and CNAs, acknowledged this was improper practice and contrary to facility policy, which requires catheter bags to be kept off the floor to prevent infection.
A resident with multiple respiratory diagnoses was given oxygen therapy without a current physician order, as required by facility policy. Staff interviews and record reviews confirmed that the oxygen order had been discontinued and not renewed in the EHR, and there was no documentation of ongoing assessment or specific care plan instructions for oxygen administration.
Staff did not follow EBP and hand hygiene protocols while providing high-contact care to a resident with a wound requiring isolation precautions. Two CNAs failed to wear gowns and did not perform hand hygiene after removing gloves, despite being aware of the requirements and having received training. Facility policies specify the use of gowns and gloves for high-contact care and mandate hand hygiene after glove removal.
The facility did not immediately report two separate allegations of staff being rough with a resident to the appropriate authorities, as required. In both cases, staff reassigned the CNAs involved but did not complete required documentation, body audits, or timely state reporting. Despite staff training on abuse reporting, the incidents were not handled according to policy, resulting in a deficiency cited at the Immediate Jeopardy level.
The facility failed to properly investigate two allegations of abuse involving a resident with intact cognition and significant care needs. In both cases, there was no documentation of resident or staff interviews, body audits, or nurse assessments, and the incidents were not reported to authorities as required. Accused staff were allowed to continue working with other residents, and the facility lacked an abuse coordinator at the time.
Surveyors found that a narcotic box containing multidose anti-anxiety medication was not permanently affixed inside an unlocked refrigerator, and expired anti-angina medication was left in a tackle-style box above the narcotic refrigerator. Staff confirmed these practices had been ongoing, and facility policy did not address the need for the narcotic box to be permanently secured.
Dietary staff did not consistently wash hands or change gloves between handling food, touching potentially contaminated surfaces, and serving residents. Staff were observed serving meals, touching residents and surfaces, and returning to food preparation without proper hand hygiene, despite facility policy and training requiring these practices to prevent cross-contamination.
Ice Machine Found Unclean During Survey
Penalty
Summary
Surveyors observed that the facility failed to maintain the ice machine in a clean and sanitary condition, as required for food service equipment. During an inspection, the Dietary Manager was asked to wipe various internal surfaces of the ice machine with white paper towels, which resulted in pink and brown discoloration transferring to the towels, indicating the presence of dirt and possible contamination. The Dietary Manager confirmed the substance was dirt and stated that the ice machine was sanitized monthly and thoroughly cleaned every three months by the Maintenance Director. However, the Maintenance Assistant reported that the machine had been cleaned the previous week and should not have shown any discoloration during the observation. Despite scheduled cleaning procedures, visible dirt and discoloration were present inside the ice machine at the time of the survey.
Infection Control Lapses in Hand Hygiene, Glucometer Cleaning, and Wound Care
Penalty
Summary
Staff failed to perform proper hand hygiene during incontinent care for a resident who was dependent on staff for toileting hygiene. During observation, a CNA did not perform hand hygiene before, during, or after providing care, nor before exiting the resident's room. The CNA later confirmed this lapse, and the Director of Nursing reported that the facility lacked both a handwashing policy and an incontinent care policy. Additionally, a LPN did not clean or disinfect a glucometer after performing a capillary blood glucose check on a resident, placing the used device back into the medication cart without cleaning. The LPN acknowledged the potential for contamination. In a separate incident, a wound care nurse used the same gauze to clean both around and inside a surgical incision, handled clean dressings with contaminated gloves, and used uncleaned scissors from his pocket during wound care. The nurse confirmed these lapses and the DON stated there was no wound care policy in place.
Failure to Ensure Hand Hygiene During Food Service
Penalty
Summary
Dietary staff failed to perform proper hand hygiene between dirty and clean tasks during meal service. Multiple dietary aides were observed handling items such as cartons of shakes and condiments with their bare hands, contaminating their hands, and then immediately handling clean glasses and placing them on resident trays without washing their hands. In several instances, staff picked up glasses by the rims and placed them on trays to be served for lunch, again without performing hand hygiene. One aide was observed pulling up his pants after washing his hands and then handling clean glasses without re-washing his hands. Another aide, after sorting tray cards, handled clean plates with unwashed hands and long, polished nails, touching the insides of the plates. The facility's hand washing policy requires employees to wash their hands before the beginning of their shift and any other time deemed necessary. However, staff did not adhere to this policy during the observed meal service. When questioned, one dietary aide acknowledged that she should have washed her hands after touching dirty objects and before handling clean dishes. No information about residents' medical history or condition at the time of the deficiency was provided in the report.
Improper Placement of Indwelling Catheter Bag Resulting in Infection Control Deficiency
Penalty
Summary
The facility failed to ensure proper handling and placement of an indwelling urinary catheter for a resident with a history of chronic kidney disease, urinary retention, and recent urinary tract infections. The resident had a urinary catheter inserted as ordered, and during observation, the catheter bag was found hanging on a trash can containing trash and was touching the floor without any barrier to prevent contamination. This placement was in direct violation of the facility's catheter care policy, which requires that catheter tubing and drainage bags be kept off the floor to prevent catheter-associated urinary tract infections. Interviews with multiple staff members, including LPNs and CNAs, confirmed that they were aware catheter bags should not be hung on dirty surfaces or allowed to touch the floor, as this could lead to infection. The Director of Nursing also acknowledged that proper placement of the catheter bag is necessary to reduce infection risk. The resident involved was cognitively intact, independent with toileting, and had a recent history of urinary tract infections, further emphasizing the importance of proper infection control practices.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A resident with a history of asthma, acute and chronic respiratory failure, sleep apnea, and COPD was observed receiving oxygen therapy via nasal cannula at 4 liters per minute from an oxygen concentrator. The resident reported using oxygen continuously and also using a BiPap machine. Review of the resident's records revealed that the physician's order for oxygen therapy had been discontinued several months prior, and there was no current order in place for oxygen administration. Additionally, the Medication Administration Record did not reflect ongoing oxygen therapy, nor was there documentation of ongoing assessment of the resident's respiratory status or response to the therapy. The resident's care plan referenced altered respiratory status and directed staff to use oxygen as ordered, but it lacked specific instructions regarding the type of delivery system, flow rates, timing, or monitoring requirements. Interviews with nursing staff and the Director of Nursing confirmed that it was the responsibility of the nurse to ensure physician orders were entered into the electronic health record (EHR) and that this had not been done for the resident's oxygen therapy. Facility policy required verification of a physician's order prior to administering oxygen, as well as documentation of the rate, route, and rationale, but these steps were not followed in this case.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
Staff failed to follow infection prevention and control protocols for a resident on enhanced barrier precautions (EBP) due to a wound on the left knee. During an early morning observation, two CNAs provided high-contact care, including transferring and changing the resident, without wearing gowns as required by the facility's EBP policy. Additionally, both CNAs did not perform hand hygiene after removing their gloves and before exiting the room, despite the facility's hand hygiene policy mandating this practice. Interviews with the involved CNAs confirmed their awareness that the resident was on EBP and that gowns and gloves were required for such care activities. Both CNAs acknowledged they did not adhere to the hand hygiene protocol after glove removal. Facility policies reviewed indicated that gowns and gloves are necessary for high-contact care under EBP, and hand hygiene is required immediately after glove removal. The Director of Nursing and Lead CNA confirmed that staff receive training on these protocols and are required to demonstrate competency.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that allegations of abuse involving a resident were reported immediately to the appropriate authorities, including the state agency, as required by regulation. Two separate incidents involving a resident and two different CNAs were not reported within the mandated timeframe. In one incident, a resident with intact cognition and multiple medical diagnoses, including Parkinson's disease and dementia, reported that a CNA had been rough with them. The incident was relayed to a registered nurse, who reassigned the CNA to another hallway but did not complete a body audit or resident interview, nor was the incident reported to the state agency until fourteen days later. In a separate incident, another CNA was also alleged to have been rough with the same resident. The CNA supervisor reassigned the CNA to another hall but did not document the incident or report it to supervisory staff or authorities. The administrator's investigation into this incident consisted of a brief two-page report, which included a statement from the CNA supervisor and a warning record for the CNA, but no body audit or nurse assessment was completed for the resident. The administrator confirmed that this allegation was not reported to the mandatory authorities or the state agency. Despite the facility's abuse and neglect policy and documented in-service training for staff, including the administrator and ADON, on the identification and reporting of abuse, the required procedures were not followed. The failure to report these allegations in a timely manner and to conduct appropriate assessments resulted in non-compliance with federal requirements and was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The deficiency was cited at the Immediate Jeopardy level.
Removal Plan
- In-service training for all staff on reporting abuse and neglect to the Administrator, the DON, and Office of Long-Term Care, ensuring all incidents are reported properly and to ensure resident safety.
- Interviewed residents regarding abuse and performed body audits on residents unable to verbalize abuse.
- Appointed the Director of Nursing (DON) to monitor, investigate, and report allegations of abuse.
- Implemented a monitoring tool for documenting and reporting of allegations.
- Appointed the DON as the Abuse and Neglect Coordinator with all corrections completed.
- Conducted staff interviews from all shifts to verify training had been completed.
- Ensured that staff not yet trained are not allowed to return to work until they have been trained.
Failure to Investigate and Report Alleged Abuse and Protect Residents
Penalty
Summary
The facility failed to thoroughly investigate two separate allegations of abuse involving a resident who required assistance with transfers and had intact cognition. In both cases, there was no evidence that a resident statement, accused staff statement, assessment of the resident, bedside staff interviews, or a police report were completed. The facility also did not document a body audit or a nurse assessment in the medical record following the allegations. The incidents were not reported to the appropriate authorities or the State Agency/Office of Long Term Care (OLTC) as required by facility policy and state regulations. When the first allegation was made that a staff member was rough with the resident, the staff member was simply reassigned to another hallway and allowed to continue working with other residents. The incident was reported to the Assistant Director of Nursing (ADON), but no formal investigation or documentation was completed at that time. The ADON did not conduct a body audit or assessment and did not know if the allegation was investigated further. The Certified Nursing Assistant (CNA) Supervisor also failed to report a separate incident involving another staff member and did not complete any write-up or formal report, only moving the accused staff member to a different hall. The Administrator later provided a minimal two-page investigation that lacked essential elements such as resident and staff interviews, body audits, and proper documentation. The Administrator admitted that the incident was not reported to mandatory authorities and that the documentation provided was the entirety of the investigation. The facility did not have an abuse coordinator at the time, and the highest-ranking person present was responsible for investigations. The Director of Nursing (DON) confirmed that the accused staff should have been separated from residents and that the incident should have been reported and investigated immediately.
Removal Plan
- Provide in-service training for all staff on reporting abuse and neglect to the Administrator, the DON, and Office of Long-Term Care.
- Report all incidents properly.
- Ensure resident safety.
- Interview residents regarding abuse and conduct body audits for residents unable to verbalize abuse.
- Appoint the DON to monitor, investigate, and report allegations of abuse.
- Implement a monitoring tool for documenting and reporting allegations of abuse.
- Appoint the DON as the Abuse and Neglect Coordinator.
- Ensure all staff complete training on reporting of abuse before returning to work.
Improper Storage and Handling of Controlled and Expired Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and labeling of drugs and biologicals in accordance with accepted professional principles. Specifically, a narcotic box containing multidose anti-anxiety medication was found inside an unlocked refrigerator in the North medication room. The narcotic box itself was locked but not permanently affixed within the refrigerator, contrary to best practices for securing controlled substances. Staff interviews confirmed that the narcotic box had never been affixed, and both the LPN and DON acknowledged this had been the practice for over two years. The facility's policy did not address the requirement for the narcotic box to be permanently affixed. Additionally, an expired bottle of anti-angina medication was discovered in a tackle-style box located in an upper cabinet above the narcotic refrigerator. The LPN stated that the medication had been left in the old emergency kit and should have been disposed of when the kit was changed out. Both the DON and the Administrator confirmed that expired medications should not have been left accessible and acknowledged that nursing staff were responsible for medication storage. The presence of expired medication and the unsecured narcotic box were both observed and confirmed through staff interviews and policy review.
Failure to Follow Hand Hygiene and Glove-Changing Protocols During Food Service
Penalty
Summary
Dietary staff failed to follow proper hand hygiene and glove-changing procedures while preparing and serving food in the facility's kitchen and dining areas. Observations revealed that one dietary employee, while wearing gloves, served food to residents, touched potentially contaminated surfaces such as tray cards and residents' shoulders, and then returned to food preparation without removing gloves or washing hands. Another dietary employee was observed handling packaged hamburger buns, removing them from the microwave and packaging, and placing them on the steam table without changing gloves or washing hands between tasks. Both employees acknowledged during interviews that they should have removed gloves and washed hands between these activities, as per facility policy and their training. Facility policy requires handwashing before food preparation, after touching potentially contaminated surfaces, and when changing tasks to prevent cross-contamination. Interviews with the Assistant Dietary Manager and Dietary Manager confirmed that staff are expected to wash hands and change gloves in these situations. The failure to adhere to these procedures was observed directly by surveyors and acknowledged by the staff involved, indicating a lapse in compliance with established infection control practices. This deficiency had the potential to affect all residents receiving food from the kitchen.
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