Inspection Reports for
Access Mental Health LLC

The facility failed to comply with multiple regulatory requirements including trust account interest distribution, window maintenance, care area assessments, care plan reviews, discharge summaries, fall interventions, sanitary food handling, COVID-19 protocols, outbreak notifications, kitchen sanitation, and ventilation.

The inspection was triggered by multiple complaints (#168052, #165309, #164108, #163977, #163857, #163385, #162944, #162864, #162061, #161733, #161426, #160819, #160784, #160553, and #168859).

The facility was found deficient in multiple areas including failure to manage residents' personal funds with interest, inadequate maintenance and cleanliness of windows, incomplete comprehensive assessments, failure to revise care plans timely, lack of discharge summaries, inadequate accident prevention interventions, unsanitary food storage and preparation conditions, ineffective infection prevention and control practices, failure to timely notify residents and families of COVID-19 outbreaks, and inadequate ventilation causing malodorous conditions.

The facility developed and implemented corrective actions addressing multiple deficiencies including resident rights, trust fund access, housekeeping and maintenance, comprehensive assessments, care planning, restorative nursing, elopement and choking risk assessments, staffing, social services documentation, cleaning schedules, COVID-19 social distancing, antibiotic stewardship, and abuse neglect training.

The investigation was triggered by complaints #155929, #155834, and #155438. The facility was found noncompliant regarding bed hold notices and nutritional care for selected residents.

The facility failed to provide written 'Bed Hold Notices' specifying the duration of the bed hold for four residents upon transfer. Additionally, the facility failed to ensure timely nutritional assessments and interventions for a resident experiencing significant weight loss.

The facility developed and implemented corrective actions to address cited deficiencies including providing written bed-hold agreements and ensuring timely registered dietitian assessments for residents.

Complaint investigation revealed a physical altercation between residents R25 and R11 on 08/13/2020. The facility failed to provide social services follow-up and counseling to resident R25 who reported feeling unsafe and having nightmares after the incident.

The facility had multiple deficiencies including failure to support resident self-determination, inadequate management of resident funds, unsanitary and unsafe environment conditions, inaccurate resident assessments, incomplete care plans especially for restorative services, inadequate staffing, failure to prevent resident elopement, inadequate supervision during meals, and infection control issues including lack of social distancing and ineffective antibiotic stewardship.

The plan addresses past non-compliance issues identified under tags F0000 and F689-J during the inspection.

The COVID-19 survey found no deficiencies at the facility.

The complaint investigation #152645 was substantiated, finding the facility not in substantial compliance with 42 CFR 483 subpart B due to failure to prevent resident elopement and immediate jeopardy conditions.

The facility failed to adequately supervise one resident who exited through a locked door, crossed a busy highway, and was found lying face down in a ditch, placing the resident in immediate jeopardy. The facility implemented corrective actions including one-on-one supervision, daily door alarm checks, resident re-assessments, staff re-education, and elopement drills.

The complaint investigation #152645 was substantiated. The resident exited through a locked door, walked across a busy highway, and was found face down in a ditch, placing the resident in immediate jeopardy.

The facility failed to provide adequate supervision to prevent one resident from leaving the facility unnoticed, resulting in the resident walking 3.5 miles away, crossing a busy highway, and being found face down in a ditch. This placed the resident in immediate jeopardy.

The complaint investigation #150975 found the facility was not in substantial compliance with 42 CFR 483 subpart B due to failure to monitor Resident 1 requiring one-to-one supervision. The resident eloped near a heavily traveled highway when left unattended in the facility van on 03/04/2020.

The facility failed to monitor a cognitively impaired resident requiring one-to-one supervision during an outing, resulting in the resident eloping near a heavily traveled highway. Staff left the resident unattended in the facility van for a minimum of five minutes, violating the resident's care plan.

The plan addresses past noncompliance issues identified under tags F0000 and F689-J during the inspection on 03/05/2020.

The Plan of Correction outlines corrective actions for multiple deficiencies related to resident care preferences, resident rights, staffing, care planning, medication administration, dietary services, infection control, and facility maintenance. The facility describes measures to prevent recurrence and monitoring plans to ensure sustained compliance.

The inspection was complaint-related, triggered by multiple complaint investigation numbers as stated in the initial comments.

The facility was found deficient in multiple areas including failure to provide resident choice in bathing, failure to inform residents of their rights on an ongoing basis, failure to notify physicians of hospital transfers, inadequate housekeeping and maintenance, failure to develop timely baseline and comprehensive care plans, failure to conduct discharge planning, inadequate nurse aide training and staffing postings, failure to monitor medication regimens and behaviors, improper food preparation, unsanitary food storage and disposal, lack of facility-wide assessment, and failure to maintain an effective infection prevention and control program including antibiotic stewardship.

The facility identified issues with elopement risk assessments, door alarms, and staff education on missing resident procedures. Corrective actions include re-education of staff, updating care plans, improving door alarm systems, and ongoing monitoring to prevent recurrence.

The complaint investigation #KS00136217 found the resident eloped from the facility on 12/7/18 without staff knowledge. The resident was found walking five blocks from the facility in cold weather. The resident's elopement risk was reassessed and found to be at risk after wandering behavior was observed. The facility's investigation identified a malfunctioning service hall door as a potential exit point. Immediate jeopardy was abated on 12/13/18 after corrective actions were implemented.

The facility failed to ensure adequate supervision and safety measures for a resident at risk of elopement, resulting in the resident leaving the facility unnoticed and walking several blocks outside in cold weather. The facility identified a malfunctioning service hall door as a possible exit point and implemented corrective actions to address the issue.

The survey found the most serious deficiencies related to F689, "J", CFR 483.25 with actual harm but not immediate jeopardy. The facility was found to have substandard quality of care and will not be given the opportunity to correct deficiencies before enforcement remedies are imposed.

The inspection was triggered by complaints identified as #KS00135619 and KS00135211. The findings substantiated multiple deficiencies related to financial management, environment, medication management, and record keeping.

The facility failed to properly manage residents' personal funds, including failure to pay interest on trust accounts, maintain accurate accounting, and notify residents of Medicaid resource limits. The environment was found unclean and unsafe with maintenance issues. The facility failed to safeguard narcotic medications and maintain accurate medication records. The kitchen was unsanitary and resident medical records were disorganized and inaccessible.

The plan addresses updating care plans for residents to include discharge needs and implementing interventions to assist residents in residing in their preferred living environment. The facility also conducted staff in-service training on patient-centered discharge planning and will audit discharge plans monthly for three months.

The complaint investigation #00131575 found the facility did not provide discharge planning for 3 residents reviewed. The facility lacked a discharge planning policy and failed to document or assist residents in discharge processes as required.

The facility failed to provide adequate discharge planning for 3 of 3 residents reviewed, including failure to develop discharge plans and assist residents in relocating to preferred living environments.

The survey found the most serious deficiencies to be a "D" level deficiency indicating no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was reviewed and accepted, resulting in a finding of substantial compliance effective August 30, 2018.

The survey found the most serious deficiencies to be a "D" level deficiency indicating no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective June 15, 2018.

The complaint investigation #129563 was substantiated. The facility failed to assess the resident's elopement history during admission and did not prevent the resident from leaving the facility unnoticed on 5/15/18. The resident was missing for about 1 hour and 30 minutes before being found by staff.

The facility failed to accurately assess a newly admitted resident for elopement risk and did not prevent the resident from eloping on 5/15/18. The resident was missing for approximately 1.5 hours before being found unharmed. Staff monitoring of doors and alarms was inconsistent, and some doors remained unlocked or alarms were disabled.

The facility identified a failure to intervene when a resident left the facility unaccompanied, resulting in staff termination and implementation of enhanced staff training and monitoring procedures to prevent future elopements.

The plan addresses multiple deficiencies including environmental issues in resident shower rooms, hallways, and rooms; care plan revisions related to resident falls; discharge planning process improvements; quality of care regarding skin integrity; medication regimen reviews focusing on black box warnings; dietary sanitation issues; infection prevention and control; and immunization compliance.

The facility was found deficient in multiple areas including maintenance and housekeeping services, care plan revisions after falls, discharge planning, skin care monitoring, fall investigations, drug regimen review with black box warnings, food safety and sanitation, infection control practices, and immunization education and documentation.

The survey found a widespread 'F' level deficiency constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 2018-04-09.

The facility identified failures in monitoring a resident on a walking pass who walked beyond the designated path. Staff training was completed on reporting adverse events, and the facility revised its wandering and elopement risk assessments and walking pass policies.

Complaint investigation #115629 focused on allegations of abuse, neglect, and failure to report an elopement incident involving Resident #2. The complaint was substantiated based on findings of inadequate investigation, reporting, supervision, and care.

The facility failed to thoroughly investigate and immediately report an elopement incident involving Resident #2, failed to provide necessary care and assessment upon the resident's return, and failed to adequately supervise and identify the resident as at risk for elopement. The resident left the facility without staff knowledge and was found near railroad tracks approximately 1.5 hours later. The facility also failed to maintain proper documentation and adherence to the walking pass program.

The survey found the most serious deficiencies related to F323, "J", CFR 483.25(d)(1)(2)(n)(1)-(3), which was determined to be immediate jeopardy. Enforcement remedies including a civil money penalty, denial of payment for new admissions, and potential termination of provider agreement were imposed.

All previously reported deficiencies identified on the CMS-2567 were corrected as of the revisit date. The report confirms completion of corrective actions for the cited regulations.

The facility was found not in substantial compliance and was cited for immediate jeopardy to resident health or safety from September 26, 2016 through October 18, 2016 related to F309, "J", CFR 483.25. Enforcement remedies including a civil money penalty and potential termination of provider agreement were imposed.

The investigation was triggered by complaint #106573 concerning inadequate monitoring and physician notification for a resident with respiratory distress.

The facility failed to adequately monitor and assess the respiratory status of a resident with significant respiratory distress over a two-day period and did not seek timely physician involvement. This failure placed the resident in immediate jeopardy.

This Plan of Correction responds to deficiencies cited in a complaint investigation (Franklin complaint 10202016) related to resident respiratory decline and change in condition notifications.

The facility identified issues with timely assessment, monitoring, and physician notification regarding changes in a resident's respiratory status. The Plan of Correction outlines staff in-service training and policy reviews to ensure compliance with notification and documentation requirements.

The plan of correction addresses infection control measures including use of a disinfectant product and housekeeping staff education, and dietary management including staff training and consultation with a Registered Dietitian.

The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of 2016-06-15. No other deficiencies or uncorrected issues are noted.

The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The visit included complaint investigations #88391 and #100428.

The facility failed to employ a full-time certified dietary manager for the 47 residents receiving meals from one kitchen. Observations and interviews confirmed that the dietary staff overseeing meal service was not certified but enrolled in dietary manager classes.

The survey found the most serious deficiencies at an 'F' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.

The report confirms that the previously cited deficiencies under regulations 483.35(i) and 483.70(c)(2) were corrected as of the revisit date.

The plan addresses deficiencies related to cleaning and maintenance of kitchen equipment, including the stove and oven, and staff training on equipment defect reporting and tagging.

The survey found the most serious deficiencies to be 'F' level deficiencies that constitute no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.

The visit was triggered by complaint investigations #89331 and #89333. The findings confirmed issues with oven cleanliness and safety hazards including fire incidents.

The facility failed to maintain cleanliness and safe operating condition of the kitchen oven used to prepare meals for residents. The oven was dirty, inoperable at times, and had caused fire incidents. Staff failed to properly clean and maintain the oven and did not promptly report safety hazards.

The plan addresses multiple deficiencies including client notification of advocacy groups, posting of survey reports, staff background checks, monitoring of liver function related to Tylenol use, sanitary maintenance of ice maker drain lines, and insulin monitoring procedures.

The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.

The inspection included a complaint investigation (#83733) related to failure to post state agency contact information and other regulatory compliance issues.

The facility was found deficient in multiple areas including failure to post state agency contact information for complaints, failure to make survey results readily accessible, lack of written evidence for criminal background checks on some employees, failure to ensure drug regimens were free from unnecessary drugs, improper sanitary conditions in the kitchen, failure to timely report drug regimen irregularities, and improper labeling of insulin pens.

The survey found isolated 'D' level deficiencies with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payment for new admissions and termination of provider agreement were outlined if substantial compliance is not achieved.

The plan addresses multiple deficiencies including care plan updates for bracelet use, medication administration and vital sign documentation, staffing requirements, dietary and housekeeping practices, and monitoring protocols to ensure compliance.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective February 11, 2014.

The visit was triggered by Complaint Investigation #71010. The complaint involved concerns about care planning, medication administration, staffing, food safety, infection control, and pharmacy oversight. The complaint was substantiated based on the findings.

The facility failed to revise a resident's care plan after applying a wanderguard bracelet, failed to ensure residents were free from unnecessary medications including failure to monitor blood pressure as ordered, failed to provide 8 consecutive hours of RN coverage daily, failed to maintain sanitary food handling practices, failed to notify the facility of medication irregularities by the pharmacy consultant, and failed to maintain infection control standards including proper cleaning and handling of linens.

The survey found the most serious deficiencies to be 'F' level, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payment for new admissions and termination of provider agreement were outlined if substantial compliance is not achieved.

The report confirms that the deficiencies previously cited under regulations 483.10(b)(11) and 483.25 were corrected by 03/18/2013.

The facility reviewed the clinical status of residents and found no residents exhibiting an Acute Change of Condition. The nursing staff were in-serviced on recognizing and documenting acute changes, physician notification, and use of the CMS INTERACT SBAR Communication Form and related tools. The facility implemented monitoring processes including hot rack charting and daily clinical meetings to ensure compliance.

Complaint Investigation #63991 triggered the survey due to concerns about failure to notify physicians of changes in condition and inadequate resident care.

The facility failed to adequately assess and monitor elevated temperatures, respiratory distress, and changes in condition for two sampled residents, resulting in delayed physician notification and treatment. This failure caused harm and placed residents in immediate jeopardy. The facility lacked standing orders or policies for timely physician notification and failed to provide consistent interventions and thorough assessments.

The report confirms that the deficiencies previously cited under regulations 483.15(a) and 483.65 were corrected by the revisit date of 10/31/2012.

The plan addresses disciplinary and reeducation actions for dietary staff regarding use of foul language and infection control practices. Compliance monitoring is assigned to various facility committees and staff.

The facility failed to promote dignity and respect for residents, evidenced by staff using inappropriate language. The facility also failed to maintain adequate infection control practices, including improper glove use and handling of open skin lesions by staff.

The report confirms that the previously cited deficiency under regulation 28-39-158(a) was corrected as of the revisit date.

The report confirms that the deficiency identified under regulation 483.30(b) was corrected as of the revisit date.

The facility failed to employ a full-time qualified dietary manager as required by regulations. Dietary staff lacked state certification for the dietary manager position.

The Plan of Correction outlines corrective actions taken for multiple cited deficiencies including resident trust account management, facility maintenance and repairs, medication management, kitchen cleanliness, and medical record organization.