5 Reports
Inspection Report — Nov 21, 2024
Complaint Investigation CMS
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding rude behavior by Certified Nurse Aides (CNAs) and to assess infection prevention practices during PEG tube care.
Complaint Details
The investigation was complaint-driven based on multiple resident grievances about rude behavior by CNAs on various shifts. The complaints were substantiated as the facility acknowledged persistent issues and inadequate resolution.
Findings
The facility failed to resolve grievances about rude CNA behavior in a timely manner for several residents and failed to prevent possible infection spread during PEG tube care due to inadequate hand hygiene by a nurse.
Deficiencies (2)
F 0585: The facility failed to ensure grievances regarding rude staff were resolved timely for five of nineteen sampled residents. Residents reported CNAs displayed rude behavior and did not assist appropriately during care.
F 0880: The facility failed to prevent possible infection spread during PEG tube care for one of three residents with PEG tubes. A nurse did not perform hand hygiene between glove changes, risking cross-contamination.
Report Facts
Residents affected: 5
Residents with PEG tubes observed: 3
Residents with PEG tube care deficiency: 1
In-service training dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Confirmed Resident Council meetings and acknowledged persistent complaints about rude CNAs | |
| Staff Development Nurse | Received grievances and acknowledged CNA rudeness issue on night shift | |
| Administrator | Confirmed grievance discussions and acknowledged recurring complaints about rude CNAs | |
| RN #1 | Registered Nurse / Wound Care Nurse | Observed failing to perform hand hygiene between glove changes during PEG tube care |
| Director of Nurses (DON) | Stated expectation for hand hygiene after each glove change and emphasized infection risk | |
| LPN #1 | Licensed Practical Nurse / Infection Preventionist | Confirmed hand hygiene failure constituted cross-contamination risk |
Inspection Report — Jul 31, 2024
Routine CMS
Date: Jul 31, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights, consent for insurance changes, and provision of a safe, clean, and homelike environment, including availability of linens and residents' autonomy in bathing and dressing routines.
Findings
The facility failed to ensure residents could exercise autonomy regarding bathing schedules and clothing preferences due to lack of clean linens and personal clothing not returned from laundry. Consent was not obtained from one resident before disenrollment from managed care insurance. The facility also failed to provide sufficient bath linens on one day of observation, impacting residents' preferred routines.
Deficiencies (3)
F 0561: The facility failed to ensure two residents had the opportunity to exercise autonomy regarding bathing schedules and clothing due to lack of clean washcloths, bath towels, and personal clothing not returned from laundry.
F 0572: The facility failed to obtain consent from one resident prior to changing private insurance plans, resulting in disenrollment from managed care without authorization.
F 0584: The facility failed to provide sufficient bath linens to allow residents to bathe at their preferred time on one of three days of observation.
Report Facts
Residents sampled: 9
Residents affected: 2
Residents affected: 1
Days of observation: 3
Residents affected: 1
Inspection Report — Jun 23, 2023
Complaint Investigation CMS
Date: Jun 23, 2023
Visit Reason
The inspection was conducted to investigate a complaint regarding inadequate care for residents who are continent or incontinent of bowel/bladder, specifically focusing on Resident #2's incontinence care.
Complaint Details
The complaint investigation found that Resident #2 did not receive appropriate incontinence care as required. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to provide appropriate incontinence care to Resident #2, who was found with a wet brief, stained sheets, and a strong urine odor. Interviews with staff confirmed that required assessments and care every two hours were not consistently provided.
Deficiencies (1)
F 0690: The facility failed to ensure that Resident #2, who was incontinent of bladder, received appropriate treatment and services, including timely assessment and assistance every two hours as required.
Report Facts
Residents reviewed for incontinent care: 5
Residents affected: 1
BIMS score: 6
Inspection Report — Mar 27, 2023
Complaint Investigation CMS
Date: Mar 27, 2023
Visit Reason
The inspection was conducted based on complaints regarding resident dignity during meal assistance, oxygen safety signage, and food quality and temperature.
Complaint Details
The investigation was complaint-driven, focusing on dignity in feeding assistance, oxygen safety signage, and food quality. The complaints were substantiated with observations, interviews, and record reviews confirming the issues.
Findings
The facility failed to provide dignified care by not feeding residents requiring assistance simultaneously. Oxygen safety signs were missing for residents using oxygen. The food served was often cold, bland, and unpalatable, leading to resident dissatisfaction.
Deficiencies (3)
F 0550: The facility failed to provide meals at the same time to all residents requiring assistance, causing one resident to watch another being fed while hungry.
F 0695: The facility failed to post cautionary oxygen-in-use signs for three residents using oxygen, compromising safety.
F 0804: The facility failed to provide food that was palatable and served at a safe, appetizing temperature for seven residents, resulting in complaints of cold and bland meals.
Report Facts
Residents reviewed for oxygen usage: 9
Residents reviewed for meal satisfaction: 7
BIMS score: 3
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Named in feeding assistance deficiency for not feeding residents simultaneously. | |
| Registered Nurse (RN) #1/Charge Nurse | Confirmed feeding practices and deficiency. | |
| Director of Nursing (DON) | Confirmed feeding and oxygen signage deficiencies. | |
| Dietary Manager | Confirmed food temperature and palatability issues. | |
| Activity Director and Social Worker | Confirmed resident complaints about food quality. |
Inspection Report — Nov 7, 2019
Complaint Investigation CMS
Date: Nov 7, 2019
Visit Reason
The inspection was conducted following a complaint regarding the removal and disposal of a resident's personal urinary drainage system without replacement or adequate compensation.
Complaint Details
The complaint involved the facility removing and destroying Resident #50's urinary drainage system, which was purchased by his brother for personal use. The resident wanted the system replaced or compensated. The facility removed the system citing infection control concerns and provided urinals instead. Compensation was provided via gift cards and a deposit to the resident's account.
Findings
The facility failed to respect a resident's right to retain personal possessions by removing a urinary drainage system and not adequately replacing or compensating for it. Additional deficiencies included inaccurate Minimum Data Set (MDS) assessments, failure to revise care plans for dementia, inadequate assistance with grooming, improper food handling leading to cross-contamination, and failure to prevent cross-contamination during medication pass.
Deficiencies (6)
F 0557: The facility failed to allow Resident #50 to retain and use a personal urinary drainage system, removing it without replacement or adequate compensation.
F 0641: The facility failed to perform accurate Minimum Data Set (MDS) assessments for Resident #19's Foley catheter and Resident #73's discharge location.
F 0657: The facility failed to revise the care plan related to a Dementia diagnosis for Resident #16 as required.
F 0677: The facility failed to assist Residents #278 and #29 with grooming/shaving as required by their care plans.
F 0812: The facility failed to prevent cross-contamination of food during dining when a CNA fed Resident #66 with bare hands.
F 0880: The facility failed to prevent cross-contamination during medication pass when a nurse carried a pulse oximeter in her pocket without cleaning it before or after use.
Report Facts
Gift card amount: 20
Compensation deposit: 44.58
Number of MDS assessments reviewed: 25
Number of residents observed for grooming: 25
Number of nurses observed for pulse oximeter use: 4
Number of dining observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided multiple interviews regarding urinary drainage system removal, compensation, grooming, and infection control issues |
| Registered Nurse #1 | MDS Nurse | Interviewed regarding inaccurate MDS assessments for Residents #19 and #73 |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Observed improperly handling pulse oximeter during medication pass |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Observed feeding Resident #66 with bare hands causing cross-contamination |
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