Sunplex Sub-acute Center

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 Certified Nurse Aide (CNA) removed a resident's debit card from her purse without permission and used it at multiple locations for unauthorized purchases. The resident, who was cognitively intact with a BIMS score of 15 and had a diagnosis of Chronic Obstructive Pulmonary Disease with acute exacerbation, reported that her card was used at liquor stores, gift shops, and a hotel. The CNA was identified through interviews and confirmation from a local hotel registry, as well as his own admission to using the card for various purchases including gas, liquor, food, and a hotel room. The incident was discovered after the resident's bank notified her of suspicious activity, and the facility's administrator was informed of the missing card and unauthorized charges. The facility's abuse and neglect policy defines misappropriation of resident property as the wrongful use of a resident's belongings or money without consent. The CNA provided conflicting accounts during interviews but ultimately admitted to using the resident's card. The incident was reported to local law enforcement, the State Agency, and the Attorney General's Office. The resident pressed charges, and the bank reimbursed her for the stolen funds. The facility did not have video surveillance to further support the investigation.

Penalty

Fine: $182,005

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 utilize its Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic failures in infection prevention and control, as well as staffing, during an influenza outbreak affecting all 59 residents. The outbreak occurred over several days, during which the facility did not recognize the outbreak, did not initiate droplet precautions, failed to notify the local health department, and did not ensure that antiviral medications were administered as prescribed. There was also a lack of monitoring for staff illness and compliance with infection control measures, resulting in continued exposure and spread of influenza within the facility. Staff interviews and record reviews revealed that the QAPI Committee did not meet during or after the outbreak, and the incident was not discussed in any quality review process. The Medical Director was not fully informed about the number of affected residents, the implementation of infection control measures, or staffing shortages. The Infection Preventionist was not aware of the specific infection control measures implemented, did not maintain illness logs, and was unfamiliar with the facility's infection control policies. The Administrator and DON did not consider the outbreak an emergency, did not update the facility assessment or contingency plan, and did not verify the implementation of appropriate precautions or notification procedures. No internal investigation was conducted regarding missed medications, and the pharmacy and state agency were not notified. During the outbreak, there was insufficient licensed nurse coverage, with only one nurse responsible for 58 residents overnight, leading to missed medications and inadequate monitoring. The facility assessment lacked required details on staffing needs by shift and unit, and the contingency plan for staffing emergencies was not actionable. The Administrator and DON described the incident as isolated and made no changes to policies or procedures as a result. The QAPI process was not used to review or address the deficiencies in infection control or staffing, and no lessons were identified or learned from the incident.

Removal Plan

• The Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
• The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
• The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
• The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
• Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in­service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
• The Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting.
• The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
• The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
• The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
• The Administrator notified the Mississippi Department of Health of the flu outbreak.
• The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.

Penalty

Fine: $182,005

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 its facility-wide assessment contained the required details regarding staffing needs by shift and by unit, and did not maintain an actionable contingency plan for staffing emergencies. The assessment only included hours per resident day (HPRD) rather than specifying the number of licensed nurses and CNAs needed per shift and per unit. During an influenza outbreak, the facility did not update the assessment or contingency plan to address the increased risk and staffing needs, and administrative staff were used to assist with care when a nurse called in sick, but no agency staff were used and no formal process was in place to secure additional coverage. On the night in question, only one nurse was responsible for 58 residents from midnight until 7 AM, resulting in missed medications and inadequate monitoring for residents on one unit. The administrator and DON were aware of the staffing shortage and attempted to contact other nurses, including those at sister facilities, but were unable to secure additional coverage. The administrator assisted at the nursing station, but the facility's contingency plan did not provide clear procedures for securing coverage during emergencies or staff call-offs, and no updates were made to the plan following the incident. The facility did not identify the influenza outbreak when three residents tested positive, did not initiate droplet precautions, notify the health department, provide timely antiviral treatment, or maintain outbreak surveillance and staff illness tracking. The facility also failed to use its QAPI program to identify and correct system failures in infection control and staffing during the outbreak. These failures resulted in the facility being unprepared for staff absences during the influenza outbreak, placing all residents at risk for serious illness, harm, impairment, or death.

Removal Plan

• The Administrator held an emergency Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse, and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for QAPI for any changes needed and as re-education in policy.
• The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies.
• Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building.
• The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist.
• Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
• The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
• The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
• The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
• Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
• The Administrator reviewed policy on QAPI plan and policy for re-education purposes and to review new policy. The QAPI plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up QAPI meeting.
• The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
• The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
• The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
• The Administrator notified the Mississippi Department of Health of the flu outbreak.
• The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.

Penalty

Fine: $182,005

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 appropriate infection prevention and control practices to prevent and contain the spread of influenza when three residents tested positive for influenza within a short period, affecting all 59 residents in the facility. The facility did not identify the presence of an outbreak, did not initiate droplet precautions, and failed to post appropriate signage or notify the local health department as required by policy and CDC guidance. Staff and family education regarding the outbreak was not provided, and the Infection Preventionist and clinical leadership did not verify isolation orders or monitor staff illness and infection-control compliance. Additionally, antiviral medications were not administered as prescribed, resulting in continued exposure and potential transmission of influenza throughout the facility. Specific failures included not implementing daily active surveillance for influenza illness among residents, healthcare personnel, and visitors after the first laboratory-confirmed case. Visual alerts and signage about respiratory hygiene and cough etiquette were not posted at entrances or in common areas, and symptomatic residents were not consistently placed on droplet precautions. Staff interviews revealed inconsistent use of personal protective equipment (PPE), with some staff wearing masks and others not, and Enhanced Barrier Precautions signage was used instead of droplet precautions for residents with confirmed influenza. Residents with flu-like symptoms were not always tested for influenza or offered antiviral treatment, and group activities and communal dining were not restricted during the outbreak. The facility also failed to implement Enhanced Barrier Precautions during high-contact care activities, such as catheter care, for a resident with an indwelling catheter. Staff did not consistently don gowns as required, and appropriate signage was not placed on resident doors. The Infection Preventionist was new to the position and was not present during critical periods of the outbreak, leading to a lack of oversight and documentation. The facility did not maintain a line list or illness log, did not track or trend new cases or staff illness, and did not provide in-service training specific to influenza precautions during the outbreak. These failures resulted in an Immediate Jeopardy situation, as determined by the surveyors.

Removal Plan

• All corrective actions to remove the Immediate Jeopardy (IJ) were completed

Penalty

Fine: $182,005

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 protect residents from neglect by not ensuring prescribed medications were administered, failing to notify physicians of missed medications, and not providing appropriate supervision and monitoring during a period of increased resident illness and high acuity related to an influenza outbreak. On the night in question, only one RN was present in the facility from approximately midnight to 7:00 AM, responsible for all 58 residents, including those on two separate units. This staffing shortage resulted from a nurse calling in sick, with no documented attempts by facility leadership to secure replacement coverage, and no nurse being assigned to one of the units. The facility's daily assignment sheets and timecards confirmed that only one licensed nurse was present during this critical period, and the facility's contingency plan for staffing emergencies was found to be inadequate and lacking actionable processes. Multiple residents did not receive their scheduled medications, including pain medications, antibiotics, and other essential treatments. For example, one resident did not receive morning doses of hydrocodone, Lasix, or gabapentin; another missed doses of pregabalin, sodium chloride, and other medications; and a resident on IV antibiotics did not receive scheduled doses. Medication Administration Records and controlled drug logs confirmed these omissions, and interviews with residents and staff corroborated that medications were missed and not administered as ordered. Additionally, the facility failed to notify physicians of these missed medications, and the medical director was unaware of the situation until informed by surveyors. During the influenza outbreak, the facility did not identify the outbreak in a timely manner, failed to initiate droplet precautions, did not notify the health department, and did not provide timely antiviral treatment or maintain outbreak surveillance and staff illness tracking. The facility's policies required adequate staffing and oversight, but these were not followed, and the Quality Assurance and Performance Improvement (QAPI) program did not identify or correct the systemic failures in infection control and staffing. Interviews with staff and leadership confirmed a lack of clear direction regarding nursing coverage responsibilities, insufficient oversight, and a lack of timely physician notification for missed medications, placing all residents at risk during the outbreak.

Removal Plan

• The Administrator held an emergency Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse, and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions included in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions, reviewing policy for QAPI for any changes needed and as re-education in policy, reviewing and updating facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies, completing a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building, in-servicing the Infection Preventionist on roles and responsibilities, and reviewing and updating policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and expectations of the Infection Preventionist. Staff were in-serviced with new policies.
• The Administrator notified the Medical Director of missed medications during the QAPI meeting. All missed medications were reviewed with the Medical Director. No new orders were given. No adverse reactions were noted due to missed medications.
• The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
• The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
• Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
• The Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The QAPI plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up QAPI meeting.
• The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
• The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
• The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
• The Administrator notified the Mississippi Department of Health of the flu outbreak.
• The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.

Penalty

Fine: $182,005

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 sufficient licensed nurse and nurse aide coverage to meet resident needs, particularly during an influenza outbreak. On one unit, only one Registered Nurse was responsible for all 58 residents in the facility overnight, resulting in missed medications and lack of resident monitoring. The facility's staffing records showed that only one nurse was present from approximately midnight to 7:00 AM, and there was no documentation of efforts to secure additional coverage after a nurse called in sick. Interviews with staff confirmed that the on-call nurse was also ill and unable to work, and that administrative staff, who were not licensed nurses, attempted to assist but could not provide necessary care or medication administration. Residents reported not receiving their scheduled morning medications, including pain medications, and staff confirmed that medication passes were missed. In addition to the nursing shortage, the facility failed to provide sufficient nurse aide staffing to ensure that residents received scheduled showers and baths. Documentation revealed that several residents missed multiple scheduled showers or baths over the course of a month, and both residents and staff reported that there were not enough CNAs to complete all required bathing care. Interviews with CNAs and LPNs indicated that staffing levels were inadequate to meet resident needs, especially on shower days, and that management was aware of the ongoing problem. The Director of Nursing and Administrator both acknowledged that CNA staffing shortages and high resident acuity were persistent issues, particularly on weekends. The facility's policies and facility assessment did not provide adequate detail on staffing needs by shift and by unit, nor did they include a specific contingency plan for staffing emergencies. The facility lacked a current policy for contingency or emergency staffing and did not have a documented process for on-call procedures in the event of staff call-ins. During the influenza outbreak, the facility did not activate its emergency plan or utilize agency staff, and no updates were made to the contingency plan following the incident. The Medical Director was not informed of the staffing shortage during the outbreak and stated that additional staff should have been provided given the increase in resident acuity.

Removal Plan

• The Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies.
• The Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications.
• The Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service.
• The Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.
• Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in-service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service.
• The Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting.
• The facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The contingency plan will be initiated and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI.
• The Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.
• The Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.
• The Administrator notified the Mississippi Department of Health of the flu outbreak.
• The Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting.

Penalty

Fine: $182,005

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 store and maintain food items in a safe and sanitary manner, as evidenced by multiple expired and spoiled products found during surveyor observation. Specifically, ten loaves of wheat bread with an expiration date that had already passed were found, along with five quarts each of nectar-consistency and moderately thick Thick & Easy milk, both past their use-by dates. Additionally, an opened gallon of Sweet Baby Ray's teriyaki sauce was stored on a dry goods shelf instead of being refrigerated as required by the manufacturer's instructions. In the refrigerator, peanut butter pudding with an expired date and three bell peppers that were deteriorating and macerated were also observed. The Head of the dietary department acknowledged these findings and confirmed that dietary staff were responsible for ensuring food items were not expired, were refrigerated appropriately, and were not overly ripe. The Administrator stated that dietary staff are expected to receive regular in-service training, perform routine checks of food storage areas, and consistently follow established procedures, noting that the staff involved had been employed at the facility for an extended period and should be familiar with these tasks.

Penalty

Fine: $182,005

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 was left with soiled bed linens for multiple days, despite facility policy requiring a safe, clean, and comfortable environment with clean bed and bath linens. Observations over several days revealed the resident's bed sheets were visibly soiled with blood and other stains, attributed to the resident's weeping and bleeding legs. The resident reported that her sheets were only changed on shower days, and on multiple occasions, she confirmed that her linens had not been changed for at least a week. Staff interviews corroborated that the soiled linens were not changed, even after being made aware of their condition, and clean linens were left in the room but not placed on the bed. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had a medical history including Type 2 Diabetes Mellitus. Despite the resident's ability to communicate her needs and the visible evidence of soiled linens, staff failed to provide timely linen changes. The DON and Administrator both acknowledged that residents should not be left on soiled linens and that linens are expected to be changed at least every other day and as needed, but these expectations were not met in this instance.

Penalty

Fine: $182,005

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 develop and implement comprehensive care plans for three residents, as required by policy. One resident with an indwelling catheter did not have a care plan addressing the use and care of the catheter, despite having a physician's order for catheter care and a diagnosis of mechanical complication of a urinary catheter. The resident's comprehensive MDS assessment also documented the presence of the catheter, but no corresponding care plan was created within the required timeframe. Additionally, two residents with scheduled bathing and shower interventions in their care plans did not receive these services as planned. Documentation showed that one resident received only one bath during the month, missing twelve scheduled showers, while another resident missed seven scheduled showers. Both residents expressed dissatisfaction with the frequency of their baths and showers, and the DON acknowledged ongoing issues with staff following care plans for bathing due to CNA staffing challenges. Interviews with staff and administration confirmed awareness of the missed care and the lack of a care plan for the resident with a catheter.

Penalty

Fine: $182,005

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

Nursing staff failed to administer prescribed medications to a resident as required by professional standards and facility policy. During a medication administration observation, an LPN did not provide the resident with Icar-C and Cyanocobalamin tablets because the medications were not available in the medication cart and were still on order. The LPN marked the medications as 'on order' in the electronic Medication Administration Record (eMAR) but did not notify the physician or the resident's representative about the missed doses, nor did she attempt to obtain the medications from an alternate pharmacy source. Interviews with the LPN, RN, DON, and Administrator confirmed that the LPN did not follow the facility's policy, which requires notification and efforts to secure medications from other sources when they are unavailable. The resident involved had a history of chronic kidney disease and a moderately impaired cognitive status, as indicated by a BIMS score of 10. The failure to administer the ordered medications and the lack of appropriate notifications or attempts to obtain the medications from another pharmacy source were directly observed and confirmed through interviews and record reviews. Facility policy required that medications be administered as prescribed and that appropriate steps be taken when medications are unavailable, which was not followed in this instance.

Penalty

Fine: $182,005

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 scheduled bathing and personal hygiene assistance to residents who were dependent on staff for activities of daily living (ADL), as required by their care plans and personal preferences. Three residents, all cognitively intact and requiring varying levels of assistance, were identified as not receiving the number of baths or showers scheduled for them. Documentation for these residents showed significant gaps, with one resident receiving only one bath in a month and others missing multiple scheduled showers. Residents expressed a desire for more frequent bathing and reported that their preferences were not being honored. Interviews with residents, family members, and staff confirmed that missed showers and baths were a recurring issue. Residents reported receiving baths only once a week despite wanting more frequent care, and family members observed signs of inadequate hygiene. Staff interviews revealed that CNA staffing shortages were a primary reason for the missed care, with CNAs unable to complete all scheduled showers and bed baths. Staff also noted discrepancies between assignment sheets and actual care provided, and acknowledged that documentation did not always accurately reflect the care delivered. Facility leadership, including the DON and Administrator, were aware of ongoing complaints and attributed the deficiencies to insufficient CNA staffing. The DON confirmed that staff were expected to honor resident preferences and make multiple attempts before documenting refusals, but acknowledged that this was not consistently happening. The Administrator also recognized the problem and stated that management had discussed revising the shower schedule, but at the time of the survey, residents continued to miss scheduled showers and baths.

Penalty

Fine: $182,005

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 was allowed to keep an inhaler at the bedside without an assessment for safe self-administration and without a physician's order authorizing the medication to be kept at the bedside. Multiple observations over several days confirmed the inhaler was in plain view on the resident's bedside table, and the empty inhaler box was also present in the room. The resident reported using the inhaler as needed and stated that staff had previously left it in her room because she did not always require it when offered. The resident did not notify staff when using the inhaler. Facility policy required an interdisciplinary team assessment and a physician's order for self-administration of medications at the bedside, neither of which had been completed for this resident. The LPN was unaware that the resident had the inhaler at the bedside and confirmed there was no request for it. The DON acknowledged that no assessment or order was in place for the resident to self-administer the inhaler. The resident was cognitively intact, with a BIMS score of 15, and had diagnoses of chronic bronchitis and asthma, with a standing order for the inhaler as needed for shortness of breath.

Penalty

Fine: $182,005

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 accurately document a resident's weight in the medical record, resulting in inconsistencies and incorrect clinical data for one of the sampled residents. Specifically, the resident's weight was recorded as 76.7 pounds on one date, while two days earlier it was documented as 167.2 pounds. Additionally, another set of weights showed a significant discrepancy, with 159.5 pounds recorded on one date and 189 pounds five days later. These errors were confirmed by both the Director of Nursing and a Registered Nurse, who identified that the weights were entered incorrectly in the electronic medical record by different LPNs. The inaccuracies led to the system incorrectly triggering weight alerts, which did not reflect the resident's actual clinical status. The resident involved had been admitted with diagnoses including heart failure, and the Minimum Data Set assessment indicated a significant weight loss over the review period. The errors in weight documentation were not identified at the time of entry, resulting in inaccurate information being maintained in the resident's medical record. The facility's process for reviewing weights was not sufficient to prevent or promptly correct these documentation errors.

Penalty

Fine: $182,005

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's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency related to food storage and sanitation. Despite having a policy in place that requires ongoing monitoring and evaluation of corrective actions, the facility was cited again for failing to ensure food items were stored and maintained in a safe and sanitary manner. Specifically, surveyors found that expired products and spoiled food were not discarded, and some items were not refrigerated according to manufacturer's instructions. These issues were observed during kitchen inspections and were consistent with similar findings from a previous survey. Record reviews and staff interviews confirmed that the facility had been cited for the same deficiency in the past, indicating a lack of effective ongoing oversight and monitoring by the QAPI Committee. The Administrator acknowledged awareness of the previous deficiencies and stated that monthly QAPI meetings were held to address high-risk concerns, but the recurrence of the same issues demonstrated that the corrective actions were not sustained or effective in preventing the deficiency from happening again.

Penalty

Fine: $19,120

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, identified as an elopement risk with a BIMS score of 6 indicating severe cognitive impairment, was able to exit the facility without authorization. The resident, who had diagnoses including Wernicke's encephalopathy and vascular dementia, was last seen in the main lobby by her assigned CNA before the CNA left for a scheduled lunch break. Upon the CNA's return, the resident was missing from both the common area and her room, prompting immediate notification to the RN/MDS nurse and the initiation of a facility-wide search. The investigation revealed that the resident followed a dietary aide out of the front door as the aide was leaving at the end of his shift. The dietary aide, who did not recognize the individual as a resident due to her street clothes and purse, assumed she was a visitor and allowed her to exit behind him. The aide later observed the resident attempting to enter a parked vehicle in the lot before returning to the facility entrance. The resident remained outside for approximately 35 minutes before being found knocking on the front door by another CNA during the search. At the time she was found, the resident was appropriately dressed, carrying her purse, and did not display signs of distress or injury. Staff interviews confirmed that the resident was care-planned as an elopement risk, wore a yellow identification bracelet, and was listed in the facility's wander book. Despite these precautions, the dietary aide was unaware of her status and allowed her to exit. The facility is located near a four-lane highway and industrial complex, with no fencing or restricted barriers between the grounds and the surrounding area. The failure to provide adequate supervision and to ensure staff could properly identify residents resulted in the resident's unauthorized exit and exposure to potential harm.

Removal Plan

• CNA#1 reported Resident #1 missing to MDS Nurse #1, who called Code W (elopement), and all staff began a search of the facility and perimeter.
• Resident #1 was brought inside with no signs of distress after being found outside.
• Administrator was notified by MDS Nurse about the incident.
• MDS Nurse completed a body audit with no signs or symptoms of injury.
• MDS Nurse completed a head count of all current residents in the facility.
• MDS Nurse notified Resident #1's representative of the incident.
• Medical Director was notified of Resident #1's incident and no new orders were given.
• Administrator arrived at the facility and checked that all doors were functioning properly.
• Administrator interviewed all employees and any residents that had interactions with Resident #1 prior to the incident.
• Administrator began in-service for all employees on elopement policy and procedures; all staff would be in-serviced before returning to their next shift.
• Administrator reported incident to State Agency.
• An emergency Quality Assurance & Performance Improvement (QAPI) committee meeting was held to discuss incident, actions taken, and further interventions.
• Social Services Director spoke with Resident #1 and noted no psychosocial harm due to incident.
• Maintenance Director conducted a quality check of all doors to make sure they were operating as expected and door alarms were added to all of the doors.
• Regional Director of Operations interviewed Resident #1 and Resident #2 for any details they remember about the incident.
• Education of elopement policy and procedures with dietary staff, including Dietary Aide #1.
• Wander assessments were completed on all active residents in the facility by DON, RN #1, LPN #1, and Medical Records LPN.
• Maintenance Director began elopement drills for all shifts.
• A follow up QAPI committee meeting was held by Administrator to discuss that all interventions were in place.
• Maintenance will conduct a quality check of all doors, an elopement drill on each shift and put alarms on each of the doors.
• Administrative nurses completed wander assessments on all current residents, update care plans and wander books accordingly; completed a 100 percent audit of care plans; completed 100 percent audit of wander books located at both nurse's stations.
• Social services would interview Resident #1 for any psychosocial harm.
• Administrative staff would in-service all employees on elopement policy and procedures before their next shift.
• Elopement drills on all shifts and one elopement drill per week for four weeks on alternating shifts and one per month for six months on alternating shifts.
• Person-centered in-services will be completed with all staff for any new residents identified as an elopement risk or any current residents who are newly identified as an elopement risk.
• Incident was reported to Attorney General's office by Administrator.

Penalty

Fine: $19,115

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 the safety of a resident during a bed bath, resulting in the resident falling from the bed and sustaining bilateral femoral fractures. The incident occurred when a Certified Nurse Assistant (CNA) was providing care and a bath to the resident, who was able to assist with bed mobility. During the bath, the resident became slippery and rolled out of bed while attempting to hold onto the side rail. The CNA was unable to catch the resident before she fell to the floor. The facility's policy on accidents and incidents emphasizes maintaining a resident environment free of hazards and providing supervision to prevent accidents. However, during the incident, the resident's slipperiness due to the bath was not adequately managed, leading to the fall. The Director of Nursing (DON) and the Administrator were notified of the incident, and an investigation was conducted, which ruled the fall as accidental. The resident had been admitted to the facility with diagnoses including Atrial Fibrillation and was assessed as having no impairment to her upper extremities and being able to roll with partial/moderate assistance.

Penalty

Fine: $19,115

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 its Quality Assurance Performance Improvement (QAPI) program effectively addressed and prevented the recurrence of resident accidents. This deficiency was highlighted by an incident involving a resident who sustained bilateral fractures. The incident occurred when a Certified Nurse Assistant (CNA) attempted to provide care and a bath to the resident. During the process, the resident was turned onto her left side, and due to being slippery, she rolled out of bed, resulting in the fractures. This incident followed a prior citation for F689 (Accident Hazards) where two CNAs improperly positioned a resident in bed, leading to a fall with injury. Despite the facility's ongoing audits to monitor compliance with safety and accident prevention measures, the recurrence of such an incident indicates that the systemic corrective actions were not sustained effectively. The Director of Nurses confirmed the review of the previous CMS-2567 survey, acknowledging the continued efforts to monitor and prevent accidents, yet the deficiency persisted.

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 protect a vulnerable resident from falling out of bed due to inadequate supervision and improper positioning by two CNAs. The incident involved a resident with paraplegia who required substantial assistance with bed mobility. On the day of the incident, two CNAs were providing care to the resident, intending to transfer her to a wheelchair. However, they noticed the resident needed a brief change. During this process, one CNA left the room, leaving the other CNA to manage the resident alone. The remaining CNA attempted to reposition the resident using a draw sheet, which resulted in the resident sliding out of bed and falling to the floor. The resident, who was cognitively intact, reported feeling as though she was pushed out of bed, although the facility's investigation concluded the fall was accidental. The resident sustained injuries, including bleeding from the right elbow, bruises on the right side, and swelling of the right knee. The bed was elevated to waist level, and the resident was found on the floor with a saturated brief and draw sheet. The facility's policy required that the resident environment be free of hazards and that residents receive adequate supervision, which was not adhered to in this case.

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 food was served at an appetizing temperature, affecting at least one resident and potentially all residents receiving meals from the dietary department. Observations and interviews revealed that the steam table used to keep food warm was partially inoperable, with two out of four compartments not functioning. The dietary staff attempted to mitigate this by pouring boiling water into one of the non-working compartments. Despite being informed, the maintenance department had not repaired or replaced the steam table. Additionally, during meal preparation, trays were not covered, which likely contributed to the food cooling down before reaching the residents. Resident #53, who was cognitively intact, along with other residents, had complained about receiving cold food for several months. The issue was not resolved despite being raised in Resident Council meetings over four of the past six months. The dietary manager confirmed that the food was lukewarm during a test tray evaluation. The facility's registered dietitian was unaware of the complaints, and the administrator was only recently informed of the issue. The resident involved had been admitted with diagnoses including bilateral primary osteoarthritis of the knee and essential hypertension.

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 proper food safety and hygiene practices in the kitchen, as observed during two separate inspections. During the first observation, three green bell peppers were found with soft, pliable spots and white biological growth, indicating spoilage. Additionally, 15 containers of seasonings were left open and exposed, which could lead to contamination. The cook acknowledged the condition of the bell peppers and the exposed seasonings, admitting unawareness of the produce's over-ripeness. The Dietary Manager (DM) confirmed that both she and the cook were responsible for maintaining food quality and ensuring that spoiled foods were discarded and seasonings were properly sealed. In a subsequent observation, a staff member was seen picking up a glove from the floor and placing it on a food prep table where pureed tomatoes and sandwiches were being prepared. The cook admitted to this action, recognizing that the glove should have been discarded instead of being placed on the table. The DM was aware of these issues and stated that it was her expectation that spoiled foods be discarded, seasonings be closed, and items picked up from the floor be discarded appropriately. The facility's Administrator also acknowledged that these issues should not have occurred, emphasizing the expectation for proper storage and disposal of items.

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 their Payroll Based Journal (PBJ) submissions to the Centers for Medicare and Medicaid Services (CMS) were accurate for the second quarter of the 2024 fiscal year. This deficiency was identified through staff interviews and a review of Certification and Survey Provider Enhanced Reports (Casper) data, which revealed excessively low weekend staffing and a one-star staffing rating. The issue arose because several employees who worked multiple roles were not correctly coded in the PBJ system, leading to inaccurate staffing data being reported. Specific instances of incorrect coding were identified on several dates, affecting the reported staffing levels. Interviews with facility staff, including the Senior Director of Operations (SDO), Business Office Manager (BOM), and Director of Nursing (DON), revealed that the coding errors were due to the system defaulting to employees' primary roles, rather than reflecting their actual duties on specific days. The BOM, after attending a training session, discovered the coding discrepancies and conducted an audit that confirmed the errors. The Administrator, who had recently assumed her role, was informed of the issue and the need for manual coding adjustments to ensure accurate reporting. The deficiency was confirmed by the Administrator, who acknowledged the facility's one-star rating and the need for corrective action.

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 resolve a grievance regarding cold food reported by Resident Council members over a period of four out of six months. The facility's policy on grievances requires active resolution and keeping residents informed of progress, but this was not adhered to. Resident Council meeting minutes documented grievances about cold food, and during a meeting, several residents confirmed the issue persisted. The Dietary Manager acknowledged the reports and had previously attempted to address the issue by coordinating with the Director of Nursing to speed up tray delivery, which initially seemed effective. However, the problem persisted due to a malfunctioning steam table, which was reported to the Maintenance Department and the past Administrator. The Maintenance Director confirmed receiving a maintenance request for the steam table and attempted a repair, but the component was dry rotted. Despite informing the previous Administrator and ordering a part, the repair was unsuccessful, and no further action was taken until the current Administrator was informed by the Regional Director of Operations. The Administrator was unaware of the issue until recently and had not been informed by the Maintenance Director or the Dietary Manager. The Maintenance Director had not scheduled a technician to fix the steam table until the day before the surveyor's interview, indicating a lack of timely follow-up on the issue.

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 treat residents in a dignified manner during a dining room observation, as evidenced by not providing meals consecutively to all residents seated at the same table. On the observed day, 20 residents were in the dining room waiting for lunch, which was delayed due to kitchen issues. Staff members, including LPNs and a CNA, began serving trays, but some residents did not receive their meals at the same time as their tablemates. This delay in service was noted for three residents, who expressed dissatisfaction with the timing of their meal service. Resident #10, who was admitted with a diagnosis of Hemiplegia and Hemiparesis, was cognitively intact and had been waiting since 11:30 AM. Despite being seated with another resident who received their meal earlier, Resident #10 did not receive his tray until much later, after repeated requests by staff. Similarly, Resident #27, diagnosed with Chronic Obstructive Pulmonary Disease and also cognitively intact, experienced a delay in receiving her meal, which was mistakenly placed on a hall cart. She expressed a desire to be served simultaneously with her tablemate. Resident #160, admitted with Paraplegia and assessed for modified independence, also faced a delay in meal service, which affected her routine, including her smoke break. The staff, including LPNs and the Dietary Manager, acknowledged the issue, confirming that not all residents were served at the same time, which was a concern for resident dignity. The Director of Nursing and the Administrator also recognized the dignity issue, emphasizing the expectation for all residents to be served simultaneously in the dining room.

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 honor the residents' requests for alternative menu options, specifically hamburgers and fries, as listed on the alternative menu. This deficiency was identified through observations, record reviews, and interviews with residents and staff. The facility's policy on resident rights and menu alternatives was not adhered to, as residents were not provided with the alternative meals they requested. The facility's policy stated that an alternative meat or entree and vegetable should be provided at every meal to accommodate personal food preferences or refusals. Resident #53, who was cognitively intact, reported that he had been requesting hamburgers and fries as an alternative meal for months, but was consistently denied. He was informed by staff that hamburgers and fries were not allowed due to previous overconsumption by residents, which led to budget concerns. Despite the alternative menu being posted in the dining room, the residents were not informed of the change in policy, and the old menu was never removed. Resident #18, who had severe cognitive impairment, also expressed a desire for hamburgers and fries, which he used to receive as an alternative meal, but was similarly denied. Interviews with staff, including LPNs, CNAs, the Dietary Manager, and the Registered Dietitian, revealed a lack of communication and awareness regarding the residents' dissatisfaction with the menu options. The Dietary Manager confirmed that the previous Administrator had decided to remove hamburgers and fries from the alternative menu due to budget concerns, but this decision was not communicated to the residents. The new Administrator, who had only been at the facility for three weeks, was unaware of the previous changes and expected the kitchen staff to honor residents' choices as per the alternative menu.

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 a medication cart was secured and locked, as observed during a survey. An unattended medication cart was found unlocked in the hallway, containing unsecured pills and a needle on top. The cart was left unattended by an LPN who was administering medications to residents down the hallway. The LPN admitted that the cart had been left unlocked due to a broken locking mechanism and had been stationed in the hallway since the previous Wednesday. The LPN was unaware of the needle and loose pills in the cart, acknowledging that a confused resident could have accessed them. The Director of Nursing (DON) explained that the medication cart was changed out by the night shift because it was broken and would not lock. The night shift failed to remove the needle and medications from the cart. The DON had not noticed the cart in the hallway and expected nurses to ensure medication carts are locked when not in use. The Administrator also expected medications and supplies to be secured in a medication room when not in use and stated that the broken cart should have been removed from 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 facility failed to prevent a significant medication error involving a transdermal medication patch for one of the residents. The facility's policy on the application of transdermal patches requires the removal of the old patch before applying a new one. However, on 1/10/24, an LPN applied a new Duragesic (fentanyl) patch to a resident without removing the old one. The LPN reported that she could not find the old patch and assumed it had been removed by the previous shift. This resulted in the resident having two fentanyl patches on when he arrived at the emergency department on 1/12/24. The Medication Administration Record for January 2024 did not document the removal of the old patch on 1/10/24, only the application of the new one. The resident involved had a history of Alzheimer's Disease and Cerebral Infarction and was admitted to the facility on 12/31/21. The physician's order required the application of a Duragesic-25 patch every 72 hours, with the old patch to be removed per schedule. The Director of Nurses confirmed that the resident had two patches on before being sent to the emergency department. This incident highlights a failure in following the facility's medication administration policy, leading to a significant medication error.