Brunswick Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #34), in a review of 15 sampled residents, received care and services in accordance with professional standards of practice when staff failed to follow the manufacturer's recommendations for the administration of an eye drop and an inhaled medication. The facility census was 29. Review of the facility policy, Administration of Eye Medications, last revised 05/06/24, showed the following:-Administer eye medications as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions;-After instillation of medication, instruct the resident to close eyes slowly to allow for even distribution over the surface of the eye and apply gentle pressure to the tear duct for one minute or by gently closing eye for three minutes. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice acceptable infection control measures during medication administration for two residents (Residents #34 and Resident #13), when staff did not perform hand hygiene and touched the residents' medications without wearing gloves prior to administration and failed to wear gloves when administering eye drops and inhaled medications to one resident (Resident #34), in a review of 15 sampled residents. The facility census was 29. Review of the facility policy, Administration of Eye Medications, last revised on 05/06/24 showed the following:-Administer eye medications as ordered by the physician and in accordance with professional standards of practice to lubricate the eye or treat certain eye conditions;-Wash hands or utilize alcohol-based hand rub and apply gloves to administer medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) eight consecutive hours a day, seven days a week and did not have a full-time director of nursing. The facility census was 36. Review of the facility's Registered Nurse (RN) Policy, revised on 4/30/24, showed the following:- Full time is defined as working 40 or more hours a week;-The facility will utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week;-The facility will designate a registered nurse to serve as the director of nursing on a full time basis. 1. Review of the nursing staff schedule, dated 7/1/25 through 7/5/25, showed no documentation of RN coverage on 7/1/25, 7/4/25, and 7/5/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), of 11 sampled residents, remained free from sexual abuse, when another resident with inappropriate sexual behaviors (Resident #2), sexually abused the resident in Resident #1's room. The facility census was 21. On 4/15/25 at 5:05 P.M., the administrator was notified of the immediate jeopardy (IJ) past non-compliance that occurred on 3/29/25. Corrective measures and an investigation began immediately. Resident #1's family and physician were notified of the allegation of abuse and the resident was placed one on one for safety until emergency medical services arrived to transport the resident to the hospital for assessment and evaluation. Resident #2 was placed on one on one supervision until local law enforcement arrived. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were employed with the appropriate competencies and skill sets to provide nursing care and related services to assure resident safety and attain the highest practicable mental and psychosocial well-being for their resident population when the facility accepted residents for admission with behavioral health needs that staff were not trained to care for. The facility census was 21. Review of the facility's Behavioral Health Services Policy, revised 10/31/24, showed the following: -Affected Personnel: All facility employees; -It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (Resident #2 and #3), of 11 sampled residents with mental disorders, received individualized treatment and services to meet their needs. Residents displayed verbal, manipulative and aggressive behaviors on multiple occasions. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being. The facility census was 21. Review of the facility's Behavioral Health Services Policy, revised 10/31/24, showed the following: -Affected Personnel: All facility employees; -Purpose: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR, an emergency lifesaving procedure performed when the heart stops beating, consisting of chest compressions and artificial respirations) certified staff were scheduled 24 hours a day seven days a week, failed to develop and implement a policy addressing CPR requirements for staff and failed to maintain documentation of CPR certifications for staff members. The facility had seven residents with full code status (residents requested to have full resuscitation efforts/CPR in the event of cardiac arrest). The facility census was 17. Review of the facility's CPR policy, dated February 2023, showed the following: -It is the policy of this facility to adhere to resident's rights to formulate advance directives. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to ensure the facility had an RN designated as the Director of Nursing (DON) on a full time basis. The facility census was 17. Review of the facility's policy titled Staffing, Sufficient and Competent Nursing, dated August 2022, showed the following: -Our Facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services with resident care plans and the facility assessment; -A registered nurse provides at least eight consecutive hours every 24 hours, seven days a week. Review of the Facility's Assessment, last updated/reviewed in April 2024, showed the facility did not have an active DON. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week and failed to ensure the facility had an RN designated as the Director of Nursing (DON) on a full time basis. The facility census was 22. 1. During an interview on 09/10/24 at 11:15 A.M., the Administrator said the facility did not have a policy for RN coverage. The facility followed the regulatory guidance. Review of the facility's staffing schedule, dated July 2024, showed no RN and no DON coverage on 7/01/24 through 7/07/24, 7/25/24, 7/26/24, and 7/29/24 through 7/31/24. Review of the facility's staffing schedule, dated August 2024, showed the following: -No RN coverage on 8/1/24 through 8/3/24, 8/7/24 through 8/9/24, 8/15/24 through 8/17/24, 8/23/24, and 8/28/24 through 8/31/24; [...]

Inspectors wroteRefer to event id 5XTS12 Based on observation, interview, and record review, the facility failed to implement effective pest control measures to eliminate pests, including flies from areas throughout the facility and in resident rooms. This effected multiple residents of the facility, including Resident #31, who had an open cancerous wound, that required medication to treat for infestation of maggots, Resident #5 who could not sleep due to flies and other residents during their meal service to the extent that they had to use fly swatters to deter the flies during their meal. The facility census was 35. Review of the facility policy, Pest Control Program, dated 11/1/23, showed the following: -It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective pest control measures to eliminate pests, including flies from areas throughout the facility and in resident rooms. This effected multiple residents of the facility, including Resident #31, who had an open cancerous wound, that required medication to treat for infestation of maggots, Resident #5 who could not sleep due to flies and other residents during their meal service to the extent that they had to use fly swatters to deter the flies during their meal. The facility census was 35. Review of the facility policy, Pest Control Program, dated 11/1/23, showed the following: -It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. This had the potential to affect all residents. The facility census was 31. During an interview on 4/18/24, at 1:15 P.M., the Administrator said the facility did not have a policy for RN coverage. The facility followed the regulatory guidance. Review of the Payroll Based Journal (PBJ) report (the facility is mandated to report staffing hours to the Centers for Medicare and Medicaid Services (CMS) and those hours are reviewed and calculated into a report) dated 10/1/23-12/31/23, showed the following dates when the facility did not have any documented RN hours: -11/6/23; -11/7/23; -11/8/23; -11/12/23; -11/14/23; -11/15/23; -12/15/23; -12/18/23; -12/24/23; -12/28/23; -12/29/23; -12/31/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary equipment was free of an accumulation of grease, oil, dust, and debris; failed to ensure food items were sealed in the freezer and dry storage room; and failed to ensure the facility's ice machine drain contained a proper air gap. The facility census was 31. Review of the facility's dietary cleaning schedule showed, by-weekly deep clean stove/hood/grill/oven/filters. 1. Observations on 4/15/24 from 9:20 A.M. to 3:34 P.M., in the kitchen, showed the following: -In the white up-right freezer, a cardboard box contained an unsealed plastic bag of frozen biscuits; -In the dry storage room, a 5-pound unsealed plastic bag of natural cocoa powder; -Above the refrigerator unit next to the service hall kitchen door, an approximate 2-foot by 3-foot ceiling vent with a moderate buildup of dust and debris; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate infection control procedures for hand hygiene and changing gloves, to prevent the spread of bacteria or other infectious causing contaminates, and when indicated by professional standards of practice during personal care for four residents (Resident #3, #12, #15 and #30), in a review of 15 sampled residents. The facility failed to develop and implement a Legionella Prevention Program. The facility failed to ensure respiratory equipment remained free of contaminates for one sampled resident (Resident #19). The facility census was 31. Review of the facility's undated policy, Hand Hygiene, showed the following: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for four residents (Residents #15, #27, #30 and #36), in a review of 15 sampled residents, who all had diagnosis of dementia, were cognitively impaired, and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning without consideration of the resident's preferences for waking and for staff convenience. The facility census was 31. Review of the facility policy, Quality of Life, dated June 2023, showed the following: -The community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being; [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable environment by failing to ensure the shower room and ceiling vents were clean and in good repair. The facility census was 31. 1. Observation on 4/15/24 at 1:10 P.M. and on 4/17/24 at 7:45 A.M., in the shower room on Cardinal hall, showed black marks on the floor near the shower stall. The shower basin had a large crack between the wall and the floor, the seam in the corner appeared black, and the tiles above the basin showed the grout was black for three of the tiles. The floor in the shower basin had brown stains by the drain. During an interview on 4/24/24 at 1:05 P.M., the Director of Nursing (DON) showed the following: -Staff were to notify maintenance if repairs were needed. -Nursing was to clean the shower room if they or the resident left a mess in the shower room. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete required pre-employment screenings for five of eight sampled employees hired since the previous survey. The facility failed to request a criminal background check for four employees, complete an Employee Disqualification List (EDL) check for four employees, and complete a Nurse Aide (NA) registry check for two employees, prior to hire. The facility census was 31. 1. Review of Activity Aide N's employee file showed the following: -Date of hire 01/03/24; -Criminal background check requested on 03/09/24 (66 days after hire date); -EDL check completed on 02/08/24 (36 days after hire date). 2. Review of the Director of Nursing's (DON) employee file showed the following: -Date of hire 02/12/24; -Criminal background check requested on 03/08/24 (25 days after hire date); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered comprehensive care plan, specific to the resident, for four residents (Resident #2, #12, #15 and #16), in a review of 15 residents and one additional resident (Resident #37). The facility was 31. A request for a facility policy for comprehensive care plans and revisions of care plans was requested and none provided. 1. Review of Resident #2's summary page, undated, showed the following: -The resident was admitted on [DATE]; -He/She was his/her own responsible party; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update interventions in the resident's care plan to reflect current safety and care needs for three residents (Resident #1, #16, and #19), in a review of 15 sampled residents. The facility census was 31. Review of the facility's Care Plan Revision Upon Status Change policy, undated, showed the following: -The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change; -Procedure for reviewing and revising the care plan when a resident experiences a status change: a. Upon identification of a change in status, the nurse will notify the Minimum Data Set (MDS, a federally mandated assessment instrument required to be completed by facility staff) Coordinator, the physician, and the resident representative, if applicable; b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide four residents (Resident #15, #25, #27 and #30), of eight sampled residents, with the assistance of activities of daily living (ADL) care that the residents required. Resident #15 and #30 were not provided appropriate perineal care, Resident #27 and #30 were not offered bathing as scheduled and Resident #25 was not provided with feeding assistance when needed. The facility census was 31. Review of the facility policy, Quality of Life, dated June 2023, showed the following: -The community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently evaluate the root cause for falls and implement and modify interventions as necessary following falls for one resident (Resident #1), in a review of 15 sampled residents. The facility failed to use or properly use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers) during transfers and/or assistance with walking for two additional residents (Residents #33 and #37). The facility census was 31. A request for a facility Fall policy was made with none provided. Review of the undated facility policy, Gait Belt Policy & Procedure showed the following: Purpose: Gait belts are used to aid in safe ambulation and transfers of resident Procedure: 2. Explain what you are going to do; 4. Lower the resident's bed to the lowest level, and lock the wheels. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for the use of bed rails/assist bars prior to installation, to have a system in place to obtain informed consent and educate residents and their responsible parties about the risks of bed rail use prior to use, assess residents for entrapment risk, and failed to assess for continued safe use of bed rails for six residents (Residents #2, #12, #15, #23, #30 and #31), in a review of 15 sampled residents. The facility census was 31. Review of the facility's undated policy, Restraints: Side Rail Utilization Assessment, showed staff was to complete this form as they went through the decision-making process of determining whether a side rail was appropriate for a particular resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of two residents, (Resident #12 and #27) in a review of 15 sampled residents, when the facility failed to provide regular baths or showers. The facility also failed to respond to resident call lights in a timely manner for three residents (Resident #2, #5 and #19 ) resulting in resident's voicing frustration/concerns over wait time. The facility census was 31. Review of the undated facility policy titled, Staffing, showed the following: -Facilities will have sufficient and competent staff to meet the needs of the residents; Policy Interpretation and Implementation: 1. Recruit and train staff according to the needs of the residents residing in the facility; 2. Facilities will identify staffing needs and educational opportunities based on the Facility Assessment; 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure four nurse aides (NA) (NA J, NA L NA K and NA F) completed a nurse aide training program within four months of their employment as an NA in the facility. The facility census was 31. During an interview on [DATE], at 1:15 P.M., the Administrator said the facility did not have a policy regarding certification of nurse assistants. The facility followed the regulatory guidance. 1. Review of NA J's employee files showed his/her employment as an NA started on [DATE] (approximately seven months and three weeks prior). 2. Review of NA L's employee files showed his/her employment as an NA started on [DATE] (one year prior); 3. Review of NA K's employee files showed his/her employment an an NA started on [DATE] (two years, eight months, and approximately one week prior); 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure gradual dose reductions (GDRs; the stepwise tapering of a medication to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose of medication can be discontinued) were attempted, or the physician documented the rationale for not attempting a GDR, on psychotropic medications (affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) for three residents (Resident #1, #13, and #22), in a review of 15 sampled residents. The facility census was 31. Review of the facility's Unnecessary Drugs F757 and F758 policy, dated June 2023, showed the following: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a medication cart was secured when unattended. The facility census was 31. Review of the facility's undated policy, Medication Storage in the Facility, showed the following: -Medications and biologicals are stored, safely, securely, and properly, following manufacturer's recommendations or those of the supplier; -The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication; -Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. 1. Observation on 04/17/24, from 5:23 A.M. to 6:01 A.M., showed the following: -Registered Nurse (RN) T passed morning medication on the west hall; -At 5:23 A.M., RN T walked away from the medication cart with cart unlocked to provide resident care; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food items at a safe and appetizing temperature. The facility census was 31. Review of the facility Food Storage Guideline and Procedure Manual, 2016 Edition, showed to keep potentially hazardous foods out of the temperature danger zone (41 degrees Fahrenheit to 135 degrees Fahrenheit). 1. During an interview on 4/17/24, at 6:22 A.M., Resident #3 said his/her food isn't hot. He/She wants his/her food to be hot. During an interview on 04/18/24, at 3:14 P.M., Resident #12 said yesterday morning when he/she went to the dining room, his/her tray was sitting on the table with a cover on it. His/Her breakfast was not warm. Breakfast today was part warm and part not. 2. Review of the Diet Spreadsheet Menu for the lunch meal on 4/15/24 showed the following: -Salisbury steak/gravy; -Cheesy noodles; [...]

Inspectors wroteBased on interview and record review, the facility failed to follow an antibiotic stewardship program as part of their infection prevention and control program that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 31. Review of the facility's undated policy, Infection Control Program - Antibiotic Stewardship F881, showed the following: -This community has established an infection prevention and control program that includes protocols to establish a system for the use and monitoring of adverse effects of antibiotics; -Residents who need an antibiotic are prescribed an antibiotic; -Antibiotic Stewardship: a set of commitments and actions designed to optimize this treatment of infections while reducing the adverse effects associated with antibiotic use; -Loeb Criteria: minimum criteria for the initiation of antibiotics; -McGeer Criteria: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal vaccine (a vaccine that can protect against pneumococcal disease) as indicated by the current Centers for Disease Control and Prevention (CDC) guidelines for five residents (Residents #2, #11, #22, #23 and #30), in a review of 15 sampled residents. The facility census was 31. Review of the facility's policy, Vaccination of Residents, Including Influenza, dated 06/2023, showed the following: -Residents will be offered pneumovax vaccinations per Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines, and when vaccines are made available to the community; -Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete inspections of bed frames, mattresses, and bed rails as part of regular maintenance program to identify areas of possible entrapment for six residents (Resident #2, #12, #15, #23, #30, and #31), in a review of 15 sampled resident who used bed rails/assist bars. The facility census was 31. Review of the facility's Potential Zone of Entrapment, undated, showed the following: -The guidance described seven zones in the hospital bed system where there is a potential for patient entrapment; -Zone 1 is any open space within the perimeter of the rail; -Zone 2 is the gap under the rail between a mattress compressed by the weight of a patient ' s head and the bottom edge of the rail at a location between the rail supports, or next to a single rail support; a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Residents #5), in a review of 15 sampled residents, were treated with dignity and respect. The facility census was 31. Review of the facility's policy, Resident Rights, dated 07/2023, showed the following: -Employees shall treat all residents with kindness, respect, and dignity; -Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. Exercise his or her rights; b. Be informed about what rights and responsibilities he or she has; f. Voice grievances and have the facility respond to those grievances; I. Retain and use personal possessions to the maximum extent that space and safety permit; -Residents are entitled to exercise their rights and privileges to the fullest extent possible; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and/or responsible party when one resident (Resident #11), in a review of 15 sampled residents, had a fall with minor injury. The facility census was 31. During an email communication on 04/30/24 at 2:09 P.M., the administrator said the facility did not have a specific policy on reporting resident condition changes or falls. 1. Review of Resident #11's summary sheet showed the following: -The resident has a responsible party to help with decision-making; -Diagnoses included dementia without behavioral disturbance. Review of the resident's significant change Minimum Data Set (MDS), a federally mandated assessment instrument, dated 01/12/24, showed the following: -Severe cognitive impairment; -Fall with major injury. Review of the resident's care plan, revised 01/23/24, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to report a resident-to-resident abuse allegation involving two residents (Resident #11 and #19), to the state agency (SA) within two hours of the incident when Resident #19 hit Resident #11 with a fly swatter. The facility census was 31. Review of the facility's undated policy, Resident-to-Resident Altercations, showed the following: -Notify family, the attending physician, the Administrator and/or the registered nurse on-call, in the absence of the Administrator, of incident; -The Administrator and/or the on-call registered nurse shall continue the investigation; -This designated staff member will hotline the incident to the state agency within 24 hours, unless there is a serious bodily injury, then the hotline is to be made within two hours of the altercation. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change status assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment, required to be completed by facility staff, for two residents (Residents #30 and #36), in a review of 15 sampled residents. This assessment should have been completed within 14 days after the facility determined, or should have determined, there had been a significant change (major decline or improvement in the resident's status) in the resident's physical or mental condition which had an impact on more than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The facility census was 31. Review of the Long Term Care Facility RAI User's Manual, version 3.0 showed a significant change is a decline or improvement in a resident's status that: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (Resident #13 and #23), in a review of 15 sampled residents, had a preadmission screening for individuals with a mental disorder and individuals with an intellectual disability (Pre-admission Screening and Resident Review -PASRR) completed prior to admission. The facility census was 31. During interview on 04/18/24, at 1:15 P.M., the administrator said the facility did not have a specific policy for PASRR screenings but followed the state guidelines related to PASRR requirements. 1. Review of Resident #13's undated summary sheet showed the following: -admission date of 07/06/16; -Diagnosis of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide one resident (Resident #39), who was discharged to his/her home, with a discharge summary that contained a recapitulation of the resident's nursing home stay. The facility census was 31. Review of an email correspondence from the administrator, dated 4/16/24, showed the facility did not have a policy regarding discharge recapitulation. 1. Review of Resident #39's summary page, undated, showed the following: -The resident was admitted on [DATE]; -The resident was his/her own responsible party. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 3/18/24, showed the following: -The resident was cognitively intact; -He/She had limited functional range of motion in bilateral lower extremities; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents with complicated feeding problems, (Resident #30 and #37), of eight residents sampled, were assisted with feeding by qualified staff. Hospitality Aide (HA) M (a paid feeding assistant and not a certified nurse aid) fed the residents without the supervision of a Registered Nurse (RN) or Licensed Practical Nurse (LPN). The facility census was 31. Review of the 2003 Federal Registry Notice Requirements for Paid Feeding Assistants in Long Term Care Facilities, dated September 26, 2003 (Volume 68, Number 187), showed the following: -Dining Assistant (DA) Programs in Nursing Homes: Guidelines for Implementation Manual: -Federal and State Requirements for a Dining Assistant Program: -Nursing homes must ensure their DA Program meets the following requirements: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information, which included the total actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care, per shift on a daily basis. The facility census was 31. Review of the facility's staffing sheet, dated 4/5/24 showed the days shift did not include staff working or total hours worked for the Nurse (RN), Licensed Practical Nurse (LPN), Certified Medication Technician (CMT), Certified Nurse Assistant (CNA) or Nurse Assistant (NA)'s. Night shift did not include staff working, the census, or the total hours worked for RN, LPN, CMT, CNA or NA's. Review of the facility's staffing sheet, dated 4/9/24 showed the night shift did not include staff working, the census, or the total hours worked for RN, LPN, CMT, CNA or NA's. [...]

Inspectors wroteBased on interview and record review, the facility failed to give appropriate Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) (CMS-10055) and the CMS Notice of Medicare Non-Coverage (NOMNC) (CMS-10123) in writing to three residents (Residents #1, #91, and #33) reviewed, when the facility initiated discharge from Medicare Part A Services when benefit days were not exhausted. The facility census was 31. During an interview on 4/18/24 at 1:15 P.M., the Administrator said the facility did not have a policy in regards to ABN and NOMNC notices. The facility followed the regulatory guidelines related to these areas. 1. Review of Resident #1's face sheet showed the resident had a durable power of attorney (DPOA) for health care. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS), a federally mandated assessment completed by staff, according to the Resident Assessment Instrument (RAI) manual for one sampled residents (Resident #15), in a review of 15 sampled residents, and for two closed records (Residents #6 and #17). The facility census was 31. Review of the Resident Assessment Instrument (RAI) Manual, dated October 2023, showed the following: -Medicare and Medicaid participating long-term care facilities are required to conduct comprehensive, accurate, standardized and reproducible assessments of each resident's functional capacity and health status. -The RAI process has multiple regulatory requirements. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures to immediately report to the administrator or on call registered nurse (RN) an injury of unknown origin for one resident (Resident #1) of three sampled residents and initiate an investigation. On 10/30/23, Licensed Practical Nurse (LPN) A identified three dark purple bruises on the resident's right hip/thigh area when staff assisted the resident to the bathroom. LPN A did not report the bruises of unknown origin to the Registered Nurse (RN) on call or the administrator until 11/3/23. The facility failed to notify the Department of Health and Senior Services (DHSS) until 11/3/23, four days after identifying the bruise. The facility census was 36. Review of the facility's policy, Abuse and Neglect Detection and Prevention, revised 2/24/17, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain and follow policies and procedures for immunization of residents against pneumococcal disease as required. The facility failed to provide and document provision of pertinent information regarding the pneumococcal vaccine including the benefits and potential side effects of the pneumococcal vaccine for 14 of 16 sampled residents (Residents #1, #2, #4, #7, #11, #13, #17, #20, #21, #24, #27, #32, #34, and #142) and four additional residents (Residents #5, #8, #15, and #19) of which six residents (Residents #1, #4, #5, #8, #19, and #21) developed pneumonia. The facility also failed to offer and vaccinate eligible residents with the pneumococcal vaccine with recommended doses of the pneumococcal vaccine as indicated by the Centers for Disease Control and Prevention (CDC) recommendations. The facility census was 41. [...]

Inspectors wroteBased on interview and record review, the facility failed to deposit residents' personal funds in excess of $50.00 into an interest bearing account and to credit interest earned to the residents' personal funds for four residents (Residents #33, #24, #21, and #10). The facility managed funds through the resident trust fund account for six residents. The facility census was 41. Review of the facility's undated admission packet regarding Resident Trust Funds, showed the following: -The trust funds account is kept under $50; -Monies in excess of $50 shall be moved into an interest bearing savings account. 1. Review of a facility ledger for Resident #33 showed the following: -On 8/3/22, a balance of $1,020.97; -On 8/4/22, a balance of $802.61; -On 8/24/22, a balance of $778.61; -No documentation of any interest credited to the resident. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to document resident assessments for one resident, (Resident #1), a resident diagnosed with pneumonia and on antibiotic medication, failed to assess wounds and obtain treatment orders for one resident (Resident #142), failed to follow physician orders for two residents (Resident #24 and #143), and failed to ensure medications were not left at bedside for later administration for two residents (Resident #28 and #40), in a review of 16 sampled residents. The facility census was 41. Review of the facility's undated Skin Assessment policy showed the following: -Residents will have a full skin assessment with each shower; -Shower aide is to report any abnormal findings to charge nurse for further investigation and assessment; -Aides are to report any abnormalities noted on skin during any care provided to charge nurse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide protective oversight for four residents (Resident #24, #13, #11, and #4) of 16 sampled residents and one additional resident (Resident #6) when facility staff failed to review/revise interventions on care plans to prevent further falls, failed to maintain resident safety during transfers, and failed to label and properly store liquid fertilizer in an area that was not inaccessible to residents. The facility census was 41. Review of the facility's undated fall protocol showed the following: -Purpose was to provide a mechanism for assessment for falls with focus on prevention, prompt investigation, and care plan updates; -Upon admission, all residents would be assessed for fall risk utilizing Fall Risk Assessment form and assessment would be updated following the MDS schedule; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent for bed rail use for three residents (Residents #7 ,#27, and #142), who had bed rails in place on their beds in a review of 16 sampled residents. The facility census was 41. Review of the Food and Drug Administration's bed safety guidelines: A Guide to Bed Safety, Bed rails in Hospitals, Nursing Homes, and Home Health Care, revised April 2010, showed the following: -Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling; -Assessment by the patient's health care team will help to determine how best to keep the patient safe; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders for as needed (PRN) psychotropic medications were limited to 14 days for three residents (Residents #7, #11, and #17), in a review of 16 sampled residents, unless otherwise indicated by the physician. The facility also failed to ensure staff implemented and documented non-pharmacological interventions prior to the administration of PRN psychotropic medications for one resident (Resident #7). The facility census was 41. Review of the facility's policy, Psychotropic Medication PRN Usage, dated 3/28/17, showed the following: -Residents do not receive PRN psychotropic medications unless necessary to treat a specific condition that is documented in the clinical records, and PRN orders for psychotropic drugs are limited to 14 days; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed the recipe when preparing pureed food items. The facility census was 41. Record review on 09/26/22 for the facility special diets showed one resident received a pureed diet. 1. Record review of the recipe for pureed cheesy eggs showed if the product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. Record review of the recipe for pureed sausage showed if the product needs thinning, gradually add an appropriate amount of liquid (NOT WATER) to achieve a smooth, pudding or soft mashed potato consistency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement sanitary practices and conditions within the dietary department to prevent the potential for contamination of food during service. The facility census was 41. Observation on 09/26/22 showed the following: -At 7:55 A.M., [NAME] Q wore gloves as he/she plated eggs, bacon, and hash browns for the residents. He/She pulled his/her mask down, wiped his/her nose, pulled the mask back up and continued serving breakfast, touching the resident's plates with his/her same gloved hands. He/She did not remove his/her gloves and wash his/her hands after touching his/her nose with his/her gloved hand; -At 8:12 A.M.,Cook Q wore gloves and grabbed the trash can. He/She did not remove his/her gloves after touching the trash can, and then cracked eggs in a bowl and scrambled them; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff washed their hands after each direct resident contact, and failed to change gloves during direct resident personal care for three residents (Resident #19, #24 and #33), in a review of 16 sampled residents. The facility also failed to practice acceptable infection control practices to prevent potential cross-contamination during wound care for two residents (Residents #40 and #142). The facility census was 41. Review of facility's undated policy for hand washing procedure showed the following: -Purpose was to prevent or minimize the spread of infection; -Hand washing before and after physical contact with each person was the single most important means of preventing the spread of infection; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment, and no more than 21 days after admission, for one resident (Resident #34). The facility census was 41. Review of the facility's comprehensive care plans policy, updated 9/20/21, showed the following: -Each resident will have a person-centered care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs; -Care plans must be all inclusive to address the following: a. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Any specialized services or specialized rehabilitative services the facility will provide; d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services consistent with acceptable standards of practice to ensure one resident (Resident #24), in a review of 16 sampled residents, received proper care after he/she had been incontinent of bowel and bladder. The resident had a history of urinary tract infections (UTIs) and sepsis (serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to malfunctioning of various organs, shock, and death). The facility's census was 41. Review of the facility's undated policy Perineal Care for the female resident showed the following: -The purpose was to clean the perineum, and prevent infection and odor; [...]

Inspectors wroteBased on observation and interview, the facility staff failed to ensure the medication or treatment carts were secured and locked when not in use. The facility census was 41. Review of the undated facility's policy, Medication Administration, showed medication cabinets and the medication room are to be locked at all times when not in use. Review of the undated facility policy, Narcotic Count, showed the following: -The narcotic supply is to be kept under two locks at all times; -The lock on the medication cart and the lock on the narcotics drawer are to be locked at all times. Observation on 9/26/22, at 7:47 A.M., showed the following: -The charge nurse medication cart sat against the wall at the central nursing station unattended and unlocked for approximately five minutes; -Numerous residents were wandering about the area of the unlocked cart; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify four residents (Resident #1, #24, #32 and #40), in a review of 16 sampled residents, and/or their representatives in writing of transfer to the hospital, including the reasons for the transfer. In addition, the facility failed to notify the regional ombudsman (a resident advocate who provides support and assistance with problems and/or complaints regarding the facility) of the transfers. The facility census was 41. 1. Record review of Resident #32's medical record showed the resident was his/her own responsible party. Record review of the resident's nurse's notes, dated 7/16/22 at 9:30 A.M., showed the following: -The resident had high blood sugar, episodes of vomiting, and a distended (abnormally swollen outward) abdomen; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold with required information to the resident and/or resident representative for four residents (Resident #1, #24, #32 and #40), in a review of 16 sampled residents, when the facility initiated a transfer to the hospital. The facility census was 41. Review of the facility policy, Bed-Hold Policy, revised 3/17/17 showed the following: -This facility bed-hold policy applies equally to all residents; 1. Notice before transfer: a. Private Pay - a bed-hold rate will be charged at the current rate per day if the individual is out of the facility for one to ten days. When the individual is out longer than ten days, the bed-hold is released. [...]