Legacy at Herington

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the 31 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 31 residents. The facility had one kitchen. Based on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the residents in the facility, who receive their meals from the kitchen. This deficient practice placed the residents of the facility at risk for food-borne illness.

Inspectors wroteThe facility had a census of 31 residents. Based on interviews and record review, the facility failed to submit complete and accurate staffing information through Payroll-Based Journaling (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 31. The sample included 12 residents. Based on record review, interview, and observation the facility failed to provide care for Resident (R)26 and R8 in a manner that protected and promoted resident dignity. This placed the residents at risk for impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to notify the State Long term Care Ombudsman (LTCO) of Resident (R)25's facility-initiated discharge to the hospital. This placed R25 at risk for impaired rights.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with one reviewed for toileting. Based on observation, record review, and interview, The facility failed to revise the care plan to address the toileting needs of one resident, Resident (R) 2. This placed the resident at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with four reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide necessary services to maintain good personal hygiene, including bathing and toileting for Resident (R)2. This placed the resident at risk for poor personal hygiene and related complications.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with one reviewed for pain. Based on observation, record review, and interview, the facility failed to adequately respond to Resident (R)2's complaints of pain. This placed R2 at risk for unresolved pain and discomfort.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 25's antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality) medication. The facility further failed to ensure the CP identified and reported irregularities in R14's blood sugar monitoring. This placed the residents at risk for physical decline, ineffective medication regimen, and side effects from unnecessary medication.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to monitor and provide interventions for bowel management for Resident (R) 18 and failed to notify the physician of blood sugars outside of physician-ordered parameters for R14. This placed the residents at risk for physical decline and other related complications.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)25's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R25 at risk for unintended effects related to psychotropic (alters mood or thought) drug medications.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label Resident (R)6, R14, and R26s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with opened and discard dates. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed diet for three residents that retained both nutritive value and palatability. This placed the affected residents at risk for impaired nutrition or decreased quality of life.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation and interviews, the facility failed to display current daily nursing staff hours.

Inspectors wroteThe facility identified a census of 30 residents. The sample included three residents reviewed for dignity. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 3 was treated with dignity. This deficient practice placed R3 at risk for impaired psychosocial well-being and decreased dignity and self-worth.

Inspectors wroteThe facility identified a census of 30 residents. The sample included three residents reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to ensure Residents (R) 1 and R2 were able to exercise their right to receive visitors of their choosing at the time of the residents' choice. This deficient practice placed R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation.

Inspectors wroteThe facility identified a census of 30 residents. The sample included three residents reviewed for visitation rights. Based on observations, record review, and interviews, the facility failed to inform Resident (R) 1 and R2 and/or their representative of their visitation rights and any visitation restrictions placed on them. This deficient practice placed R1 and R2 at risk for impaired resident rights, impaired psychosocial well-being, and social isolation.

Inspectors wroteThe facility identified a census of 29 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 1 remained free from verbal abuse. On 09/18/23 at approximately 07:30 PM, Certified Nurse's Aide (CNA) M and CNA N were transferring R1 with a full lift from R1's wheelchair to her recliner. During the transfer, R1 began swatting at CNA M and CNA M yelled at R1 and caalled her a derogatory name. This deficient practice placed R1 at risk for psychosocial impairment due to the verbal abuse.

Inspectors wroteThe facility identified a census of 29 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview, the facility failed to ensure staff immediately reported verbal abuse to the facility administrator (LNHA). On 09/18/23 at approximately 07:30 PM, Certified Nurse's Aide (CNA) M and CNA N were transferring R1 with a full lift from R1's wheelchair to her recliner. During the transfer, R1 began swatting at CNA M and CNA M yelled at R1 and called her a derogatory name. CNA N did not report the incident until 09/19/23 in an e-mail to the Human Resources GG. This deficient practice placed R1 at risk for further mistreatment and psychosocial impairment.

Inspectors wroteThe facility identified a census of 32 residents. The sample include 17 residents with one resident reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)7 remained free from neglect when facility staff failed to transfer R7 as required by R7's plan of care. On 04/21/23 R7, who required extensive assistance of two staff and a full body lift, slipped forward in her wheelchair. Certified Nurse Aide (CNA) N called out to non-CNA staff (Dietary Staff CC) to assist with repositioning R7 in the wheelchair. CNA N and Dietary Staff CC lifted R7 by her upper arms and pulled R7 back in the wheelchair without the use of the full body lift. During this action, R7's left shoulder made a loud popping noise, which CNA O, who sat at a nearby table, heard. [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample include 17 residents with five residents reviewed for accidents. Based on observation, record review, and interview the facility failed to ensure Resident (R) 7 remained free from preventable accidents when the facility staff failed to transfer R7 as required by R7's plan of care. On 04/21/23 R7, who required extensive assistance of two staff and a full body lift, slipped forward in her wheelchair. Certified Nurse Aide (CNA) N called out to non-CNA staff (Dietary Staff CC) to assist with repositioning R7 in the wheelchair. CNA N and Dietary Staff CC lifted R7 by her upper arms and pulled R7 back in the wheelchair without the use of the full body lift. During this action, R7's left shoulder made a loud popping noise, which CNA O, who sat at a nearby table, heard. [...]

Inspectors wroteThe facility identified a census of 32 residents. The facility had one main kitchen. Based on observation, record review and interview, the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs.

Inspectors wroteThe facility identified a census of 32 residents with one kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to equipment testing and storage of kitchenware. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 05/17/23 at 07:42 AM an observation revealed plates and bowls stored on top of a cart were not covered or inverted. On 05/17/23 at 07:43 AM an observation revealed plates and bowls stored in a metal bin under a table. The dishes were stored below waist level and the side of the bin was open leaving the plates and bowls exposed. The plates and bowls were uncovered and not inverted. [...]

Inspectors wroteThe facility census totaled 32 residents. Based on observation, interview, and record review the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the 32 residents who reside in the facility.

Inspectors wroteThe facility identified a census of 32 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to develop corrective actions plans and monitor them to correct identified quality deficiencies prior to survey. This deficient practice placed the residents at risk for ineffective care. Findings Included: The facility failed to ensure a surety bond was in place to protect resident's trust accounts. This deficient practice placed 30 residents at risk for complication related to monetary issues. (Refer to F570) The facility failed to ensure Resident (R)7 remained free from neglect when facility staff failed to provide the necessary number of qualified staff members along with the required medical equipment to provide appropriate assistive cares for R7. [...]

Inspectors wroteThe facility census totaled 32 residents. Based on observation, interview, and record review the facility failed to ensure the Quality Assurance Performance Improvement (QAPI) team meet quarterly with the required personnel in attendance. This deficient practice placed all the residents at risk for ineffective care. Findings Included: - A review of the facility's Quality Assurance Performance Improvement (QAPI) team meeting sign-in sheet indicated a QAPI meetings were held 02/08/22, 03/08/22, 04/12/22, 07/27/22, and 10/26/22. The facility was unable to provide documentation showing meetings held after October 2022. The review indicated no quality measures, concerns, monitoring, performance improvement plans (PIPs), or QAPI guidance/education occurred after 10/26/22. [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents. Based on interview and record review, the facility failed to ensure the principles of antibiotic stewardship were followed to ensure antibiotics were used in a safe and effective manner to prevent unnecessary side effects of antibiotics and antibiotic resistance in an ongoing, proactive manner when the facility Infection Preventionist (IP) failed to document and maintain an accurate antibiotic stewardship log monthly. This placed the residents who resided in the facility at risk for unnecessary side effects of antibiotics and antibiotic resistance.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents. Five residents were reviewed for activities of daily living (ADLs) care. Based on observation, record review and interview the facility failed to ensure staff provided consistent bathing cares for Resident (R) 29, R7, R11, and R30 who required extensive assistance from staff with bathing. This deficient practice placed the residents at risk for complications due to poor personal hygiene and impaired psychosocial wellbeing.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents with five residents sampled for medication review. Based on observation, record review and interview, the facility failed to implement a system to ensure the monthly Consultant Pharmacist (CP) recommendations were addressed/followed up by the physician and facility staff for the five residents sampled for medication review. Resident (R) 5, R9, R12, R29, and R30's chart lacked physician responses to the monthly pharmacy recommendations. This placed the residents at risk for complcations related to unecessary medications.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents. Based on observation, record review and interview, the facility failed to ensure nursing staff cleaned/sanitized shared equipment after each use. The facility failed to ensure nursing staff placed a protective barrier down when using a glucometer (a medical device used to measure the approximate concentration of glucose in the blood). The facility failed to use appropriate hand hygiene while providing care to residents. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents with three reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Residents(R)2, R19 and R30 were treated in a dignified manner during meal service. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: On 05/17/23 at 11:40AM R2, R19, and R30 were in the dining room eating lunch. An unidentified staff stood at the table supervising and providing meal assistance with feeding. The staff member held R2's fork and fed R2 her food while standing over her. R2 complained the food was stuck in her upper denture but staff continued to insist she take a bite of her food. While feeding R2, the staff member told R19 to keep eating his meal while she stood over R2. [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents with three residents reviewed for notice requirements before transfer/discharge. Based on observation, record review, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer for Resident (R)11 or her representative. This deficient practice placed R11 at risk of delayed care or uncommunicated care needs.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents with two residents reviewed for treatment/services to prevent /heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to provide physician ordered pressure reducing devices for Resident (R) 10 who had an unstageable pressure injury (base of the sore is covered by a thick layer of other tissue and pus that may be yellow, grey, green, brown, or black) to the right heel. This deficient practice placed R10 at increased risk of development and or worsening of pressure related injuries for R10.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents with two residents reviewed for range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension) or mobility. Based on observation, record review, and interviews, the facility failed to identify and resolve inappropriate wheelchair positioning for Resident (R)12. This placed R12 at risk for loss of independence, and impaired mobility.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 17 residents with two residents reviewed for bowel/bladder incontinence and nephrostomy tube (an artificial opening between the kidney and the skin which allows urine to drain from the body). Based on observation, record review, and interviews, the facility failed to provide appropriate hand hygiene during peri-care for Resident (R) 11 who had a foley catheter (tube inserted into the bladder to drain urine) and history of sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) and urinary tract infections (UTI). The facility also failed to evaluate and provide an individualized toileting plan for R7. [...]

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents with four reviewed for nutrition. Based on observation, record review, and interviews, the facility failed toprovide consistent support during meal services for Resident (R) 19, who had unintended weight loss. This deficient practice placed R19 at risk for further weight loss and impaired nutrition. Findings Included: - The Medical Diagnosis section within R19's Electronic Medical Records (EMR) included diagnoses hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), cerebral infarction (sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), muscle weakness, unsteadiness on feet, and chronic kidney disease. [...]

Inspectors wroteThe facility identified a census of 32 resident. The sample included 17 residents with one Resident (R) sampled for respiratory care. Based on observation, record review and interview, the facility failed to ensure R10 received her supplemental oxygen (O2) continuously as physician ordered. The facility failed to ensure that R10's O2 tubing and nasal cannula (NC-a hollow tube that helps provide supplemental oxygen) and continuous positive airway pressure (CPAP-machine used to deliver a stream of oxygenated air into the airways through a mask and a tube) mask and tubing were properly stored in a sanitary manner when not in use. This deficient practice placed R10 at risk for increased respiratory infection and complications.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents. Five residents were sampled for unnecessary medication review. Based on observation, record review and interview the facility failed to monitor Resident (R) 29's pulse before administration of the beta blocker (a type of medicine that makes the heart beat more slowly and lower blood pressure) metoprolol (a beta blocker medication used to treat heart conditions). This deficient practice place R29 at risk for unnecessary medication administration and adverse side effects.

Inspectors wroteThe facility identified a census of 39 residents. The sample included 17 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered diagnostic laboratory test results were signed and scanned into the clinical record for Resident (R) 10 and R12. This deficient practice could result in unnecessary tests and delayed treatment.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents with five sample residents reviewed for influenza (a contagious respiratory illness that infect the nose, throat, and sometimes the lungs) and pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) immunizations. Based on record review and interview the facility failed to ensure that sampled Resident (R) 29 and R30 that had consented to receive the influenza and pneumococcal vaccine were administered the vaccinations. This deficient practice placed these residents at risk for acquiring, transmitting, or experiencing complications from influenza and pneumococcal disease.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 17 residents with five residents sampled for COVID-19 (an acute respiratory illness in humans caused by coronavirus, capable of producing severe symptoms and in some cases death) vaccinations. Based on record review and interviews, the facility failed toassess and document the COVID-19 vaccination status for Resident (R) 30. The facility failed to offer and obtain signed consents or declinations for COVID-19 vaccinations for R30. This deficient practice had the risk for physical complications and the risk to spread illness among residents, a high-risk population.

Inspectors wroteThe facility had a census of 20 residents. The sample included 12 residents, with three reviewed for Medicare Liability Notices. Based on record review and interview, the facility failed to provide the resident (or their representative) the Advance Beneficiary Notice (ABN) for skilled services for Resident (R) 2, R7, and R11.

Inspectors wroteThe facility had a census of 20 residents. The sample included 12 residents with two residents reviewed for respiratory services. Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services when they failed to ensure staff stored oxygen delivery devices in a sanitary manner for Resident (R) 7.

Inspectors wroteThe facility had a census of 20 residents. The sample included 12 residents. Based on observation, interview, and record review the facility failed to perform adequate infection control during wound care for two residents, Resident (R) 7, R14 and toileting for R10.