Menig Nursing Home

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a system that enables residents to file an anonymous grievance. This has the potential to impact all residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the food and nutrition services manager has necessary qualifications to manage dietary services. This has the potential to impact all residents.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety. This has the potential to impact all residents.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate infection control practices related to legionella monitoring and update the infection control policies yearly. This has the potential to impact all residents. The facility also failed to implement Enhanced Barrier Precautions for 1 of 12 sampled residents (Resident #2).

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the State Agency for 1 of 2 sampled residents (Resident #20).

Inspectors wroteBased on interview and record review, the facility failed to adequately assess a resident with a chronic pressure ulcer for 1 of 1 sampled residents (Resident #2).

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans contained triggers related to PTSD [Post- Traumatic Stress Disorder] for one of one sampled resident (Resident #5).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Residents' rights were maintained by not allowing unrestricted visitation based on resident choice. This has the potential to affect all residents of the facility and all visitors, including family, legal representatives and advocates. Per interview with Resident #1 on 7/22/24 at 2:36 PM visitors are only allowed 10:00 AM -7:00 PM. Per interview with a Resident's family member on 7/22/24 at 3:48 PM they are asked not to visit between noon and 1:00 pm because staff are busy helping others with their meals and can't stop to let visitors in and out. Sometimes it is difficult because visiting hours end at 7:00 PM. While exiting the facility on 7/22/24 at 4:12 PM a sign with visiting hours was observed posted between the two entrances. [...]

Inspectors wrote2. Per record review Resident #28 has diagnoses that include Alzheimer's disease and wanders throughout the facility. Review of Nursing Progress Notes from 3/4/2024 - 7/25/24 reveals that there were 78 entries that indicated Resident #28 was expressing behaviors such as wandering throughout the facility, wandering into other Resident's rooms, and exit seeking. On 12 of the 78 occasions documentation reflected that resident was exit seeking or focused on the exit door. A Wandering Assessment done on admission, 3/4/24, states that Resident #28 is not at risk for elopement. Another Wandering assessment dated [DATE], also states the Resident is not at risk of elopement. A care plan focus dated 6/19/24 indicates that Resident #28 moves about the unit: independently with supervision or touching assistance when s/he goes into areas that s/he should not be in, such as other's rooms. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to address in their facility assessment what staff trainings and policies are necessary to provide the level and types of care needed for the population identified in the facility assessment. This deficient practice had the potential to affect all 27 residents residing in the facility.

Inspectors wroteBased on interview and policy review, the facility failed to ensure the Medical Director assisted the facility with the development and implementation of resident care policies. This deficient practice had the potential to affect all 27 residents residing in the facility.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff related to QAPI (quality assurance and performance improvement), communication, compliance, and ethics training, and behavioral health training for 10 of 10 of sampled direct care staff and failed to develop a system that demonstrated the required 12 hours of annual training for the Licensed Nurse Aides (LNA's), for 4 of 4 of sampled staff.

Inspectors wroteBased on staff interviews and record review, the facility failed to include mandatory training that outlines and informs staff of the elements of effective communication, including speaking to others in a way they can understand, active listening, and observing verbal and nonverbal cues.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to include mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI (Quality Assurance Performance Improvement) program as part of the QAPI program.

Inspectors wroteBased on record review and interview, the facility failed to include mandatory training on compliance and ethics that outlines and informs staff of the standards, policies, and procedures through a training program or in another practical manner that explains the requirements under the program.

Inspectors wroteBased on record review and interview, the facility failed to develop a system to document the minimum 12 hours of nurse aide training per year required to ensure the continuing competence of the nurse aides.

Inspectors wroteBased on staff interviews and record review, the facility failed to develop, implement, and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health care and service that is appropriate and effective, as determined by staff need and the facility assessment for 7 of 7 sampled staff. The facility's Facility Assessment [an assessment that determines what resources are necessary to care for the residents competently during both day-to-day operations and emergencies], last updated 1/24/2024, indicates that the facility can provide care and services for individuals with Psychiatric/Mood Disorders Part 2 Services and care we offer based on our Resident's needs .mental health and behavior: [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure each resident has a right to self-determination and access to persons and services outside of the facility, by locking all doors to the facility 24 hours a day, 7 days a week. By creating a locked facility, there is a failure to ensure the right of each resident to exercise their rights as a citizen (or resident) of the United States or make personal choices about going outside without interference. This has the potential to affect all residents of the facility and all visitors, including family, legal representatives and advocates. Per observation on 7/22/24 at approximately 10:00 AM at the entrance to the building, the main front entrance doors within the foyer were locked. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise resident care plans for 3 residents related to falls (Residents #15, #20, and #21), for 1 resident related to refusal of care (Resident #15), and 1 resident related to nutrition (Resident #15) out of a sample of 17 residents.

Inspectors wroteBased on observation and staff interview the facility failed to store and prepare food in accordance with professional standards for food safety.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to complete a Significant Change in Status (SCSA) Minimum Data Assessment (MDS) for one of 17 sampled residents (Resident #15).

Inspectors wroteBased on interview and record review, the facility failed to monitor weights as care planned for 1 of 18 residents sampled (Resident #15) and the facility failed to develop policies that ensure that each resident receives adequate supervision to maintain nutrition status related to weight monitoring and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient supervision for residents with a history of aggressive, disruptive, and intrusive behaviors for 2 applicable residents (Resident #1 and #2). As a result, many residents are at risk of being involved in a resident to resident altercations.

Inspectors wroteBased on interview and record review, the facility failed to ensure that allegations involving abuse are reported to the Administrator of the facility and other officials in accordance with State law for 1 applicable resident (Resident #1) and the facility failed to develop policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act, potentially impacting all residents in the facility.

Inspectors wroteBased on facility policy review and staff interview, the facility failed to develop written policies and procedures that include all the required topics to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property, potentially impacting all residents in the facility.