Reginald P White Nursing Facility

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from neglect when two (2) staff members completed a resident transfer with a mechanical lift without using the required four (4) staff members for resident safety, which resulted in the resident falling backward for one (1) of three (3) sampled residents. Resident #1.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan interventions related to transferring a resident with a Hoyer (type of mechanical lift) for one (1) of three (3) residents reviewed for care plan implementation. (Resident #1)

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to maintain infection control practices during an annual recertification survey on 1/11/2024 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of three (3) deficiencies cited. (F880) Findings Include: A review of the facility's Quality Assurance document (undated) revealed, .The Outcome Services Division will .Periodically assess information based on established indicators, taking action to solve problems and pursue opportunities to improve quality . [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff followed appropriate infection prevention and control practices for two (2) of 18 sampled residents, Resident #13 and Resident #45. Specifically, the facility failed to ensure Registered Nurse (RN) #2 performed hand hygiene and donned appropriate personal protective equipment (PPE) while administering medications through a Percutaneous Endoscopic Gastrostomy (PEG) tube for Resident #13 who required enhanced barrier precautions (EBP) and failed to ensure Licensed Practical Nurse (LPN) # 1 followed EBP and glove-changing protocols during wound care for Resident #45. The scope/severity for F880 was increased to E due to previous citation on the annual recertification survey on 1/11/24.

Inspectors wroteBased on observation, staff interview, record review, and policy review, the facility failed to ensure nursing services were provided in accordance with professional standards of practice by not verifying Percutaneous Endoscopic Gastrostomy (PEG) placement prior to administering medications for one (1) of four (4) residents observed for medication administration. Resident #13.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical abuse by a staff member for one (1) of three (3) sampled residents. Resident #1. Resident #1 was physically abused on 12/31/24 when a Certified Nurse Assistant (CNA) #1 dragged him by his shirt, the collar, and the shoulders of his jacket up the hallway into Resident #1's room. One nurse observed the abuse and failed to intervene, allowing the abuse to escalate. The facility's failure to protect Resident #1 from abuse placed this resident and all residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy and Substandard Quality of Care (SQC) that began on 12/31/24. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to implement its abuse policy, allowing an abusive act to occur without staff intervening or prompt reporting for one (1) of three (3) sampled residents. Resident #1. Resident #1 was physically abused on 12/31/24 when Certified Nurse Assistant (CNA) #1 dragged him by his shirt, the collar, and the shoulders of his jacket up the hallway into Resident #1 room. One nurse observed the abuse and failed to intervene, allowing the abuse to escalate. The facility's failure to implement abuse policies and protect Resident #1 from physical abuse and the facility's failure to intervene placed this resident and all residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy and Substandard Quality of Care (SQC). [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to report abuse in a timely manner for one (1) of three (3) sampled residents. Resident #1. Resident #1 was physically abused on 12/31/24 when a Certified Nurse Assistant (CNA) #1 dragged him by his shirt, the collar, and the shoulders of his jacket up the hallway into Resident #1 room. One nurse observed the abuse and failed to report it to the Director of Nursing (DON) or other staff. The facility's failure to report Resident #1's abuse placed this resident and all residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be Immediate Jeopardy and Substandard Quality of Care (SQC) which began on 12/31/24. The State Agency (SA) notified the Administrator of the IJ and SQC on 2/11/25 at 4:45 PM and provided an IJ Template. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for a resident with behaviors for one (1) of three (3) sampled residents. Resident #1. Resident #1 was physically abused on 12/31/24 when Certified Nurse Assistant (CNA) #1 dragged him by his shirt, the collar, and the shoulders of his jacket up the hallway into Resident #1 room. One nurse observed the abuse and failed to intervene, allowing the abuse to escalate. The facility's failure to implement the care plan interventions placed this resident and all residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 12/31/24. The State Agency (SA) notified the Administrator of the IJ on 2/11/25 at 4:45 PM and provided an IJ Template. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to record daily temperatures for refrigerators and a freezer for the last six (6) days prior to survey entrance on 01/08/24 and failed to date and label stored food in the facility refrigerator for one (1) of two (2) kitchen observations. The deficient practice had the potential to affect 50 of 59 residents in the facility.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident had a dignified dining experience for (1) one of seven (7) resident dining observations. (Resident #160)

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by staff failing to correctly wear a face mask on one (1) of four (4) days of survey and failed to perform hand hygiene during wound care for one (1) of five (5) wounds observed. (Resident # 57)

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents had readily available and reasonable access to their personal funds, seven (7) days a week, for four (4) of 15 residents sampled. Resident #8, Resident #10, Resident #34, and Resident #45 Findings Included: A review of the facility's Money Policy for Individuals Receiving Services/Residents, revised March 2020, revealed, . F. Money Call is the time established by the Division Director or Fiscal Services Director, during which, an IRS (Individual Receiving Service)/resident is distributed money from his/her RFMS (Resident Fund Management Service) account, held by their designated money custodian .G. Money day is one of the scheduled days when Patient Accounts issues cash and checks from the (Proper Name of Facility) Resident Trustee Account to the money custodians . [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to accurately code the admission Minimum Data Set (MDS) related to a resident's reentry into the facility from an acute care hospital for one (1) of 17 residents reviewed for MDS accuracy. Resident #46. Findings Included: A review of the facility's Minimum Data Set (MDS) policy, revised August 2022, revealed, .2. Purpose: The purpose of this policy is to .establish the framework for organizing an individual plan of care . A record review of the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2019, revealed, .A1800: Entered From .Item Rational .Understanding the setting that the individual was in immediately prior to facility .reentry informs care planning and may also inform discharge planning and discussions . [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide mail delivery on Saturdays for three (3) of 15 sampled residents and had the potential to affect 57 of 57 residents residing in the facility. Resident #10, Resident #45, and Resident #46 Findings Included: Review of the facility's policy Mail Distribution, with a revision date of May 2021, revealed, 1. Policy It is the policy of (Proper Name of Facility) that Mail Room staff will distribute and process all internal, external, and accountable mail that is delivered to the .Nursing Home Division (NHD) .9. USPS (United State Postal Service) delivers all NHD residents incoming mail to the facility mailbox on Saturday to ensure residents receive mail six days a week. Mail will be sorted and disturbed to the residents and or the residents Social Worker . [...]