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HIGHLANDS HEALTH AND REHABILITATION CENTER – EMPLOYEE ALLOWS RESIDENT TO EXIT BUILDING...

HIGHLANDS HEALTH AND REHABILITATION CENTER LOCATED: 1705 STEVENS AVENUE, LOUISVILLE, KY 40205 HIGHLANDS HEALTH AND REHABILITATION CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility’s policy, it was determined the facility failed to have an effective system to ensure residents received adequate supervision to prevent an incident of elopement for three (3) of twelve (12) sampled residents, Residents #1, #2, and #3. On 10/21/16, Resident #1 eloped from the facility without staff knowledge. The resident was found, at approximately 4:00 PM, off the facility’s grounds walking down the sidewalk. At 3:00 PM, Licensed Practical Nurse (LPN) #3 observed Resident #1 seated in his/her room, upset, and stating he/she needed to go home. LPN #3 did not provide supervision or redirectional activities per the care plan and walked into the closed medication room. No other staff was available on the unit at the time. The facility’s investigation determined the resident took the elevator to the lobby where Receptionist #2 keyed in the alarm code to the front door and allowed the resident to exit the building. The recorded weather conditions on 10/21/16 at 2:31 PM included a high of sixty-two (62) degrees Fahrenheit with cloudy skies. The resident was returned to the facility uninjured. Additionally, the facility failed to provide supervision to mitigate the risk of elopement for Residents #2 and #3. The facility assessed Resident #2 as at risk for elopement; however, allowed the resident to sign himself/herself out of the facility and sit on the front porch unsupervised on eleven (11) occasions. Resident #3 was care planned for supervision when he/she went off the unit; however, the facility allowed the resident to wander the building unsupervised and he/she attempted to elope from the facility on 10/30/16. Interview with the Activities Assistant, on 11/02/16 at 9:20 AM, revealed he observed Resident #1 through a window and the resident was out of the facility unsupervised. He stated he was in the smoking room on the ground floor of the facility located across...

DIVERSICARE OF NICHOLASVILLE – RESIDENT VERBALLY ABUSED MULTIPLE TIMES...

DIVERSICARE OF NICHOLASVILLE LOCATED: 100 SPARKS AVENUE, NICHOLASVILLE, KY 40356 DIVERSICARE OF NICHOLASVILLE was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS. LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility’s Policy, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse for one (1) of eight (8) sampled residents (Resident #1). Per staff interview Certified Nurse Aide (CNA) #1, and other staff witnessed verbal abuse on 02/18/17 at approximately 4:25 PM when Licensed Practical Nurse (LPN) #1 was in Resident #1’s face yelling it’s not happening today. I’m not doing it LPN #1 then told the resident he/she was lying about smoking after the resident requested a smoke break. CNA #1 immediately reported this to the Director of Nursing Service (DNS). The DNS immediately questioned LPN #1, who denied the allegation, stating she had to talk loudly because Resident #1 had his/her radio turned up loud and ear buds in at the time. However, staff interviews revealed Resident #1 was not listening to the radio and did not have ear buds in at the time of the incident. The DNS counseled the nurse on the resident smoking policy; however, did not further investigate the allegation. Subsequently, per staff interview, CNA #2 and other staff witnessed verbal abuse again on 02/18/17 at approximately 5:00 PM between LPN #1 and Resident #1. CNA #2 pushed Resident #1 via wheelchair to the nurses’ station per the resident’s request. LPN #1 then yelled in front of the resident (he/she) can’t sit here with all this stuff! I don’t want (him/her) here. I don’t want to see (his/her) face. LPN #1 then told CNA #2 in front of Resident #1, I don’t care if it’s (his/her) home or not, it’s not happening. CNA #2 immediately went to the DNS to report the incident. However, the DNS only interviewed CNA #1, CNA #2 and LPN #1 after the incidents, and failed to question any additional employees or residents who may have been witnesses. Also, the DNS failed to report the incidents to the facility’s Administrator. On...

DIVERSICARE OF NICHOLASVILLE – RESIDENT VERBALLY ABUSED MULTIPLE TIMES...

DIVERSICARE OF NICHOLASVILLE LOCATED: 100 SPARKS AVENUE, NICHOLASVILLE, KY 40356 DIVERSICARE OF NICHOLASVILLE was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS. LEVEL OF HARM –IMMEDIATE JEOPARDY **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility’s Policy, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse for one (1) of eight (8) sampled residents (Resident #1). Per staff interview Certified Nurse Aide (CNA) #1, and other staff witnessed verbal abuse on 02/18/17 at approximately 4:25 PM when Licensed Practical Nurse (LPN) #1 was in Resident #1’s face yelling it’s not happening today. I’m not doing it LPN #1 then told the resident he/she was lying about smoking after the resident requested a smoke break. CNA #1 immediately reported this to the Director of Nursing Service (DNS). The DNS immediately questioned LPN #1, who denied the allegation, stating she had to talk loudly because Resident #1 had his/her radio turned up loud and ear buds in at the time. However, staff interviews revealed Resident #1 was not listening to the radio and did not have ear buds in at the time of the incident. The DNS counseled the nurse on the resident smoking policy; however, did not further investigate the allegation. Subsequently, per staff interview, CNA #2 and other staff witnessed verbal abuse again on 02/18/17 at approximately 5:00 PM between LPN #1 and Resident #1. CNA #2 pushed Resident #1 via wheelchair to the nurses’ station per the resident’s request. LPN #1 then yelled in front of the resident (he/she) can’t sit here with all this stuff! I don’t want (him/her) here. I don’t want to see (his/her) face. LPN #1 then told CNA #2 in front of Resident #1, I don’t care if it’s (his/her) home or not, it’s not happening. CNA #2 immediately went to the DNS to report the incident. However, the DNS only interviewed CNA #1, CNA #2 and LPN #1 after the incidents, and failed to question any additional employees or residents who may have been witnesses. Also, the DNS failed to report the incidents to the facility’s Administrator. On...

SIGNATURE HEALTHCARE AT HERITAGE HALL – NURSE AIDE FAILS TO REPORT FALL...

SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS CENTER LOCATED: 331 SOUTH MAIN STREET, LAWRENCEBURG, KY 40342 SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS. LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility’s policy, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision and assistance devices to prevent a fall when one (1) staff member attempted to transfer the resident without assistance and without use of a mechanical lift as directed by the facility’s policy and the resident’s Comprehensive Care Plan. On 08/19/16, at approximately 5:00 AM, State Registered Nurse Aide (SRNA) #10 independently attempted to transfer Resident #1 from the bed to the wheelchair without requesting assistance and without utilizing a mechanical lift. Review of the facility’s investigation findings, revealed Resident #1 slid off the side of the bed onto the floor during the transfer. After Resident #1 sustained the fall, SRNA #10 failed to report the fall to the nurse in order for the resident to be assessed for injuries, and instead transferred the resident to the wheelchair with a gait belt, with the assistance of SRNA #7. The resident was not assessed for injuries until 08/19/16 at approximately 1:30 PM. an order for [REDACTED]. On 08/19/16 at 10:45 PM Emergency Medical Services (EMS) was contacted to transfer the resident to the local hospital emergency room and the resident was admitted to the hospital.   Review of Resident #1’s Diagnostic Imaging Report from the ED, dated 08/20/16, revealed a Intertrochanteric Left Femoral Neck Fracture of the Left Hip. Further interview with RN #2, revealed the ARNP was present in the facility at the time she assessed Resident #1, and she obtained orders from the ARNP for an X-ray at 2:00 PM; however, she stated at that point she had not been notified the resident had sustained a fall during the previous shift. She revealed she was notified by the Director of Nursing (DON) on the afternoon of 08/19/16,...

SIGNATURE HEALTHCARE AT HERITAGE HALL – NURSE AIDE FAILS TO REPORT FALL...

SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS CENTER LOCATED: 331 SOUTH MAIN STREET, LAWRENCEBURG, KY 40342 SIGNATURE HEALTHCARE AT HERITAGE HALL REHAB & WELLNESS CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS. LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility’s policy, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision and assistance devices to prevent a fall when one (1) staff member attempted to transfer the resident without assistance and without use of a mechanical lift as directed by the facility’s policy and the resident’s Comprehensive Care Plan. On 08/19/16, at approximately 5:00 AM, State Registered Nurse Aide (SRNA) #10 independently attempted to transfer Resident #1 from the bed to the wheelchair without requesting assistance and without utilizing a mechanical lift. Review of the facility’s investigation findings, revealed Resident #1 slid off the side of the bed onto the floor during the transfer. After Resident #1 sustained the fall, SRNA #10 failed to report the fall to the nurse in order for the resident to be assessed for injuries, and instead transferred the resident to the wheelchair with a gait belt, with the assistance of SRNA #7. The resident was not assessed for injuries until 08/19/16 at approximately 1:30 PM. an order for [REDACTED]. On 08/19/16 at 10:45 PM Emergency Medical Services (EMS) was contacted to transfer the resident to the local hospital emergency room and the resident was admitted to the hospital.   Review of Resident #1’s Diagnostic Imaging Report from the ED, dated 08/20/16, revealed a Intertrochanteric Left Femoral Neck Fracture of the Left Hip. Further interview with RN #2, revealed the ARNP was present in the facility at the time she assessed Resident #1, and she obtained orders from the ARNP for an X-ray at 2:00 PM; however, she stated at that point she had not been notified the resident had sustained a fall during the previous shift. She revealed she was notified by the Director of Nursing (DON) on the afternoon of 08/19/16,...

LAS PALOMAS CENTER– SANE EXAM SHOWED TRAUMA

LAS PALOMAS CENTER LOCATED: 8100 PALOMAS AVENUE, ALBUQUERQUE, NM 87109 LAS PALOMAS was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies: PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here. FACILITY FAILED TO PROTECT EACH RESIDENT FROM ALL ABUSE, PHYSICAL PUNISHMENT, AND BEING SEPARATED FROM OTHERS LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents were free from alleged sexual abuse for 1 (R #1) of 4 (R #1, 2, 3, 4) residents reviewed for abuse. This deficient practice resulted in R #1 experiencing feelings of anxiety, fear, discomfort and led to her having nightmares. The findings are: On 12/30/16 at 8:22 am, during an interview with the PTA (physical therapy assistant), she stated that R #1 came to therapy and told her that something strange happened. R #1 told PTA that on 09/12/16 she woke up to CNA #1 (certified nursing assistant) massaging her. PTA stated that R #1 told her that she woke up and CNA #1 was sitting on her bed and rubbing her. PTA also stated that R #1 was very concerned when telling her what happened. On 12/30/16 at 8:31 am, during an interview with the DON (Director of Nursing), she stated that R #1 told her that there was not penile penetration, but that CNA #1 did put his hand in R #1’s vagina. The DON stated that after R #1 disclosed this to her she (R #1) did agree to get a SANE (Sexual Assault Nursing Exam). On 12/30/16 at 10:10 am, during an interview with the SSD (social services director) she stated that she was the first person to interview R #1 regarding the alleged abuse. The SSD stated that R #1 informed her that the encounter took place after she (R #1) went to bed and lasted around thirty minutes. The SSD also stated that R #1 wasn’t able to pinpoint the exact time of the alleged abuse because it was very dark in the room at that time. R #1 told SSD #1 that CNA #1 was going to massage her leg and she told him that is not my leg. On 12/30/16 at 10:45 am, during an interview with CNA #1, he stated that he was called in by the Administrator...