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PRUITTHEALTH–CRESTWOOD: FAMILY STATED, “NO ONE RESPONDED” TO THEIR CALL FOR HELP.”...

PRUITTHEALTH – CRESTWOOD LOCATED: 415 PENDLETON PLACE, VALDOSTA, GA 31602 PRUITTHEALTH – CRESTWOOD 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 PROVIDE NECESSARY CARE AND SERVICES TO MAINTAIN THE HIGHEST WELL BEING OF EACH RESIDENT LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined the facility failed to provide care and services in a timely manner for one resident (R#39) of 28 sampled residents. Resident (R) #39 was found unresponsive to voice and touch on 4/4/16. The nurse failed to assess and provide treatment to the resident. R#39 was transported to the hospital via ambulance four hours after the initial nursing assessment. This standard was cited at harm level. On 2/28/17 at 11:35 a.m., an interview with complainant in R#39’s room stated, my sister received a call to come see about our mother. I was just coming to visit and she (R#39) was non- responsive in her room in the bed. Pushed the call light and no one responded. Told a CNA (Certified Nursing Assistant) to go get LPN HH. She never came. I went to go find LPN HH. LPN HH tried to wake her up and I insisted that she call 911. Someone finally called 911. One of the hospital nurses said that she (R#39) had been given too much medicine. They gave her [MEDICATION NAME] (treats narcotic overdose) more than once to bring her back. Review of nurse’s notes dated 4/3/16 at 2:50 p.m., for R #39 revealed Resident noted c (with) slight SOB (shortness of breath) .placed on 3 (three) day charting for observation. Will cont. (continue) to observe. There was no documentation indicating LPN HH assessed nor provided recommended interventions for R #39 at that time. Nurse’s notes dated 4/3/16 at 4:30 p.m., revealed Blood sugar 238, resident non-responsive to physical or verbal stimuli, 10 units [MEDICATION NAME] (insulin) given .Family at bed side. The nurse’s note lacked documentation indicating R#39’s oxygen level was being monitored due to the display of SOB. The following events were documented on 4/3/16: At 4:45 p.m., R#39 remains unresponsive O2 sat @ (at) 88% on 3L (three) O2. (The physician’s orders [REDACTED]. 5:30 p.m., Daughter called this nurse into see resident. Unable...

CLAIRMONT LONGVIEW -RN A TOLD HIM THAT SHE GAVE RESIDENT #1 A SANDWICH AND ASKED CNA D “NOT TO TELL ANYBODY”...

CLAIRMONT LONGVIEW LOCATED: 3201 N FOURTH ST, LONGVIEW, TX 75605 CLAIRMONT LONGVIEW 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 observation, interview, and record review, the facility failed to ensure 1 of 8 residents reviewed for neglect (Resident #1) was free from neglect. The facility did not ensure Resident #1 received the physician ordered diet. Resident #1 had orders for a pureed diet, and ate a peanut butter sandwich. Resident #1 choked on the sandwich which likely contributed to his death. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]; however, the facility remained out of compliance at isolated actual harm due to the facility’s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 38 residents receiving mechanically altered diets, including pureed diets, at risk for harm or death. A physician progress notes [REDACTED] #1 had dysphagia and required aspiration precautions. During an interview on [DATE] at 3:31 p.m., CNA C said on [DATE] she was working on the secure unit. She said between 8:45 p.m. and 8:55 p.m., she saw Resident #1 sitting in a chair with a bed side table in front of him, by the nursing station of Hall 100. She said they spoke to each other and then she went into the secure unit. She said approximately, [DATE] minutes later, she came out of the secure unit and Resident #1 was lying across the bedside table, his eyes and mouth were open, and his lips were blue. She said she began screaming at the 2 nurses sitting behind the nursing station that Resident #1 was blue. She said she pulled Resident #1 from the chair and began performing the [MEDICATION NAME] maneuver. She said a piece of bread that smelled like peanut butter came out of his mouth. She said the nurses began CPR and EMS arrived. She said the nurses were seated behind the nursing station and they could not have seen Resident #1 where he was seated. She said the snack tray that included peanut butter sandwiches were...

HOSPITAL NOTES, “CAME FROM NH WITH BEDSORES, CRUSTY CATHETER, DRIED BOWEL MOVEMENT ON SKIN AND BRUISES”...

FOREST HILLS CARE AND REHABILITATION CENTER LOCATED: 4300 WEST HOUSTON, BROKEN ARROW, OK 74012 FOREST HILLS CARE 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 GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW BED (PRESSURE) SORES OR HEAL EXISTING BED SORES. LEVEL OF HARM –ACTUAL HARM **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined the facility failed to identify and provide treatment to prevent the development of an avoidable pressure ulcer for two (#375 and #385) of three sampled residents who were reviewed for pressure ulcers. The facility identified 12 residents who had pressure ulcers. Resident # 385 had multiple untreated unstageable pressure ulcers to his buttocks and penis. A history and physical report from the hospital, dated 01/19/17 at 3:54 a.m., documented, .patient’s nursing home staff noticed that his urine was darker than normal and they thought he might be getting dehydrated or have a urine infection so he was subsequently transferred to (hospital name deleted) for further evaluation and treatment .Skin: warm and dry color appropriate in all limbs. No [DIAGNOSES REDACTED], or induration on exposed observed areas of head, neck, and limbs. A case management discharge planning note from the hospital, dated 01/19/17 at 2:08 p.m., documented, nursing staff informed that they are very concerned about possible abuse/neglect while at the nursing home .pt is very excoriated on his bottom and has an unstageable pressure ulcer on his bottom as well. pt’s catheter does not appear to have been cared for .pt has a pressure ulcer on his penis. A hospital progress note, dated 01/19/17 at 4:36 p.m., documented, .Pt came from NH with unshakeable (sic) wound on sacrum, and one on tip of penis also has blister on left heel. His f/c very crusty and peri area red with blisters and dried bowel movement on skin .also has bruising around waist. Wound consult ordered. A hospital medical discharge summary, dated 01/28/17, documented, .Discharge [DIAGNOSES REDACTED].sepsis present on admission secondary to the above .multiple unstageable decubitus ulcer. At 11:35 a.m., LPN #2 was asked when she was aware of the skin breakdown on the resident’s sacrum and coccyx. She stated It was about nine p.m., on the evening he was transferred....

STAFF STATES,” FORMER ADMINISTRATOR JUST WALKED OUT OF THE ROOM AND NEVER ACKNOWLEDGED THAT WE TOLD HIM ANYTHING.”...

SIGNATURE HEALTHCARE AT JACKSON MANOR REHABILITATION & WELLNESS LOCATED: 96 HIGHWAY 3444, HOUSTON, ANNVILLE, KY 40402 SIGNATURE HEALTHCARE AT JACKSON MANOR REHABILITATION & WELLNESS 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 1) HIRE ONLY PEOPLE WITH NO LEGAL HISTORY OF ABUSING, NEGLECTING OR MISTREATING RESIDENTS; OR 2) REPORT AND INVESTIGATE ANY ACTS OR REPORTS OF ABUSE, NEGLECT OR MISTREATMENT OF RESIDENTS. 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 ensure allegations of abuse were thoroughly investigated, failed to ensure residents were protected from further abuse, and failed to report allegations to state agencies as required, for one (1) of two (2) sampled residents (Resident #2). Facility staff reported to the former Director of Nursing (DON) and the former Assistant DON on [DATE] that Resident #1 was observed to take Resident #2’s hand and place it on his/her private part and rub himself/herself. The facility failed to conduct an investigation related to the alleged incident, failed to protect residents from further abuse, and failed to report the alleged incident to state agencies. The facility’s failure to ensure allegations of abuse were thoroughly investigated, failure to ensure residents were protected from further abuse, failure to ensure abuse allegations were reported to state agencies, as well as failure to review/revise residents’ plans of care when inappropriate sexual behavior was observed, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE], and was determined to exist on [DATE]. The facility submitted an acceptable Allegation of Compliance (AOC) on [DATE] alleging the Immediate Jeopardy was removed on [DATE]. Based on the State Survey Agency’s (SSA) validation of the AOC it was determined the Immediate Jeopardy was removed on [DATE] prior to the SSA initiating the investigation on [DATE]; therefore, it was determined to be Past Immediate Jeopardy. Interview on [DATE] at 3:45 PM with the Assistant Business Office Manager revealed she had witnessed Resident #1 take Resident #2’s hand and place it on his/her private part and rub himself/herself on [DATE]. She stated she felt the incident was potential abuse and immediately reported the incident...

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...