State Findings:
Harm-level deficiencies were cited regarding abuse/neglect, falls and accidents, timely assessment and treatment after accidents with injury, and behavioral and mental health services.
These deficiencies were cited previously during a recertification survey ending on [DATE]. Although the facility corrected the deficiencies, based on the finding below, the facility had not maintained compliance with these regulatory requirements with additional failures of reporting of alleged violations, services provided meet professional standards, quality of life, sufficient nursing staff, free of medication error rates of 5% or more, and labeling of stored drugs and biologicals.
-F600, abuse and neglect, cited at harm level. The facility failed to ensure residents were free from
resident-to-resident and staff-to-resident abuse, resulting in residents experiencing verbal, physical and psychosocial abuse. A resident expressed fear after being repeatedly pursued and verbally and physically abused by another resident. Residents on the secure unit suffered resident-to-resident physical abuse, and a resident experienced verbal abuse/neglect by staff that the facility failed to prevent and investigate.
-F604, right to be free from physical restraints. A resident’s wheelchair brakes were repeatedly locked so the resident struggled and was unable to maneuver away from the dining room table. Staff said they typically locked residents’ wheelchair brakes so they would not leave the dining room before meals were served.
-F658, professional nursing standards, cited at harm level. The facility failed to provide timely assessment and treatment after a resident fell and sustained a fractured ankle. Assessment and treatment were delayed, causing the resident undue pain. The facility further failed to perform neurological checks after falls with potential head injuries, and administer medications per physician orders.
-F686, treatment/services to prevent/heal pressure ulcers. A resident was readmitted to the facility with a stage II pressure ulcer and nursing staff failed to provide treatment for [MEDICAL RECORD OR PHYSICIAN
ORDER] .
-F688, increase/prevent decrease in ROM/mobility. The facility failed to provide physician-ordered treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] .
-F689, free of accident hazards/supervision/devices, cited at harm level. A resident suffered second degree [CONDITION(S)] during misuse of diathermy equipment during therapy. A second resident, who needed supervision for ambulation, fell multiple times culminating in a fall with head injury resulting in a hospital visit and sutures.
-F725, sufficient nursing staff. The facility failed to provide sufficient and competent staff to meet residents’ needs. Residents in a group interview said they had been complaining for months about short staffing and the facility failed to respond.
-F740, behavioral health services, cited at harm level. A resident with court-ordered medications refused and did not receive medications, decompensated, experienced a mental health decline, and was hospitalized as a result.
-F744, treatment/services for residents with dementia. The facility failed to provide person-centered dementia care to residents to ensure their needs were met, which contributed to resident-to-resident abuse.
-F759, failure to ensure the medication error rate was 5% or less
-F761, failure to properly label/store drugs and biologicals
-F812, failure to ensure resident snacks were not expired, creating the potential for foodborne illness
-F838, facility assessment and failure to ensure plans were developed and followed for residents who required court-ordered medications
-F842, failure to document complete and accurate medical records
-F867, QAPI/QAA improvement activities. The facility failed to identify and create effective action plans to prevent recurrence and address quality of life and quality of care deficiencies.
-F921, safe/functional/sanitary/comfortable environment. The facility failed to ensure resident rooms and showers were safe, clean, functional and homelike.
Your Experience Matters
...and we want to hear it.
NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
You can make a difference, even if your loved one has already passed away.
Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
Personal Note from NHA-Advocates
NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety.
If you are struggling and upset, click here to understand your options, or contact us through our contact form or call our toll free hot line number: 1-800-645-5262.
