Citadel Post Acute

Based on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that residents were free from abuse from another resident. The sample size was four out of nine residents.

Resident # 192 and # 3

A facility report submitted to the SA (State Agency) on June 6, 2021, stated that on June 6, 2021, resident # 192 and resident # 3 were in their room. When LPN/staff # 204 (Licensed Practical Nurse) went in the room to give medications to resident # 3, LPN/staff # 204 noticed resident # 3 had a red mark in her eye. LPN/staff # 204 assessed resident # 3 and asked her what happened, resident # 3 stated, "I don't know." While LPN/staff # 204 was assessing resident # 3, resident # 192 approached LPN/staff # 205 and stated, "I did something bad. I hit my roommate, I didn't mean to but she was annoying me."

Resident # 192 was admitted to the facility on November 23, 2019 with diagnoses that included COPD (Chronic Obstructive Pulmonary Disease), heart failure, lupus, emphysema, and left below-the-knee amputation.

A review of resident # 192's clinical record revealed that resident # 192 was assessed on November 23, 2019, with a BIMS score of 15/15 (Brief Interview for Mental Status), indicating that resident # 192 was cognitively intact at the time of this incident.

Resident # 3 was admitted to the facility on October 26, 2018, with diagnoses that included schizophrenia, type 2 diabetes, dementia with behavioral disturbance, osteoporosis, depression, and hypertension.

A review of resident #'s clinical record revealed that resident # 3 was assessed on October 26, 2018, with a BIMS score of 9/15, indicating that resident # 3's cognition was moderately impaired at the time of this incident.

An interview with LPN/staff # 205 was conducted on June 7, 2021, she stated, "Resident # 192 came to me and stated, "I did something bad, I hit my roommate (resident # 3) because she was annoying me." I went to look for resident # 3, separated them and made sure that both resident # 192 and resident # 3 were safe."

An interview with LPN/staff # 204 was conducted on June 6, 2021, she stated, "I noticed a red mark on resident # 3, I took her to the activities room to speak with her and she stated, "I don't know what happened to my eye but I don't want to go back to my room because of my roommate."

Resident # 200 and # 197

A facility report submitted to the SA on August 3, 2021, stated that on August 3, 2021, staff heard yelling coming from resident # 197 and resident # 200's room. LPN/staff # 206 and CNA/staff # 207 (Certified Nurse Assistant) immediately ran in the room. Resident # 197 hit resident # 200 across the head. Resident # 200 stated that resident # 197 struck him across the head. Resident # 200 and resident # 197 were separated and moved resident # 200 to another room.

Resident # 200 was admitted to the facility on July 19, 2021, with diagnoses that included epilepsy, congestive heart failure, major depressive disorder, hypertension, and insomnia.

A review of resident # 200's clinical record revealed that he was assessed on August 6, 2021, with a BIMS score of 11/15, indicating that resident # 200's cognition was moderately intact at the time of this incident.

Resident # 197 was admitted to the facility on July 30, 2021, with diagnoses that included fracture of the right clavicle, muscle weakness, cardiomyopathy, and ventricular tachycardia.

A review of resident # 197's clinical record revealed that resident # 197 was assessed on July 26, 2021, with a BIMS score of 15/15, indicating that resident # 197 was cognitively intact at the time of this incident.
An interview with LPN/staff # 206 was conducted on August 4, 2021, she stated, "they were fine up until resident # 197 lost it and we heard screaming. I separated them immediately. I have never seen behaviors between resident # 200 and resident # 197 prior."

An interview with CNA/staff # 207 was conducted on August 4, 2021, she stated, "I ran into the room after I heard screaming, resident # 200 told me his roommate (resident # 197) hit him across the head when he would not turn off the bathroom light."

The facility's policy on abuse (last reviewed on 9/2020 and last revision on 11/28/2017) states that "It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation." The facility's policy further states, "Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm."

Based on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen; and, failed to ensure that expired food items were not available for resident use. The deficient practice could result in a potential for food borne illness.

Findings include:

An initial observation of the kitchen was conducted with kitchen manager (staff #35) on April 1, 2023 at 8:30 a.m. The following expired food items were found in the refrigerator:
-One open one-gallon container of Kraft mayonnaise with an expiration date of March 23, 2023;
-Open bag of lettuce with a use by date of March 29, 2023; and,
- A 4-quart container of parmesan cheese with a use by date of April 6, 2023.
A testing of four buckets of the sanitizer solution was conducted; and, three out of four buckets tested did not change the color of the test strip. An interview was conducted immediately following the observation with a kitchen staff who stated they had not changed the bucket sanitation fluids since earlier that morning. The kitchen manager stated that the expectations was that the sanitation buckets are at the required 200 ppm (parts per minute) at all times to prevent food borne illness and cross contamination of working surfaces for food and staff complete the logs following completion of their tasks.

During an observation of puree food preparation was conducted with staff #199, #200, #35 and #221 on April 13, 2023 at 11:05 a.m. Staff #199 prepared the main dish of goulash to what she stated was a pureed consistency; and that, the food was ready. She did not taste the food then placed the pureed goulash in a heating dish to be served to those with a puree diet. Staff #199 stated that she knew the goulash was in a pureed consistency just by looking at the food. The pureed goulash was tasted during the observation and reveled that the pureed goulash was thick and grainy, with large particles of food and did not have a smooth consistency. Staffs #221, #35 and #220 sampled the pureed goulash and staffs #221, #35 and #220 stated that the pureed goulash was not prepared at the required consistency. Staff #221 stated the risks of serving the pureed goulash could pose a risk for choking or aspiration for a resident with a puree diet.

Review of the facility policy on General Food Preparation and Handling dated 2018 included that food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. The kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate.

The facility policy on Employee Sanitary Practices revealed that all nutrition and food service employees will practice good personal hygiene and safe handling procedures.

Based on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen; and, failed to ensure that expired food items were not available for resident use.

Findings include:

An initial observation of the kitchen was conducted with kitchen manager (staff #35) on April 1, 2023 at 8:30 a.m. The following expired food items were found in the refrigerator:
-One open one-gallon container of Kraft mayonnaise with an expiration date of March 23, 2023;
-Open bag of lettuce with a use by date of March 29, 2023; and,
- A 4-quart container of parmesan cheese with a use by date of April 6, 2023.
A testing of four buckets of the sanitizer solution was conducted; and, three out of four buckets tested did not change the color of the test strip. An interview was conducted immediately following the observation with a kitchen staff who stated they had not changed the bucket sanitation fluids since earlier that morning. The kitchen manager stated that the expectations was that the sanitation buckets are at the required 200 ppm (parts per minute) at all times to prevent food borne illness and cross contamination of working surfaces for food and staff complete the logs following completion of their tasks.

During an observation of puree food preparation was conducted with staff #199, #200, #35 and #221 on April 13, 2023 at 11:05 a.m. Staff #199 prepared the main dish of goulash to what she stated was a pureed consistency; and that, the food was ready. She did not taste the food then placed the pureed goulash in a heating dish to be served to those with a puree diet. Staff #199 stated that she knew the goulash was in a pureed consistency just by looking at the food. The pureed goulash was tasted during the observation and reveled that the pureed goulash was thick and grainy, with large particles of food and did not have a smooth consistency. Staffs #221, #35 and #220 sampled the pureed goulash and staffs #221, #35 and #220 stated that the pureed goulash was not prepared at the required consistency. Staff #221 stated the risks of serving the pureed goulash could pose a risk for choking or aspiration for a resident with a puree diet.

Review of the facility policy on General Food Preparation and Handling dated 2018 included that food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. The kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate.

The facility policy on Employee Sanitary Practices revealed that all nutrition and food service employees will practice good personal hygiene and safe handling procedures.

Based on document review and interview, the facility failed to review and update the Emergency Preparedness (EP) Plan annually. Failure to develop an emergency plan may cause harm to the patients and staff during an emergency and failure to ensure the EP plan was reviewed annually poses a potential risk that all required revisions to the plan will not be recognized and revised as needed.

Findings include:

Based on document review and interview on April 13, 2022, revealed the facility failed to update the Emergency Preparedness book located at the nurses station. The book was last updated on January 3, 2017.

During the exit interview on April 13, 2022, the above finding was again acknowledged by the management team.

Based on observation the facility failed to maintain two doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on April 13, 2023, revealed the following;

1) patient room 202 had a 1/2 gap on the upper handle side of the door
2) patient room 115 had a 1/2 gap on the upper handle side of the door

Both doors would not contain smoke during a fire.

During the exit conference conducted on April 13, 2023, the above findings were again acknowledged by the management team.

Based on observation, the facility allowed an electrical power cord to be ran through a wall from the kitchen to the dining room. Failure to ensure proper use of electrical cords could lead to circuit overloads or fire which could cause harm to the patients and/or staff.

NFPA 101 2012, 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1 . 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70 , National Electrical Code , unless such installations are approved existing installations, which shall be permitted to be continued in service. NFPA 70 2011, 400.8 Uses Not Permitted. Unless specifically permitted in 400.7 , flexible cords and cables shall not be used for the following: 1. As a substitute for the fixed wiring of a structure. 2. Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors

Observations made while on tour on April 13, 2023, revealed a black power cord was seen in the kitchen plugged into an electrical outlet. The power cord went through the drywall into the dining room. The cord was to a water cooler.
During the exit conference conducted on April 13, 2023 the above finding was again acknowledged by the management team.