Falkville Rehabilitation And Healthcare Center

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an effective process was developed and implemented to record and honor residents’ end-of-life decisions. Survey review found that multiple DNR forms were incomplete or inaccurate, including missing or incorrect signatures and dates, and that supporting POA, Living Will, or surrogate documentation was absent from the medical records for several residents. The deficiency affected 13 of 36 residents reviewed for code status and was cited under F578 for failure to honor the right to request, refuse, or discontinue treatment and to formulate an advance directive. The most serious event involved a resident with vascular dementia, diabetes mellitus, heart failure, and unspecified convulsions. The resident’s chart contained a care plan directing staff to withhold life-saving measures and an invalid DNR form. The DNR form had the wrong section signed, and the record did not contain the necessary surrogate paperwork. When the resident’s condition declined, staff initiated life-saving measures and CPR after a spouse/roommate verbally requested help, without verifying the resident’s code status. The resident received manual chest compressions and an intraosseous catheter was inserted before the resident expired. Surveyors also found that staff were not aware of the process to rescind a DNR in an emergent situation. Interviews showed conflicting understanding among staff and leadership about who could revoke a DNR and what documentation was required. Additional residents had incomplete or unsupported DNR documentation: one resident’s DNR was signed in the health care proxy section without POA or Living Will documents in the record; another resident’s DNR was signed in the surrogate section without surrogate paperwork until later during the survey; another had a physician signature without a date; and another had surrogate consent documented by nurses based on a telephone request but no supporting surrogate document in the record until later during the survey. The report also identified two residents who were not provided an opportunity and instructions on how to formulate an advance directive.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and an environment free of potential fire hazards when a resident repeatedly vaped in bed and in the resident room despite the facility’s vaping policy requiring use only in designated areas. Resident #3 had diagnoses including epilepsy, hemiplegia and hemiparesis, PTSD, anxiety, major depressive disorder, delusional disorders, visual hallucinations, mood disorder, dementia with behavioral disturbance, suicidal ideations, and nicotine dependence. The resident’s MDS showed a BIMS score of 6, indicating moderate cognitive impairment, and the resident was documented as using tobacco products. The resident’s record showed smoking/vaping assessments stating the resident used vape products and followed the facility’s policy, and the care plan directed staff to monitor vaping safety and ensure use in a designated location. However, progress notes documented the resident enjoying lying in bed and vaping, and a NP observed the resident resting in bed and vaping. Multiple staff members stated the resident was frequently seen vaping in the room, hiding vape devices, and obtaining replacement devices from a family member after staff removed them. Staff also stated this behavior was widely known, but the resident’s care plan was not revised to address the noncompliance. Survey observations found the resident’s vaping materials stored at the nurses’ station in a labeled container that contained six different brands of vaping devices with lithium-ion batteries. Interviews with the NP, CNA/CMA staff, UM, SSD, DON, ADM, and the resident confirmed that the resident continued to vape in the room and that family members repeatedly brought in new devices. The report also identified that another resident, Resident #60, who had chronic respiratory failure with hypoxia, dysphagia, pleural effusion, and cognitive communication deficit, had smokeless tobacco and used tobacco packets at the bedside, but no Resident Safe Smokeless Tobacco Assessment was documented and the care plan did not address smokeless tobacco use.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address repeated resident vaping behaviors and failed to provide behavioral health care and services for a resident who was known to vape in the room, including in bed, and to hide vape paraphernalia from staff. Resident #3 had diagnoses including epilepsy, hemiplegia and hemiparesis affecting the left dominant side, PTSD, anxiety, major depressive disorder, delusional disorders, visual hallucinations, mood disorder, dementia with other behavioral disturbance, suicidal ideations, and nicotine dependence. The resident’s BIMS score was 6, indicating moderate cognitive impairment, and the resident currently used tobacco products. The resident’s records showed a smoking safety assessment and care plan that identified vaping in a designated area, but the care plan was not revised to reflect repeated non-compliance with the vaping policy or the family member’s repeated provision of vape supplies. The record also showed no interventions for staff to observe for vape paraphernalia in the room or instructions for what staff should do when non-compliance was witnessed. Multiple staff members stated the resident was frequently seen vaping in the room or had vape devices on the bedside table, and that the resident hid vape devices from staff. Staff also stated family members repeatedly brought in replacement vape devices after staff removed them. Progress notes documented that the resident enjoyed lying in bed and vaping, and a nurse practitioner documented the resident resting in bed, watching TV, and vaping. Despite these observations, the behavior monitoring record contained no documentation of vaping-related behaviors or non-compliance, and the incident log showed no incidents involving the resident’s non-compliance with the vaping policy. Staff interviews reflected that the behavior was widely known, but it was not consistently documented or incorporated into the resident’s care plan, and the resident’s family member stated they were unaware they needed to bring vape devices to the nurse’s station instead of giving them directly to the resident.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Administration failed to address ongoing resident non-compliance with the facility’s vaping policy. The facility had created a QAPI plan for vaping non-compliance, but the report states that no further action was taken to address continued non-compliance by one resident who kept vaping in his/her room. Staff interviews described that the resident repeatedly hid vaping devices in the room, and family members continued bringing in replacement devices after staff confiscated them. Multiple staff members, including the NP, ADON/IP, UM, SSD, DON, and ADM, were aware of the repeated vaping in the resident’s room, but the behavior continued to be described as ongoing and long-standing. The report also states that the resident did not have a signed Facility Non-Smoking & Vaping Policy Acknowledgement or Vapers Sign In Sheet on file, despite the facility’s vaping policy requiring indoor vaping to be prohibited and vaping devices to be stored with nursing staff. The SSD stated that when the resident was non-compliant, she would tell the DON or ADM, but she did not document it anywhere. The DON stated the resident’s care plan was not up to date with the resident’s non-compliance and should have been, and also stated there were no care conference notes about discussing the family member bringing vape supplies to the resident’s room. The report further describes a separate deficiency involving Advance Directives and code status documentation. Records for 13 residents reviewed for code status were incomplete and/or invalid and did not include required POA, Living Will, or Surrogate paperwork as indicated. The Medical Director stated he had signed DNR forms in pen when prepared and was not aware of a blank DNR with his signature on it. The MRD was found to have a folder containing a blank DNR form with a photocopied physician signature, along with completed DNR forms that also contained photocopied physician signatures and no dates. Staff interviews showed that the AD, SSD, MRD, and previous MR staff had not received training on the DNR process, and the Regional Nurse Consultant stated she was not sure whether those people had been trained or educated on the process.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Medical Director failed to provide oversight to ensure residents’ end-of-life wishes were honored, including completion of the Alabama portable physician DNR form and oversight of a facility process for rescinding a DNR order in emergent situations. Survey findings showed that staff were unsure how to revoke a DNR, and the facility did not have a clear, consistently understood process for handling a change in code status during an emergency. The deficiency was identified after staff provided CPR to a resident who had a DNR order. The resident’s DNR form was invalid, and the resident’s surrogate paperwork was not in the medical record. The resident later expired. During interviews, multiple staff members, including an LPN, the SSD, the MRD, and the AD, stated they were unsure of the correct process for rescinding a DNR. The MRD stated she did not know whether the facility had a policy for rescinding a DNR in an emergent situation. The Medical Director stated that in the situation involving the resident, staff should do what the family said and provide CPR if the spouse or family member wanted it, even if a DNR order existed. He also stated he expected DNR forms to be completed correctly and that the facility should have all required documents, but he could not recall who notified him that the resident’s DNR had been rescinded and did not recall documenting it. Survey review also found blank and completed DNR forms with photocopied physician signatures and no dates in a folder maintained by the MRD.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure its QAPI program was developed, implemented, and monitored for effectiveness after adverse events involving resident vaping and code status management. A facility QAPI plan had been created after the Administrator learned that residents were vaping in their rooms and that new admissions were arriving with vaping devices, but the survey found the plan was not fully executed or audited for effectiveness. The record showed the facility identified that staff were not educated on the vaping policy and that an established system for compliance was lacking, yet the resident involved continued to vape in the room unsupervised, including vaping in bed, while the facility’s documentation did not show that the QAPI process had effectively addressed the issue. The facility also failed to properly manage and review an incident in which staff initiated CPR on a resident who had an active DNR order. Staff did not check the resident’s code status before starting chest compressions and activating EMS, and they did not provide rescue breaths during the resuscitation efforts. The resident’s medical record contained incomplete and invalid documentation regarding DNR status, and the survey found that the QAPI committee did not identify that DNR forms needed to be reviewed for accuracy and completeness, including supporting POA, Living Will, or surrogate paperwork. In addition, the QAPI process did not identify that staff needed education on code status procedures or that the facility needed a process to ensure staff were aware of how a DNR could be rescinded. The deficiency affected 13 residents reviewed for code status and had the potential to affect all residents in the facility. The report also states that the facility’s noncompliance with participation requirements caused or was likely to cause serious injury, serious harm, serious impairment, or death to residents.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure staff provided BLS in accordance with accepted guidelines during an attempted resuscitation of a resident who had diagnoses including vascular dementia, diabetes mellitus, heart failure, and unspecified convulsions. The resident’s care plan identified an Advance Directive that included a DNR, and the record also contained an Alabama Portable Physician Do Not Attempt Resuscitation Order, although the consent section was signed by a family member and was noted as invalid. Staff later reported they could not locate the resident’s code status in the electronic record at the time of the emergency. After the resident fell and was assisted from the floor to the bathroom and then back to bed, staff documented that the resident became diaphoretic, had decreasing oxygen saturations, and continued to decline. The resident then became unresponsive. An LPN began chest compressions, and a CMA attempted to provide breaths, but both staff members stated the manual respirator did not fit correctly and they could not say for sure that rescue breaths were given. Another staff member stated she did not recall rescue breaths being administered. The facility record contained no other documentation of the resuscitation efforts. Interviews showed that staff believed the resident was DNR, but CPR was still initiated and continued until EMS arrived. The resident’s RP and family member both stated the resident was DNR. EMS documentation stated a facility healthcare provider was the first to initiate CPR, that nursing facility staff were doing manual compressions when EMS arrived, and that EMS then continued CPR, started an IO line, and administered emergency medications before pronouncing the resident deceased. The EMS report did not document that facility staff provided rescue breaths or that EMS was informed of the resident’s DNR status.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its infection prevention and control program by not carrying out a water management program that identified areas of the water system vulnerable to Legionella growth. The facility’s undated Water Management Program stated that part of its scope was identifying potentially hazardous areas or devices where Legionella could grow and spread. Review of the program showed that on [DATE], Legionella testing was performed at four locations in the facility, and the room [ROOM NUMBER] sink, room [ROOM NUMBER] sink, room [ROOM NUMBER] sink, and room [ROOM NUMBER] sink were reported positive at concentrations of 0.40 CFUs/mL, 0.40 CFUs/mL, 2.0 CFUs/mL, and 1 CFU/mL, respectively. The program stated that results below 10 CFUs/mL were below detectable limits and required no remedial action. Interviews with the Maintenance Director and the President of Operations showed there was no flow chart for the water system, no diagram identifying areas of stagnant water, and no assessment of other areas such as air conditioner units or ceiling condensation. The Maintenance Director stated the facility tested water semi-annually and relied on the testing company’s recommendations, and that the company had never entered the building to conduct an assessment. The facility also failed to fit-test employees for N95 respirators according to CDC/NIOSH guidance. The DON stated the facility followed CDC recommendations for fit testing, but the Infection Preventionist reported that fit testing was intended to occur yearly and that there had been a gap in testing. She stated she had contacted a university to conduct fit testing and that approximately 45 staff were fit tested, while the facility employed 135 staff. She also stated staff were not being fit tested on hire and that the last fit test before the outbreak was in June 2023. A staffing list showed approximately 44 staff had been fit tested. Interviews confirmed that an LPN hired in [DATE] had not yet been fit tested and the Maintenance Director also had not been fit tested. The DON stated there was turnover in the IP position in 2024, causing the gap in fit testing, and that there was no formal fit testing for staff who provided care during the COVID-19 outbreak in 12/2024.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report suspected abuse allegations within required timeframes for two residents. The facility policy stated that all allegations of abuse, including verbal and mental abuse, neglect, suspicious injuries of unknown origin, exploitation, and misappropriation of resident property, were to be reported immediately to the Administrator/designee, and all allegations of abuse and instances resulting in serious bodily injury were to be reported within 2 hours. The report identified two incidents that were not reported to the state as required: a resident-resident altercation involving one resident pushing another resident in a wheelchair, and an allegation of abuse made by another resident against an LPN. Resident #34 was admitted with diagnoses including cognitive communication deficit, schizophrenia, unspecified dementia, and depression, and had severe cognitive impairment with a BIMS of 5. Resident #85 was admitted with vascular dementia and unspecified psychosis and had severe cognitive impairment with a BIMS of 00. A nursing progress note documented that Resident #34 became aggressive with Resident #85, yelling and aggressively pushing Resident #85 while Resident #85 was sitting in a chair. The DON later stated she found the note during a 24-hour progress note review, interviewed staff, and none of the staff felt the incident constituted abuse. The Assistant Administrator and Administrator stated the incident should have been reported to the abuse coordinator and then to the state, but it was not reported within the required timeframe. Resident #107 was admitted with chronic respiratory failure, polyneuropathy, and type 2 diabetes mellitus, and had moderate cognitive impairment with a BIMS of 9. The resident’s care plan identified the resident as potentially very aggressive to staff and caregivers related to anxiety and noted inappropriate and derogatory comments toward female staff. An incident report showed that the resident alleged an LPN was abusive and rude, shut the resident’s bedroom door when the resident wanted it open, and did not use an alcohol prep when administering insulin. The Unit Manager confirmed the allegation and stated it was immediately reported to the DON and the LPN was removed from the unit. The DON and Administrator later stated that allegations of abuse should be reported to the State of Alabama within 2 hours, but the allegation was not reported within that timeframe.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure resident records were complete, accurately documented, and readily accessible for 6 of 19 residents reviewed. The deficiency involved missing, late, or incomplete documentation in the medical record, including assessments, care plan-related documentation, and medication administration records (MARs), contrary to the facility policy requiring documentation to be accurate, relevant, complete, timely, and in chronological order. For one resident admitted with diagnoses including cognitive communication deficit, mood disorder, delirium, and psychotic disorder with hallucinations, the BIMS evaluation progress note was entered as a late entry with an effective date that did not match the actual date of completion. The SSD stated she documented assessments on paper and discarded the paper after entering the information into the computer, and the DON stated the record did not accurately reflect when the assessment occurred because the paper documentation was no longer available. The Administrator stated she expected medical records to be complete and accurate so the best decisions could be made for residents. For another resident with Alzheimer’s disease, the care plan contained a revised focus area, but the report text provided does not include the full details of that item. For a resident with vascular dementia, cerebral infarction, atrial fibrillation, hypothyroidism, hyperlipidemia, and mood disorder, the June 2025 MAR contained multiple blank entries for scheduled medications and treatments, including psychotropics, anticoagulation, topical medications, pain scale documentation, and other ordered medications, with no documentation of completion or reason for non-completion on several dates. Staff stated the blanks were related to hospitalization, but the MAR had a way to document hospitalization and that was not done. For a resident with CADASIL, diabetes, a urinary catheter, oxygen therapy, and vascular dementia, the MARs showed missing documentation for oxygen tubing changes, catheter output, and insulin glargine administration on multiple dates across June and July 2025. Staff stated there should not be blanks on the MARs, that refusals should have been documented, and that there were options to document hospitalization or when an order was not applicable. The DON and Administrator both stated there should never be blanks on the MARs, but the record still contained missing documentation.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide notification of the rights and rules of the facility for 1 resident, Resident #34. Neither the resident nor the resident's representative signed the facility's notification of rights and rules at admission. The resident was admitted on 11/17/2023 with diagnoses including cognitive communication deficit, schizophrenia, unspecified dementia, and depression. The quarterly MDS with an ARD of 06/05/2025 showed a BIMS score of 5, indicating severe cognitive impairment, and the care plan dated 11/28/2023 identified impaired cognitive function related to dementia. During interviews, the Administrator stated there was no policy for informing residents of their rights other than what was in the admission agreement. The facility's admission policy stated that a Resident Handbook and/or facility orientation material should be provided prior to or upon admission. The admission agreement contained a Resident Rights document with a signature page, but the facility did not have the admission packet for Resident #34, and the Admissions Director confirmed there was no admission agreement for the resident. The Admissions Director stated the facility had audited records and discovered the resident had no admission agreement, and the DON and Administrator both confirmed that the admission process was how residents were informed of their rights and rules.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident’s right to be free from physical abuse by another resident. The deficiency involved one resident hitting another resident in the back during an altercation in a shared room. The facility’s abuse policy stated that all residents have the right to be free from abuse, and defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Resident #106 was admitted with diagnoses including anxiety disorder, mood disorder due to a known physiological condition, adjustment disorder with mixed anxiety and depressed mood, unspecified dementia with other behavioral disturbance, and Alzheimer’s disease with late onset. A quarterly MDS dated 06/06/2025 showed a BIMS score of 15 and no behavioral symptoms during the lookback period. Resident #106’s care plan included impaired social interaction with an intervention to monitor interactions with others. Resident #91 was admitted the day before the incident and had diagnoses including cognitive communication deficit, persistent mood disorder, delirium due to a known physiological condition, and psychotic disorder with hallucinations due to a known physiological condition. A 5-day MDS dated 06/30/2025 showed a BIMS score of 15 and no behavioral symptoms during the lookback period. According to the investigation, Resident #91 was rummaging through Resident #106’s closet, which caused Resident #106 to become angry and yell. Staff were present in the adjoining bathroom and intervened, but CNA #7 observed Resident #106 push her and then hit Resident #91 in the back with a closed fist multiple times. LPN #9 later confirmed the altercation, and NP #1 stated Resident #106 admitted to hitting Resident #91. The NP note documented that Resident #91 said their jaw hurt from being “sucker punched,” although no significant injuries were noted on assessment. The facility determined the incident was abuse, and the Administrator stated the expectation was to prevent resident-to-resident abuse by addressing behaviors in care planning and with the IDT.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse policies and procedures related to identifying, reporting, and investigating abuse for two residents. One incident involved a resident-to-resident altercation between a resident with diagnoses including anxiety disorder, mood disorder, unspecified dementia with behavioral disturbance, and Alzheimer’s disease, and a roommate with diagnoses including cognitive communication deficit, mood disorder, delirium, psychotic disorder with hallucinations, and Alzheimer’s disease. The facility’s investigation record showed the roommate struck the other resident in the back with a closed fist three times during an altercation after the first resident was rummaging through the roommate’s closet. Staff removed the resident from the room and placed the roommate on 1:1 supervision until transfer to the hospital, but the facility initially determined the event was not abuse because the CNA witness did not think it was abusive and because there were no injuries noted on assessment. The same incident was not fully identified and reported when the resident later told the NP that the resident’s jaw hurt from being “sucker punched.” The NP documented the statement in a progress note but did not report the allegation to facility staff. The NP stated she did not know the reporting requirements and did not recall abuse training. Facility leadership later acknowledged that the roommate hit the resident and that the initial conclusion that the event was not abuse was incorrect, but the allegation of being punched in the jaw was not reported or investigated at the time it was made. A second incident involved a resident with severe cognitive impairment and diagnoses including schizophrenia, unspecified dementia, and depression, who was observed aggressively pushing another resident in a wheelchair away from the doorway of the resident’s room. The resident who was pushed also had severe cognitive impairment and diagnoses including vascular dementia and unspecified psychosis. A nursing progress note documented the aggressive pushing, but the event was not reported as abuse at the time. Later review by the DON identified the note, and staff interviews indicated no one had reported the incident as abuse or knew anything about it. Facility leadership stated the event should have been reported to the Abuse Coordinator and then to the state, but it had not been handled that way when it occurred.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide bed-hold notification for two residents who were hospitalized or transferred out of the facility. Resident #36 was admitted with vascular dementia and a mood disorder, had a BIMS score of 3 indicating severe cognitive impairment, and was documented as leaving the facility by ambulance or for evaluation on multiple occasions. Staff interviews showed the LPN understood administration notified families of bed-hold policy, while the BOM stated Medicaid residents automatically received a four-day bed hold and that she was unsure whether the appropriate notifications were sent for Resident #36. The DON later stated Resident #36 did not receive the bed-hold notifications and that there were omissions in the process, which she attributed to the BOM transitioning into the position. The facility also failed to notify the ombudsman of Resident #101's discharge to the hospital and did not provide bed-hold notification for that resident. Resident #101 was admitted with COPD, Alzheimer's disease, polydipsia, hypo-osmolality and hyponatremia, and alcohol dependence, and was discharged to a short-term general hospital after a critical sodium level was identified and the resident was transported out of the facility. The DON stated the facility did not have the ombudsman notification for Resident #101, and later explained that a technical glitch in the electronic medical record stopped the transfer notification from being sent. The BOM stated that Medicaid pending residents were offered bed-hold and that the family would need to sign a form, but she was unsure whether the form could be found for Resident #101.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to resubmit a Level 1 PASARR when residents developed new qualifying psychiatric diagnoses after admission. Facility policy stated that any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition must be promptly referred for a Level II resident review. Survey review found that this process was not followed for two residents whose records showed new psychiatric diagnoses added after admission, but no new PASARR was completed for those changes. Resident #59 was admitted with diagnoses including ADHD, major depressive disorder, and generalized anxiety disorder. After admission, additional psychiatric diagnoses were added, including delirium, major depressive disorder with severe psychotic features, psychotic disorder with delusions, and major depressive disorder with severe psychotic symptoms. A significant change MDS showed the resident was cognitively intact with a BIMS score of 14, had daily other behavioral symptoms, and was receiving antipsychotic, antianxiety, and antidepressant medications daily. The resident’s PASARR Level I screening on file was dated more than two years before the admission, and a later PASARR completed by the facility did not include all current psychiatric diagnoses. Resident #34 was admitted with schizophrenia, unspecified dementia, anxiety, and depression, with depression added after admission. The resident’s quarterly MDS showed severe cognitive impairment with a BIMS score of 5. The resident’s PASRR Level 1 screening identified schizophrenia, but no new PASARR was completed after the later depression diagnosis was added. Interviews with the Admissions Director, DON, Medical Records Director, and Administrator showed differing understanding of when PASARRs needed updating, but all acknowledged that new SMIs had been added after admission and that another PASARR should have been completed.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a PASARR Level I screening was completed prior to admission for one resident. The facility policy stated that all applicants are to be screened for serious mental disorders or intellectual disabilities before admission, and that a negative Level I screen permits admission while a positive screen requires a Level II evaluation before admission. However, the resident was admitted on 01/06/2025, and the PASARR Level I Screening & Results report in the record was dated 12/13/2023, more than two years before the resident’s admission. The resident’s record showed a history of attention deficit hyperactivity disorder, major depressive disorder, and generalized anxiety disorder on admission, with additional psychiatric diagnoses added later including delirium, major depressive disorder with severe psychotic features, psychotic disorder with delusions, and major depressive disorder with severe psychotic symptoms. The resident’s significant change MDS showed a BIMS score of 14, daily other behavioral symptoms, and daily use of antipsychotic, antianxiety, and antidepressant medications. The care plan documented verbal aggression, angry outbursts, frequent yelling, and anxiety related to a diagnosis of anxiety disorder. During interview, the Admissions Director stated the PASARR from December 2023 should not have been accepted as the admission PASARR and that another one should have been completed.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise and update Resident #91’s baseline care plan after an abuse incident in which the resident was allegedly rummaging through the roommate’s closet and the roommate struck the resident on the back with a closed fist three times. Resident #91 was admitted on 06/28/2025 with diagnoses including cognitive communication deficit, other specified persistent mood disorders, delirium due to known physiological condition, and psychotic disorder with hallucinations due to known physiological condition. The 5-day MDS showed a BIMS score of 15 and no behavioral symptoms during the lookback period, and the baseline care plan only addressed elopement/wandering with supervision. Facility records and staff interviews showed the resident was transferred to another unit after the incident, but the baseline care plan and care plan report did not reflect the rummaging behavior or interventions to prevent future abuse. The DON stated the resident had exhibited rummaging and wandering and that behaviors should be documented on the baseline care plan within the first 48 hours of admission for a resident moved to memory care. The SSD stated the behavior that resulted in the incident should have been care planned, and the Administrator stated the behaviors that led to the abuse should have been identified and care planned to prevent future abuse.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary assistance with bathing, grooming, and personal hygiene for a resident who was dependent on staff for a shower or bath. The resident had diagnoses including epilepsy, hemiplegia and hemiparesis affecting the left dominant side, dementia with other behavioral disturbance, muscle weakness, and chronic pain syndrome. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 6, and the care plan identified a need for assistance with ADLs related to dementia and decreased mobility, with later revision noting that the resident sometimes refused baths/showers and refused to allow staff to shave them. During interviews, the resident stated they wanted to be shaved, said a friend had shaved them because staff had not shaved them for a couple of weeks, and reported they might get one shower a week. Observations showed the resident’s hair was unkept and greasy, later still greasy with white flakes, and the resident remained unshaved. On another observation, the resident was in bed wearing a shirt and adult brief with no pants, and food debris from breakfast remained on the shirt and bed linens around them. The resident also stated they had not gotten a shower in a while. Record review showed no data in the bathing log for self-performance, bathing support provided, or type of bath offered and provided for the 30-day period reviewed. The behavior monitoring log showed no behaviors observed, and the last documented refusal of a shower or bed bath was months earlier. Staff interviews indicated the shower book was used as a communication tool, but documentation was not consistently completed or entered into the EMR, and the DON stated there was no evidence in the EMR to show showers were being offered or refused and no documentation to show showers were being given because the paper shower sheets were not kept.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's food preferences by not providing breakfast choices and by not meeting with the resident to review likes and dislikes after admission. Resident #9 was admitted with diagnoses of muscle weakness and iron deficiency anemia, had a BIMS score of 15 indicating intact cognition, and was on a no added salt, regular texture, thin consistency diet. The resident stated there was no variety at breakfast and that the same items were served every day, including scrambled eggs, sausage, and a biscuit, while the resident preferred dry cereal and milk and did not want oatmeal. The Culinary Director stated she had three to seven days after a new admission to meet with the resident about food preferences and document them on a preference sheet, but she had not met with newly admitted residents in three months. Observations showed the resident's breakfast tray included scrambled eggs, a biscuit, and sausage, with no hot or cold cereal present. CNAs stated they asked residents about lunch and dinner choices but not breakfast, and they described breakfast as a set menu. The DON and Administrator stated they expected resident food preferences to be honored and reviewed upon admission, but the resident reported staff had not asked about breakfast preferences and had not offered dry cereal.

Penalty

Inspection fine: $56,472

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the nursing home survey results were posted in a location accessible to all residents and representatives. Survey results were placed behind the first floor nurses' station, and the posted signage instructed people to ask the nurse if they wanted to review the surveys. During observation, the only location of the survey results was behind the nursing station on the first floor, and staff confirmed that the binder was behind every nurses' station. During interviews, the Regional Nurse Consultant stated there was no policy on the survey results location and confirmed the results had been moved from the visitor sign-in area to the nursing station. The Administrator stated the survey results were behind the first floor nursing station, and later stated she moved them because the building was being refurbished and did not realize that requiring people to request access violated the regulation. The DON stated the survey results binder should be accessible to the public without having to ask and confirmed that the binder behind the first floor nurses' station was an inherent obstacle to access.

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility's Administrator failed to provide oversight to ensure the facility's abuse policies were implemented. This included not reporting suspected abuse, not investigating documented allegations of abuse, and not implementing protective measures for residents. Facility staff documented occurrences of potential abuse in a resident's medical record over a period of time, but there was no evidence that these occurrences were reported, investigated, or that protective measures were implemented. When the Administrator became aware that two cognitively impaired residents needed to be assessed for their capacity to consent to sexual contact, the Administrator made a decision on the residents' capacity to consent without a policy and procedure in place. This decision was made without ensuring the assessment was completed accurately and interpreted ethically and without conflict of interest. Based on the Administrator's determination that the residents were in a consensual relationship, the incident was not reported or investigated, and no protective measures were implemented. Interviews with the Director of Nursing, Social Service Director, and other staff revealed that the incident involving inappropriate touching between the two residents should have been reported and investigated as potential sexual abuse. The Administrator admitted that an investigation should have been conducted but did not think immediate safety measures were needed because she believed the residents were consenting. The failure to report and investigate the incident, as well as to implement protective measures, was a significant oversight that had the potential to affect all residents in the facility.

Removal Plan

• The facility's Administrator failed to ensure the facility's Abuse policies were implemented, including reporting, protection, and investigation of abuse allegations or suspected abuse. The facility Administrator conducted an assessment without a policy supporting the ability to conduct a consent assessment and made the decision of RI #13 and RI#19 capacity to consent.
• VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding reporting abuse and investigating.
• The Administrator was in-serviced on revised Abuse Policy to include when any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record.
• Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and Case Manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
• No other incidents regarding not reporting timely or investigating allegations of abuse were noted through the staff and resident interviews.
• Corporate QAPI completed to ensure that 1 member of the corporate team, either the Executive VP, VP of operations, or Nurse Consultant will be in the facility to ensure operational and clinical meetings are being held and to provide oversight of Administrator's management practices (to include abuse reporting, investigating allegations of abuse).

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from sexual and verbal abuse by another resident on the Memory Care Secured Unit (MCSU). Resident Identifier (RI) #13, who had dementia, exhibited sexually inappropriate behaviors towards other residents, including entering residents' rooms, disrobing in public, and making sexual comments. Despite these behaviors being documented in RI #13's medical record, the facility did not report or investigate the incidents, nor did they implement protective measures to safeguard other residents. The facility also failed to assess the capacity of residents on the MCSU to consent to sexual activity. RI #13's behaviors were noted to have worsened over time, with multiple incidents of inappropriate sexual conduct documented. These included touching another resident's upper thigh, making sexual comments, and attempting to engage in sexual activity with other residents. Staff members, including Licensed Practical Nurses (LPNs) and Certified Nursing Assistants (CNAs), reported these incidents to their supervisors, but no investigations were conducted, and no protective measures were put in place. The Director of Nursing (DON) and other administrative staff were not notified of these incidents, which were considered abusive given the residents' cognitive impairments. Interviews with staff and review of progress notes revealed that the facility's failure to act on these incidents put residents at risk. The facility's policy on abuse did not provide clear guidelines on determining residents' capacity to consent to sexual activity. The facility's inaction and lack of supervision allowed RI #13's behaviors to continue, causing potential harm to other residents. The Immediate Jeopardy (IJ) was identified, and the facility was found to be non-compliant with the requirement to protect residents from abuse, neglect, and exploitation.

Removal Plan

• The facility failed to implement protective measures and provide supervision to residents on the Memory Care Secured Unit (MCSU) after identifying RI #13, a male resident with dementia, was exhibiting sexual inappropriate behaviors towards staff and other residents. No residents on the MCSU were properly assessed for the capacity to consent to sexual activity.
• VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding ensuring residents are kept safe from all types of abuse and neglect. This in-service was completed, and no concerns were noted.
• Abuse policy was updated to include (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record)
• Progress notes all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no abuse allegations have gone unreported. No incidents or issues noted in these notes. This review of note was completed.
• All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
• VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding updated abuse policy. The facilities abuse policy has always included that all residents have the right to be free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected. The administrator and don were in-serviced on (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record)
• Education was completed with all staff regarding the abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected. New hires will be educated on the new revision of the abuse policy.
• DON/Designee completed an audit to ensure they were not aware of any other allegations of abuse; this was completed by questionnaire. No issues were identified.
• Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
• There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and implement policies and protocols to prevent sexual abuse, including a protocol to identify when, how, and by whom determinations of capacity to consent to sexual contact would be made. This failure was highlighted by the case of a resident in the Memory Care Secured Unit (MCSU) who had a history of escalating sexual behaviors. Despite multiple documented incidents of inappropriate sexual behavior, the facility did not report, investigate, or implement protective measures to safeguard other residents from potential abuse. The resident in question, identified as having moderate to severe cognitive impairment, exhibited inappropriate sexual behaviors towards other residents on several occasions. These behaviors included rubbing, grabbing, and making verbal sexual remarks. On one occasion, the resident was found touching another resident's upper thigh in a private room. The facility's administrator used an unsanctioned questionnaire to assess the capacity of both residents to consent to sexual contact, without any supporting policy or guidelines to ensure the accuracy of this determination. Interviews with facility staff revealed that the administrator was not notified of several incidents of inappropriate behavior, and no investigation or safety measures were put in place. The facility's policy on abuse was found to be inadequate, lacking specific guidelines on how to handle situations involving residents' capacity to consent to sexual activity. This deficiency had the potential to affect all residents in the MCSU, as the facility failed to protect them from potential sexual abuse.

Removal Plan

• The facility failed to implement an abuse policy and procedure to protect residents on the Memory Care Secured Unit from abuse including affectionate physical touching, and verbal sexual statements made to female residents about their body parts. Abuse policy was instituted.
• The facility further failed to develop and implement a policy and to ensure resident's capacity to consent to sexual contact prior to the Administrator deciding RI #19 and RI #13, residents residing on the MCSU, could consent to sexual contact.
• Abuse policy was updated to include (When any resident expresses the desire to engage in sexual activity. Refer to the supplemental questions for determination of capacity related to sexual decisions. This will be completed by Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. This final determination will be documented in the medical record).
• This had the potential to affect all residents on the memory care secured unit. No residents are engaging in sexual conduct currently. All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
• VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding updated abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, and immediately protecting residents when abuse is suspected and the seven components of abuse: screening, training, prevention, identification, reporting, protection and investigation. Residents will be assessed when they desire or display to engage in sexual activity.
• Education was completed with all staff regarding the abuse policy. The facilities abuse policy has always included that all residents have the right free from abuse, identification of abuse, an immediately protecting residents when abuse is suspected and the seven components of abuse: screening, training, prevention, identification, reporting, protection and investigation. Residents will be assessed when they desire or display to engage in sexual activity. New hires will be educated on the new revision of the abuse policy.
• Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
• There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to immediately report incidents of suspected abuse by a resident identified as RI #13 to the Administrator, resulting in a failure to investigate and protect other residents on the Memory Care Secured Unit (MCSU). RI #13 exhibited inappropriate sexual behavior towards other residents on multiple occasions, including making sexual comments, touching female residents inappropriately, and entering female residents' rooms with inappropriate intentions. These incidents occurred on several dates, including 01/03/2024, 01/04/2024, 01/08/2024, 01/11/2024, and 01/12/2024, but were not reported to the Administrator or the State Agency as required by the facility's abuse policy. The facility's policy mandates that any incident or allegation of abuse must be reported immediately to the Administrator, who is then responsible for reporting to the State Agency within two hours. However, interviews with staff members, including LPNs and the DON, revealed that the incidents involving RI #13 were either not reported at all or were reported to supervisors who did not escalate the reports to the Administrator. This lack of reporting prevented timely investigation and intervention, leaving other residents at risk. The failure to report these incidents was confirmed through interviews with the DON and the Administrator, who both stated that they were not informed of the incidents involving RI #13. The DON acknowledged that the inappropriate touching of a female resident by RI #13 should have been considered sexual abuse and reported to the State Agency. The Administrator also confirmed that the incidents were not reported to her, which was a violation of the facility's abuse policy. This deficiency was identified during the investigation of a complaint and was determined to have the potential to affect all residents on the MCSU.

Removal Plan

• Immediate action(s) taken for the resident(s) found to have been potentially affected include: The facility failed to immediately report incidents of suspected abuse by RI #13 to the Administrator which resulted in failure of the Administrator to investigate and protect female residents residing on the Memory Care Secured Unit (MCSU).
• According to the facility's abuse policy facility staff must immediately report to the Administrator any incident or allegation that could constitute an instance of abuse. The staff is to immediately protect or safeguard the resident in question and any other residents at potential risk of the alleged abuse. The administrator is to report to ADPH the allegation of suspected abuse or neglect within 2 hours of being notified and complete the investigation within 5 business days.
• VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding reporting abuse and investigating according to F-609. This includes safeguarding the identified residents at risk for abuse or potential for abuse and reporting to ADPH according to the reporting guidelines from ADPH.
• Identification of other residents having the potential to be affected: This had the potential to affect all residents. Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
• Actions taken/systems to be put into place to reduce the risk of future occurrences include: Education was completed with staff members in person and staff members via telephone; Education was completed when to report, who to report and what to report.
• According to the facilities abuse policy it has always been for facility staff to report immediately any suspected allegation of abuse to the administrator. New hires will be educated on the new revision of the abuse policy.
• DON/Designee completed an audit with staff members in person and staff members via telephone; Education was completed on abuse policy, when to report, who to report and what to report. According to the facilities abuse policy it has always been for facility staff to report immediately any suspected allegation of abuse to the administrator. Also, to ensure they were not aware of any other allegations of abuse; this was completed by questionnaire. No issues were identified.
• Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). Facility discussed ensuring residents are kept safe from all types of abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
• There are no residents known to the facility to be consented and engaging in current sexual activity. Any sexual activity will be reported immediately. In the event that the Administrator and DON are unavailable, the activity will be reported immediately to a member of the Ethics Committee to complete the assessment for the capacity to consent.
• Facility requests for IJ removal plan to be effective.

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate incidents of abuse by a resident identified as RI #13, which led to repeated inappropriate sexual behavior towards other residents. The incidents began on 01/03/2024, when RI #13 exhibited inappropriate sexual behavior, and continued on multiple occasions, including making sexual comments and touching a female resident's thigh. Despite these behaviors being reported by an LPN to the Administrator (ADM) and Director of Nursing (DON), there was no evidence that these incidents were investigated as required by the facility's abuse policy. Interviews with the ADM and DON revealed that they were either not made aware of the incidents or did not have specific details about them. Both acknowledged that the incidents should have prompted an investigation. The ADM admitted that any type of allegation of abuse would necessitate an investigation, while the DON confirmed that she should have been notified to make a judgment call on how to proceed. The lack of investigation allowed RI #13's inappropriate behavior to continue, putting other residents at risk. Further review of RI #13's progress notes and additional interviews with staff, including another LPN and the Social Service Director (SSD), confirmed that the incidents were not properly communicated or investigated. The SSD was unaware of specific incidents and emphasized the importance of reporting such behaviors to the Administrator for investigation. The Regional Director of Health Services (RDHS) also highlighted the need for administrative staff to be aware of incidents to ensure proper follow-up. The failure to investigate these incidents resulted in a finding of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation.

Removal Plan

• VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding investigating abuse allegations. Administrator and DON were instructed on when to initiate an abuse investigation and how the investigation will be conducted and reviewed.
• Progress notes on all residents were reviewed by the Regional Nurse Consultant, Clinical Nurse educator, and case manager to ensure that no sexual abuse allegations have gone unreported. No incidents or issues noted in these notes.
• All residents on the Memory Care unit were interviewed and/or assessed by the Memory Care Unit Manager to verify that no resident was exhibiting any sexually inappropriate behavior, nor had any complaints or verbalized any allegations of abuse. No residents were engaging in sexual behaviors. However, if residents desire to engage in sexual activity refer to the supplemental questionnaire for determination of capacity related to sexual decisions. This will be completed by the Administrator and Director of Nursing. If it is determined that residents have the capacity to consent it will be referred to the facility Medical Director and member of the ethics committee for final determination. The final determination will be documented in the medical record.
• VP of Operations and Regional Nurse Consultant provided 1:1 in-service education to Administrator and DON regarding investigating abuse allegations.
• DON/Designee completed an audit with staff to ensure staff were made aware of what to report, when to report and who to report to. This is to ensure the administrator could complete a thorough investigation. This was completed by questionnaire. No issues were identified.
• Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Regional Director of Health services, [NAME] President of Operations, RN Infection Control and medical director). QAPI Discussed RI#13 and the incident surrounding this incident Discussed in QAPI, Administrator would investigate thoroughly all allegations of abuse timely, investigate immediately by way of staff interviews, resident medical records, and will be reviewed by Director of Health Services and/or VP of Operations before submitting.
• Facility requests for IJ removal plan to be effective. This plan was written by VP of Operations, Director of Health Services, Clinical Nurse Educator, Executive VP of Operations.

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician and family of a resident's pain and subsequent medical orders. The resident exhibited facial grimaces indicating pain on two consecutive days, 11/26/2023 and 11/27/2023, but the physician was not notified until the second day. Additionally, the resident's family was not informed about the order for X-rays on 11/27/2023, despite the facility's policies requiring such notifications. The resident, identified as RI #14, had a care plan in place for pain management, which included notifying the physician of any changes in pain symptoms. Despite this, the resident's facial grimaces and complaints of pain were not communicated to the physician promptly. The resident's Progress Notes confirmed the presence of pain and bruising, but there was no documentation of physician notification until the second day of pain complaints. Interviews with staff, including LPNs and the Director of Nursing, corroborated the failure to notify the physician and family as required. The physician also confirmed that he expected to be notified about any pain issues and that such notifications should be documented in the Progress Notes. The deficiency was identified during an investigation of a complaint/report and affected one of five residents sampled for falls.

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's pain was assessed on a daily basis, especially after the resident fell. According to the facility's policy, an ongoing assessment of pain utilizing either a numerical scale of 0-10 or a verbal descriptor scale should be conducted daily and documented on the Medication Administration Record (MAR). However, upon review of the resident's MAR, there was no evidence that the resident's pain was being assessed daily, nor was there a physician's order for pain management. This deficiency was particularly concerning given that the resident exhibited facial grimacing, a symptom of pain, on multiple occasions following the fall, yet was never medicated for the pain. The resident, who had a history of falls, was originally admitted to the facility on a previous date and readmitted on another date. The resident's care plan included interventions to observe for worsening pain symptoms and notify the physician of changes, as well as to assess pain daily using a 1-10 scale. Despite these interventions, the resident's pain was not assessed daily, and there was no documentation of pain assessments on the MAR. The resident exhibited facial grimacing when his/her leg was moved and complained of pain when turned to the left side, yet no pain medication was administered. X-rays later revealed that the resident had a fracture of the right hip and left and right femurs, necessitating a transfer to the hospital for treatment. Interviews with multiple Licensed Practical Nurses (LPNs) and the Director of Nursing (DON) confirmed that pain assessments were supposed to be completed every shift and documented on the MAR. However, there was no evidence that these assessments were conducted for the resident on several dates. The DON acknowledged that the resident's pain was not managed appropriately and that the physician should have been notified when symptoms of pain were observed. The facility's failure to assess and manage the resident's pain appropriately led to the resident suffering from untreated pain and subsequent fractures that were only identified days after the initial fall.

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the nutritional needs of residents on Pureed, Regular, and Mechanical Soft diets were met according to the established menus. On 04/24/2024, residents receiving Pureed diets were served a 3-ounce portion of pureed Lasagna instead of the required 6-ounce portion. This discrepancy was observed during the resident tray line for supper, where the AM Cook used a smaller, green-handled scoop instead of the appropriate #6 scoop. The AM Cook acknowledged the error, attributing it to a routine practice of using the green-handled scoop for pureed meats. The Dietary Manager confirmed that residents on Pureed diets did not receive a full serving of Lasagna, thus not meeting their nutritional needs as per the menu guidelines. The Registered Dietitian (RD) also confirmed that the residents were not given all the calories or nutrients required by the menu due to the incorrect portion size served. On 04/25/2024, a similar issue was observed with the serving of hot dogs for supper. Residents on Regular, Mechanical Soft, and Pureed diets were served portions that did not meet the menu requirements. The PM Cook used a #12 scoop, which is smaller than the required #10 scoop, resulting in portions less than the 3 ounces specified by the menu. The PM Cook and the Dietary Manager both acknowledged the error, with the Dietary Manager noting that the residents were not getting enough protein. The RD confirmed that the residents on Regular, Mechanical Soft, and Pureed diets were not receiving the necessary calories and nutrients due to the incorrect portion sizes served. The facility's policies for Menus and Adequate Nutrition and Nourishment, dated 02/20/2024, were not followed, leading to these deficiencies. The policies state that menus should meet the nutritional needs of residents and be reviewed by a dietitian for nutritional adequacy. However, the observed practices on 04/24/2024 and 04/25/2024 did not align with these policies, resulting in residents not receiving the appropriate portions of their meals. This failure had the potential to affect all 84 residents receiving meals from the facility's kitchen.

Penalty

Inspection fine: $90,1437 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received whole milk at each meal as ordered by the physician. This deficiency was observed during the dinner meal on 04/24/2024 and the lunch meal on 04/25/2024. The resident, who had Vitamin B and Vitamin D deficiencies, was supposed to receive whole milk with all meals according to the April 2024 Medication Review Report and the resident's tray cards. However, during these meals, the resident was not served whole milk as required by the physician's orders. The issue arose because the facility's food vendor could not provide individual cartons of whole milk due to a packaging problem. Despite having whole milk available in gallon containers, the dietary staff did not pour the milk into cups for the resident. Both the Administrator and the Dietary Manager confirmed that whole milk was available in the facility and could have been served in cups. The Dietary Manager admitted that the dietary staff probably did not think of pouring the milk into cups and had to be instructed to do so. The Registered Dietitian confirmed that not serving whole milk as ordered meant the physician's orders were not being followed, and the resident was not receiving the prescribed intervention.