Concordia Nursing & Rehab, Llc

Penalty

Inspection fine: $113,71062 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 the employment of a full-time Director of Nursing (DON) and did not provide registered nurse (RN) coverage for at least 8 consecutive hours per day, as required. Review of employee files and timecard reports revealed that the facility was without 8 consecutive hours of RN coverage on 53 out of 65 days, and there were periods when the DON position was vacant or filled by staff who did not fulfill the required duties. The lack of RN oversight and management led to significant lapses in care planning, assessment, and intervention for multiple residents. Several residents were directly affected by these deficiencies. One resident with severe cognitive impairment and a history of falls suffered two major falls with injuries, including fractures to both arms, without appropriate updates or escalation of interventions in their care plan. Another resident with a peripherally inserted central catheter (PICC) line did not receive RN assessment or care of the line for 18 days, and intravenous medications were administered by LPNs, some of whom were not verified as IV certified. Additional residents were admitted without timely completion of Minimum Data Set (MDS) assessments or comprehensive care plans, resulting in a lack of documented interventions for their care needs for extended periods. Interviews with staff confirmed that in the absence of an RN or DON, LPNs and CNAs were left to make assessments and update care plans, often without proper oversight or knowledge of the requirements. The Assistant Director of Nursing (ADON) did not assume DON responsibilities and was unaware that MDS assessments and care plans had not been completed. The facility's own documentation and staff statements indicated a lack of clear processes for ensuring RN coverage, verifying LPN IV certification, and maintaining compliance with federal and state regulations regarding nursing services.

Removal Plan

• Hire Interim Registered Nurse/Director of Nursing. Provide Registered Nurse weekend coverage and replace Director of Nurses in event of a call in. Update schedule to reflect Registered Nurse Coverage. Ensure Registered nurse coverage is 8 consecutive hours daily.
• In-service Administrator by Regional Director on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week.
• Remove Resident #33 peripherally inserted central catheter (PICC) Line. Review and update care plan as needed.
• In-service bedside LPN 1:1 by administrator about scope of practice regarding PICC line and site care.
• In-service all LPNs/RNs by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care.
• In-service all staff by administrator and/or director of nursing in person or by phone on ESP and infection control.

Penalty

Inspection fine: $113,71062 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 administration failed to implement and enforce policies necessary for the effective management and operation of the facility, resulting in multiple deficiencies. There was no full-time RN working eight consecutive hours per day, and the facility lacked a Director of Nursing (DON) for an extended period. The responsibilities of the DON, including care planning, fall assessments, and MDS completion, were not being fulfilled, as confirmed by staff interviews. The Assistant Director of Nursing (ADON) was unable to assume these duties due to other responsibilities, and the Med Records Nurse had been working as a bedside nurse for six months, leaving medical records unattended. Employee files for former DONs showed no signed job descriptions, and there was no evidence of staff orientation or training programs as required by facility policy. The facility also failed to ensure that LPNs managing peripherally inserted central catheters (PICC) were properly certified or trained. The Administrator admitted to not tracking which LPNs were IV certified and confirmed there was no IV training provided in the facility. Bed rails were installed on most beds without proper assessments, consent, or documentation. The Housekeeping/Maintenance Supervisor, responsible for installing and maintaining bed rails, had not read manufacturer guidelines and did not keep logs or forms related to bed rail safety. Staff interviews revealed a lack of knowledge about bed rail assessments and documentation, and the process for determining bed rail use was informal and based on resident preference rather than clinical assessment. Residents who experienced falls did not receive fall assessments or updated care plans, and interventions to prevent further falls were not identified or implemented. A newly admitted resident was not assessed for mobility function, and necessary interventions and equipment to maintain independence were not provided. The facility was unable to provide a policy for Activities of Daily Living/Mobility when requested. These failures in administration and oversight led to Immediate Jeopardy findings for multiple federal regulations, with the potential to cause serious harm to all residents in the facility.

Removal Plan

• In-service/meeting given via phone by regional director to governing body members (Manager, medical director) and in person to administrator.
• Administrator in-serviced management staff (DON, COM, SS, HR, MOS) regarding the following: Responsibility of the Governing Body (facility oversight, operations and policy/procedure), Survey findings and Plan of Removal to correct: Fall Clinical Protocol, Registered Nurse requirement, Competent staff, Mobility, Bed rail usage and Supervision to prevent accidents, Plan moving forward to improve findings.
• In-service provided to Administrator by Regional Director.
• In-service provided to nursing staff regarding policy and procedure of bed rails, assessing, consent to use and physician order required.
• Consent forms for residents with bed rails obtained.
• Bed rail assessments for residents with bed rails completed.
• Assessments and consents obtained for six residents identified as having bed rails with no assessments/consents.
• Monitoring sheets completed by Administrator and Director of Nursing (DON), by Housekeeping Supervisor and by Administrator and DON, for bed rail assessment and consents.
• File containing manufacturer guidelines for bed rails provided.
• Housekeeping Supervisor in-serviced by the Administrator regarding bedrails, maintenance, ensuring bedrails are compatible with the bed frame, and has reviewed and will refer to guidelines if needed.
• Staff in-serviced on bed rails and enhanced barrier precautions.
• Staff who were not physically present to receive the in-services were in-serviced by telephone, with the in-service information provided and the employee acknowledging receipt and voicing understanding.

Penalty

Inspection fine: $113,71062 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 at high risk for falls received proper assessments and interventions to prevent further accidents. The resident, who had severe cognitive impairment and required substantial assistance for mobility, experienced multiple falls within a short period. Despite documented incidents, including unwitnessed falls resulting in significant injuries such as fractures to both arms, the facility did not update the resident's care plan or implement new interventions after each event. The care plan remained unchanged even after the resident returned from the hospital with a cast, which the resident repeatedly removed, leading to additional falls and injuries. Staff interviews revealed that after each fall, assessments and incident reports were completed, but immediate interventions were not consistently documented or added to the care plan. The process for updating care plans and communicating new interventions to staff was not followed, particularly in the absence of a Director of Nursing (DON). The Assistant Director of Nursing (ADON) acknowledged that fall assessments and care plan updates were not being completed due to the lack of a DON, and that there was confusion among staff regarding their responsibilities in monitoring and preventing falls. The facility's policy required staff to identify and implement pertinent interventions after each fall, but this was not adhered to. The lack of timely and appropriate interventions, failure to update care plans, and insufficient staff training and oversight contributed to repeated falls and serious injuries for the resident. These actions and omissions resulted in non-compliance with federal requirements for quality of care and accident prevention.

Removal Plan

• Fall assessments and interventions reviewed and updated as needed for Residents #15 and #25 by facility nurse.
• In-service by administrator, regional director and nurse consultant for Nursing staff (RN, LPN, CNA) present and via phone for those not in facility regarding the following: Assessing, monitoring and intervening in falls to prevent injury and/or reduce falls; Proper interventions for falls; Care plans related to falls; Notification of PCP, DON, family and administrator.
• DON/Administrator in-serviced by regional director in regards to monitoring of incident and accident (I&A), fall records and daily nurse documentation to identify and address any concerns immediately.

Penalty

Inspection fine: $113,71062 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 proper assessments, informed consents, and compatibility checks were completed prior to the installation and use of bed rails for two residents. Observations revealed that bed rails were in use on both sides of the beds for these residents, but there was no documentation of bed rail assessments, informed consent from the residents or their representatives, or evidence that the bed rails were compatible with the beds according to manufacturer guidelines. Staff interviews confirmed a lack of understanding and inconsistent practices regarding bed rail assessments, installation, and documentation, with some staff unaware of the requirements or the process for determining bed rail use. For one resident with a history of falls, dementia, and chronic ischemic heart disease, bed rails were observed in the up position on multiple occasions. However, neither the care plan nor the closet care plan indicated the use of bed rails, and staff were unsure if the resident was supposed to have them. The spouse of this resident reported never being informed about the bed rails or asked for consent. Maintenance staff responsible for installing bed rails admitted to not measuring beds for compatibility, not reading manufacturer guidelines, and not keeping records of maintenance or safety checks, despite acknowledging that loose bed rails could be unsafe. For another resident with multiple diagnoses including dementia and insomnia, bed rails were also observed in use, but the care plan and MDS did not reflect this. Staff interviews indicated that bed rails were already installed upon admission and that housekeeping, not nursing, installed them. The resident's family confirmed they were not informed about the bed rails, the risks involved, or asked for consent. There was also evidence of gaps between the mattress and bed rails, raising concerns about entrapment, and no documentation was found to support the safe and appropriate use of bed rails for either resident.

Removal Plan

• Provide in-service to Administrator by Regional Director regarding bed rails and assessing, getting signed consent and order prior to use.
• Administrator to provide in-service to nursing staff in person and via phone regarding policy and procedure of bed rails, assessing, consent to use and physician order requirement.
• Review records to be completed by nurse manager to identify other residents with bed rails.
• Identified residents will be assessed by nurse and consent obtained.
• Administrator and DON will monitor care areas weekly to ensure bed rails are assessed and consent obtained and in the record.
• Care plan and MDS will be updated by LPN Nurse consultant.
• IDT team will work with environmental services supervisor to ensure bed frame and bed rails are compatible for the provided bed per manufacturers guidelines and recommendations.
• Provide in-service by administrator to environmental service supervisor regarding bed rails, bed maintenance and ensuring bedrails and bedframe are compatible to prevent entrapment zones.

Penalty

Inspection fine: $113,71062 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 nurses and nurse aides possessed the appropriate competencies to care for every resident in a manner that maximized their well-being. Specifically, the facility did not ensure that LPNs with IV certification were the only staff accessing and managing a resident's PICC line, including administering IV antibiotics, performing IV flushes, and assessing the line's condition. Documentation revealed that multiple LPNs, some without documented IV certification, administered IV medications and performed assessments that were outside their scope of practice according to state regulations. The facility's own policies required consultation of state laws regarding scope of practice, but there was no evidence that the facility verified or tracked IV certification for LPNs, nor did it provide IV training to its staff. A review of the facility's staffing assessment and policies showed a lack of clear guidelines for RN coverage and no self-assessed staffing standards. The facility's job descriptions and interviews with staff indicated that LPNs were expected to perform assessments and interventions that should have been conducted by an RN, particularly for residents with complex needs such as those with a PICC line. The Arkansas Board of Nursing regulations specify that LPNs must work under the direction of an RN for tasks requiring substantial specialized judgment and skill, such as IV therapy and PICC line management. However, the facility did not ensure RN oversight or presence for these tasks, and staff interviews confirmed that LPNs were performing assessments and interventions independently. The deficiency was identified after a review of records for several residents, including one who was admitted with a PICC line for IV antibiotics and wound care. There were multiple days when no RN assessment or care of the line was documented, and IV antibiotics were administered by LPNs without verification of their IV certification. The facility's failure to ensure appropriate staffing, competency verification, and adherence to scope of practice requirements resulted in non-compliance with federal and state regulations, creating a situation that was determined to have caused, or was likely to cause, serious injury, harm, impairment, or death to residents.

Removal Plan

• Hire Interim Registered Nurse/Director of Nursing. Provide Registered Nurse weekend coverage and replace Director of Nurses in event of a call in. Update schedule to reflect Registered Nurse Coverage. Ensure Registered nurse coverage is 8 consecutive hours daily.
• In-service Administrator by Regional Director on registered nurse and director of nursing coverage and requirement to have a full time DON and at least 8 hours of registered nurse coverage 7 days a week.
• Remove Resident #33 peripherally inserted central catheter (PICC) Line. Review and update care plan as needed.
• In-service bedside LPN 1:1 by administrator about scope of practice regarding PICC line and site care.
• In-service all LPNs/RNs by phone or in person by director of nurses on Scope of Practice regarding PICC line and site care.
• Provide in-services by the Administrator and/or Director of nursing to licensed nursing staff regarding: Care plans-Baseline, comprehensive, and closet care plans completed timely; MDS Timeliness; RN Assessments and interventions; Fall Documentation; Enhanced Barrier Precautions (EBP)/INFECTION CONTROL.
• Regional Director to provide in-service via phone to Administrator regarding LPN Administration of IV medication. Administrator to in-service DON and Human Resource Coordinator on tracking IV certifications of LPNs in event of another PICC line admission.

Penalty

Inspection fine: $113,71062 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 assess and address the mobility needs of a resident with multiple complex medical diagnoses, including respiratory failure, diabetes mellitus, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and Raynaud's syndrome. Upon admission, the resident was documented as requiring assistance for most activities of daily living (ADLs) and was using a wheelchair for mobility. However, the initial evaluation was not a comprehensive assessment, and a required admission MDS was not completed by the deadline. The resident did not have a comprehensive, individualized care plan in place until well after admission, and the only care plan available was a generic, undated document with limited information. Observations and interviews revealed that the resident became totally dependent on staff for mobility and ADLs, resulting in a significant decline in functional status and psychosocial well-being. The resident reported feeling imprisoned, totally dependent, and expressed distress over the loss of independence. The resident was unable to maneuver the manual wheelchair due to multiple finger amputations and blackened fingertips, and staff did not provide or assess for appropriate adaptive equipment to promote independence. The resident's own mobility aids from home were not supplemented or replaced by the facility, and staff did not inquire about or provide interventions to support the resident's independence until prompted by surveyors. Staff interviews confirmed that care planning responsibilities were neglected due to the absence of a Director of Nursing, and no one had assumed those duties. The resident's psychosocial harm was compounded by missed opportunities to participate in activities due to lack of assistance and appropriate equipment. The facility also failed to communicate with the resident and their representative regarding available tools and interventions to improve mobility and independence, only reaching out after surveyor involvement. The lack of assessment, individualized care planning, and provision of necessary equipment led to a preventable decline in the resident's mobility and psychosocial health.

Removal Plan

• Provide in-service to Administrator by Nurse Consultant regarding preventing decline in residents' level of activities of daily living (ADL) functions, including providing necessary equipment appropriate for resident and facility.
• Administrator to provide in-service to DON regarding preventing decline in resident ADL functions, including providing necessary equipment and assessing for appropriate interventions to prevent declines.
• Administrator and Nurse Consultant to in-service nursing staff to identify and respond appropriately to a resident's decline in ADL functions, including assessing, monitoring and providing interventions. Nurses will be responsible for assessing and providing appropriate interventions.
• Contact Resident #184 family to bring specialized equipment (special belt for foot movement and trapeze bar) from home that is being requested by resident to facility so it can be used to assist with his independent transfer and repositioning.
• Administrator and DON to monitor care areas routinely to ensure equipment is in place.
• Notify Primary Care Physician of Resident #184 of mental health concerns and request further direction/orders. Contact family to bring personal items from home, notify Physician for any new orders and contact pharmacy for medication consult.
• Complete care plan and MDS for Resident #184.

Penalty

Inspection fine: $113,71062 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 post the most recent survey results in an accessible location for residents to review. During interviews with four resident council members and the council president, all stated they were unaware of any posted survey results available for their viewing. Observations by surveyors confirmed that the survey results binder was not easily visible, as it was found in a metal and wicker rack on the floor beside a table near the entrance. Additionally, the binder contained outdated survey results from several months prior, rather than the most recent recertification survey. The Administrator acknowledged that the binder had not been updated and admitted to forgetting about it.

Penalty

Inspection fine: $113,71062 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 Certified Nursing Assistants (CNAs) were certified in the State of Arkansas and did not complete required background checks for two nurse aides. Review of employee files revealed that both CNAs were certified in Oklahoma, but there was no documentation of Arkansas certification, current abuse registry checks, or other background checks specific to Arkansas. Additionally, annual employment screening required by Oklahoma regulations was not documented for either CNA. Skills check-off documentation was only present for one CNA, and neither file contained evidence of Arkansas-specific qualifications or screenings. Interviews with the CNAs confirmed that they were unsure of their certification status in Arkansas and relied on their Oklahoma credentials. One CNA was unfamiliar with Enhanced Barrier Precautions and could not clearly articulate infection control procedures. Facility policies and job descriptions required state-approved training and certification, but the documentation and interviews indicated these requirements were not met for the two CNAs reviewed.

Penalty

Inspection fine: $113,71062 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 conduct a comprehensive facility-wide assessment as required by its own policy and regulatory standards. The assessment did not include a thorough evaluation of available staffing, staff competencies, or training, nor did it incorporate a community-based risk analysis to identify potential natural disasters and their impact on residents and operations. The facility also did not formulate a plan for staff recruitment or retention to meet resident needs, and the assessment lacked up-to-date information on staffing needs by shift, relying instead on outdated ratios and an incomplete addendum that did not specify actual staffing requirements. A review of the facility's assessment profile revealed that while intravenous (IV) therapy was provided as a nursing service, there was no documented plan for education or training of LPNs in IV medication administration or care of specialized IV access devices. The facility did not assess or reassess nurse qualifications to ensure they could meet the identified nursing services. Additionally, the facility did not conduct a self-assessment to identify potential natural disasters or analyze their impact on residents, staff availability, utilities, or supplies, instead referring to a separate emergency preparedness binder that was not integrated into the facility assessment process. Interviews with staff indicated significant gaps in leadership and staffing. The facility was operating without a DON, and the ADON, who was also the Infection Preventionist, was unable to assume DON duties due to bedside responsibilities. The Medical Records Nurse reported being unable to perform her primary duties for an extended period due to working on the floor. These staffing challenges were not addressed in the facility assessment, and there was no outlined plan for recruitment or retention of staff to fill critical roles.

Penalty

Inspection fine: $113,71062 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 maintain an organized and accurate medical record management system, resulting in incomplete and inaccessible resident records. Staff interviews revealed that the individual responsible for medical records was also working as a floor nurse and had not been able to keep up with documentation, prioritizing resident care over paperwork. There was no Director of Nursing (DON) in place, and as a result, essential documentation such as care plans, Minimum Data Sets (MDS), Medication Administration Records (MAR), and Treatment Administration Records (TAR) were not being completed or maintained. Staff reported that care plans had not been generated, and only basic admission evaluations were available, which were not comprehensive or updated. Record reviews for multiple residents showed missing or incomplete documentation, including the absence of MDS assessments, baseline and comprehensive care plans, physician progress notes, activity notes, provider orders, and diagnoses. In one instance, a resident's oxygen orders and CPAP documentation could not be found in the paper chart, and the medical director was unable to locate the necessary orders or explain how staff accessed the information needed for care. The medical director acknowledged a system failure and was unaware of the process for maintaining or reviewing care plans and assessments. Staff interviews further confirmed that no one had assumed responsibility for care plans, fall assessments, or MDSs in the absence of a DON, and the assistant director of nursing was overwhelmed with floor duties and infection control. Facility policy reviews indicated clear requirements for timely and comprehensive assessments and care plans, but these were not being followed. The job descriptions for the DON and medical director outlined responsibilities for oversight and quality assurance of medical records and care planning, but these duties were not being fulfilled. Additionally, the former human resources director reported witnessing falsification of records, including forged signatures on assessments and in-service documentation, and manipulation of time records to falsely indicate RN presence. These actions and inactions led to a breakdown in the facility's ability to safeguard resident-identifiable information and maintain medical records in accordance with professional standards.

Penalty

Inspection fine: $113,71062 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 provide disclosure of ownership paperwork upon repeated requests by surveyors. On three separate occasions, the Administrator was asked to supply the required documentation, but it was not provided. The Administrator indicated that the Director of Operations would be arriving to address the request, but even after this assurance, the paperwork was still not submitted by the time the survey concluded. No information regarding residents or their medical conditions was included in the report. This deficiency was identified based on the facility's inaction in responding to multiple direct requests for ownership disclosure documentation, as required by regulations.

Penalty

Inspection fine: $113,71062 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 provide mandatory Quality Assurance and Performance Improvement (QAPI) training to all staff members upon hire and did not conduct in-service training on QAPI for direct care staff. Review of the QAPI Binder, which was last revised in April 2023, showed no documentation of QAPI training for staff, despite committee signatures indicating that staff are to be trained in QAPI systems and principles. Additionally, the facility assessment listed monthly in-services on various topics such as disaster drills, abuse/neglect, and resident rights, but did not include QAPI training. Employee file reviews for a CNA and an LPN revealed no evidence of QAPI training at the time of hire, although other required trainings were documented. Interviews with the Administrator and Director of Operations confirmed that QAPI in-services were not conducted and that QAPI meetings were held quarterly with participation from the executive team, but there was no evidence of QAPI training for all staff as required.

Penalty

Inspection fine: $113,71062 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 provide required Compliance and Ethics training to all staff members upon hire and did not include compliance and ethics in its ongoing in-service education. Record reviews of the Required In-Service Book and Facility Assessment showed that in-services covered topics such as dementia/behavioral training, resident rights, infection control, emergency response, abuse and neglect, misappropriation of property, disaster drills, staff burnout, oral hygiene, lock out tag out, elopement, and coronavirus, but did not include compliance and ethics. Interviews with the Administrator confirmed that if a topic was not listed in the in-service book, it was not covered, and the Administrator did not respond when specifically asked about ethics training. Further review of employee files for a CNA and an LPN revealed no documentation of Compliance and Ethics training upon hire, with only other topics such as abuse, neglect, misappropriation of property, burnout, enteral feeding, tracheostomy care, and suctioning acknowledged. Staff interviews confirmed that in-services were limited to the topics listed and did not include compliance and ethics. This lack of training was consistent across staff roles and was confirmed by both documentation and staff testimony.

Penalty

Inspection fine: $113,71062 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 complete Minimum Data Set (MDS) assessments within the required 14-day timeframe for four residents reviewed. Facility policy requires a comprehensive assessment within fourteen days of admission, with the Assessment Coordinator responsible for ensuring timely completion. Record reviews showed that for multiple residents, including those with complex medical conditions such as congestive heart failure, dementia, diabetes, respiratory failure, and chronic kidney disease, the MDS assessments were either not completed or were significantly overdue. For example, one resident's quarterly MDS was still in progress well past the Assessment Reference Date, and another had both entry and admission MDSs overdue by 12 to 18 days. In some cases, the admission MDS was not completed until well after the deadline. Interviews with staff revealed a lack of clarity and accountability regarding MDS responsibilities. The LPN newly assigned to the MDS role reported that some residents did not have MDS assessments completed and that the previous DON, who was terminated, had not completed any MDSs during her tenure. The Assistant Director of Nursing stated she was unaware of the MDS and care plan status and had not assumed DON responsibilities. The Medical Director acknowledged the importance of timely MDS completion but stated he was not involved in the process. These findings indicate that the absence of a responsible party for MDS assessments during a period of leadership transition led to the deficiency.

Penalty

Inspection fine: $113,71062 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 accurate completion of the Minimum Data Set (MDS) assessments for two residents, specifically regarding the use of bedrails and respiratory support devices. For one resident, the quarterly MDS did not indicate the use of bedrails, despite documentation and interviews revealing that bedrails were in use. The resident experienced multiple falls, resulting in fractures to both arms, and there was no documentation of family education or consent regarding bedrail use. Facility policy required assessment and documentation of bedrail use, including risks and appropriate interventions, but these steps were not followed. For another resident, the admission MDS did not reflect the use of continuous oxygen via nasal cannula or CPAP, even though these treatments were being provided. Interviews with nursing staff revealed confusion and lack of knowledge about where to find or document oxygen orders, and the absence of a DON led to incomplete assessments and missing documentation. The staff responsible for MDS completion either lacked access to necessary systems or were unaware of their responsibilities, resulting in incomplete and inaccurate resident assessments. Facility policies required comprehensive assessments to guide care planning and interventions, but these were not adhered to during the period when the DON position was vacant. Staff interviews confirmed that essential assessments, including fall and bedrail assessments, were not performed, and there was no clear delegation of responsibilities. The lack of accurate MDS documentation and failure to follow established protocols contributed directly to the deficiencies identified for both residents.

Penalty

Inspection fine: $113,71062 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 develop and implement comprehensive, person-centered care plans for four residents as required by policy. For one resident, no Minimum Data Set (MDS) was completed after admission, resulting in the absence of a care plan with interventions to guide care for 26 days. Another resident receiving hospice services did not have a completed MDS or baseline care plan, with MDS assessments overdue by up to 18 days. A third resident's quarterly MDS was not completed, and although a care plan was eventually initiated, it was delayed and only addressed certain risks such as skin breakdown, falls, and pain. The fourth resident, with multiple medical diagnoses including malignant neoplasm, also did not have a completed MDS or comprehensive care plan at the time of review. Interviews revealed that the Director of Nursing (DON) was responsible for care plans, fall assessments, and MDSs, but these duties were not reassigned after the DON position became vacant. As a result, some residents only had limited care plans addressing basic needs such as transfers, incontinence, or eating, rather than comprehensive plans derived from thorough assessments. These findings were based on observations, interviews, record reviews, and facility document reviews.

Penalty

Inspection fine: $113,71062 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 review and revise the comprehensive person-centered care plans within the required timeframe for two residents who experienced multiple falls, including one with a major injury. For one resident with severe cognitive impairment and a history of 22 falls, the care plan was not updated to reflect each fall or to include new or escalated interventions. Documentation showed that only four of the 22 falls had any interventions recorded, and the majority of falls lacked both interventions and updates to the care plan. Staff interviews confirmed that fall interventions were not consistently included in the care plan used by direct care staff, and some interventions, such as the use of a floor mat, were not maintained or documented in the care plan. For the second resident, after an unwitnessed fall resulting in a major injury and subsequent readmission, the care plan was not revised to address the new risks or to include interventions following the incident. Review of records indicated that several falls occurred without corresponding updates to the care plan, and some incident reports lacked any documented interventions. Staff interviews revealed that care plans had not been generated or updated due to the absence of a Director of Nursing, and the care plans available to staff were incomplete, focusing mainly on basic care needs rather than comprehensive fall prevention or response. Facility policy requires that comprehensive, person-centered care plans be developed within seven days of the comprehensive assessment and updated with any significant change in condition, such as falls. The failure to update care plans after repeated falls and significant injuries, as well as the lack of documented interventions, demonstrates noncompliance with facility policy and regulatory requirements. Staff interviews further confirmed that the care plans in use did not reflect current risks or interventions, and there was a lack of leadership oversight to ensure care plans were maintained and revised as needed.

Penalty

Inspection fine: $113,71062 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

Surveyors identified multiple deficiencies in the facility's food storage, preparation, and sanitation practices. During an inspection of the kitchen and unit refrigerators, they observed expired food items, food without proper labeling or dating, and food that was not covered as required by facility policy. Specific findings included bags of lettuce, biscuit mix, crackers, and other items with expired or missing dates, as well as prepared foods such as cherry delight, apple pie, and ice cream that were not labeled or dated. Additionally, some food items were found uncovered in the walk-in refrigerator, and the facility's policy requiring all food to be labeled, covered, and dated was not consistently followed. The kitchen equipment was also found to be inadequately maintained. The fryer contained dried oil, grease, and food particles, and the oil was dark and contained visible debris, indicating it had not been cleaned as required. The ice machine was found to have black specks after being wiped, and cleaning logs showed it had not been cleaned according to the facility's weekly schedule. These observations were confirmed by dietary staff and the Certified Dietary Manager, who acknowledged that cleaning had not occurred as frequently as required. Further, the surveyors found that employee and resident food items were stored together in unit refrigerators, contrary to facility policy, which prohibits staff food from being stored with residents' food. Items belonging to both staff and residents were found without proper labeling, dating, or identification. Interviews with staff and the administrator revealed a lack of consistent adherence to these policies, with some staff believing it was acceptable to store items together if they were dated, despite the written policy stating otherwise.

Penalty

Inspection fine: $113,71062 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 its arbitration agreement, which was presented to residents or their representatives during the admission process, clearly stated that signing the agreement was not a condition of admission. Review of the facility's undated Arbitration Agreement and accompanying checklist revealed that there was no statement indicating that signing was not required for admission, although the agreement did mention that signing was voluntary and could be rescinded within ten days. During an interview, the Business Office Manager confirmed that while she verbally informed residents and representatives that signing was not a condition of admission, this information was not included in the written agreement. Additionally, the facility did not have a policy regarding arbitration agreements.

Penalty

Inspection fine: $113,71062 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 its arbitration agreement, which was signed by residents or their representatives, included a provision specifying that the venue for arbitration disputes would be convenient for both parties. Review of the facility's undated Arbitration Agreement and Arbitration Checklist showed no mention of a mutually convenient location for arbitration proceedings. During interviews, the Business Office Manager confirmed that the agreement did not address venue details and that she informed residents and their representatives that signing the agreement was not a condition of admission. Additionally, the Administrator stated that the facility did not have a policy regarding arbitration.

Penalty

Inspection fine: $113,71062 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 properly identify and implement necessary infection prevention and control measures for two residents requiring special precautions. One resident with wounds infected by Pseudomonas aeruginosa was not placed on Transmission Based Precautions (TBP), as there were no TBP orders, signage, or personal protective equipment (PPE) available outside the room or in the hallways. During wound care, a registered nurse performed hand hygiene and changed gloves but did not use a gown as required for TBP. Laboratory results confirming the infection were present in the resident's record, but appropriate precautions were not initiated. Another resident with an indwelling urinary catheter was not identified for Enhanced Barrier Precautions (EBP), and there were no EBP orders or signage posted. PPE was not available outside the resident's room or in common areas. During catheter care, a certified nursing assistant donned PPE but failed to maintain clean technique, touching contaminated surfaces and her own mask without changing gloves or performing hand hygiene before continuing care. This improper technique increased the risk of cross-contamination. Interviews with staff revealed inconsistent and insufficient training on infection control practices, including EBP and the correct use of PPE. Some staff were unclear about the requirements for EBP, and several had not received training on donning PPE. The former Director of Nursing was unfamiliar with the differences between EBP and TBP, and there was no clear leadership overseeing infection control responsibilities at the time of the survey.

Penalty

Inspection fine: $113,71062 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 implement a dietary recommendation for a resident with significant medical conditions, including metabolic encephalopathy, atherosclerotic heart disease, multiple sclerosis, and type 2 diabetes mellitus. The resident, who had severe cognitive impairment and required assistance with eating, experienced documented weight loss of 5% or more in the last month or 10% or more in the last six months. A dietary recommendation was made by the Registered Dietician (RD) for high calorie snacks between meals due to the resident's oral intake being less than 25% and a 17% weight loss over three months. Despite this recommendation, staff interviews revealed that no morning or afternoon snacks were routinely provided, and the resident confirmed not receiving in-between meal snacks. The Certified Dietary Manager (CDM) stated that the kitchen did not send out snacks between meals and was unaware of the RD's recommendation, possibly due to email communication issues. The RD reported that dietary recommendations were typically communicated via email to the CDM, but could not specifically recall the recommendation for this resident without reviewing the chart. Other dietary recommendations from the same date were being followed, indicating a lapse in communication or implementation for this particular resident.

Penalty

Inspection fine: $113,71062 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 develop a baseline care plan within 48 hours of admission for one resident who was admitted with chronic obstructive pulmonary disease and was also receiving hospice services. Review of the resident's records showed that no baseline care plan was completed as required by facility policy. Interviews with nursing staff revealed confusion regarding responsibilities for care plan development, with some staff lacking access to the electronic health record and relying on co-workers or paper notes. At the time of review, there was no baseline care plan available in the resident's room or chart, and staff confirmed the absence of such documentation. The baseline care plan was only placed in the resident's closet after the deficiency was identified.