All Saints Healthcare Subacute

Penalty

No penalty information released

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 a deficiency in the facility’s implementation of its pneumococcal vaccination policies for two residents reviewed under the infection control task. Resident 85 was admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and ventilator dependence, and was documented in the H&P and MDS as lacking capacity to understand or make decisions and being dependent on staff for all ADLs. The immunization record for this resident showed receipt of Prevnar 13 on 12/27/2012, but there was no documentation that the resident was screened for, offered, administered, or refused an updated pneumococcal vaccine, nor was there documentation of a medical contraindication. Additionally, the facility’s 2025–2026 flu, pneumonia, and COVID consent tracker did not list this resident at all. Resident 41 was admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and cerebral palsy, and the H&P and MDS documented that the resident lacked capacity to understand or make decisions and was dependent on staff for all ADLs. The immunization record indicated Pneumovax 23 was administered on 5/9/2003, but there was no documentation that the resident was screened for, offered, administered, or refused an updated pneumococcal vaccine, nor any documentation of a medical contraindication. The facility’s consent tracker listed this resident as completed for the pneumonia vaccine despite the absence of documentation of updated vaccination, consent, or declination in the medical record. The Infection Preventionist stated that, per current CDC and ACIP adult immunization guidelines, both residents were eligible for and recommended to receive updated pneumococcal conjugate vaccines, and the DON acknowledged that not offering vaccines upon admission was not aligned with the facility’s policies, which require all new residents to be assessed for vaccination status and offered the pneumococcal pneumonia vaccine with consent or refusal documented in the record.

Penalty

No penalty information released

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 a deficiency in the facility’s process for assessing and documenting COVID-19 vaccination status upon admission. One sampled resident, admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and ventilator dependence, was found to lack capacity to understand and make decisions per the admission History and Physical and the MDS assessment. Review of this resident’s immunization record showed no documentation that the COVID-19 vaccine was offered, administered, or declined. The facility’s 2025–2026 flu, pneumonia, and COVID consent tracker also did not list this resident. During interviews, an LVN who assisted the Infection Prevention Nurse with vaccine data entry confirmed there was no documentation in the clinical record that the resident was offered, declined, or received the COVID-19 vaccine upon admission. The DON stated that not offering vaccines to residents upon admission was not aligned with the facility’s vaccination policy and that each resident should be screened by the Infection Preventionist upon admission. Review of the facility’s vaccination policy, last reviewed in January 2025, indicated that all new residents must be assessed for current vaccination status upon admission and that all vaccinations require consent or declination, with any refusal documented in the medical record. These required assessments and documentation were not completed for this resident.

Penalty

No penalty information released

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 deficiency involves the facility’s failure to ensure that a ventilator‑dependent resident with chronic respiratory failure and an anoxic brain injury received care and documentation consistent with professional standards and facility policy during a change of condition. The resident, who required total care and constant supervision and was dependent for activities of daily living, experienced tachycardia and tachypnea on 12/30/2025. A STAT chest x‑ray was ordered by a nurse practitioner (NP) via phone at 6:08 p.m., and a respiratory therapist documented at 6:28 p.m. that the resident had tachycardia and tachypnea. However, there was no corresponding Change of Condition (COC) documentation by the responsible RN that described the signs and symptoms or the events that led to the STAT diagnostic order. The facility’s Director of Nursing (DON) and RN 1 both confirmed during record review that no COC form or nursing note was completed on that date to explain why the STAT chest x‑ray was ordered. RN 1 stated that tachycardia is a change of condition and that a STAT order is definitely a change of condition, and therefore should have been charted. The DON explained that a COC is any change from a resident’s baseline, such as abnormal vital signs or breathing, and that staff who observe a COC must report it to the primary nurse, who then notifies the charge nurse. The charge nurse is then responsible for assessing the resident, contacting the physician, and completing COC documentation, including documenting physician notification and any ordered care. Because no COC documentation was completed, it was unknown whether the resident’s physician was notified of the tachycardia, tachypnea, or the STAT chest x‑ray ordered by the NP. The NP’s documentation was also deficient. Although the NP stated that nurse practitioners function under a collaborative agreement with a physician, typically notify the attending physician of COCs and orders, and that physicians co‑sign NP orders, there was no timely progress note by the NP on or immediately after 12/30/2025 explaining the clinical indications for the STAT chest x‑ray or whether the attending physician was notified. A Medical Professional Note was entered six days later, on 1/05/2026, stating that the patient had tachycardia and was placed on backup ventilator settings due to work of breathing, but the note did not clearly specify whether these findings occurred on 12/30/2025 or 1/05/2026, nor did it document physician notification regarding the STAT order. The DON stated that, as a professional standard of practice, NPs should document in their progress notes when they notify the physician about a COC or when they give an order, and that verbal or phone orders should be supported by timely documentation explaining why the order was given. Facility policies on Reporting Changes in Condition and Documentation Principles required timely communication of significant changes to the attending physician and maintenance of a current, detailed health record consistent with good medical and professional practice, which did not occur in this case.

Penalty

No penalty information released

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 deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident by not documenting a clear change of condition (COC) and related medical decision-making. The resident was admitted with chronic respiratory failure, a tracheostomy, ventilator dependence, and an anoxic brain injury requiring total care and constant supervision. On the date in question, the order summary showed that a nurse practitioner (NP 1) gave a STAT chest x-ray order by phone at 6:08 p.m. However, there was no COC documentation by the responsible RN (RN 2) describing what occurred with the resident that led to this STAT order. The only contemporaneous entry was a respiratory therapy note at 6:28 p.m. indicating tachycardia and tachypnea, which RN 1 and the DON both identified as changes from baseline that should have been documented as a COC. The facility’s Director of Nursing (DON) confirmed that there was no COC documentation in the electronic medical record describing the signs or symptoms present on that date that prompted the STAT chest x-ray. The DON stated that a COC is anything that differs from a resident’s baseline, such as abnormal vital signs or breathing, and emphasized that timely COC documentation is important to communicate significant events and ordered care to subsequent shifts and to avoid duplicate orders. The facility’s policy on Documentation Principles required that health records be current, detailed, and consistent with good medical and professional practice, and that entries be accurate, timely, specific, concise, clear, and descriptive. The absence of a COC entry for this event meant the record did not meet these stated standards. In addition, the NP did not timely document a progress or medical note explaining the clinical indications for the STAT chest x-ray or whether the attending physician was notified. NP 1 stated that typically the attending physician is updated about a resident’s COC and that the physician completes progress notes, while NP 1 documents certain procedures and family conversations. Review of the resident’s record with RN 1 showed no NP progress note on the date of the STAT order or the following day. Instead, NP 1 entered a Medical Professional Note six days later stating the patient had tachycardia and was placed on backup ventilator settings due to work of breathing, without clearly specifying whether these findings occurred on the date of the STAT order or on the date of documentation, and without indicating if the attending physician had been informed. The DON stated that, as a professional standard, a nurse practitioner should document when contacted about a COC requiring medical interventions and that NP documentation must be clear, detailed, and separate from other nurses’ notes, reinforcing that if there is no documentation, it is considered not done.

Penalty

Fine: $126,15043 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

A two-year-old pediatric resident with severely impaired cognition, chronic respiratory failure with tracheostomy, ventilator dependence, and a history of liver transplant was admitted to the facility. The resident was dependent on staff for all activities of daily living and had a documented high risk for falls, with care plans and assessments indicating the need for frequent visual checks and not being left unattended. Despite these documented needs, the facility failed to ensure the resident remained free from accident hazards during bathing. On the day of the incident, a Certified Nursing Assistant (CNA) transferred the resident from a crib to an adult-sized shower bed, which had significant gaps in the side rails. The CNA raised the side rails but then turned her back on the resident to retrieve a bed sheet, leaving the resident unattended. During this time, the resident slipped through the gap in the shower bed rail and fell to the floor, sustaining a bruise on the right cheek. The CNA did not request assistance from the Registered Nurse (RN) present in the room, nor did she maintain physical contact or line of sight with the resident as required by facility policy and the equipment manufacturer's instructions. The facility had not completed an assessment to determine the safety of using adult-sized shower beds for pediatric residents and did not provide size-appropriate equipment. The facility's annual assessment and relevant policies did not address the need for pediatric-sized shower beds, and the resident's fall risk assessment was not updated after the incident. Staff interviews confirmed that the use of adult-sized shower beds for pediatric residents was standard practice, and that the risks associated with the equipment had not been adequately addressed or mitigated.

Removal Plan

• RN 3 assessed Resident 1 for any injuries and transferred to the GACH for further evaluation and was readmitted back at the facility.
• The PNM and RN 2 provided an in-service to CNA 1 regarding Patient Safety Prevention of Falls During Shower and Bathing Procedures.
• The IP revised the P&P titled, Status Post Falls/ Accident, to require an immediate post-fall IDT meeting and a care plan/risk assessment revision within 24 hours of any fall.
• The PNM and SDC started an in-service regarding Shower Beds/ Flexi Bath/ Bed Baths/ Grooming/ Falls/ Infection Control Reminders to all pediatric clinical staff including CNA 1 to not leave residents unattended and ensure residents remain in line of sight when providing bath/shower.
• Use of size-appropriate pediatric shower bed for pediatric resident with weight of less than 50 pounds. The PNM and the Infection Preventionist (IP) approved the new pediatric shower bed to ensure appropriateness for pediatric use.
• The SDC provided in-services regarding Shower Beds/Flexi Bath/ Bed Baths/ Grooming/Falls/Infection Control Reminders for pediatric licensed nurses and CNAs. The in-services required that all pediatric residents must never be left unattended/out of line of sight during bathing/showering or while on assistive devices (pediatric shower beds). The in-services included the updated P&P titled, Use of Shower Bed, and hands-on competency validation for pediatric transfers and the proper use of the new pediatric shower beds. The PNM, RN 1 and RN 2 will perform the quality and safety checks when the new pediatric shower beds arrive. Any new pediatric staff and pediatric staff on leave will receive the in-services and policies regarding pediatric equipment and bathing safety prior to giving shift baths/showers.
• The facility stopped the use of standard-sized shower beds for pediatric residents under 50 lbs.
• The facility purchased size-appropriate pediatric shower beds to be used for all pediatric residents.
• RN 1 and RN 2 provided a mandatory re-education regarding the topic Bathing Safety and Demonstration and P&Ps titled, Falls Prevention, Precautions, and Assessment, and Use of Shower Bed, on proper bathing and safety.
• RN 1 and RN 2 verbally notified staff during the beginning of each shift huddles that no pediatric residents under 50 lbs. were bathed on the standard (adult) sized shower beds.
• The IP updated the P&P titled, Use of Shower Bed, to ensure residents below 50 lbs. are not bathed/showered in standard (adult) shower bed. Residents under 50 lbs. will be showered in the pediatric-sized shower beds when they arrive. Before the arrival of the pediatric-sized shower beds, all pediatric residents less than 50 lbs. are to be given bed baths in their respective beds.
• The facility's leadership team conducted a Root Cause Analysis (RCA) to determine the cause of the deficient practice.
• The IP updated the P&P titled, Use of Shower Bed to include Resident is to always stay in line of sight of the CNA performing bath/shower. If at any moment the CNA needs to leave the resident's side during bath/shower, the CNA is to ensure there is coverage by a clinical staff member.
• The SDC, the PNM, and RN 2 in-serviced CNA 2 regarding Bathing Safety Demonstration with a return demonstration.
• The Interdisciplinary Team (IDT) reviewed and revised Resident 1's comprehensive care plan and Fall Risk Assessment. The updated plan of care included:
• The DON and RN 2 evaluated all 33 pediatric residents for potential risk for falls from the adult size shower bed. Seven (Residents 1, 3, 4, 5, 6, 7, and 8) out of 33 residents were identified at risk for falls during bathing.
• The DON and RN 2 completed evaluations for potential risk for falls from a shower bed for all 33 pediatric residents that included: a review of each resident's current Fall Risk Assessment and comprehensive care plan to ensure bathing procedures are followed, supervision needs are met, and the required bathing equipment is used; the PNM and IP performing a physical inspection and assessment of all bathing equipment used for each pediatric resident to ensure proper sizing and safety; RN 1 and RN 2 completing care plan updates for any pediatric resident requiring changes to bathing procedures and bathing equipment.
• The SDC, the PNM, RN 1 and RN 2 will be responsible for daily unit supervision and monitoring effectiveness. The SDC or Unit Charge Nurses will conduct random observational audits to ensure: only size-appropriate equipment is used for pediatric residents; care-planned bathing procedures and supervision levels are consistently followed; no pediatric resident is left unattended on any assistive device; staff can verbalize understanding of the new and revised policies.
• The SDC will report audit findings to the DON weekly and to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will review the data, analyze trends, and make recommendations for further action as needed. The QAPI committee will monitor on an ongoing basis until sustained compliance is achieved for three consecutive months.

Penalty

Fine: $126,15043 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 Business Office Staff (BOS) were knowledgeable about the residents' and their representatives' rights to rescind a binding arbitration agreement within 30 days of signing. During interviews and record reviews, it was found that the BOS did not inform the resident representatives (RRs) for three sampled residents that they could rescind their signatures on the arbitration agreement. The BOS admitted to not reading the arbitration agreement and was unaware of the 30-day rescission period, as outlined in the facility's own policy and procedure. The sampled residents all had severe cognitive impairments and were dependent on medical interventions such as tracheostomies, ventilators, and gastrostomies. In each case, the arbitration agreement was signed by the RR and the BOS, but there was no documentation or evidence that the RRs were informed of their right to rescind the agreement within the specified timeframe. The facility's policy clearly states that residents or their representatives have 30 days after signing to cancel or rescind the agreement, but this information was not communicated to the RRs by the BOS. Further interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the facility's policy includes a 30-day rescission period and that the BOS was responsible for explaining this to the RRs. However, both the DON and BOS acknowledged gaps in their understanding and communication of the arbitration process, resulting in the RRs not being properly informed of their rights regarding the arbitration agreement.

Penalty

Fine: $126,15043 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

During the respiratory virus season, the facility failed to implement its infection control measures as required by its own policy. Observations revealed that three out of five sampled staff members, including an LVN and two RNs, were not wearing masks while in the facility, despite posted signage and a policy indicating that masking was mandatory in all resident care areas starting from a specified date. The staff were seen in hallways and near resident rooms without masks, and one staff member assisted a surveyor without wearing a mask. Interviews with staff indicated confusion and lack of awareness regarding the updated masking policy, with one staff member stating she was not informed of the change and did not see the posted signage due to using a different entrance. Another staff member acknowledged forgetting to wear a mask, while others confirmed they had been informed of the policy but did not comply. Review of the facility's policy and procedure confirmed that all staff were required to wear masks in resident care areas, including hallways, during the respiratory virus season, regardless of vaccination status. Both the Infection Preventionist and the Director of Nursing affirmed that hallways are considered resident care areas and that the masking policy was in effect. The failure of staff to adhere to the masking policy was acknowledged by facility leadership, who recognized that non-compliance could contribute to the spread of respiratory illnesses among residents, staff, and visitors.

Penalty

Fine: $126,15043 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 accurate and up-to-date facility-wide assessment regarding the resources necessary to care for its resident population, specifically omitting critical equipment and technology updates. The assessment did not reflect the use of pediatric shower beds and other pediatric-specific bathing equipment, despite the presence of 33 pediatric residents in the facility. Interviews with the Administrator and Director of Nursing revealed that the facility assessment only listed shower chairs, and did not include pediatric shower beds or gurneys, even though these were in use or had been requested by staff. The omission was confirmed during multiple record reviews and staff interviews, with the DON acknowledging that the assessment was incomplete and missing essential equipment details for the pediatric population. Additionally, the facility assessment failed to accurately document the transition to electronic health records (EHR). Although the facility began using EHR on April 1, 2025, the assessment continued to state that medical records were paper documents and only referenced a future transition to EHR. Both the Administrator and Staff Development Coordinator confirmed in interviews that the assessment was not updated to reflect the current use of EHR, and the DON also stated that the assessment was not complete or accurate in this regard. These deficiencies were identified through interviews and record reviews, which demonstrated that the facility's assessment did not accurately represent the resources and technology in use. The lack of accurate documentation in the facility assessment had the potential to delay necessary care and services for residents, particularly for the pediatric population and in the management of health information technology.

Penalty

Fine: $126,15043 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 accurate and complete medical records for a resident with complex medical needs, including a history of extreme prematurity, chronic respiratory failure with tracheostomy, ventilator dependence, and liver transplant status. On the date in question, the resident was scheduled to receive tacrolimus, a critical immunosuppressive medication, at 9 a.m. The Medication Administration Record (MAR) for that time was left blank, and there was no contemporaneous documentation by the Registered Nurse (RN) who administered the medication. Although a late entry was made nearly a month later by a Licensed Vocational Nurse (LVN) who witnessed the administration, facility policy required that the original staff member document medication administration at the time of service. Multiple staff interviews confirmed that if medication is not documented, it is considered not given, and the facility's policies emphasized the importance of timely and accurate documentation. Additionally, the resident's Baseline Care Plan inaccurately documented the resident's cognitive status as intact, despite multiple assessments and staff interviews indicating the resident had severely impaired cognition and was dependent on staff for activities of daily living. The inaccurate documentation in the care plan did not reflect the resident's true condition, as confirmed by the staff and the Minimum Data Set (MDS) assessment. These documentation failures were identified through interviews, record reviews, and policy reviews. The Director of Nursing (DON) and other staff acknowledged that documentation must be accurate and completed at the time care is rendered, and that inaccurate or missing documentation could lead to confusion in care and an inaccurate plan of care for the resident.

Penalty

No penalty information released

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 the State Survey Agency (SSA) with a written report of the findings from its internal investigation of an alleged abuse incident within five working days, as required by policy. The incident involved a resident with severe cognitive impairment and significant care needs, including dependence for eating, personal hygiene, and dressing, who was admitted with diagnoses such as hypertension, tracheostomy, and gastrostomy. The alleged abuse occurred when a Certified Nurse Assistant was reported to have yelled at the resident while providing care. The Infection Preventionist was assigned to conduct interviews and prepare the final investigation report, but as of the time of the survey, the report had not been submitted to the SSA within the required timeframe. The facility's own policy mandates that a thorough investigation be conducted and a final written report be submitted to the Department of Health Services within five business days. The Administrator confirmed that while the initial report of suspected abuse was submitted, the final written investigation findings were not provided within the mandated period.

Penalty

No penalty information released

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

A Certified Nurse Assistant (CNA) provided oral suctioning to a resident who had chronic respiratory failure, a tracheostomy, and a gastrostomy, despite not being trained or authorized to perform this procedure. The resident's care plan specified that oral suctioning was to be performed only by licensed staff such as Licensed Vocational Nurses (LVN), Registered Nurses (RN), or Respiratory Therapists (RT). The CNA used a Yankauer suction tip to remove secretions from the resident's mouth, during which the resident bit down on the device, and the CNA had to instruct the resident to open her mouth several times to remove it. Interviews with the CNA, another CNA present, and the Director of Nursing (DON) confirmed that CNAs are not trained or permitted to perform oral suctioning, and that the facility's policy restricts this procedure to licensed clinical staff. The DON acknowledged that the CNA should have called for licensed staff assistance instead of performing the procedure. The resident's care plan and facility policy were not followed, resulting in care being provided by an unqualified person.

Penalty

No penalty information released

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 an allegation of abuse within the required two-hour timeframe to the State Survey Agency (SSA) after a resident disclosed to the Social Worker (SW) that a certified nursing assistant (CNA) had touched him inappropriately. The resident, who was cognitively intact and required maximal assistance with daily activities, reported the incident to the SW, stating it had occurred about a year prior while he was in the shower. The SW documented the allegation and notified the President of Operations, but the report to the SSA was not made until the following day, exceeding the mandated reporting window. Interviews and record reviews confirmed that the SW and the President of Operations were aware of the allegation on the day it was made, but delayed reporting to the SSA because the resident did not have any injuries. The facility's policy required allegations of abuse to be reported as soon as possible, but no later than 24 hours if there was no serious bodily injury, and within two hours if abuse was involved. The delay in reporting placed the resident at risk for further abuse.

Penalty

No penalty information released

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 attending physician when a significant change in condition occurred for one resident. The resident, who had a history of chronic respiratory failure, anxiety disorder, and dependence on a respiratory ventilator, was comatose and fully dependent on staff for care. On the date in question, the resident experienced tachycardia and a low-grade temperature, which constituted a change of condition. The resident was subsequently transferred to a general acute care hospital at the request of the responsible party, who was present and aware of the transfer. Upon review of the resident's records and interviews with facility staff, it was determined that no Change of Condition (COC) form was completed for this event, and there was no documented evidence that the physician was notified of the resident's change in status. The facility's policy requires immediate notification of the physician and responsible party in the event of a significant change in condition. The Director of Staff Development confirmed that the lack of a completed COC form could result in missed communication to required parties, and acknowledged that the physician had not been notified as required by policy.

Penalty

No penalty information released

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 policy and procedure for reporting an allegation of abuse involving a resident who alleged being physically abused by an employee. Despite the resident's cognitive skills being intact, the facility did not investigate or report the allegation to the California Department of Public Health (CDPH) as required. The Director of Staff Development confirmed that all staff are mandated reporters and that abuse should be reported immediately or within two hours to the appropriate authorities, including the local police, Long-term Care Ombudsman, and CDPH. However, the facility did not adhere to these protocols. During interviews and record reviews, it was revealed that the allegation of abuse was documented in the resident's progress notes, and the abuse coordinator was informed. However, the Administrator was unaware of the allegation and could not provide an investigation report or evidence of attempts to contact external investigative agencies. The facility's policy requires that any employee witnessing or being informed of an abuse allegation must report it immediately, and a thorough investigation should be conducted. The policy also mandates contacting the Department of Health within two hours of the initial report, which was not done in this case.

Penalty

No penalty information released

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 was free from significant medication errors by not adhering to the physician's orders regarding the administration of midodrine, a medication used to treat low blood pressure. The resident, who was admitted with diagnoses including unspecified chronic respiratory failure, unspecified hypotension, and Down syndrome, was dependent on staff for all activities of daily living and was in a persistent vegetative state. The physician's order specified that midodrine should be administered every 12 hours via gastrostomy tube and held if the systolic blood pressure exceeded 110 mmHg. The deficiency occurred when the facility administered midodrine to the resident on six occasions despite the resident's blood pressure being above the threshold specified in the physician's order. Additionally, there was a failure to administer the medication on one occasion when the resident's blood pressure was below the threshold, which was necessary for blood pressure support. These actions were confirmed during interviews and record reviews with the Director of Nursing, who acknowledged that the nurses should have followed the physician's order to prevent potential increases in the resident's blood pressure. The facility's policies and procedures, including the Ten Medication Rights and Medication Administration Techniques, were reviewed and indicated that nurses should read medication labels carefully and compare them with the physician's orders to prevent medication errors. The policies also emphasized the importance of checking necessary parameters such as blood pressure before administering medications. Despite these guidelines, the facility's failure to adhere to the physician's orders resulted in significant medication errors for the resident.

Penalty

No penalty information released

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 effective infection prevention and control program, as evidenced by the actions of Registered Nurse 4 (RN 4) during the care of two residents. RN 4 did not adhere to Enhanced Barrier Precautions (EBP) when providing gastrostomy (GT) care to Resident 5, who was comatose and dependent on staff for various activities. Despite the facility's policy requiring the use of gowns, gloves, goggles, and masks during high-contact tasks like GT care, RN 4 only wore gloves and a mask, neglecting to don a gown. Additionally, RN 4 did not perform hand hygiene after removing gloves and before preparing medication for Resident 6, who also had significant medical needs, including chronic respiratory failure. This lapse in protocol occurred after RN 4 accessed Resident 5's GT, potentially risking cross-contamination between residents. The facility's infection preventionist and Director of Nursing both acknowledged that RN 4 should have worn a gown and performed hand hygiene to prevent the transmission of microorganisms. The facility's policy on Enhanced Barrier Precautions, last reviewed in early 2024, clearly outlines the necessity of wearing appropriate protective attire during high-risk tasks to prevent the spread of multidrug-resistant organisms. The failure to follow these guidelines during the care of Residents 5 and 6 highlights a significant deficiency in the facility's infection control practices, as observed and documented by the surveyors.

Penalty

No penalty information released

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 pharmaceutical services by not following the physician's orders for a resident, which had the potential to affect the resident's blood pressure management. The resident was admitted with chronic respiratory failure, end-stage renal disease, and diabetes mellitus, and was noted to have severely impaired cognitive skills. The care plan included an intervention to administer medication as ordered, specifically hydralazine for hypertension, to be given every eight hours via a gastrostomy tube. However, a review of the resident's medication record for October revealed that on one occasion, the administration of hydralazine was not documented, indicating the medication was not given. Interviews with a registered nurse and the Director of Nursing confirmed that if the medication record is left blank, it means the medication was not administered. This oversight was contrary to the facility's policy, which requires nurses to sign the medication record after administering medication to ensure accurate documentation and prevent medication errors.

Penalty

No penalty information released

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 accurate and complete medical records for a resident, which had the potential to cause confusion in care and delay the delivery of care. The resident was admitted with chronic respiratory failure, end-stage renal disease, and diabetes mellitus. The resident's cognitive skills for daily decisions were severely impaired. On a specific date, the resident's blood pressure was recorded as extremely high, and medications were administered by an LVN as instructed by an RN. However, the Medication Record for that day was incomplete, with lisinopril left blank and captopril recorded at an incorrect time. During interviews, the LVN admitted to administering the medications but forgetting to sign the Medication Record, acknowledging that such omissions could lead to medication errors. The DON confirmed that unsigned medication records imply that the medication was not given, emphasizing the importance of signing the Medication Record after administration. The facility's policy on Medication Error and Record Completion was reviewed, which mandates maintaining accurate and complete health records, and correcting deficiencies timely in accordance with professional standards.

Penalty

No penalty information released

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 pad call lights were within reach for four of the six sampled residents, which could potentially delay the provision of necessary care and services. Resident 463, who was admitted with a tracheostomy, gastrostomy, and nontraumatic intracranial hemorrhage, was observed with the pad call light placed on top of the ventilator, out of reach. The Director of Staff Development confirmed that the call light should be within reach to allow the resident to call for help when needed. The Director of Nursing also acknowledged that the failure to keep the call light within reach could result in the resident being unable to call for help and potentially falling while trying to reach it. Resident 75, diagnosed with chronic respiratory failure, tracheostomy, and spastic quadriplegia cerebral palsy, was observed with the call light placed on top of a pulse oximeter machine, not within reach. The Licensed Vocational Nurse verified that the call light should have been placed closer to the resident's cheek area to enable them to call for assistance. The facility's policy and procedure on call lights, which mandates that call lights be placed within reach and monitored for positioning, was not followed. Resident 18, with similar diagnoses and impairments as Resident 75, had their call light hanging between the mattress and the left upper siderail, out of reach. The Licensed Vocational Nurse confirmed that the call light should be within reach to allow the resident to ask for assistance. Similarly, Resident 4, diagnosed with cerebral palsy and gastrostomy, had their call light on the floor outside the bed frame enclosure. The Certified Nurse Assistant stated that the call light should be within reach to enable the resident to call for help. The Director of Nursing reiterated the importance of having the call light within reach to prevent delays in meeting the residents' needs.

Penalty

No penalty information released

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 the confidentiality of residents' protected health information (PHI) by not properly disposing of medication labels containing sensitive information. During an observation in the biohazard room, it was found that medication bubble packs for two residents had their pharmacy labels intact and visible through clear plastic bags in a waste container. This oversight exposed the residents' PHI, including their names, dates of birth, and medication details, to potential unauthorized access. Interviews with the Director of Nursing (DON) and Registered Nurse (RN) 3 revealed that the facility's process for disposing of medication labels was not consistently followed. The DON acknowledged that the labels should have been removed, shredded, or covered with an Identi-Hide label before disposal to protect resident confidentiality. RN 3 confirmed that the failure to cover or remove resident information from medication bubble packs was a violation of HIPAA guidelines, as it exposed PHI to third-party vendors responsible for waste disposal. The Director of Staff Development (DSD) and the Consultant Pharmacist (CP) both emphasized the importance of adhering to HIPAA guidelines, which require PHI to be shredded or covered before disposal. The facility's policy and procedures, as well as the in-service lesson plan, clearly outlined the need to protect resident information by shredding or covering it. Despite staff being educated on these guidelines, the facility did not consistently implement the necessary measures to safeguard resident privacy, resulting in a breach of confidentiality.

Penalty

No penalty information released

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 residents were free from the use of physical restraints unless needed for medical treatment. This deficiency was observed in six residents who were subjected to physical restraints without proper assessments, physician orders, informed consent, or care plans. The facility did not perform the required Bedrail/side rail Use and Entrapment Risk Evaluation quarterly for several residents, including those with severe cognitive impairments and physical disabilities, which could lead to potential harm such as entrapment. For Resident 37, the facility did not obtain a physician's order, assess the need for the restraint, or obtain informed consent for the use of a restraint bed placed against the wall. Additionally, there was no care plan developed or implemented for this restraint. Similarly, Resident 71 was subjected to the use of a left-hand mitten without the necessary initial and quarterly restraint assessments or informed consent, and Resident 45 had a right-hand mitten applied without quarterly assessments. The facility's policies and procedures required evaluations and informed consent for the use of restraints, but these were not followed. Interviews with staff, including the Director of Nursing and the Minimum Data Set Coordinator, confirmed that the necessary assessments and consents were not completed as per facility policy. This lack of compliance with established protocols resulted in the inappropriate use of restraints, potentially restricting residents' freedom of movement and increasing the risk of physical harm.

Penalty

No penalty information released

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 care plans for three residents, leading to potential delays in care and services. Resident 45, who was admitted with chronic respiratory failure, tracheostomy, and gastrostomy, had a physician's order for the application of a right-hand mitten to prevent pulling out life-sustaining tubes. Despite the order, no care plan was developed to address the use of the mitten, as confirmed by the Minimum Data Set Coordinator. This oversight meant that staff were not adequately informed of the resident's care needs, risking delays in care. Resident 37, admitted with chronic respiratory failure and dependence on a respirator, had their bed placed against the wall, which was considered a restraint. The resident required moderate assistance with mobility and activities of daily living. However, there was no care plan in place to address the bed's placement, as noted by Registered Nurse 6. The lack of a care plan for this restraint meant that the resident's safety and mobility needs were not formally documented or communicated to the care team. Resident 463, who had severe cognitive impairment and was dependent on mobility and activities of daily living, had an order for the use of full side rails for safety. Despite this, no care plan was developed to ensure the safe use of the bedrails, as observed by Registered Nurse 2. The absence of a care plan for the bedrails posed a risk of accidents such as entrapment, as the care team lacked formal guidance on managing this aspect of the resident's care.

Penalty

No penalty information released

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 licensed nursing staff failed to adhere to professional standards of care by not rotating the subcutaneous insulin administration sites for a resident, identified as Resident 81. This resident was admitted with chronic respiratory failure, a tracheostomy, and type 2 diabetes mellitus, and was noted to have severely impaired cognition, requiring total assistance with activities of daily living. The failure to rotate insulin injection sites was identified during a review of the resident's Medication Administration Record (MAR) for the months of August, September, and October 2024. The MAR indicated that both Humulin N and Regular insulin injections were repeatedly administered in the same areas, such as the left lower quadrant and right lower quadrant, without proper rotation. This practice was confirmed by Registered Nurse 2 (RN 2) and the Director of Nursing (DON), who both acknowledged that the insulin administration sites were not rotated as per the standards of practice and the manufacturer's guidelines. The facility's policy and procedure for insulin administration, as well as the manufacturer's guidelines, clearly stated the need for site rotation to prevent complications such as lipodystrophy and localized cutaneous amyloidosis. The DON verified that the nurses did not follow the manufacturer's guidelines, which emphasized the importance of changing injection sites to reduce the risk of skin complications and ensure proper medication absorption. The facility's policy also required the use of proper subcutaneous techniques, which were not adhered to in this case. This oversight in insulin administration practices had the potential to adversely affect the resident's health by causing skin lumps, bruising, and affecting insulin absorption.

Penalty

No penalty information released

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 appropriate services to prevent decline in joint range of motion (ROM) for three residents, as observed during a survey. Resident 15 was found to have been wearing hand splints for longer than the physician-ordered duration of one hour, which could potentially lead to skin irritation or lesions. The Restorative Nursing Aide (RNA) admitted to applying the splints for two hours instead of the prescribed one hour, and this discrepancy was confirmed by both the Registered Nurse (RN) and the Director of Rehabilitation. The facility's policy required adherence to physician orders regarding the duration of splint application, which was not followed in this case. Resident 93 was observed with hand rolls improperly placed around the wrists instead of inside the hands, contrary to the physician's order for them to be worn at all times. This improper application was noted by a Licensed Vocational Nurse (LVN), who corrected the placement. The RN and Director of Nursing (DON) confirmed that hand rolls are essential to prevent contractures and skin issues, and they should be applied correctly as per the orders. The facility's policy also emphasized the importance of following physician orders for hand roll application. Resident 94 was found without the required hand rolls and heel protectors, which were ordered to be worn at all times. An LVN observed the resident without these devices and proceeded to apply them, noting that their absence could lead to contractures and pressure injuries. The RN and DON reiterated the necessity of following orders for these protective devices to prevent skin breakdown and other complications. The facility's policy mandated that such orders be noted and carried out, which was not adhered to in this instance.

Penalty

No penalty information released

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 safe environment free from accident hazards for four residents. Resident 19's medications, Albuterol and Atrovent, were left at the bedside, posing a risk of accidental overdose. The resident, who lacked the capacity to understand and make decisions, was at risk due to the staff's failure to store medications safely. The facility's policy required an assessment and a physician's order for self-administration of medications, which was not followed in this case. Resident 35's bottle of milk of magnesia was also left at the bedside, despite the resident having the capacity to understand and make decisions. The staff did not adhere to the facility's policy of storing medications safely unless a physician's order and interdisciplinary team assessment deemed the resident capable of self-administration. This oversight could lead to accidental overdosing, as acknowledged by the Licensed Vocational Nurse and the Director of Nursing. Resident 100's fall mat was improperly used, with the bed's wheels resting on it, compromising its effectiveness in preventing injury from falls. The resident, who had impaired vision and required substantial assistance, was at risk due to the sitter's inattention to environmental hazards. Additionally, Resident 87's bed was left in a high position by an X-ray Tech, increasing the risk of falls for a resident with severely impaired cognition and high fall risk. The facility's policies on fall prevention and accident prevention were not followed, as staff failed to ensure the bed was returned to a safe position after the procedure.

Penalty

No penalty information released

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 appropriate care for residents with urinary catheters, leading to potential risks of catheter-associated urinary tract infections (CAUTIs). Resident 80, who had a suprapubic catheter, was observed without a securement device or leg strap, which is necessary to prevent pulling and trauma to the stoma. This oversight was confirmed by both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged that the absence of a securement device could lead to skin trauma and serve as a portal for infection. Residents 7 and 94 were found with coiled urinary catheter tubing, which can impede urine flow and increase the risk of infection. Resident 7, who had an indwelling catheter, was observed with coiled tubing below the bed, confirmed by an LVN who noted the potential for infection and catheter dislodgement. Similarly, Resident 94's catheter tubing was coiled, with visible sediment in the urine, indicating improper drainage. The DON confirmed that catheter tubing should be free of coils to ensure proper urine flow and prevent urinary retention, which can lead to UTIs. The facility's policy and procedure on catheter care, last reviewed in January 2024, emphasized the importance of securing catheter tubing to prevent kinks and loops. However, the observations and interviews revealed that these guidelines were not consistently followed, resulting in deficiencies in catheter care for the residents involved. These practices put the residents at risk for developing CAUTIs due to improper catheter management.

Penalty

No penalty information released

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 appropriate care for residents receiving enteral feeding, leading to potential complications. For Resident 75, a Licensed Vocational Nurse (LVN) did not discard the enteral feeding formula left in the irrigation bottle after medication administration, leaving the medication syringe inside. This oversight could lead to infection control issues and feeding intolerance symptoms such as nausea, vomiting, and diarrhea. The resident had severe cognitive impairment and required total assistance with daily activities, relying on a gastrostomy tube for nutrition. Resident 38's enteral feeding formula bottle was not labeled with the start date, which is necessary to ensure the formula is not expired. The resident also had severe cognitive impairment and required total assistance with daily activities. The Director of Nursing confirmed that the facility's policy requires labeling the formula with the time, date, resident's name, and nurse's initials to prevent the administration of expired formula, which could lead to feeding intolerance symptoms. Resident 11's enteral feeding bag was not labeled with the resident's name, date, and time, which could result in administering spoiled nutrition. The resident had cerebral palsy and was dependent on a feeding tube. Additionally, the facility failed to change the irrigation trays for Residents 104 and 65 as per policy, which could lead to gastrointestinal infections. Both residents had feeding tubes and required specific care to prevent infections. The facility's infection control program was not adequately followed, increasing the risk of gastrointestinal problems for these residents.

Penalty

No penalty information released

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 administer parenteral fluids or medications consistent with professional standards of practice. This was evidenced by the failure to label peripheral intravenous catheter dressings per facility policy for multiple residents, including those with chronic respiratory failure and other serious conditions. Observations revealed that IV dressings were not labeled with the date, time, and initials of the nurse who inserted or changed the dressing, which is a requirement according to the facility's policy. Additionally, the facility did not ensure that residents with IV catheters had physician orders for the IV catheters. This was noted in several cases where there was no documented evidence of physician orders for the insertion and maintenance of IV catheters. The lack of physician orders and proper documentation placed residents at risk for complications such as infection. The facility also failed to routinely remove and replace IV catheters every 72 hours as per their policy. Interviews with nursing staff and the Director of Nursing revealed a lack of awareness and adherence to the facility's procedures regarding IV catheter maintenance. This included not verifying with physicians if the IV catheter was still needed after the completion of IV antibiotic treatments, further increasing the risk of infection and other complications for the residents.

Penalty

No penalty information released

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 and sufficient nursing staff to meet the needs of residents requiring Restorative Nursing Aide (RNA) services. Observations, interviews, and record reviews revealed that the facility had only one or two RNAs scheduled per day for the 7:00 a.m. to 3:30 p.m. shift, despite having 70 adult subacute residents with physician's orders for daily RNA treatments. These treatments included range of motion exercises, application of splints or braces, and ambulation. The RNAs reported that they could not complete all RNA treatments for every resident each day, as they were only able to see about 18-20 residents daily. The Director of Staffing Development confirmed that the staffing levels were insufficient to meet the RNA orders, as some residents required more time or two RNAs for certain treatments. Interviews with the RNAs and the Director of Nursing (DON) highlighted that the lack of sufficient RNA staff led to incomplete RNA treatments, which could result in tighter muscles, increased contractures, and stiffness in residents. The facility's policy indicated that residents should receive restorative nursing care as needed, but the staffing assignments did not align with the individual residents' plans of care. The DON acknowledged that all residents with RNA orders should be seen for treatments as ordered, and the failure to do so could lead to additional care problems.

Penalty

No penalty information released

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 pharmaceutical services to meet the needs of a resident, specifically by not having an available supply of simethicone and renal multivitamin in the medication carts. This affected one resident, who did not receive these medications as prescribed on a specific date. The resident, who was admitted with diagnoses including end-stage renal disease and required renal dialysis, was observed not receiving the prescribed medications during a medication administration task. The Licensed Vocational Nurse (LVN) administering the medications confirmed that the medications were not available in the medication cart or the medication room, and the nurse did not have access to the Central Supply Room where additional stock might be stored. The facility also failed to dispose of controlled drugs within the required 90 days of order for discontinuation, as observed in the Director of Nursing's (DON) office. Six controlled drugs were found in a locked cabinet, with accountability records indicating they had not been disposed of within the regulatory timeframe. The DON acknowledged the failure to comply with state and federal regulations regarding the disposal of controlled drugs, which is crucial to prevent diversion and accidental exposure to harmful substances. Interviews with facility staff revealed that the current process for medication access and disposal was inefficient. The Director of Central Supply and the DON both recognized that licensed nurses did not have access to the Central Supply Room, which contributed to the unavailability of medications and delayed administration. The facility's policies and procedures were reviewed, highlighting the importance of timely medication administration and proper disposal of controlled drugs, but these were not adhered to, leading to the deficiencies observed.

Penalty

No penalty information released

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 manage and monitor the medication regimen of residents to promote their highest practicable well-being. Specifically, the facility did not monitor for adverse effects of psychotropic medications such as Remeron and Buspar for Resident 50, and Sertraline for Resident 104. This lack of monitoring could lead to the use of unnecessary psychotropic drugs and potential adverse effects. Resident 50, who was admitted with diagnoses including chronic respiratory failure, anxiety disorder, and major depressive disorder, was prescribed Buspar and Remeron. However, the facility did not obtain informed consent that included the dosage, frequency, and indication for these medications. Additionally, there was no physician's order to monitor for adverse effects, which was confirmed by the Minimum Data Set Coordinator (MDSC) and the Director of Nursing (DON). The facility's policy required informed consent to include medication details and for staff to monitor adverse effects, but these were not followed. Resident 104, admitted with chronic respiratory failure and major depressive disorder, was prescribed Sertraline. The facility did not have an order to monitor for adverse effects of Sertraline, as confirmed by Registered Nurse 2 and the DON. The facility's policy on medication regimen review required monitoring to prevent adverse consequences, but this was not implemented for Resident 104.

Penalty

No penalty information released

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 a medication error rate below 5%, resulting in a 9.09% error rate during a medication administration task. This was due to three medication errors out of 33 opportunities, affecting two residents. Resident 44 did not receive labetalol at the scheduled time, and Resident 106 did not receive simethicone and a renal multivitamin as prescribed. These errors were primarily due to the unavailability of medications and oversight by the nursing staff. The unavailability of medications was a significant factor in the errors. Licensed Vocational Nurse (LVN) 11 was unable to administer simethicone and renal multivitamin to Resident 106 because these medications were not available in the medication cart or the Medication Room. LVN 11 did not have access to the Central Supply Room, where additional stock was kept, and relied on Central Supply Employees (CSEs) to replenish the medications. The Director of Central Supply confirmed that simethicone was not available in the facility on the day of the observation, and the process of relying on CSEs for medication access was deemed inefficient by the Director of Nursing (DON). In another instance, LVN 13 failed to administer labetalol to Resident 44 due to oversight. The medication was not prepared or administered at the scheduled time, which was acknowledged as a medication error by LVN 13. The facility's policy allows a 60-minute window for medication administration, and any administration outside this window is considered an error. The DON confirmed that these incidents were medication errors and highlighted the need for licensed nurses to have access to medications throughout the facility to ensure timely administration.

Penalty

No penalty information released

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 was free from significant medication errors by not rotating subcutaneous insulin administration sites. This deficiency was identified for one resident who was investigated under unnecessary medications. The resident, who had been admitted and readmitted to the facility with diagnoses including chronic respiratory failure, tracheostomy, and type 2 diabetes mellitus, was found to have insulin injections administered repeatedly in the same areas, contrary to standard practice. The resident's medical records, including the Medication Administration Record (MAR), indicated that insulin injections were not rotated as required. The MAR showed repeated use of the same injection sites over several months, which was confirmed by a registered nurse and the Director of Nursing (DON). Both acknowledged that the failure to rotate injection sites could lead to adverse effects such as bruising, pain, and lumps, and that this practice did not adhere to the manufacturer's guidelines or the facility's policy. The facility's policy and procedure documents, as well as the manufacturer's guidelines for the insulin used, clearly stated the need to rotate injection sites to prevent complications like lipodystrophy and localized cutaneous amyloidosis. The DON verified that the nurses did not follow these guidelines, resulting in a medication error as defined by the facility's policy. This oversight in insulin administration was considered a significant medication error due to its potential impact on the resident's health.

Penalty

No penalty information released

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 store and label medications in accordance with manufacturer's requirements and facility policies, as observed during a survey. Specifically, one vial of lorazepam for Resident 7 was found in a medication refrigerator without a label indicating when it was first opened, contrary to the manufacturer's specifications and facility procedures. Additionally, an open and expired lorazepam vial for Resident 11 was found, which was labeled with a date indicating it had been opened beyond the allowable 28-day period. Furthermore, an Epogen vial for Resident 92 was found in another medication refrigerator without a label indicating when it was first opened, which is required by the manufacturer's guidelines. The manufacturer's instructions specify that Epogen multi-dose vials should be discarded 21 days after opening. The absence of proper labeling and adherence to expiration dates for these medications increased the risk of residents receiving ineffective or potentially harmful treatments. The Director of Nursing (DON) confirmed during the survey that the medications were improperly stored and labeled, acknowledging that the vials for Residents 7, 11, and 92 were expired and should not be used. The facility's policies and procedures, which require all injectable medications to be dated when first opened and expired medications to be disposed of properly, were not followed. Daily checks of medication refrigerators for expired medications were also not conducted as required by the facility's policies.

Penalty

No penalty information released

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 safe and sanitary food storage and preparation practices in the kitchen, as observed during a survey. A cell phone was found placed next to boxes of nutritional supplements in the dry storage area, which was confirmed by the Dietary Supervisor (DS) as inappropriate due to the risk of cross-contamination. The Director of Nursing (DON) also acknowledged that personal belongings should be stored separately to prevent contamination with residents' food. The facility's policy and procedure (P&P) on employee personal belongings, last reviewed in April 2022, clearly states that personal items should not be placed in food storage areas. Additionally, a dented can of mandarin oranges was found stored with non-dented cans, contrary to the facility's P&P on food storage, which requires dented cans to be separated and returned to the vendor. The DS confirmed this practice during the survey, and the DON reiterated the importance of not storing dented cans with non-dented ones to avoid cross-contamination. Furthermore, two cans of soda were found on the floor beneath the shelves in the dry storage area, which the DS confirmed should not occur as it poses a risk of cross-contamination. The facility's P&P on food storage mandates that food items be stored at least six inches above the floor to facilitate cleaning and prevent contamination.

Penalty

No penalty information released

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 safe and sanitary storage, handling, and consumption of food brought in by family or visitors for a resident. Specifically, the facility did not label food brought from home with the resident's name, date, and time it was brought into the facility. This oversight was identified during a review of the kitchen facility task for a resident who had been admitted with chronic respiratory failure, dependence on a respirator, and hypoglycemia. The resident was capable of understanding and making decisions and was on a therapeutic diet. During an observation of a resident refrigerator, a bottle of honey was found labeled only with a room number, lacking the date it was opened. Interviews with two registered nurses confirmed that the bottle should have been dated to prevent the consumption of spoiled or expired food. The Director of Nursing also acknowledged that staff should have labeled the food with the date, time, and resident's name to avoid gastrointestinal issues from spoiled food. The facility's policy required such labeling, and food not consumed within 72 hours was to be discarded.

Penalty

No penalty information released

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 effective infection prevention and control program, leading to several deficiencies. One issue involved Resident 26, who was connected to a ventilator with a sterile water bag that was not replaced every three days as per facility policy. The bag was labeled with an outdated date, and the respiratory therapist and infection preventionist acknowledged that the equipment should have been changed upon the resident's return from the hospital. This oversight could potentially lead to bacterial growth and infections. Another deficiency was observed with Resident 12, whose ventilator circuit tubing was found on the floor. The CNA did not report this to the LVN, who later confirmed that the tubing had not been changed. The infection preventionist emphasized that tubing on the floor could lead to cross-contamination and infection. Additionally, Resident 95 had a used inner cannula left in their bed, which was not disposed of properly, posing a risk of infection and discomfort. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident 87, as an X-ray technician did not wear a gown while performing high-contact activities. Housekeepers were observed cleaning EBP rooms without proper protective gowns, and a medication cart was left inside an EBP room, risking contamination. Furthermore, clean linens were inadequately protected with permeable covers, and the facility's water system did not maintain temperatures to prevent Legionella growth, as required by CDC guidelines.

Penalty

No penalty information released

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 a homelike environment for Resident 97 by not ensuring that the privacy curtains were free of splash stains. The resident, who was admitted with serious medical conditions including chronic respiratory failure, dependence on a ventilator, and end-stage renal disease, was observed in a room with two large brown splash stains on the privacy curtain. This observation was made during a visit when the resident was lying in bed, awake, and facing the stained curtain. Licensed Vocational Nurse 1 acknowledged the presence of the stains and indicated that maintenance should have been notified to change the curtains. The Infection Preventionist later confirmed that the stains appeared to be dried body fluid, which should have been addressed immediately due to potential infectious risks. The Director of Nursing also stated that the curtains should have been changed promptly and that the presence of such stains did not provide a homelike environment for the resident. The facility's policy emphasized the importance of maintaining a clean and homelike environment, which was not adhered to in this instance.

Penalty

No penalty information released

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 comprehensive care plans for three residents were reviewed and revised by an interdisciplinary team to meet their individual needs. For Resident 93, the care plan did not align with the physician's order regarding the use of bedrails. The resident's care plan indicated the use of two side rails, while the physician's order required all four side rails to be up for safety. This discrepancy was observed during a room visit, where the resident was found with all four side rails up, contrary to the care plan. The Registered Nurse acknowledged the inconsistency and highlighted the importance of updating the care plan to reflect the actual care being provided. Similarly, Resident 37's care plan also failed to match the physician's order concerning bedrail usage. The care plan indicated the use of two side rails, while the resident was observed with all four side rails up. The Registered Nurse confirmed that the care plan should accurately reflect the interventions being implemented for the resident's safety. The Director of Nursing emphasized the necessity of revising and updating care plans to ensure they provide an accurate picture of the resident's health status and care requirements. For Resident 15, the care plan did not reflect the current Restorative Nursing Assistant (RNA) orders. The care plan indicated passive range of motion (PROM) exercises once a day, whereas the physician's orders required these exercises twice a day. Additionally, the care plan lacked specific instructions for the use of hand splints, which were part of the physician's orders. The Registered Nurse supervisor noted the importance of aligning the care plan with the physician's orders to ensure the resident receives appropriate care. The Director of Nursing reiterated that care plans should provide an overview of the resident's care and be based on actual physician's orders.

Penalty

No penalty information released

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 scheduled showers for a resident, identified as Resident 104, who was dependent on assistance for activities of daily living, including bathing. The resident was admitted with chronic respiratory failure, dependence on a respirator, and major depressive disorder. According to the Minimum Data Set, the resident was always incontinent of urine and bowel and required assistance with showering. Despite the facility's shower schedule indicating showers on Wednesdays and Sundays, the resident reported not receiving a shower on the scheduled days, specifically missing a shower on a Wednesday and a Sunday. Interviews and record reviews revealed inconsistencies in the documentation of showers provided to the resident. The facility's records showed that the resident received partial or bed baths instead of scheduled showers on several occasions. The Registered Nurse confirmed the absence of shower records for the resident in October 2024, and the Licensed Vocational Nurse stated that the resident had not refused showers. The Director of Nursing emphasized the importance of adhering to the shower schedule to maintain the resident's dignity and hygiene, as outlined in the facility's policy and procedure for shower procedures.

Penalty

No penalty information released

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 low air loss mattress (LALM) was set to the correct weight for a resident, identified as Resident 261, who was at risk for pressure ulcers. Resident 261, who had quadriplegia and was dependent on staff for activities of daily living, was admitted to the facility with a care plan that included checking the LALM pressure every shift and setting it according to the resident's weight. However, during an observation, it was found that the LALM controller was set to 320 pounds, significantly higher than the resident's actual weight of 75.84 pounds. The Director of Nursing confirmed that the LALM should be set to the resident's weight to prevent skin breakdown, and acknowledged that incorrect settings could place the resident at risk. The facility's policy and the LALM manufacturer's operating manual both indicated the importance of adjusting the mattress pressure according to the resident's weight to prevent pressure ulcers. This oversight in setting the LALM correctly had the potential to compromise Resident 261's skin integrity.

Penalty

No penalty information released

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 Respiratory Therapist (RT 1) provided tracheostomy care according to the physician's orders for a resident, identified as Resident 15. Resident 15 had a history of chronic respiratory failure, tracheostomy, sepsis, and pneumonia, and was in a persistent vegetative state, dependent on staff for all activities of daily living. The physician's orders required tracheostomy care every shift, including cleansing the stoma with water and rinsing with normal saline (NS). However, during an observation, RT 1 was seen using dry gauze to wipe the resident's stoma without using water or NS, contrary to the physician's orders. RT 1 admitted during an interview that he did not follow the proper procedure due to nervousness and forgetting to moisten the gauze. The Infection Preventionist (IP) explained that using dry gauze is inadequate for removing dry secretions, which can lead to reduced tracheostomy opening diameter and potential respiratory infection. The facility's policy, last reviewed in January 2024, emphasized the importance of keeping tracheostomies clean and clear of mucus to prevent complications. This oversight placed Resident 15 at risk for respiratory distress and infection.

Penalty

No penalty information released

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 an allegation of abuse involving a resident with a bruise of unknown origin to the State Survey Agency, Ombudsman Program, and law enforcement within the required timeframe. A Certified Nursing Assistant observed a fading bruise on the resident's left jaw, which was reported to a Licensed Vocational Nurse and subsequently to a Registered Nurse. However, the Director of Nursing and the Administrator were not informed of the incident until much later, and no investigation was conducted to rule out abuse. The resident involved had been admitted to the facility with chronic respiratory failure, dependence on a respirator, cerebral palsy, and essential hypertension. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder functions. Despite the facility's policy requiring immediate reporting of injuries of unknown source, the incident was not reported to the appropriate authorities, leaving the residents at risk for further abuse.

Penalty

No penalty information released

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 proper infection control measures for a resident who was on enhanced standard precautions due to the presence of multidrug-resistant organisms (MDRO) and indwelling devices. During an observation, a Licensed Vocational Nurse (LVN) was seen administering medication via a gastrostomy tube to the resident without wearing a protective gown, despite the enhanced standard precaution signage posted by the resident's room. This oversight was confirmed during interviews with the Infection Preventionist and the LVN, who admitted forgetting to wear the gown. The resident involved had been admitted to the facility with chronic respiratory failure, dependence on a respirator, and essential hypertension. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder functions. The facility's policy required the use of gowns, gloves, goggles, and masks during high-contact care activities to prevent the transmission of MDROs. The Director of Nursing also confirmed that nurses should wear protective gowns when administering medications through a gastrostomy tube.