Angels Nursing Health Center

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 accountability for 17 Percocet tablets, a Schedule II controlled substance, prescribed to a resident with muscle weakness and spina bifida. The medication was ordered to be discontinued, but at the time of discontinuation, 17 tablets were unaccounted for. The medication administration record showed the last dose was given on one date, but additional doses were documented as administered after that date. The narcotic inventory sheets, which are supposed to be signed and checked at each shift change, did not indicate any discrepancies, and the process for handling discontinued medications was not consistently followed. Multiple interviews with nursing staff revealed lapses in the required procedures for controlled substance inventory and handoff. Nurses did not consistently perform or document narcotic counts together at shift changes, and there was confusion about the presence and handling of the discontinued Percocet bubble pack. At one point, the medication cart key was left unattended in a drawer, contrary to facility policy, which increased the risk of unauthorized access to controlled substances. Staff members gave conflicting accounts regarding whether the discontinued medication and its accompanying documentation were present during inventory counts. Facility policies require that controlled substances be stored under double lock, that only authorized personnel have access, and that a physical inventory be conducted and documented by two licensed nurses at each shift change. The policies also state that any discrepancies must be reported immediately to the director of nursing. In this case, these procedures were not consistently followed, resulting in the unaccounted loss of 17 Percocet tablets and a breakdown in the facility's controlled substance accountability system.

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 standardized recipes and menus were followed during lunch service, resulting in multiple dietary errors. Seven residents on fortified diets did not receive the required calorie-enriched foods as indicated on their meal tickets, because the dietary aide did not communicate the fortified diet orders during tray line service and the cook did not add the additional food items per the fortified menu. The dietary aide admitted to forgetting to read the fortified diet orders, resident food preferences, and specific diet requirements, which led to residents not receiving the appropriate meals. Additionally, 14 residents on regular diets did not receive the seasoned peas as specified on the menu, and residents on renal diets received three-bean salad instead of the prescribed wheat roll with margarine. Both the cook and dietary aide were unfamiliar with the menu and did not review the spreadsheet or meal tickets properly, resulting in incorrect food items being served. Observations confirmed that residents on regular diets received plates missing vegetables, and those on renal diets received inappropriate items. Facility policy required menus to be served as written unless substitutions were made for preferences or unavailability, but this was not followed during the observed meal service.

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

Dietary staff failed to follow safe and sanitary food preparation practices in the kitchen. One dietary aide was observed rinsing soiled dishes and loading them into the dish machine while wearing gloves, then removing the soiled gloves and immediately handling clean, sanitized dishes without washing hands. The aide acknowledged not washing hands could contaminate clean dishes, and the dietary supervisor confirmed that proper hand hygiene was not followed due to a second staff member being late. Facility policy and FDA Food Code require handwashing after handling soiled equipment and before touching clean items. The kitchen environment was not maintained in a clean and sanitary condition. The coffee machine's glass gauge pipe was found to be stained with dark brown residue, and neither the dietary supervisor nor the cook could locate the special brush required for cleaning it. The cleaning schedule did not specify cleaning the gauge and pipe, and the cook was unaware of how to clean this part of the machine. Additionally, the dry storage area had a dirty floor with food particles, and an open, unsealed bag of pasta was found on the shelf. The dietary supervisor confirmed these conditions and stated that all packages should be sealed and storage areas kept clean to prevent contamination. During tray line service, several serving plates were observed to be dirty with dried food stains. The cook did not notice the dirty plates before service, and the dietary supervisor confirmed the plates were not clean and should have been scrubbed and rinsed before being loaded into the dish machine. Facility policy and FDA Food Code require that food only contact surfaces that are cleaned and sanitized, and the presence of dirty dishes and equipment in the kitchen was directly observed by 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 ensure that three residents had properly documented advance directives upon admission or readmission, as required by facility policy and federal regulations. For one resident with quadriplegia and dementia, the admission record showed readmission, but the advance directive acknowledgment (ADA) form was incomplete, lacking the necessary signatures from the resident or their representative. The resident was determined to lack decision-making capacity, and staff interviews confirmed that the ADA was not official without the required signatures. The facility's policy required that advance directives be completed and included in the medical record upon admission and readmission, but this was not done for this resident. Another resident with vascular dementia and metabolic encephalopathy was admitted without an advance directive. The resident was found to be unable to make medical decisions and had no family or friends to act as a representative. The social services director stated that the interdisciplinary team (IDT) could make decisions for the resident per facility policy and had applied for a conservator. However, the process was ongoing, and the resident remained without a documented advance directive. Staff interviews indicated that, in the absence of an advance directive, the resident would be considered a full code, but the facility did not know the resident's wishes. A third resident with dementia and a history of mental and behavioral disorders was also found to lack a completed advance directive. The resident's responsible party was identified, but the ADA form was not signed by the resident or their representative, only by the physician. Key sections of the ADA form were left blank, including those indicating that the resident or representative had been informed of their rights regarding medical treatment and advance directives. Staff confirmed that the ADA was incomplete and should have been filled out upon readmission, as required by facility policy. These failures resulted in the facility not having documentation of the residents' wishes regarding medical treatment and end-of-life 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 failed to maintain appropriate settings on Low Air Loss Mattresses (LALM) for two residents with significant risk factors for pressure ulcers. For one resident with contractures, diabetes, quadriplegia, and a gastrostomy, the LALM was observed to be set at 230 lbs, despite the resident weighing 153 lbs and manufacturer guidelines indicating a setting between 150-180 lbs. Staff interviews revealed that CNAs were not permitted to adjust the LALM, and there was confusion among nursing and maintenance staff regarding responsibility for the settings and the facility's policy. The Infection Control Nurse and Director of Nursing both acknowledged that incorrect LALM settings could result in the mattress being too hard, potentially causing or worsening pressure ulcers. Another resident, with diagnoses including stage 4 and stage 3 pressure ulcers, diabetes, and quadriplegia, also had a LALM set incorrectly. The resident weighed 135 lbs, but the LALM was observed set at 230 lbs, while a sticker on the pump indicated it should be set to 130 lbs. The treatment nurse stated that the LALM should be set based on the resident's weight and that she evaluated the settings daily, but was unaware of the current setting and was unsure of the facility's LALM policy. The care plan for both residents specified that the LALM should be set according to the resident's weight. Record reviews, observations, and staff interviews consistently showed a lack of adherence to physician orders and manufacturer guidelines for LALM settings. There was also a lack of clarity among staff regarding who was responsible for checking and adjusting the LALM, and insufficient knowledge of the facility's policy on LALM management. These actions and inactions led to the deficiency in providing appropriate pressure ulcer care and prevention.

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 inform two residents of the medications being administered to them during medication pass, as required by the facility's policies and procedures. During direct observation, a nurse administered multiple medications to both residents without identifying the medications by name or explaining their purpose and indications. This occurred despite the facility's policy and educational materials, which require that each procedure, including medication administration, be explained to the resident beforehand. One of the residents had a complex medical history, including hypertensive heart disease, iron deficiency anemia, hyperlipidemia, type 2 diabetes mellitus, paranoid schizophrenia, schizoaffective disorder, bipolar disorder, and anxiety disorder. This resident was assessed as having severely impaired cognition and required assistance with activities of daily living. The nurse administered nine different medications to this resident without providing information about the medications prior to administration. The other resident, who was determined to have the capacity to understand and make decisions, was also administered thirteen medications without being informed of their names or purposes. During interviews, the nurse stated that she typically only explained medications if they were new or if the resident was receiving blood pressure medications, believing that long-term residents were already familiar with their medications. However, the Director of Nursing clarified that nurses are expected to identify the name, indication, and possible side effects of medications to residents during administration, especially for those who are alert and oriented. Facility policies and recent in-service education also emphasized the importance of informing residents about their medications as part of ensuring resident rights.

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

On 5/20/2025 at 10:30AM, surveyors observed that one of two large garbage dumpsters outside the kitchen back door was overfilled with trash bags and left uncovered. The other dumpster, which was empty, was behind gates and not accessible to staff. During concurrent interviews, both the Dietary Supervisor and Maintenance Supervisor confirmed that trash should be covered to prevent the accumulation of flies and pests. The Maintenance Supervisor also stated that trash pickup occurred three times a week and acknowledged that the accessible dumpster was overfilled while the other, inaccessible dumpster remained empty. A review of the facility's policy from 2023 indicated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area and that lids are closed. Additionally, the FDA Food Code 2022 requires that outdoor refuse receptacles be kept covered with tight-fitting lids or doors and stored in a manner that makes them inaccessible to insects and rodents. The facility failed to follow these requirements, resulting in unsanitary conditions in the dumpster area.

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 investigate and determine how a resident with a history of schizophrenia, anxiety disorder, and moderately impaired cognitive skills was able to leave her room unattended and was subsequently found in the facility's parking lot. The resident had been assessed as having intermittent confusion, was ambulatory, and was identified as being at risk for elopement. Despite these risk factors, there was no documentation or investigation into how the resident exited her room and reached the parking lot. Interviews with facility staff, including security guards, an LVN, the DON, and the administrator, confirmed that the resident was found outside on facility property, but none could explain how she left her room. The incident was not documented, and no investigation was conducted because the resident was found within the facility's property. The facility's policy requires individualized safety measures and analysis of risks, but these procedures were not followed 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 protect a resident from physical abuse by another resident, resulting in a deficiency. Resident 1, who had a history of aggressive behavior and multiple psychiatric diagnoses, including schizophrenia and bipolar disorder, was not properly managed according to the facility's policies. The facility did not document Resident 1's aggressive behaviors consistently, nor did they update the care plan to address the increase in aggression and behavioral changes. This lack of documentation and care plan updates contributed to an incident where Resident 1 physically assaulted Resident 2. Resident 1 had been admitted to the facility with a history of mental health issues, including schizophrenia, generalized anxiety disorder, and bipolar disorder. The resident exhibited aggressive behavior on numerous occasions throughout February 2025, but the facility failed to document the specific types of aggressive behaviors or update the care plan accordingly. Despite the facility's policy requiring regular updates to care plans and documentation of behavioral symptoms, these actions were not taken, leaving Resident 1's aggressive tendencies inadequately managed. On February 25, 2025, Resident 1 approached Resident 2, who was in a wheelchair, and demanded money. When Resident 2 refused, Resident 1 struck Resident 2 on the chest, causing Resident 2 to lose balance and sit on a trash can. The facility's failure to follow its own policies and procedures for behavior management and care planning resulted in this altercation, highlighting the deficiency in protecting residents from 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 readmit a resident after hospitalization, as per their policy titled Readmission. The resident, who had quadriplegia and type two diabetes, was initially admitted to the facility and had intact cognitive skills to make daily decisions. After being hospitalized, the resident was ready for discharge back to the facility on 2/12/2025, with orders to continue intravenous antibiotics. However, the facility denied readmission, citing a lack of available female beds and insufficient staffing to manage the resident's intravenous antibiotic needs. The facility's census records indicated that there was a female bed available from 2/12/2025 to 2/18/2025, but it was held for another resident without documented discharge orders. Interviews with facility staff confirmed the denial of readmission due to staffing limitations and bed availability, despite the resident's discharge plan being communicated well in advance. This failure to readmit the resident placed them at risk for psychosocial harm, as they were unable to return to their home in the facility.

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 revise the care plan for a resident with bipolar disorder on a quarterly basis, as required. The resident, who was admitted and readmitted with diagnoses including bipolar disorder, anxiety, and schizophrenia, had a care plan that was last revised several months prior. The care plan included interventions such as approaching the resident in a calm manner and administering lithium carbonate as ordered. However, the care plan was not updated quarterly or when there was a change in the resident's condition, as confirmed by the Director of Nursing (DON). The facility's policy mandates that comprehensive care plans be periodically reviewed and revised by a team of qualified persons after each assessment, including quarterly reviews. Despite this policy, the care plan for the resident with moderate cognitive impairment and delusions was not updated as required, potentially affecting the provision of care and services. The DON acknowledged the importance of having an updated plan of care to ensure appropriate interventions and goals for 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 implement its infection prevention and control policies effectively, leading to a potential risk of COVID-19 transmission. Licensed Vocational Nurse 3 (LVN 3) tested positive for COVID-19 while on duty but continued to work for an additional hour, preparing medications for approximately 20 residents. This action was contrary to the facility's policy, which required staff to leave immediately upon testing positive. Interviews with the Infection Preventionist, Public Health Nurse, Director of Staff Development, and Director of Nursing confirmed that LVN 3 should have left the facility immediately to prevent the spread of infection. The facility's policy and procedures, as outlined in their Infection Prevention and Control Program, were not followed, as LVN 3 remained in the facility after testing positive. The Director of Nursing highlighted the importance of contact tracing, which was not initiated promptly, potentially exacerbating the spread of COVID-19 within the facility. The facility's COVID-19 Mitigation plan was being used as the policy while the current procedures were under review, indicating a lapse in adherence to established 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 implement a comprehensive care plan for a resident at risk of elopement, which was identified as a deficiency. The resident, who was admitted with conditions including chronic obstructive pulmonary disease, metabolic encephalopathy, and schizophrenia, was assessed as having moderately impaired cognitive skills and a history of wandering and elopement. Despite these assessments, the care plan did not adequately address the resident's risk of elopement, as evidenced by an incident where the resident left the facility unsupervised. On the day of the incident, the resident expressed a desire to go to the hospital and was observed leaving the facility through the front gate. Staff members, including a Licensed Vocational Nurse and a Treatment Nurse, witnessed the resident's departure but failed to document the incident in the resident's progress notes or notify the resident's physician. The resident was verbally aggressive and walked several blocks away from the facility before complaining of chest pain, prompting staff to call emergency services. The Director of Nursing acknowledged that the incident should have been documented and that an Interdisciplinary Team meeting should have been initiated. The facility's policies and procedures required documentation of elopement incidents and updates to the care plan to prevent recurrence, but these were not followed. This lack of documentation and failure to update the care plan contributed to the deficiency identified in the survey.

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 proper supervision and implementation of policies to prevent the elopement of a resident, identified as Resident 1 (R1). R1, who has a history of chronic obstructive pulmonary disease, metabolic encephalopathy, and schizophrenia, was assessed as having moderately impaired cognitive skills and a history of wandering and elopement. Despite these known risks, the facility did not adhere to its elopement policy or the resident's care plan, which included monitoring R1's whereabouts every hour and investigating reports of wandering. On the day of the incident, R1 was observed leaving the facility unsupervised, and staff failed to document the event or notify the resident's physician. Interviews with staff revealed that R1 was seen walking out of the facility and was not stopped effectively, despite attempts by a treatment nurse to convince R1 to return. The resident became verbally aggressive and walked several blocks before complaining of chest pain, leading to a 911 call and transfer to a hospital. The Director of Nursing acknowledged that the incident should have been documented and reviewed by the Interdisciplinary Team, as per the facility's policy. The lack of documentation and communication with the medical team highlights the facility's failure to follow its procedures for managing elopement risks.

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 Certified Nursing Assistant (CNA) had the appropriate competencies to provide nursing and related services, specifically by not maintaining and updating the Basic Life Support/Cardiopulmonary Resuscitation (BLS/CPR) certification. This deficiency was identified during a record review of the CNA's staff file, which revealed that the BLS/CPR certification was missing. During an interview, the Director of Nursing (DON) acknowledged that staff files should be updated and that BLS/CPR certifications should be current and filed. The facility's policy and procedures, as well as the job description for CNAs, require that CNAs be certified in CPR. This oversight had the potential to place residents at risk of not receiving proper immediate care during a life-threatening situation.

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 properly manage and monitor the psychotropic medication regimen for a resident, leading to a deficiency in ensuring the resident's highest practicable mental, physical, and psychosocial well-being. Specifically, the facility did not implement behavior monitoring for episodes of anxiety related to the resident's use of Ativan, an anti-anxiety medication, and for episodes of psychosis related to the use of Depakote, an anti-psychotic medication. These medications were prescribed to address the resident's conditions, including schizophrenia and bipolar/mood disorders, but the necessary behavior monitoring was not ordered or implemented as required. The resident, who was readmitted to the facility with diagnoses including chronic obstructive pulmonary disease, metabolic encephalopathy, and schizophrenia, was found to have moderately impaired cognitive skills and required assistance with daily activities. Despite having specific physician orders for behavior monitoring related to the use of psychotropic medications, the facility did not ensure that these orders were followed. The Director of Nursing acknowledged that all psychotropic medications should have behavior monitoring specific to the resident's behavior, as ordered, to properly monitor the effects of the medication. The facility's policies and procedures emphasized the importance of individualized care and monitoring of target behaviors, but these were not adhered to in this case.

Penalty

Inspection fine: $37,6815 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 adequate supervision and assistance for a resident with a high risk of falls, leading to an accident. The resident, who had a history of falls and was assessed as high risk, was not provided with the necessary assistance and supervision when ambulating to the bathroom. This lack of supervision resulted in the resident being found on the floor with a head injury, including a four-centimeter laceration and subdural hematomas, after attempting to walk to the bathroom without assistance. The resident had a documented history of falls and was admitted with multiple diagnoses that increased their fall risk, including subarachnoid hemorrhage, hemiplegia, hemiparesis, and abnormalities of gait and mobility. The resident's care plan specifically indicated the need for assistance with ambulation and transfers, yet on the night of the incident, the resident attempted to walk to the bathroom without using the call light for help. Despite being observed by a CNA, the resident was not assisted, leading to a fall and subsequent head injury. Interviews with facility staff, including CNAs, a physical therapist, and the director of nursing, confirmed that the resident required assistance and supervision when ambulating. The facility's fall management policy emphasized the importance of providing assistance to high-risk residents, yet this was not adhered to in the case of the resident. The failure to provide necessary supervision and assistance directly contributed to the resident's fall and injury.

Penalty

Inspection fine: $33,885

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 follow the physician's order for a resident who had difficulty swallowing and was at risk for aspiration. The resident was supposed to receive a pureed diet, but this was not adhered to, leading to the resident consuming regular textured food brought in by the family. The staff did not assess the resident's tolerance for the diet as required by the care plan, nor did they develop a comprehensive person-centered dysphagia care plan. Additionally, the staff failed to monitor the resident for any changes in condition and inform the physician as stipulated in the care plan. The resident, who had a history of stroke and other medical conditions, was admitted to the facility and was initially stable. However, after consuming regular food, the resident vomited and later became congested, had difficulty breathing, and became cyanotic. The staff did not perform timely assessments or notify the physician about the resident's condition changes. The resident eventually became unresponsive and required CPR, but was pronounced dead shortly after. Interviews with staff revealed that the CNA observed the resident eating the wrong food but did not intervene or notify the nurse immediately. The RN on the prior shift did not document the incident or notify the physician about the resident's vomiting and subsequent condition changes. The facility's policies on change of condition and comprehensive care planning were not followed, contributing to the resident's deteriorating condition and eventual death.

Removal Plan

• The Minimum Data Set (MDS) nurse reviewed the diet orders of all current residents to determine if their diet texture and fluid consistency needed to be clarified with the physician.
• The Nurse Consultant provided an in-service to Interdisciplinary Team (IDT) members to inform the resident's family about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources.
• The IDT reviewed current residents who were on a therapeutic diet and informed their family members about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources.
• The consultant provided an in-service to RNs, Licensed Vocational Nurses, Certified Nursing Assistants, and Restorative Nurse Aides regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility.
• Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service.
• The Nurse Consultant checked competencies of RNs, LVNs, and CNAs in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies.
• The Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources.
• The Nurse Consultant provided an in-service to CNAs and RNAs regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources.
• The Nurse Consultant provided an in-service to RNs and LVNs regarding the facility's policy on Change of Condition.
• The Medical Records staff will conduct changes in condition audits to identify changes in condition, determine completeness of documentation, and determine if physician notification had occurred.
• RN 2 was dismissed from the facility.
• The Director of Nursing (DON) or Director of Staff Development (DSD) would evaluate licensed nurses' competencies related to identifying, managing, and notifying the physician, alternate physician, or medical director of any changes in condition upon hire and annually.
• The Nurse Consultant provided a one-to-one in-service with the Administrator regarding the statute on Reporting Unusual Occurrences.
• The Nurse Consultant provided in-service to facility staff regarding the statute on Reporting Unusual Occurrences.
• The Administrator will review changes of condition during the stand-up meeting to identify abuse, suspicious deaths, major injuries, and other types of unusual occurrences and ensure that they are reported timely.

Penalty

Inspection fine: $33,885

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 with difficulty swallowing and at risk for aspiration received care and monitoring of food consumption within the guidelines of the diet order. The facility did not implement its policy and procedure for food brought in from outside sources, which required that such food be shown to the Charge Nurse for approval to ensure it was within the diet order. Additionally, the facility did not provide the resident's family with the information sheet about bringing in food for a resident, nor did it ensure ongoing communication and coordination among staff to support the resident's nutritional well-being and safety. As a result, the resident consumed regular textured food brought in by a family member, which was not consistent with the prescribed pureed diet. The Certified Nursing Assistant (CNA) observed the resident eating the food but did not report it to the Charge Nurse. Subsequently, the resident became congested, had difficulty breathing, and became cyanotic. The resident became unresponsive and required cardiopulmonary resuscitation (CPR) but was pronounced dead shortly after. Interviews and record reviews revealed that the facility staff did not follow the established procedures for monitoring and approving outside food. The resident's diet and diet texture were not discussed during the initial interdisciplinary team (IDT) conference, and the family was not educated on the resident's special diet. The CNA did not intervene or report the incident when the resident was observed eating the wrong food texture, leading to the resident's adverse health event and subsequent death.

Removal Plan

• The Minimum Data Set (MDS) Nurse reviewed the diet orders of all current residents to determine if their diet texture and fluid consistency needed to be clarified with the physician. The MDS Nurse completed the clarification of diet orders.
• The Nurse Consultant provided an in-service to six Interdisciplinary Team (IDT) members to inform the resident's family, during the initial IDT meeting and subsequent IDT meetings as needed, about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The resident's family would be asked to sign a form acknowledging they received this information. The DON was the only remaining IDT member who would be provided with an in-service by the Nurse Consultant upon their return to work.
• The IDT reviewed current residents who were on a therapeutic diet and informed their family members via telephone conversation about the resident's prescribed diet order and the facility's policy on Food for Resident from Outside Sources. The information was provided using the family members' native language. The IDT members documented in the resident's chart that the family has been informed.
• Consultant provided an in-service to Registered Nurses (RNs), Licensed Vocational Nurses (LVN), Certified Nursing Assistants (CNA) and Restorative Nurse Aides (RNA), regarding the facility's policy on Food for Resident from Outside Sources and the different diet textures available in the facility. The in-service emphasized the following: Diet orders will be printed daily by the licensed nurse and will be made available as a reference at the nurses' station. Food brought in by family from outside sources must be consistent with the resident's prescribed diet; Food brought in by family from outside sources should be shown to the licensed nurse for evaluation if it matches the resident's prescribed diet. The licensed nurse must be notified if the resident is observed to be eating food that does not match the diet order or when the family is observed to have brought in food for the resident that is different from the diet order. The licensed nurse will check on residents who have food brought in by family every 2 hours and as needed; and, The licensed nurse will record both the evaluation of the food brought from outside and every two-hour visual checks in a log that would be submitted to the DON or designee for further review.
• Licensed nurses and CNAs were asked questions at the end of the in-service to evaluate their knowledge of the information provided in the in-service. In-services would be completed for all the active nursing staff by the Nurse Consultant. Staff who were currently on vacation or on leave will be provided the in-service upon their return to work.
• The Nurse Consultant checked competencies of RNs, LVNs and CNAs, as in identifying different diet textures by presenting them with different sample meal trays and asking them to correctly identify different diet textures and fluid consistencies. Competency evaluations would be performed by the Nurse Consultant and completed for all active nursing staff. Staff who were currently on vacation or on leave would have their competencies evaluated upon their return to work.
• The Nurse Consultant provided a one-to-one in-service with CNA 1 regarding the facility's policy on Food for Resident from Outside Sources, emphasizing the importance of reporting to the licensed nurse when the resident was observed to be eating food that was different from the diet order. At the end of the in-service, the CNA was asked questions to evaluate his knowledge about the information provided to him and was able to answer questions correctly.
• The Nurse Consultant provided an in-service to CNAs and RNAs regarding the importance of immediately reporting to the licensed nurse any observed changes in the resident's condition and acting upon any actions that do not match the facility's policy on Food for Resident from Outside Sources. The Nurse Consultant would complete the in-service for all the active CNAs and RNAs. Staff who were currently on vacation or on leave would be provided the in-service upon their return to work.
• The RD would review diet orders once a week to ensure diet orders were clear and correct. She would conduct rounds once a week to ensure that residents were provided the correct diet texture and fluid consistency. Findings would be reported to the Director of Nursing (DON) and Administrator weekly for follow-up.

Penalty

Inspection fine: $33,885

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 three residents received the necessary care and services to prevent accidents and falls. Resident 13 was not accurately assessed for a high fall risk on 11/3/2023, and appropriate measures and interventions were not identified before the resident's fall on 1/20/2024. This fall resulted in a left femoral neck fracture, requiring surgery. The facility also did not complete quarterly Fall Risk Assessments for Residents 29 and 36, as per their policy, placing them at increased risk for recurrent falls. Resident 13 had a history of multiple diagnoses, including a previous femur fracture, chronic pain syndrome, schizophrenia, and muscle weakness. Despite these conditions, the resident was inaccurately assessed as having a normal gait and low fall risk. On 1/20/2024, Resident 13 fell while wearing inappropriate footwear, leading to a hip fracture. The facility failed to develop a care plan with person-centered interventions for the resident's fall risk, and staff did not document the resident's weak gait accurately. Resident 29, who had severe cognitive impairment and was on psychoactive medication, did not have a quarterly fall risk assessment completed in March 2023. Similarly, Resident 36, who had a history of repeated falls and severe cognitive impairment, did not have a fall risk assessment completed after 12/15/2023. The facility's failure to adhere to its fall prevention policies and procedures contributed to the increased risk of falls and injuries for these residents.

Penalty

Inspection fine: $33,885

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 safe, sanitary environment to help prevent the spread of airborne infections by not conducting annual fit tests for N95 masks for six sampled staff members. The last fit test for these staff members was completed on 8/26/2022, and no subsequent fit tests were conducted despite the facility experiencing a COVID-19 outbreak in July 2023. The Director of Staff Development confirmed that fit testing was required to be done yearly and acknowledged that the lack of fit testing could spread respiratory disease to the residents. Interviews with the staff members also confirmed that their last fit test was in 2022 and that fit tests should be completed annually. The facility Administrator admitted that no fit tests were conducted since 8/26/2022 because the fit test was scheduled the day after the former Infection Preventionist resigned. The facility's policy and procedures indicated that fit testing should be conducted annually and before employees are required to wear a respirator. The policy also stated that fit tests should be done when a different size, make, model, or style of respirator is used. The failure to conduct these fit tests as per the policy and procedures led to the deficiency noted in the report.

Penalty

Inspection fine: $33,885

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 employ an Infection Preventionist Nurse (IP) at least part-time as required by their facility assessment dated January 2024. The assessment indicated that the facility needed a full-time equivalent IP. However, during interviews, it was revealed that the designated IP, a Licensed Vocational Nurse (LVN 3), was actually working as a charge nurse and not fulfilling the IP role. The facility Administrator confirmed that the last IP had quit after one day of work, leaving the facility without a designated IP. The facility's policy and procedure titled 'Scope of Infection Control Program' dated June 2022, stated that the infection preventionist is responsible for the infection prevention and control program. The lack of a designated IP had the potential to affect the facility's ability to prevent and manage the spread of infections and diseases, as highlighted by the interviews with the Medical Records Designee and LVN 3. Both emphasized the importance of having an IP for the safety and health of the residents, including providing updates on immunizations and antibiotics and preventing contamination.

Penalty

Inspection fine: $33,885

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 submit the required complete information contained in the Minimum Data Set (MDS) for four residents within 14 days of initiation to the Centers for Medicare & Medicaid Services (CMS) System. This deficiency was identified during interviews and record reviews, revealing that the MDS assessments for Residents 2, 29, 32, and 34 were not submitted on time. The delay in submission was attributed to the MDS Nurse being busy with admissions, which resulted in the assessments being opened but not submitted within the required timeframe. Resident 2 was originally admitted on 11/16/2027 and readmitted on 11/27/2023 with multiple diagnoses, including chronic obstructive pulmonary disease, urinary tract infection, type 2 diabetes, anxiety disorder, bipolar disorder, and hyperlipidemia. The MDS indicated that Resident 2 had moderately impaired cognition and required various levels of assistance for daily activities. Resident 29, admitted on 5/22/2020 and readmitted on 5/25/2021, had diagnoses including hepatic failure, atrial fibrillation, chronic kidney disease, and benign prostatic hyperplasia. The MDS showed that Resident 29 had severely impaired cognition and required significant assistance for daily activities. Resident 32, admitted on 3/11/2021 and readmitted on 3/14/2022, had diagnoses including hemiplegia, hemiparesis, chronic obstructive pulmonary disease, gastrostomy, dementia, adult failure to thrive, and benign prostatic hyperplasia. The MDS indicated severely impaired cognition and dependency on staff for daily activities. Resident 34, admitted on 6/24/2022 and readmitted on 1/24/2023, had diagnoses including congestive heart failure, type 2 diabetes, chronic pulmonary edema, adult failure to thrive, chronic kidney disease, bipolar disorder, and major depressive disorder. The MDS showed severely impaired cognition and dependency on staff for daily activities. The facility's policy required MDS assessments to be submitted within 14 days, but this was not adhered to, leading to potential delays in care for the residents.

Penalty

Inspection fine: $33,885

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 perform the required annual staff competency evaluations for three of seven sampled staff members, including a Registered Nurse (RN) and two Licensed Vocational Nurses (LVNs). The RN was hired in 2018 and had a competency evaluation in 2020, but no evaluations were found for 2021, 2022, 2023, or 2024. The LVNs, hired in 2022 and 2008 respectively, also had no competency evaluations on file. The Director of Staff Development (DSD) confirmed the absence of these evaluations and acknowledged that they are supposed to be conducted annually to ensure staff can perform their responsibilities correctly and safely. Interviews with the staff members revealed that they were unsure or could not remember when their last competency evaluations were conducted. The Administrator confirmed that the evaluations for the three staff members could not be located and acknowledged that the lack of annual competency evaluations could negatively affect the quality of care provided to residents. The facility's policy, reviewed in 2023, mandates annual competency evaluations for all employees, but this policy was not followed in these cases.

Penalty

Inspection fine: $33,885

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 professional standards of practice and facility policy and procedures for the disposal of medications and medication-related supplies were followed. During an observation and interview, it was found that the medication room contained a container bin with various unused medications, including Hydralazine, Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution, Latanoprost, Brimonidine, Atorvastatin, Cyclobenzaprine, Gabapentin, Risperidone, Metformin, Mirtazapine, Memantine HCL, Folic Acid, and Celecoxib. These medications were supposed to have been disposed of in the medication waste bin immediately, as per the facility's policy. However, RN 1 admitted that the medications had not been disposed of immediately and did not know how long they had been in the container. The Administrator confirmed that medications awaiting disposal should be stored in a locked, secure area and disposed of immediately to prevent misuse. The facility's policy indicated that medications should be marked as discontinued or stored in a separate location and later destroyed when expired, discontinued, or when a resident is transferred, discharged, or deceased. The failure to follow these procedures had the potential to result in the misuse of medications, as they were not stored securely or disposed of in a timely manner.

Penalty

Inspection fine: $33,885

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 resident-centered comprehensive care plan for three residents, leading to potential inadequate care. For Resident 9, the care plan did not address the specific type of tube feeding the resident was receiving, despite the resident having a gastrostomy tube and being on a therapeutic diet. Both the Minimum Data Set Nurse and a Registered Nurse acknowledged that the care plan should have been more specific to ensure adequate care for the resident's nutritional needs. Resident 13, who experienced chronic pain and had undergone surgery for a left hip injury, did not have a care plan addressing pain management. The resident's Minimum Data Set indicated almost constant pain that affected daily activities, yet there was no individualized care plan with measurable objectives and interventions for pain. The Director of Staff Development confirmed that a care plan should have been initiated to manage the resident's pain effectively. Resident 28, diagnosed with dementia, paranoid schizophrenia, and major depressive disorder, was prescribed antipsychotic and antidepressant medications. However, the care plan did not include any information about these medications. A Registered Nurse verified the absence of a care plan for the medications, which could lead to unmonitored side effects and impact the resident's overall well-being. The facility's policy emphasized the importance of comprehensive care plans, but this was not adhered to in these cases.

Penalty

Inspection fine: $33,885

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 with an ileostomy received the necessary care and services to prevent complications. The resident, who was admitted with an ileostomy and had intact cognition, required partial to maximal assistance with personal hygiene and other activities. The resident's care plan included specific interventions such as assessing bowel sounds and monitoring the ileostomy site for symptoms like swelling, redness, pain, and skin breakdown. However, the Treatment Administration Records (TAR) for February, March, and April 2024 showed no documentation of these assessments being performed or recorded as required by the physician's orders. During interviews, the Registered Nurse Supervisor and the facility's Administrator confirmed that the licensed staff did not document the required assessments and did not follow the physician's orders or the care plan interventions. The lack of documentation and failure to implement the care plan interventions had the potential to result in insufficient care and risk for skin breakdown and injury to the resident. The facility's policy on colostomy and ileostomy care emphasized the importance of monitoring the stoma and surrounding skin, but this was not adhered to in the case of the resident in question.

Penalty

Inspection fine: $33,885

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 Resident 144, who was at risk for severe weight loss, received the necessary care and services to prevent this condition. Despite physician orders for weekly weight monitoring starting from 4/1/2024, the facility did not implement these orders. Resident 144 experienced significant weight loss, dropping from 109 lbs. on 3/18/2024 to 94 lbs. on 4/4/2024, a 14.55% weight loss in one month. The last recorded weight was on 4/4/2024, and no subsequent weights were documented, indicating a failure to follow the prescribed monitoring schedule. Resident 144 had a history of colon cancer, liver failure, and dementia, and was on speech therapy for dysphagia. The resident's nutritional assessments and care plans indicated a need for close monitoring of weight, intake, and diet tolerance due to significant weight loss over the past six months. Despite these documented needs and physician orders, the facility staff did not consistently monitor the resident's weight, as evidenced by the lack of weight records after 4/4/2024. Interviews with facility staff, including a Registered Nurse Supervisor and a Registered Dietician, confirmed that Resident 144 was on weekly weight monitoring due to poor oral intake and high risk for weight loss. The staff acknowledged that the failure to weigh the resident weekly as ordered placed the resident at risk of continued weight loss and that this oversight was part of the nutrition risk care plan. The facility's policy on unplanned weight loss emphasized the importance of regular weight assessments, which were not adhered to in this case.

Penalty

Inspection fine: $33,885

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 with a gastrostomy tube (g-tube) received appropriate treatment and services to prevent complications. Specifically, the resident's tube feeding (TF) was found disconnected, and the resident was not wearing an abdominal binder as required by the care plan. This resulted in the resident's bed being saturated with the TF, indicating that the resident did not receive the full dose of nutrition as ordered by the physician. The resident, who had moderately impaired cognition and a history of pulling out the g-tube, was dependent on facility staff for eating and other activities of daily living. During observations and interviews, it was confirmed that the resident's TF was disconnected, and the resident was not wearing the abdominal binder. Licensed Vocational Nurse (LVN) 4 and the Minimum Data Set Nurse (MDSN) both verified that the resident had a tendency to pull and disconnect the TF and that the abdominal binder was not in place as per the care plan. The MDSN and Registered Nurse (RN 1) acknowledged that the absence of the abdominal binder increased the risk of the resident disconnecting the TF and not receiving the prescribed nutrition. The facility's policies and procedures for comprehensive care planning and enteral feeding via pump administration were reviewed. These policies emphasized the importance of following the care plan, including the use of an abdominal binder to secure the g-tube and ensure the resident received the full dose of TF. The failure to adhere to these policies and the care plan interventions led to the identified deficiency, putting the resident at risk for further complications related to their nutritional needs.

Penalty

Inspection fine: $33,885

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 Resident 6 received a therapeutic diet as prescribed by the physician. The resident, who has diagnoses including dementia, a history of falling, and chronic pain syndrome, was ordered a mechanical soft, fortified, finely chopped diet. However, during an observation in the dining room, Resident 6 was served food that was not finely chopped, including chopped pasta, carrots in a circle shape, and chunks of beef in a sauce. This was confirmed by Licensed Vocational Nurse 3 (LVN3), who acknowledged that the food did not meet the prescribed diet requirements and requested a new lunch tray for the resident. The deficiency was further highlighted during an interview with the facility's Administrator, who stated that staff are required to check residents' meal trays against physician orders to ensure the correct diet is served. The Administrator acknowledged the potential risks of not providing a finely chopped diet, including aspiration and the resident's inability to consume the food. The facility's policy on therapeutic diets, reviewed on 1/18/2024, mandates that therapeutic diets be provided in accordance with physician orders, but this policy was not followed in the case of Resident 6.