Autumn Hills Health Care 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 deficiency involves the facility’s failure to protect a resident from physical abuse and to follow its Abuse Prevention Program and abuse/neglect protocols. The resident, who had hemiplegia and hemiparesis following a cerebral infarction and was documented as having capacity to understand and make decisions, reported that during a therapy session he touched the back of a physical therapist’s head to get his attention. In response, the therapist turned toward him and slapped him on the right thigh with an open hand. The resident stated the slap stung his leg, that the therapist appeared very angry and mean, and that he felt angry, shocked, upset, and assaulted. The resident reported that he had previously considered the therapist a friend and did not initially want to complain because he did not want to get anyone in trouble and considered himself a strong person. Another physical therapist in the room (PT 2) witnessed the incident and stated that the resident flicked the back of PT 1’s head, after which PT 1 rotated his chair and struck the resident once on the right thigh with an open hand. PT 2 described the slap as very loud, like someone slamming their hands on a desk, and reported that the resident yelled, “no, you can’t do that,” and “you beat me,” and appeared shocked and upset. PT 2 also reported that PT 1 often seemed annoyed with the resident and had, on multiple occasions, spoken loudly to him, telling him he talked too much and needed to be quiet. PT 1 acknowledged that the resident had touched or slapped the back of his head, that he was startled, and that he immediately turned and slapped the resident, though he claimed he slapped the resident’s hand and spoke in a low voice telling him to stop. The facility failed to identify and respond to this incident as abuse at the time it occurred. The incident was not immediately reported to the Administrator or nursing staff on the day it happened, and the resident was not immediately monitored after the slap. PT 2 allowed therapy to continue with both therapists remaining in the room and did not remove PT 1 from the resident’s presence, despite witnessing the slap and the resident’s reaction. PT 2 stated she did not report the incident immediately because she believed there was a 24‑hour reporting window, wanted to give PT 1 an opportunity to report it himself, and the resident had asked her not to report it. The incident was reported the following day after it was learned that PT 1 had not reported it. The facility’s Abuse Prevention Program stated that residents have the right to be free from abuse, including physical abuse and corporal punishment, and that administration would protect residents from abuse by anyone, but these protections were not implemented at the time of the event.

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 immediately report an incident of physical abuse by a physical therapist toward a resident to the Administrator within the required timeframe, as outlined in the facility’s Abuse Prevention Program and Abuse Investigation & Reporting policies. On 02/23/2026, while beginning physical therapy, Resident 1 entered the rehabilitation room and touched PT 1 on the back of the head to get his attention. In response, PT 1 rotated his chair and struck the resident once on the right thigh with an open hand, producing a loud sound described by PT 2 as similar to slamming hands on a desk. Resident 1, who had hemiplegia and hemiparesis following a cerebral infarction and had documented capacity to understand and make decisions, immediately protested, stating, "no, you can't do that" and "you beat me," and later reported feeling angry, assaulted, and that the slap stung his leg. Despite witnessing the event, neither PT 1 nor PT 2 reported the incident to the Administrator on the day it occurred. PT 2 stated that she believed there was a 24-hour reporting window and wanted to give PT 1 an opportunity to report the incident himself, and only reported it the following day to the Director of Rehabilitation after learning PT 1 had not done so. PT 1 stated he did not notify the Administrator or Director of Rehabilitation because, in his experience, when he reported concerns, no action was taken. During this time, therapy continued in the same room with both therapists present, and Resident 1 stated that no one asked him how he was or whether he was okay following the incident. Interviews with facility leadership confirmed that the incident met the definition of physical abuse and should have been reported immediately. The DON stated the incident between Resident 1 and PT 1 was considered physical abuse and should have been reported immediately to facility administration in accordance with facility policy and abuse reporting requirements. Review of the facility’s Abuse Investigation & Reporting, Abuse Prevention Program, and Abuse and Neglect Clinical Protocol policies showed that all allegations or incidents of abuse, neglect, exploitation, misappropriation, mistreatment, or injuries of unknown origin were to be promptly and immediately reported to appropriate facility management and external agencies, and that management and staff were required to address suspected or identified abuse and report it in a timely manner. The failure of PT 1 and PT 2 to immediately report the witnessed physical abuse resulted in a delay in the facility’s investigation and protection of Resident 1 from 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 deficiency involves the facility’s failure to provide treatment and services in accordance with professional standards of practice for a resident with Type 2 DM following readmission from a GACH. The resident’s GACH discharge recap dated 1/11/2026 included orders to renew fingerstick blood sugar monitoring AC and HS, with parameters to notify the physician for BG >250 mg/dL or <70 mg/dL and to implement a hypoglycemia protocol. Upon readmission, the facility’s admission record reflected diagnoses of Type 2 DM and sepsis, and nursing notes documented that the attending physician’s orders were “verified and carried out.” However, the physician order report from 1/11/2026–1/31/2026 did not include any orders for AC/HS fingerstick BG monitoring or monitoring for signs and symptoms of hyperglycemia, only an order to monitor for signs and symptoms of hypoglycemia three times daily. The nurse who spoke with the physician at readmission did not document that the physician declined to reorder fingerstick monitoring or the rationale, and there was no documentation in the physician or NP progress notes explaining why BG monitoring was not continued despite the diagnosis of Type 2 DM and the GACH discharge instructions. The resident’s existing care plan, titled “Risk for Unstable Blood Glucose Level,” required staff to observe for signs and symptoms of low and high BG and to check BG if it was below 70 mg/dL, with instructions to administer IM glucagon and call 911 if the resident was unconscious or without vital signs. However, the care plan did not specify how licensed nurses would measure BG levels (e.g., via fingerstick) to determine whether levels were low or high. Facility policies on blood glucose monitoring for diabetic residents experiencing a change of condition and on diabetic management required BG monitoring for residents with DM, particularly when they had changes in condition, infections, poor oral intake, or were receiving dextrose-containing IV fluids, and indicated that failure to monitor BG in such situations may place residents at risk for hyperglycemia, hypoglycemia, dehydration, and hospitalization. Despite these policies and the resident’s diagnosis of Type 2 DM, staff and the NP acknowledged that the resident was not being monitored with fingerstick BG checks and that DM management relied on oral hypoglycemic medications and periodic blood work. On 2/5/2026, a stat CMP showed a fasting BG of 351 mg/dL. Nursing documentation indicated that this abnormal lab result was communicated to the attending physician via text and voicemail, and the lab results were faxed, but the nurse did not document which value was abnormal. Another nurse later texted a screenshot of the stat lab results, including the elevated BG, to the physician. The physician did not issue new orders to address the hyperglycemia but instead ordered a 1 L NS bolus via IV (from the NP) and then, on 2/6/2026, ordered D5W IV at 60 cc/hr for a total of 3 L due to poor appetite. Nursing staff started and continued the D5W infusion without reviewing or acting on the elevated BG of 351 mg/dL, without clarifying the appropriateness of D5W in the setting of hyperglycemia, and without initiating or obtaining orders for BG monitoring. Multiple RNs later acknowledged they had not reviewed the stat lab results before starting or continuing D5W, did not clarify DM monitoring parameters with the physician, and did not monitor for signs and symptoms of hyperglycemia while the D5W was infusing. On 2/8/2026, the resident experienced a change in condition characterized by non-responsiveness, shallow respirations, tachypnea, tachycardia, fever, oxygen saturation in the 80s, and a BG of 463 mg/dL documented by facility staff. An SBAR reflected these findings and the administration of oxygen via non-rebreather at 15 L, with improved oxygen saturation. EMS was called, and paramedics found the resident with altered level of consciousness, tachycardia, labored respirations, fever, and an IV of D5W still infusing at 60 cc/hr. Paramedics reviewed prior lab results showing a fasting BG of 351 mg/dL from 2/5/2026, requested that nursing staff check a current BG (which was 530 mg/dL), and instructed the nurse to discontinue the D5W, which they observed being stopped at that time. EMS documentation and ED records indicated that the resident had been receiving D5W despite hyperglycemia, with ED notes stating that the facility had treated a BG of 350 mg/dL with dextrose. The resident was transferred to the GACH ED, where BG readings remained critically elevated, and diagnoses included uncontrolled DM and severe hyperglycemia. The facility’s DON and medical director later stated that the D5W infusion in the presence of hyperglycemia would further elevate BG and that residents with Type 1 or 2 DM should be monitored with fingerstick BG AC and HS, and the DON acknowledged that the lack of BG monitoring and failure to clarify orders contributed to the resident’s elevated glucose levels and subsequent transfer. Throughout this period, there was ineffective communication among nursing staff, the physician, and the NP regarding the resident’s change in condition, critical lab results, and ordered treatments. Nurses reported that abnormal lab results were not clearly endorsed between shifts, that they did not review the stat lab results before implementing IV fluid orders, and that they did not inform the NP about the elevated BG or the change from NS to D5W. The NP stated she was unaware of the elevated BG of 351 mg/dL, unaware that D5W was being infused instead of NS, and would not have ordered D5W in a hyperglycemic state. The attending physician stated he intentionally did not reorder fingerstick BG monitoring at readmission and ordered D5W despite knowing the resident was hyperglycemic, but did not document this plan in the record. The combination of not implementing or clarifying BG monitoring orders, not operationalizing the care plan to include specific BG measurement methods, not acting on critical lab results, and continuing D5W infusion in the presence of hyperglycemia led to the resident not receiving required monitoring and timely intervention for hyperglycemia.

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 a failure by the attending MD, NP, and licensed nursing staff to adequately supervise and manage the medical care of a resident with Type 2 DM, including failure to follow and/or appropriately modify GACH discharge orders, failure to document clinical reasoning and treatment decisions, and failure to communicate effectively among providers. The resident had a care plan for "Risk for Unstable Blood Glucose Level" that instructed staff to check blood glucose if it was below 70 mg/dL and to administer glucagon and call 911 if the resident was unconscious or without vital signs, and to observe for signs and symptoms of high blood glucose and report them to the physician. However, the care plan did not address how licensed nurses would measure the resident’s blood glucose levels to determine if they were below 70 mg/dL. GACH discharge orders dated 1/11/2026 directed renewal of fingerstick blood sugar checks AC & HS, with additional PRN checks and parameters to notify the physician for blood sugars greater than 250 mg/dL or less than 70 mg/dL and to implement a hypoglycemia protocol. Upon readmission on 1/11/2026 with diagnoses including Type 2 DM and sepsis, the facility’s Physician Order Reports from 1/11/2026 through 1/31/2026 did not include orders for AC & HS fingerstick blood sugar monitoring or monitoring for hyperglycemia, but only an order to monitor for signs and symptoms of hypoglycemia three times a day. A nursing progress note on 1/11/2026 documented that the attending MD was notified of the readmission and that physician orders were “verified and carried out,” but there was no documentation that the nurse clarified with the MD whether blood sugar monitoring should continue as per GACH discharge instructions. In interview, the RN stated that the MD verbally declined to renew the AC & HS fingerstick orders and said he would assess the resident the next day, but this decision and rationale were not documented in the medical record. There was no progress note by the MD on or after 1/12/2026 documenting an assessment, plan, or justification for not monitoring blood sugars, and the NP’s H&Ps and progress note did not document how blood sugar monitoring should be performed or any coordination with the MD regarding the decision not to follow the GACH blood sugar monitoring orders. From admission on 12/11/2025 through 2/8/2026, only three provider visits were documented, all authored by the NP (two H&Ps and one progress note), with no progress notes by the MD. The NP reported that she was managing the resident’s care with the MD, knew the resident had Type 2 DM, and that the DM was being monitored with random blood work (CBC, BMP), but stated the resident should have had AC & HS fingerstick monitoring and that she was unaware the GACH readmission orders for AC & HS blood sugar checks were not renewed. On 2/5/2026, the NP ordered 1 liter of NS IV for poor oral intake and hyponatremia, but she was not informed whether this was carried out, was not informed of a STAT fasting blood glucose result of 351 mg/dL, and was not informed that the MD later ordered D5W IV instead of NS. The DON confirmed that on 2/6/2026 the MD ordered 3 liters of D5W at 60 cc/hr after being notified of the high fasting blood glucose, and that licensed nurses did not clarify this order despite the elevated glucose level or question the absence of fingerstick monitoring. The MD acknowledged ordering D5W for nutrition and comfort despite knowing the resident was hyperglycemic and did not document this plan or rationale in the record. On 2/8/2026, nursing documentation and SBAR showed a significant change in condition: the resident was non-verbal, with shallow respirations, oxygen saturation of 87%, respiratory rate of 33, temperature of 100.7°F, heart rate of 133 bpm, and a blood glucose of 463 mg/dL. Oxygen at 15 L via non-rebreather was initiated, improving saturation to 95%, and 911 was called. The paramedic run report documented arrival at 4:16 PM, altered level of consciousness, non-responsiveness to name, sinus tachycardia at 130 bpm, respiratory rate of 32 with labored breathing, temperature of 101°F, and discontinuation of D5W due to a blood glucose of 530 mg/dL. GACH ED records indicated the resident was admitted for altered level of consciousness, fever, and hyperglycemia, and noted that the facility had treated a blood sugar of 350 mg/dL with dextrose. ED testing showed blood sugars of 530 mg/dL and 434 mg/dL and high urine glucose. The NP stated she was unaware of the resident’s hyperglycemic state, the administration of D5W, or the change in condition and hospitalization. The Medical Director stated that keeping a resident in a hyperglycemic state and infusing D5W in that context would not benefit the resident and that residents with Type 1 or 2 DM need AC & HS blood glucose monitoring. Facility policies on Physician Services and Physician Orders required medical evaluation, review of orders and plan of care at each required visit, appropriate progress notes, and clear physician orders, but the record lacked documentation of assessments, clinical reasoning, treatment decisions, and communication among the MD, NP, and licensed staff regarding the resident’s DM management, change in condition, critical lab results, and ordered treatments.

Penalty

7 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 deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a high fall-risk resident in accordance with its own policies, including the Falling Star Program and Safety Supervision of Residents. The resident was admitted with unsteadiness on feet, a history of falls, osteoarthritis, and cognitive decline, and was later assessed as having moderately impaired cognition and requiring partial to moderate assistance with ADLs. A Fall Risk Collection record dated 12/15/2025 scored the resident at 14, indicating high fall risk and a need for increased supervision. Despite this, the resident’s care plans primarily focused on the use of a bed and wheelchair pad alarm and a self-release soft belt, with no individualized or specific interventions describing the type and frequency of monitoring or supervision required. The resident experienced an unwitnessed fall on 12/15/2025 when the bed pad alarm sounded and nursing staff found the resident on the floor next to the bed with no apparent injury. Subsequent care plan updates for falls and actual fall events continued to emphasize the use of pad alarms and a soft belt but did not add new, individualized interventions or specify additional monitoring or supervision. The facility’s Fall Management and Falling Star Program policies required staff to identify interventions related to specific risks, implement additional or different interventions if falls recurred, and determine the type and frequency of supervision based on assessed needs. However, the care plans remained general, and there was no documentation identifying specific monitoring requirements or scheduled safety rounds as outlined in the Falling Star Program policy. On 1/25/2026, the resident sustained a second unwitnessed fall when a CNA heard the bed pad alarm and found the resident lying on the floor on her back. Initial assessment documented no visible injuries, but the resident complained of left leg pain and was medicated with Tylenol. Later that day, the resident reported increased left leg pain rated 8/10, and nursing staff observed the left leg slightly externally rotated, leading to transfer to a general acute care hospital where imaging revealed a left femur fracture requiring ORIF surgery. Interviews with nursing staff and the DON confirmed that the resident was a high fall risk, that residents on the Falling Star Program were supposed to receive closer monitoring, and that there was no monitoring conducted between 11 PM and 7 AM. The DON acknowledged that the resident should have been on the Falling Star Program since admission, that care plan interventions were general and not specific to the type and frequency of monitoring, and that monitoring was only visual and not documented, demonstrating a failure to implement and document required supervision and safety measures. Additionally, although the resident was identified as high risk and on the Falling Star Program after multiple falls, there was no indication in the care plan of specific monitoring interventions such as defined observation intervals or documented safety rounds. The facility’s policies required ongoing identification of safety risks and environmental hazards and adjustment of supervision based on changes in the resident’s condition or environment, but the record did not show such individualized adjustments. After the resident’s return from the hospital with a left femur fracture and ORIF, observations showed that there was no fall mat at the bedside, and staff interviews confirmed that the resident did not have a fall mat. The DON stated that a fall mat was not used due to concern it would be an environmental hazard for the resident, but this did not change the fact that the facility had not clearly determined or documented the type and frequency of supervision required for this high-risk resident, nor had it implemented the full scope of monitoring and safety measures contemplated by its own 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

A deficiency occurred when a resident with moderate cognitive impairment and total dependence for toileting hygiene did not receive timely assistance with incontinence care. Documentation showed that after receiving toileting assistance in the late morning, the next documented care was not provided until the evening, resulting in a gap of approximately 6.5 hours. During this period, the resident remained in a wet brief, and both the resident and a family member reported that requests for assistance were not answered. The family member observed the resident in a wet brief for several hours and reported that staff did not respond to the call light or provide care during this time. The resident had a history of heart failure, diabetes, and acute embolism, and was assessed as lacking capacity to make decisions. Care plans indicated the resident was at risk for skin breakdown and required frequent incontinence care and skin protection measures, including the use of topical ointment for moisture-associated skin damage (MASD) at the coccyx. Despite these interventions being documented, the resident developed MASD with superficial skin breakdown and bleeding, as confirmed by staff and family observations. The wound was first noted by a CNA and later reported to the wound care nurse by the family member. Interviews with staff confirmed the importance of frequent brief changes for this resident due to frequent episodes of incontinence, including loose stools. Facility policy required routine checks and assistance with hygiene and elimination for residents unable to perform activities of daily living independently. However, the lack of timely incontinence care and failure to respond to requests for assistance directly contributed to the resident's skin breakdown and discomfort.

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 effective infection prevention and control practices for a resident diagnosed with scabies. After a dermatology evaluation confirmed scabies, the resident was not placed under contact precautions until two days after the diagnosis, despite recommendations to treat as scabies being made earlier. The resident continued to share a room with two other residents, who were not placed on isolation or monitored for symptoms, even though they were in close contact. The facility did not have an available room for isolation, and only the affected resident was placed on isolation precautions within the shared room, while the roommates were allowed to move freely within the room and the facility. The prescribed treatment for scabies, including Ivermectin and Permethrin cream, was not administered as ordered. Documentation showed that Permethrin cream was not given until twelve days after the diagnosis and eight days after the physician's order, with notes indicating delays due to waiting for the family to provide the medication. There was no evidence that the physician was notified about the missed doses on the specified dates. The resident, who had limited cognitive capacity and required maximal assistance with activities of daily living, experienced worsening skin conditions, including open, severe skin wounds, and was eventually transferred to a general acute care hospital for further evaluation and treatment. There was also a lack of monitoring and assessment for the two roommates who were exposed to the resident with scabies. Progress notes and interviews confirmed that no formal documentation, daily assessments, or diagnostic testing were conducted for these close contacts. The facility did not establish an effective surveillance system or maintain an accurate line listing of symptomatic residents and staff, as required by their own policies and CDC guidelines. This failure to follow infection control protocols and physician orders contributed to the spread and worsening of the 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 develop and implement comprehensive care plans for three residents with significant medical and cognitive needs, as required by facility policy and procedure. For one resident with a history of epilepsy, severe cognitive impairment, and a care plan intervention to apply sheep skin padding to side rails to prevent injury during seizures, observations revealed that the required padding was not in place. Both the assigned LVN and the DON confirmed that the care plan was not followed, and the intervention to confirm placement of the padding every shift was not implemented. Another resident, admitted with dementia, a maxillary fracture, and concussion, was prescribed medications for dementia and was assessed as moderately cognitively impaired and dependent for multiple activities of daily living. Despite these findings and documented behavior concerns related to dementia, there was no evidence of a comprehensive care plan addressing cognitive impairment or dementia care. The baseline care plan and progress notes lacked goals or interventions for dementia, and staff interviews confirmed the absence of a dementia care plan since admission. A third resident, with dementia, difficulty walking, and muscle wasting, was assessed as severely cognitively impaired and requiring supervision for mobility. Although informed consent for the use of bilateral half side rails was documented, there was no care plan initiated to address the use of these side rails. Both the reviewing RN and the DON acknowledged the lack of a care plan for side rail use, which is necessary to guide staff in meeting the resident's needs and monitoring the effectiveness of interventions. These deficiencies were identified through record reviews, staff interviews, and direct observations.

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

During a kitchen tour, surveyors observed an open plastic bag containing six hashbrowns in the facility's freezer that was not labeled with the date it was opened or a use-by date. The Dietary Service Supervisor (DSS) confirmed that, according to facility policy, all foods in the kitchen should be labeled with both an opened date and a use-by date. The DSS acknowledged that failing to label the bag could result in shortened shelf life and potential contamination. The Director of Nurses (DON) also stated that food in the kitchen should be labeled with an opened date and a use-by date, as per facility policy, to ensure staff know when to discard food and prevent serving it to residents. A review of the facility's policy and the 2022 Food Code confirmed the requirement for date marking of ready-to-eat, time/temperature control for safety foods. The deficiency was identified due to the lack of labeling on the open bag of hashbrowns, which was not in accordance with professional standards or facility 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 obtain valid informed consent for the administration of psychotropic medications, specifically Quetiapine and Divalproex, for a resident with diagnoses including dementia, psychotic disorder, and mood disorder. The resident was assessed as having severely impaired cognitive status and required varying levels of assistance with daily activities. Physician orders for these medications were present in the resident's records, but a review of the electronic health record and facility documentation revealed that informed consent forms for these drugs were either incomplete or missing the prescriber's signature, rendering them invalid. Interviews with facility staff, including a registered nurse, the medical record director, and the director of nursing, confirmed that the required informed consent process was not properly completed. Facility policy mandates that the prescriber must obtain and sign the informed consent form when psychotropic medications are ordered, ensuring that the resident or their representative is fully informed and agrees to the treatment. The lack of a valid, signed informed consent for these medications constituted a violation of the resident's rights to be informed and to participate in decisions regarding their care and treatment.

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 two residents by not ensuring the presence and accuracy of wall clocks in their rooms. For one resident with dementia, depression, and muscle wasting, the wall clock in the room displayed an incorrect time, as observed by both the resident and the Infection Preventionist Nurse (IPN). The IPN confirmed that the clock was not showing the correct time during the observation. For another resident with dementia, osteoarthritis, and osteoporosis, there was no wall clock present in the room. The IPN acknowledged that all rooms should have a wall clock to help residents with time orientation. During interviews, the resident without a clock expressed frustration at having to repeatedly ask staff for the time, indicating that the absence of a clock affected her comfort. The DON also stated that having an accurate wall clock in every resident's room is important for orientation and maintaining a comfortable, homelike environment. The facility's policy on quality of life and homelike environment requires staff to provide a setting that emphasizes residents' comfort, independence, and personal needs, which was not met in these instances.

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 a baseline care plan within 48 hours of admission for a resident with significant medical needs, including chronic congestive heart failure, a history of pneumonia, and acute respiratory failure with hypoxia. Upon review, it was found that the resident had physician orders for oxygen therapy and albuterol as needed for shortness of breath, and required varying levels of assistance with daily activities. Despite these needs and orders, the electronic health record did not contain a baseline care plan addressing the management of the resident's respiratory and cardiac conditions or the interventions required for shortness of breath. Interviews with nursing staff and the Director of Nursing confirmed that a baseline care plan was not created as required by facility policy, which mandates such a plan within 48 hours of admission to ensure proper care and communication among staff. The absence of this care plan was acknowledged by staff as having the potential to delay necessary care and services for the resident, as it failed to provide guidance on managing the resident's immediate medical and physical 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 provide a safe and hazard-free environment for two residents by not implementing required safety interventions as outlined in their care plans and physician orders. For one resident with diagnoses including respiratory failure, chronic kidney disease, and unspecified dementia, the care plan and physician order required the use of a bed pad alarm to alert staff if the resident attempted to get out of bed unassisted. Despite being identified as high risk for falls, the resident was observed in bed without a pad alarm and attempting to get up. Interviews with nursing staff and the Director of Nursing confirmed that the bed alarm was not in place, and the physician order and care plan were not followed. Another resident, diagnosed with epilepsy, hypertension, and pneumonia, was at risk of injury during seizures. The care plan required sheep skin padding on both side rails to prevent injury during seizure activity and mandated that staff confirm placement every shift. Observations revealed that the resident's side rails were not padded, and interviews with nursing staff and the Director of Nursing confirmed that the intervention was not implemented as required by the care plan. Review of facility policies indicated that physician orders and individualized care plans are to be followed to ensure resident safety and minimize risks such as falls and injuries. In both cases, the required interventions were not in place at the time of observation, and staff acknowledged that the care plans and physician orders were not followed, resulting in an unsafe environment for the residents involved.

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

Nursing staff failed to provide necessary respiratory care to a resident with chronic obstructive pulmonary disease (COPD), acute respiratory failure, and congestive heart failure, as indicated by physician orders and professional standards of practice. The staff did not properly assess or document the resident's baseline oxygen saturation (SpO2) level prior to administering oxygen therapy, nor did they consistently monitor and document oxygen saturation every shift as ordered. There was also a lack of documentation regarding respiratory assessments, including signs and symptoms of respiratory distress or shortness of breath, before and after oxygen therapy was provided. Observations revealed that the resident's oxygen tubing was compressed within the side rail, and the nasal cannula was not properly positioned in the resident's nose, which could have impeded oxygen delivery. Interviews with nursing staff indicated a lack of awareness and adherence to the physician's PRN order for oxygen therapy, with some staff keeping the resident on continuous oxygen without documented need or assessment. The care plan did not specify the frequency of monitoring, safe oxygen saturation ranges, or include detailed clinical examination or assessment instructions. Further review of facility policies and interviews with the Director of Nursing and other staff revealed that there was no specific policy for COPD or respiratory failure care, and staff were not fully aware of the standards of practice for respiratory care. The facility's policy on oxygen administration required monitoring for signs of hypoxemia and documentation of vital signs and resident response before and after therapy, but these practices were not consistently followed 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

A Licensed Vocational Nurse (LVN) failed to follow facility policy by documenting the administration of hydrocodone-acetaminophen on both the Medication Administration Record (MAR) and the Controlled Drug Record before actually giving the medication to a resident. The nurse was observed preparing the medication, signing both records, and then administering the medication several minutes later. During an interview, the LVN confirmed that it was her practice to sign the records prior to administration to ensure the times matched on both documents. The resident involved had a history of rheumatoid arthritis, an artificial hip joint, and a history of falls, and was receiving pain medication as needed. Facility policy and the Director of Nursing (DON) both specified that documentation on the MAR should only occur after the medication has been administered, as residents may still refuse the medication. The facility's policy required immediate documentation following administration, but this was not followed in this instance.

Penalty

Fine: $14,069

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 resident with a history of NSTEMI, Parkinson's disease, and atherosclerotic heart disease experienced multiple episodes of chest pain while under the care of the facility. The resident had physician orders for sublingual nitroglycerin to be administered every five minutes for up to three doses for chest pain, with instructions to notify the physician if pain persisted. On several occasions, nursing staff administered only one dose of nitroglycerin, documented the effect as 'Not Effective' or 'Somewhat Effective,' and failed to administer subsequent doses as ordered. Additionally, staff did not consistently reassess the resident's pain after administration, nor did they notify the physician or document the change in condition as required by facility policy. The facility also failed to monitor and document the resident's complaints of chest pain every shift for 72 hours following episodes of unrelieved pain, as outlined in their policy for changes in condition. There were delays in carrying out physician orders for diagnostic testing, including a stat EKG, which was performed several hours after being ordered. Furthermore, there was a significant delay in transferring the resident to an acute care hospital despite ongoing severe chest pain and abnormal vital signs, with emergency services not being called until hours after the resident's condition had deteriorated. Interviews with nursing staff revealed a lack of understanding and adherence to the physician's orders and facility protocols regarding the management of chest pain and notification of changes in condition. Staff admitted to not administering additional doses of nitroglycerin, not reassessing the resident, and not promptly notifying the physician or documenting the events. The resident ultimately suffered an acute myocardial infarction, was transferred to the hospital, and died after further cardiac events. The survey identified these failures as constituting Immediate Jeopardy due to the facility's noncompliance with professional standards of practice, care planning, and physician orders for the management of chest pain.

Removal Plan

• LVN 1 and LVN 2 were provided a one-to-one re-education and training by the DON focusing on the proper evaluation of resident's change in condition (COC) particularly about residents experiencing chest pain, accurate administration of medications, timely notification of physicians, laboratory and diagnostic testing procedures (verifying that the vendor will perform the testing without delay) and appropriate documentation practices.
• The DON and the Registered Nurse Supervisor evaluated all other 9 residents who were receiving Nitroglycerin for any change in condition (COC).
• The facility would designate RN or Nursing Supervisor to evaluate residents experiencing a COC, particularly chest pain, to ensure timely and appropriate interventions.
• The DON initiated daily morning meetings for COC audits, focusing on residents with chest pain, diagnosis of NSTEMI or with prescribed nitroglycerin.
• The DON will initiate in-services for all licensed nurses (LN) for proper evaluation of residents' change in condition, with an emphasis on residents experiencing chest pain, diagnosed with NSTEMI, and prescribed nitroglycerin. The Inservice will be repeated quarterly, and incorporated into the orientation program for newly-hired LN.

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 residents had reasonable access to and privacy in their use of communication methods, specifically telephones. Station B's portable phone was missing, and there was no alternative phone readily available for residents to use. This issue was highlighted during an interview with a resident's representative, who reported ongoing problems with the facility's phone system, including long wait times and dropped calls. The representative noted that these issues had persisted for over eight years, affecting their ability to communicate with their family member residing in the facility. Licensed Vocational Nurse (LVN) 1, who was assigned to Station B, confirmed that the portable phones often had poor connections or were unavailable, leading her to use her personal cell phone to facilitate communication between residents and their families. However, LVN 1 was unaware of any additional facility cell phones available for resident use. The Director of Nursing (DON) and the Administrator (ADM) acknowledged the missing phone and the lack of in-service training for staff regarding the use of a facility cell phone as an alternative. The facility's policy and procedure on resident access to telephones emphasized the importance of providing residents with reasonable access to a private phone. However, the facility did not adhere to this policy, as evidenced by the missing phone at Station B and the lack of documentation for staff training on alternative phone use. The DON and ADM both stated that staff should not use personal phones for resident communication, yet there was no evidence of in-service training to inform staff of the available facility cell phone for such situations.

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 treated with dignity and respect, as outlined in their policies and procedures. The resident, who was admitted with a diagnosis of diabetes and diabetic neuropathy, reported an incident involving a certified nurse assistant (CNA) who made inappropriate comments and gestures with a hard-boiled egg. The resident felt embarrassed and disrespected by the CNA's actions, which included making a loud comment about the resident's need for assistance and suggesting that no one wanted to assist the resident due to their COVID-19 positive status. The resident reported the incident to the Administrator the following day, but the facility did not take appropriate steps to protect the resident from further contact with the CNA. The Administrator brought the CNA to the resident's room to apologize, which was against the facility's policy on abuse prevention. Additionally, the facility did not conduct follow-up monitoring of the resident's mood or behavior, nor did they address the resident's feelings or preferences regarding the CNA's continued involvement in their care. The facility's policies on dignity and abuse prevention were not followed, as staff failed to promote the resident's well-being and self-esteem. The facility did not conduct an in-service for licensed nurses regarding abuse, nor did they monitor the resident for changes in mood or behavior after the incident. The lack of appropriate response and monitoring placed the resident at risk for further emotional distress and potential 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 ensure that a resident with type 2 diabetes mellitus received proper care and services according to the facility's policy and procedure for blood glucose testing. The resident, who required blood sugar checks, had their blood sugar level checked by a certified nurse assistant (CNA) instead of a licensed nurse (LN), as per the facility's policy. This occurred because the licensed vocational nurse (LVN) was busy and asked the CNA to perform the task, despite the facility's policy stating that only licensed staff should conduct blood glucose tests. The resident, who was admitted with a diagnosis of diabetes and diabetic neuropathy, expressed feeling uncomfortable with the CNA performing the blood sugar check, as it was not a usual practice. The CNA confirmed that it was their first time performing such a task and did so at the request of the LVN. The facility's administrator and director of staff development both acknowledged that the CNA should not have performed the blood sugar check, as it was against the facility's policy. The LVN admitted to asking the CNA to perform the check while they monitored from the doorway, as the resident was in an isolation room.

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 incident of unusual occurrence to the California Department of Public Health (CDPH) as per its policy and procedure. This involved a resident who was admitted with a diagnosis of major depressive disorder and paraplegia. The resident, who was cognitively intact, reported feeling threatened by a certified nurse assistant (CNA) who allegedly pointed fingers like a gun at her. The police were involved, but the facility did not report the incident to CDPH. The investigation summary revealed that the resident had gone to the police department, alleging that the CNA was carrying a gun in the facility. The resident later withdrew the allegation, stating it was a misunderstanding related to a Valentine's Day gift from the CNA. Despite the resident's retraction, the facility did not report the incident to CDPH, as required by their policy. The facility's interdisciplinary team discussed the incident, but the administrator decided not to report it, citing the resident's alertness and orientation. Interviews with the resident, family member, and staff indicated that the resident felt mistreated by the CNA and had previously been reluctant to report due to fear of retaliation. The facility's policy mandates prompt reporting of all allegations of abuse or unusual occurrences to appropriate authorities, but this was not followed. The Director of Nurses acknowledged the incident as an unusual occurrence but confirmed it was not reported to CDPH.

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 a resident-centered care plan for a resident who was admitted with major depressive disorder and paraplegia. Despite the resident's capacity to understand and make decisions, as indicated in their medical records, the facility did not create a care plan addressing a specific incident where the resident reported feeling threatened by a CNA. The resident alleged that the CNA pointed fingers like a gun at them, leading to police involvement. The facility's investigation suggested that the resident made a false report due to personal feelings towards the CNA, but no care plan was developed to address this incident or the resident's emotional state. The Director of Nursing acknowledged that a care plan should have been initiated to address the false allegation incident. The facility's policy requires a comprehensive care plan to meet residents' medical, nursing, mental, and psychosocial needs, but this was not followed in this case. The resident's care plan only addressed mood disorder without specific reference to the incident involving the CNA, leaving a gap in addressing the resident's psychosocial needs and the situation's impact on their well-being.

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 complete Physician Orders for Life-Sustaining Treatment (POLST) for four residents, which resulted in a lack of documentation regarding advance directives. For Resident 82, the POLST was signed by the physician but lacked details on discussions with the responsible party, and no advance directive notification form was present in the chart. This oversight could delay care in emergencies. Similarly, Resident 91's POLST was signed without a date, and there was no documentation indicating that the resident was informed about their rights to formulate an advance directive. Resident 59's POLST was signed by the responsible party but not by the physician, and there was no documentation showing that the responsible party was informed about the right to formulate an advance directive. The Social Service Director (SSD) indicated that such documentation should be accessible in the resident's clinical chart to ensure immediate access during emergencies. However, the SSD found the documentation in the electronic medical record, not in the physical chart, highlighting a gap in the facility's process. For Resident 79, the POLST forms were incomplete, with sections on medical interventions and advance directives left blank. Although the SSD documented the refusal of an advance directive in the electronic medical record, this information was not transferred to the physical chart. The facility's policies require that the POLST be reviewed for completeness and that any omissions be referred to the attending physician, but these steps were not consistently followed, leading to incomplete documentation and potential conflicts with residents' healthcare wishes.

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 food storage and handling practices, as observed during a kitchen tour. Specifically, 26 containers of applesauce were found in the refrigerator without labels or dates, and a gallon of milk was open without a date indicating when it was opened. The Dietary Supervisor acknowledged that labeling and dating food items are crucial to prevent the consumption of expired food and to protect residents from potential foodborne illnesses. Additionally, a kitchen staff member was observed entering the kitchen without wearing a hair net, which is a violation of the facility's food handling policy. The staff member admitted to forgetting to wear the hair net due to being in a rush, acknowledging the importance of wearing it to prevent hair contamination in food and drinks. The Dietary Supervisor reiterated the significance of wearing hair nets as a protective measure to prevent contamination and ensure resident safety.

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 respect and dignity for a resident by not maintaining eye contact during feeding. The incident involved a resident with dementia and hypertension, who was admitted to the facility initially in 2021 and readmitted in 2024. The resident required supervision or assistance with eating and other personal care activities due to severely impaired memory and cognition. During an observation, the resident was seen struggling to eat independently, and a CNA assisted by feeding the resident while standing, without sitting at eye level. The CNA acknowledged the importance of treating the resident with respect and dignity by sitting at eye level during feeding. The Director of Nursing confirmed that staff should sit at eye level to ensure dignity and respect. The facility's policy on assisting residents to eat also emphasized the need for staff to sit at eye level when feeding residents. This deficiency was identified through observation, interviews, and a review of 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 ensure that a resident's call light was within reach, as observed during a survey. The resident, who was admitted with an anxiety disorder and had severely impaired cognition, required maximum assistance for daily living activities. During an observation, the call light was found hanging below the mattress, out of the resident's reach, which was against the facility's policy. Interviews with the Social Services Director and a Certified Nurse Assistant confirmed that the call light should always be within the resident's reach to enable them to call for help. The facility's policy, approved and revised earlier in the year, mandates that staff must ensure the call light is accessible to maintain resident safety. This oversight had the potential to harm the resident by preventing them from calling for assistance when needed.

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 involuntary physical restraints, as observed with the use of an overbed table. The resident, who had a history of metabolic encephalopathy, upper gastrointestinal bleed, and unspecified dementia, was found with an overbed table positioned over him after breakfast, restricting his freedom of movement. The resident's cognitive skills for daily decision-making were severely impaired, and he required assistance with activities of daily living. During an observation, the overbed table was placed on top of a floor mattress, which prevented the resident from moving it away. The Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) both acknowledged that the overbed table should not have been left over the resident, as it restricted his movement and could be considered a form of restraint. The CNA admitted that the normal process after meal setup was to remove the table to allow the resident to move independently. The Director of Nursing (DON) confirmed that the overbed table should not be on top of the floor mattress or over the resident when not in use, as it could restrict the resident's freedom of movement. The facility's policy on physical restraints indicated that any device restricting a resident's movement, which they could not remove themselves, was considered a restraint. This oversight resulted in the resident being restrained in his bed, unable to move freely.

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 appropriate interventions to prevent the development or worsening of pressure ulcers for two residents, as observed during a survey. For one resident, the Alternating Pressure Mattress (APM) was not set according to the resident's weight, as recommended by the manufacturer. The resident, who was severely impaired and required substantial assistance with daily activities, was observed with the APM set at 100 pounds, despite weighing only 79.8 pounds. This discrepancy was acknowledged by both the Licensed Vocational Nurse (LVN) and the Treatment Nurse (TN), who were responsible for ensuring the correct settings. The facility's policy and the manufacturer's guidelines both emphasized the importance of setting the APM according to the resident's weight to prevent skin breakdown and promote wound healing. Another resident, who was also at high risk for developing pressure ulcers, did not have heel protectors applied as ordered by the physician. This resident, with severe mental impairment and limited mobility, was observed without heel protectors, despite having a physician's order and care plan intervention to apply them at all times. The Treatment Nurse and Registered Nurse (RN) confirmed the absence of heel protectors and acknowledged the oversight. The facility's policy on pressure ulcer and skin care management required the implementation of appropriate treatment procedures, which was not followed in this case. The Director of Nurses (DON) confirmed the deficiencies in both cases, acknowledging that the APM should have been set according to the resident's weight and that heel protectors should have been applied as ordered. The facility's failure to adhere to its own policies and procedures, as well as professional standards of practice, resulted in the potential for the residents to develop new pressure ulcers or for existing ones to worsen.

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 maintained acceptable nutritional status parameters, leading to a significant weight loss of more than 5% in 30 days. The resident, who had a history of diabetes, protein-calorie malnutrition, and dementia, was admitted with a care plan that included monitoring for undesirable weight changes and risk for dehydration. Despite these interventions, the resident's weight dropped from 84.4 pounds in April to 79.8 pounds in May, indicating a 4.6-pound loss. The deficiency was exacerbated by the lack of consistent documentation of the resident's food intake throughout May. Numerous entries for meals were missing, which hindered the ability to monitor the resident's nutritional intake effectively. Interviews with staff revealed that the facility had hired many registry CNAs, which may have contributed to the lack of documentation. The Dietary Supervisor and the Director of Nursing (DON) acknowledged the oversight in monitoring the resident's weight and intake. The Registered Dietician (RD) admitted to not following the facility's policy of recognizing a 5% weight loss as significant, which contributed to the lack of timely intervention. The DON also recognized the failure to initiate care plan interventions, such as weekly weight monitoring, and the importance of consistent documentation of the resident's oral intake. This oversight had the potential to lead to further weight loss and associated medical complications 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 adequate respiratory care for a resident, identified as Resident 51, who required oxygen therapy. The deficiency was observed when the facility did not follow the physician's order dated 5/5/2024, which specified administering oxygen at 3 liters per minute (LPM) as needed for shortness of breath, with the option to titrate up to 5 LPM. Instead, the resident's oxygen was consistently administered at 2 LPM, as evidenced by multiple entries in the Vitals Report from 5/20/2024 to 6/10/2024, despite the updated physician's order. Additionally, the facility failed to ensure that the resident's oxygen tubing was free of obstructions, which is crucial for consistent oxygen therapy. Observations on 6/3/2024 and 6/6/2024 revealed that the nasal cannula tubing was pinched and obstructed at the connection site, which could impede the proper flow of oxygen. Licensed Vocational Nurse 1 and Treatment Nurse 1 both acknowledged the obstruction and its potential negative impact on the resident's ability to receive the necessary oxygen flow. The resident, who had a history of pneumonia, respiratory failure, and chronic congestive heart failure, was admitted with a diagnosis of pneumonia and required oxygen therapy. The resident's cognitive skills were severely impaired, necessitating complete staff assistance for daily activities. Despite these needs, the facility's staff did not adhere to the prescribed oxygen therapy protocol, leading to episodes of labored breathing and desaturation, as documented in the Nursing Progress Notes and observed during staff interviews.

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 Social Services Director (SSD) confirmed the completion of the Physician Orders for Life-Sustaining Treatment (POLST) form for a resident with a history of traumatic brain injury and severely impaired cognition. The POLST form, which communicates the resident's wishes regarding life-sustaining treatment, was not signed by the physician, nor was there evidence of the resident's conservator's signature. This oversight occurred despite the facility's protocol to have the POLST form filled out during admission, either by the resident or their responsible party. Interviews revealed a lack of clarity regarding the responsibility for ensuring the POLST form's completion. Registered Nurse 1 indicated that the SSD was responsible for this task, while the SSD herself was unaware of who should ensure the form's signatures and completion. The Administrator confirmed that it was indeed the SSD's responsibility. The SSD's job description also indicated that she was responsible for completing required forms in accordance with company policy and regulations.

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 hospice binders for two residents, who were under hospice care, were properly completed and maintained. The hospice binders, which are essential for communication between hospice nurses and facility staff, were found to be lacking necessary documentation such as nursing notes, resident assessments, and care plans. This deficiency was identified during interviews and record reviews involving a registered nurse and the Director of Nursing. The absence of these critical documents in the hospice binders meant that facility staff were unaware of the care being provided by hospice nurses, potentially affecting the delivery of appropriate hospice care. Resident 77, admitted with diagnoses including dementia and heart failure, had a hospice binder that was missing nursing notes, assessments, and a care plan. Similarly, Resident 59, admitted with dementia and hypertension, also had a hospice binder lacking a care plan and consistent visiting notes from hospice staff. The facility's policy required that a coordinated plan of care be maintained in the hospice binders, but this was not adhered to, leading to a breakdown in communication and collaboration between the facility and hospice staff.

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 staff failed to maintain a safe environment for residents by leaving a Hoyer lift unattended in a resident's room. During an observation, the lift was found near a resident's bed, posing a risk for accidents and injury. A Certified Nursing Assistant (CNA) admitted to leaving the lift unattended while assisting a resident to a wheelchair and transporting them to the dining area. The CNA acknowledged that the lift should not be left in the room as it could cause residents to trip and get injured. The Director of Nurses (DON) confirmed that the lift should be stored outside the resident's room to prevent injuries.