Berkley West Healthcare 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

Licensed nursing staff failed to follow facility policy and procedure regarding the interdisciplinary (IDT)/Bioethics review process for a resident with fluctuating capacity to understand and make decisions. The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, memory deficit, and cerebrovascular disease, exhibited moderate cognitive impairment and was dependent on staff for activities of daily living. Documentation and interviews confirmed that the resident experienced periods of confusion and disorientation, with staff noting difficulty in communication and episodes of hallucination. Despite the resident's fluctuating decision-making capacity, the facility did not ensure that an IDT/Bioethics review was conducted as required by their policy. The social worker was not involved in obtaining consent, and the facility administrator could not demonstrate how consent was obtained during periods when the resident had capacity. The facility also failed to document efforts to identify or involve a legal decision-maker or resident representative, as outlined in their policy, thereby violating the resident's right to make informed decisions about care and the use of psychoactive medications.

Penalty

No penalty information released

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

Summary

A Certified Nursing Assistant (CNA) recorded a video of a resident without obtaining consent from the resident or the resident's responsible party. The CNA subsequently posted the video on her personal social media account, specifically Instagram, which was confirmed through interviews and review of the complaint submitted to the District Office. The resident involved had severe cognitive impairment, as documented in the Minimum Data Set, and required moderate to maximal assistance with activities of daily living. The resident was not aware that a video had been taken or posted and expressed distress upon learning about the incident, stating a desire for privacy regarding his stay and condition. The facility's Director of Nursing (DON) reviewed the complaint and confirmed that the images in question were of the CNA and the resident. The DON acknowledged that the CNA did not follow facility policies and procedures regarding the prohibition of taking or releasing images or recordings of residents without explicit written consent. The facility's policies clearly state that staff may not take or release images or recordings of any resident without explicit written consent, and that unauthorized disclosure of resident information is prohibited. The CNA initially denied taking or sharing photos but later admitted to posting a video of the resident on social media without informing the resident or obtaining consent. Interviews with the resident's responsible party revealed that the resident was a private individual who would not have consented to being photographed or having his image shared, especially in his current condition. The responsible party expressed concern about the violation of the resident's privacy, dignity, and respect, and questioned how many people had access to the unauthorized images. Additional interviews with facility staff confirmed that taking photos or videos of residents without consent is not allowed and is considered a violation of residents' rights and privacy.

Plan Of Correction

Immediate corrective action(s) for those Resident(s) affected by the deficient practice: • HIPAA Privacy Consultant was notified by the Administrator via email of the incident on 6/5/25 at 5:38 PM and an investigation was initiated. • CNA 1 was interviewed by the Administrator and Director of Nursing (DON) on 6/5/25 at 3:30 PM, and the nature of the video clip was assessed at approximately 7:00 PM. The Administrator witnessed CNA 1 delete the video from her private Instagram account and trash bin; and verified that it was not stored in the cloud. CNA 1 received verbal 1:1 counseling regarding policy violations at this time. The 5 facility employees who had potential to view the video clip were interviewed on 6/7/25 by the Administrator and QA Nurse at approximately between 1:00-1:30 PM and 4:18 PM. MR 1, CNA 3, and CNA 5 stated they did not view the video, and CNA 2 and CNA 4 stated they viewed the video but did not screenshot, forward, or share it. CNA 1's employee file was reviewed by the Administrator on 6/5/25 at 4:30 PM. Her background and reference checks were completed. No previous disciplinary actions were noted. CNA 1 received written counseling for her HIPAA violation and 1:1 re-training with the facility Administrator on 6/5/25 at approximately 6:00 PM. The topics covered included responsibilities in protecting personal health information (including patient images) and the facility policy prohibiting unauthorized audio/visual recordings of Residents and/or posting PHI to social media. CNA 1 signed for HIPAA Retraining Inservice. CNA 1 was suspended on 6/6/25 at approximately 12:45 PM as a provision for immediate jeopardy abatement plan acceptance. The HIPAA Privacy Consultant provided an additional re-education on HIPAA with CNA 1, and she signed her Corrective Action Form on 6/6/25 at approximately 8:00 PM. The HIPAA Privacy Consultant determined that HIPAA Sanctions Policy will be followed for corrective action and remediation for CNA 1. At the direction of CDPH, CNA 1 was to remain suspended until CMS-2567 Form is received. On 6/18/25, the facility received notice from CDPH that it opened an investigation into the CNA involved in this incident. Resident 1's wife was notified of the incident on 6/5/25 by the Social Services Director (SSD) at 5:04 PM. The wife verbalized that she was satisfied with the steps the facility took, and she feels no harm was done. Resident 1's Physician was notified by the Administrator on 6/5/25 at 9:30 PM. No new orders were noted. Beginning on 6/7/25, Resident 1 was monitored and observed for any changes in mood, behavior, or exhibiting any distress by the SSD; and beginning on 6/8/25 by nursing staff. On 6/6/25, the SSD referred Resident 1 for a third-party psychological evaluation and determination of any residual effects related to this social media incident. The psychiatrist is scheduled to visit on 6/9/25 at approximately 3:00 PM. Plan/Process to identify other Resident(s) potentially affected by the same deficient practice: From 6/6/25 through 6/7/25, our SSD or designee conducted interviews with 115 facility Residents to determine if any had experienced privacy violations, including being videotaped or having their picture taken without written consent. No issues or concerns were identified and noted in their clinical record progress notes. The 115 residents were interviewed by the social services staff on 6/7/25 to assess if they are aware of or have experienced any privacy violations, including being videotaped or having their picture taken. No issues or concerns were identified and noted in their clinical record progress notes. On 6/6/25, facility grievances and Resident Council minutes were reviewed by the Administrator at approximately 2:00 PM for the past 3 months, and no other instances of unauthorized images, recordings, or PHI disclosures were reported. Facility measures and systemic changes to ensure the deficient practice does not recur: By 6/9/25, Department Managers will be in-serviced by the Clinical Resource Consultant regarding Resident Rights to Privacy and Dignity, and HIPAA policies prohibiting disclosure of photographs or audio/visual recordings of Residents without explicit written consent. Facility policies prohibiting the use of personal cell phones or other handheld computer devices while working will also be reviewed, and a HIPAA Competency Test will be completed. By 6/30/25, facility staff will receive in-service training with the DON and/or designee on Resident Rights to Privacy and Dignity, and HIPAA policies prohibiting disclosure of photographs or audio/visual recordings of Residents without explicit written consent. Facility policies prohibiting the use of personal cell phones or other handheld computer devices while working will be reviewed, and a HIPAA Competency Test will be completed. Upon hire, facility staff will receive training on Resident Rights policies and HIPAA policies prohibiting audio or visual recordings of Residents without explicit written consent. Employees will acknowledge receipt and understanding of the employee handbook, which includes policies for Resident Rights and prohibiting the use of personal cell phones or other handheld computer devices while working. On 6/7/2025, the facility provided postings in common areas to remind staff and/or visitors regarding common HIPAA violations and no personal cellphone use while working in residents' care areas. The DON advised RN supervisors and/or Licensed Nurses on duty to remind staff during nursing huddles that personal cellphones are prohibited in residents' care areas. Department Managers were also advised to remind staff that personal cellphones are prohibited in resident care areas. Monitor performance to ensure solutions are sustained: Beginning 6/7/25, interdisciplinary team members will conduct random quality monitoring rounds three times per week to monitor staff compliance in maintaining a cell phone-free environment in resident rooms and other areas where residents gather. DSD and/or designee will conduct random observation rounds and resident interviews three times per week to monitor staff compliance with personal cell phone use. Identified non-compliance will be addressed immediately through counseling and re-education. The Administrator or designee will conduct a weekly QAPI subcommittee, including the DON, DSD, HR, Social Services Director, Activity Director, or designees, to review quality rounds results for any instances of non-compliance requiring additional follow-up or remedial planning. The Activities Director or designee will conduct targeted queries during monthly Resident Council meetings to monitor compliance with cell phone use and maintaining residents' rights to privacy and dignity. Results of quality rounds, Resident Council feedback, and grievance reports will be reviewed by the facility QAPI Committee to monitor compliance with maintaining residents' rights, privacy, and dignity each month, or until substantial compliance is maintained for a minimum of three months. Compliance trends will be evaluated for additional remedial planning and monitoring needs as indicated. Responsible Person: Administrator Date of Completion: 6/30/2025

Removal Plan

• CNA 1 was interviewed by the ADM and DON, and the nature of video clip was assessed. The ADM witnessed CNA 1 deleted the video from her private Instagram account and trash bin; and verified it was not stored in the cloud.
• CNA 1's employee file was reviewed by ADM. Her background and reference checks were completed. No previous disciplinary actions noted.
• RP 1 was notified of incident by the Social Services Director (SSD). RP 1 verbalized that she was satisfied with the steps the facility took, and she feels no harm was done.
• Health Insurance Portability and Accountability Act (HIPAA) Privacy Consultant was notified by the ADM via email of the incident and an investigation was initiated.
• CNA 1 received immediate counseling for her HIPAA violation and 1:1 re-training with the facility ADM. The topics covered included responsibilities in protecting personal health information (including patient images); and facility policy prohibiting unauthorized audio/visual recordings of residents and/or posting PHI to social media. CNA 1 signed the HIPAA Retraining Inservice.
• Resident 1's Physician was notified by the ADM. No new orders were noted. The Primary Physician and MDR was informed of the incident. The ADM will monitor for compliance and report findings or trends to the QAA/QAPI Committee. A weekly QAA/QAPI Meeting will be conducted to review for compliance and any further recommendations for improvement as needed until substantial compliance is achieved.
• CNA 1 was suspended. The HIPAA Privacy Consultant provided an additional re-education on HIPAA with CNA 1, and she signed her Corrective Action Form. The HIPAA Privacy Consultant determined that the HIPAA Sanctions Policy will be followed for corrective action and remediation for CNA 1. CNA 1 remains on suspension until CMS-2567 form is received. The facility will report CNA 1 to the certification board.
• The SSD referred Resident 1 for a 3rd party psychological evaluation and determination of any residual effects related to this social media incident. The psychiatrist is scheduled to visit.
• Facility grievances and Resident Council Minutes were reviewed by the ADM for the past 3 months, and no other instances of unauthorized images, recordings, or PHI disclosures were reported.
• Resident 1 was monitored and observed for any changes in mood, behavior, or exhibiting any distress by the SSD; and by nursing staff.
• Facility provided postings in common areas to remind staffs and/or any visitors regarding common HIPAA violations and no personal cellphone use while working in residents care areas.
• The five facility employees who had potential to view the video clip were interviewed by the ADM and Quality Assurance Nurse (QAN). Medical Record Assistant 1 (MRA 1), Certified Nursing Assistant 3 (CNA 3) and Certified Nursing Assistant 5 (CNA 5) stated they did not view the video and Certified Nursing Assistant 2 (CNA 2) and Certified Nursing Assistant 4 (CNA 4) stated they viewed the video, but did not screenshot the video or forwarded or shared the video.
• The SSD and/or Designee conducted interviews with the 11 residents CNA 1 was assigned to to determine if any had been photographed or recorded without their written consent. No issues or concerns were identified and noted in their clinical record progress notes. The 115 residents were interviewed by the social services staff if they are aware of or have experienced any privacy violations including being videotaped or having their picture taken. No issues or concerns were identified and noted in their clinical record progress notes.
• The ADM, DON, ADON, Director of Staff and Development (DSD), SSD, Minimum Data Set Nurse (MDSN), Rehabilitation and Maintenance/Housekeeping Directors were in-serviced by the CRC regarding Resident Rights to Privacy and Dignity; and HIPAA policies prohibiting disclosure of photographs or audio/visual recordings of residents without explicit written consent. Facility policies prohibiting use of personal cell phones or other handheld computer devices while working was also reviewed. The additional Department Heads will be in-serviced by the CRC and a HIPAA Competency Test completed prior to their next scheduled shift.
• The DON and/or Designee began in-serving facility staff regarding Resident Rights to Privacy and Dignity; and HIPAA policies prohibiting disclosure of photographs or audio/visual recordings of Residents without explicit written consent. Facility policies prohibiting use of personal cell phones or other handheld computer devices while working was also reviewed and a HIPAA Competency Test completed. Education and training for staff on leave, vacation, per diem or registry status will be completed prior to their next scheduled shift, until substantial training compliance is achieved.
• During huddles, Registered Nurse (RN) supervisor's and/or Licensed Vocational Nurses (LVN) on duty; and Department Managers will remind staff that personal cellphones are prohibited in residents care areas. Department managers will assist on monitoring compliance during random rounds utilizing the Compliance Monitoring Quality Assurance (QA) Checklist. The HIPAA Sanctions Policy will be followed if any staff are found not in compliance. The ADM will monitor for compliance.
• The Quality Assurance Quality Assurance and Assessment/Quality Assurance Performance Improvement (QAA/QAPI) Meeting, (attendees: Medical Director (MDR), ADM, DON, DSD, Infection Preventionist (IP), SSD, Director of Community Relations, Dietary Manager, Activities Director (AD), Medical Records, Customer Service, Business Office Manager (BOM), Staffing Coordinator (SC) led by the ADM, addressed Root Cause Analysis and a QAPI for HIPAA, Privacy and 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

The facility failed to ensure a safe and orderly discharge for four residents, leading to incomplete and ineffective discharge planning. Resident 1, who had diagnoses including ALS and dysphagia, was discharged without proper setup of home health services as per the physician's orders. The facility did not document any discharge planning or follow-up calls, and the home health agency did not receive the necessary referral or orders, resulting in a delay in care. Similarly, Resident 2, with a fracture and depression, was discharged without documented discharge planning or follow-up. The facility failed to include the Social Services Director in the Interdisciplinary Team meetings, and there was no documentation of the setup of home health services or medication management. This lack of coordination and documentation was also evident in the cases of Residents 4 and 5, who were discharged without proper planning or follow-up, despite requiring significant assistance with activities of daily living. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of necessary documentation and follow-up procedures. The facility's policy and procedure on discharge planning, which requires a comprehensive discharge summary and post-discharge plan, was not adhered to, resulting in a failure to ensure continuity of care and safety for the discharged residents.

Penalty

Fine: $155,455

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 adequately monitor and document the vital signs of a resident as per physician's orders for several medications, including Amiodarone, Metoprolol, Spironolactone, and Entresto. These medications required specific parameters to be checked, such as apical pulse and blood pressure, before administration. However, there were multiple instances where doses were either held or administered without the necessary vital signs being documented. Additionally, the facility did not notify the physician when vital signs were out of the prescribed range or when medications were held repeatedly. The resident involved had a complex medical history, including acute on chronic systolic cardiac heart failure, paroxysmal atrial fibrillation, essential hypertension, and other cardiac-related conditions. Despite these conditions, the facility administered medications that had severe drug-to-drug interactions without proper monitoring. The electronic health record system alerted staff to these interactions, but there was no evidence that the physician was notified, which could have prevented potential adverse effects. Furthermore, the resident received an excessive dose of Lidoderm patch, with two doses applied on the same day without proper documentation of removal. This oversight, combined with the administration of other medications, led to the resident being discharged to an assisted living facility, where they were pronounced deceased upon arrival. The lack of adherence to medication administration protocols and failure to act on drug interaction alerts contributed to the deficiency identified by the surveyors.

Removal Plan

• Contracted with an outside Pharmacist Consultant to conduct a Medication Regimen Review of residents.
• Contracted with an outside Physician to conduct a medication regimen review of the facility residents.
• Outside contracted Pharmacy Consultant reviewed in-house residents' medication regimen.
• Educated Director of Nursing Services, and Clinical Nurse Resource Consultant on safe medication administration and drug-to-drug interaction alerts.
• Contracted with an outside Nurse Consultant to conduct in-services and complete medication administration observations.
• Director of Nursing Services educated licensed nurses on safe medication administration and adherence to ordered medication parameters.
• Training for licensed nurses on safe medication administration practices using the 10 Rights of administration.
• Medication Pass Competency Assessments completed with Licensed Nurses upon hire.
• New admissions, change-of-condition, and Medication Regimen Reviews conducted through contracted Pharmacy.
• Contracted with an outside Pharmacist Consultant to conduct concurrent Medication Regimen Review.
• Contracted a Medical Records Consultant to conduct concurrent audits with facility Medical Records Director.
• Director of Nursing Services responsible for monitoring Pharmacy compliance of new admission reviews, change of condition, and medication regimen reviews.
• Director of Nursing Services to conduct random med pass observations to monitor compliance with safe medication administration practices.
• Facility Medical Records Director to conduct medication administration record audits of in-house Residents.

Penalty

Fine: $155,455

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

Summary

The facility failed to notify Resident 1's physician of a severe drug-to-drug interaction warning between Amiodarone and Metoprolol Succinate ER. Despite the presence of negative side effects such as bradycardia and hypotension, the facility continued to administer these medications from October 24, 2024, to December 9, 2024. Additionally, the facility did not inform the physician when medications were administered below the ordered parameters or when medications were frequently held due to low blood pressure readings. Resident 1, who was admitted on October 24, 2024, had a medical history that included acute on chronic systolic cardiac heart failure, paroxysmal atrial fibrillation, essential hypertension, and other cardiac-related conditions. The resident's Minimum Data Set indicated moderately impaired cognition and dependence on staff for various activities of daily living. The facility's records showed multiple instances where medication administration orders triggered severe drug-to-drug interaction warnings, yet there was no documentation of physician notification. Interviews with facility staff, including the Director of Staff Development, Licensed Vocational Nurses, and the Director of Nursing, revealed a lack of adherence to protocols for notifying physicians of severe drug interactions and changes in resident conditions. The facility's policies required immediate notification of physicians in such cases, but this was not followed. The Medical Director, who was also Resident 1's physician, confirmed not being informed about the medication issues, highlighting a significant communication breakdown within the facility.

Penalty

Fine: $155,455

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

Summary

The facility failed to ensure that a resident was free from significant medication errors by not adhering to the prescribed medication administration parameters. Specifically, the resident was administered Metoprolol Succinate, Spironolactone, and Entresto despite their systolic blood pressure (SBP) being below the acceptable threshold of 100 mmHg as indicated in the physician's orders. These medications were given on multiple occasions when the resident's SBP was recorded below the specified parameters, which could have led to adverse effects. The resident involved had a complex medical history, including acute on chronic systolic cardiac heart failure, paroxysmal atrial fibrillation, essential hypertension, and other serious cardiac conditions. The resident was admitted to the facility with these diagnoses and had moderately impaired cognition, requiring substantial assistance with daily activities. The medication administration errors occurred despite clear orders to withhold the medications if the resident's SBP was below 100 mmHg. Interviews with facility staff, including the Director of Staff Development, Licensed Vocational Nurses, and the Director of Nursing, revealed a lack of adherence to the facility's policy and procedures for administering medications. Staff acknowledged the importance of checking vital signs before administering medications and admitted to administering the medications outside of the ordered parameters. The facility's policy required medications to be administered safely and as prescribed, with vital signs checked and verified prior to administration, which was not followed in this case.

Penalty

Fine: $155,455

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 complete and accurate medical records for a resident, specifically regarding the administration of several medications. The medications in question included Amiodarone HCL, Metoprolol Succinate, Spironolactone, and Entresto, all of which required specific vital sign parameters to be documented before administration. However, the facility did not consistently document the necessary vital signs, such as apical pulse and blood pressure, leading to doses being held or administered without proper documentation. The resident involved had a complex medical history, including acute on chronic systolic cardiac heart failure, paroxysmal atrial fibrillation, essential hypertension, and other serious cardiac conditions. The resident was dependent on staff for various activities of daily living and had moderately impaired cognition. Despite these needs, the facility's records showed multiple instances where medications were held or given without the required documentation of vital signs, such as apical pulse and blood pressure, which are critical for safe medication administration. Interviews with facility staff, including the Director of Staff Development, Licensed Vocational Nurses, and the Director of Nursing, revealed that there was a lack of adherence to the facility's policies and procedures regarding medication administration and documentation. The staff acknowledged the importance of checking and documenting vital signs before administering medications, especially for residents on multiple blood pressure medications, due to the risk of hypotension and bradycardia. However, the facility's failure to document these vital signs as required by their policies resulted in incomplete medical records and potential risks to the resident's health.

Penalty

Fine: $155,455

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 orderly discharge for a resident by not reassessing vital signs prior to discharge, despite the resident's known history of low blood pressure. The resident, who had multiple complex medical conditions including systolic cardiac heart failure, paroxysmal atrial fibrillation, and essential hypertension, was on several medications that required careful monitoring of blood pressure and pulse. On the day of discharge, the resident was administered multiple blood pressure medications and a Lidoderm patch without a reassessment of vital signs before leaving the facility. The resident's medical records indicated that vital signs were last documented several hours before discharge, and there was no evidence of reassessment before the resident was transported to an alternate living facility. The resident was discharged in a wheelchair and was pronounced deceased upon arrival at the new facility. Interviews with facility staff revealed a lack of awareness regarding the interactions between the resident's medications and the importance of monitoring vital signs, especially when administering multiple antihypertensives and antiarrhythmics. The facility's policy required that vital signs be current upon discharge, but this was not adhered to in this case. Additionally, there was a failure to remove a previously applied Lidoderm patch before applying a new one, which could have contributed to the resident's condition. The pharmacy consultant emphasized the importance of regular medication administration and monitoring to prevent fluctuations in blood pressure and pulse, which was not consistently done for this resident.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive care plans for four residents, leading to potential negative impacts on their care and services. Resident 201, who was admitted with anxiety, insomnia, COPD, and end-stage renal disease, had no care plans for the psychotropic medications prescribed for anxiety and insomnia. Additionally, the care plan for impaired renal function was incomplete, lacking specific reasons for the condition. This oversight was confirmed by a registered nurse who acknowledged the absence of necessary care plans to monitor medication interventions. Resident 28, diagnosed with Alzheimer's disease, Parkinsonism, and dysphagia, was observed with a dry oral cavity and crusty secretions due to mouth breathing. Despite being dependent on staff for oral hygiene, there was no specific care plan addressing these issues. The facility administrator confirmed the resident's condition and the lack of a care plan to manage the oral hygiene and mouth-breathing concerns. Resident 147, with a history of alcohol dependence and spinal stenosis, was identified as a high risk for elopement but lacked a corresponding care plan. The resident left the facility without staff knowledge, carrying luggage, and was later found at a hotel. The facility administrator and staff were unaware of the resident's departure, and no documentation was provided for leaving against medical advice. Lastly, Resident 144, who required bilateral bed siderails for mobility and protection, did not have a care plan or physician's order for their use, as confirmed by a registered nurse. This lack of care planning was contrary to the facility's policy for comprehensive, person-centered care plans.

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 adhere to its medication administration policy for a resident, leading to a deficiency. A Licensed Vocational Nurse (LVN) was observed crushing and mixing multiple medications, including Apixaban, Lisinopril, Vitamin D, and a multivitamin, into a single dose with applesauce. This practice was contrary to the facility's policy, which mandates that crushed medications should be administered separately to ensure proper identification and administration. The resident involved had a history of hemiplegia, type II diabetes, and Parkinson's disease, requiring significant assistance with daily activities. Additionally, the facility did not maintain accurate records for controlled substances, specifically Oxycodone, for another resident. The Medication Administration Records (MAR) did not match the Controlled Drug Record (CDR) or the bubble pack inventory, indicating discrepancies in the administration and documentation of the medication. The resident, who had intact cognitive skills, was prescribed Oxycodone for pain management due to spinal stenosis and low back pain. The LVN admitted to not verifying the bubble pack against the physician's orders, leading to inaccuracies in the narcotic count. The facility's policy on controlled substances requires accurate documentation and reconciliation of medication counts at the end of each shift. However, the failure to follow these procedures resulted in discrepancies between the MAR, CDR, and bubble pack for the resident's Oxycodone medication. This oversight was confirmed during an interview with a Registered Nurse, who acknowledged the inaccuracies and the need for proper documentation and reconciliation of controlled substances as per the facility's 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 ensure proper disposal of expired and open sterile supplies, which included one open sterile intravenous (IV) administration set, eight expired sterile collection swabs, seven expired specimen collection tubes, and ten expired specimen collection kits. During an observation and interview with the Infection Preventionist Nurse (IPN), these expired supplies were found in the medication storage closet. The IPN confirmed the expiration dates and acknowledged that the supplies were not accurate since they were expired. This oversight in maintaining up-to-date supplies could potentially compromise the safety and effectiveness of medications and sterile supplies. Additionally, the facility did not maintain cleanliness and sanitation of medication storage and preparation areas. During an observation with a Licensed Vocational Nurse (LVN), a medication cart was found with medication bottles in a plastic container that had brown and black spots, and a pill cutter with whitish particles. The LVN acknowledged that the medication bottles and pill cutter should be cleaned and sanitized after each use to prevent contamination. The facility's policy and procedures indicated that nursing staff are responsible for maintaining these areas in a clean, safe, and sanitary manner, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that kitchen staff were competent in safe and effective food preparation and handling practices. During an observation, a cooked roast pork was left on the kitchen counter to cool down without proper documentation of the time it was removed from the oven. The cook did not know the correct temperature at which to place the roast in the refrigerator and did not monitor the cool down process as per facility policy. The Dietary Supervisor confirmed that the facility policy required cold food to be held at 41 degrees or lower and that large pieces of meat should be cut into smaller pieces to cool down faster. The roast pork was eventually discarded due to improper handling. Additionally, the facility failed to ensure that the kitchen staff were knowledgeable about the correct concentration of chlorine sanitizer used for cleaning food contact surfaces. During an observation, a cook prepared a sanitizer solution with a concentration of 200 parts per million (PPM), which was above the recommended range of 50-100 PPM. The Dietary Supervisor and Registered Dietitian confirmed that the facility policy required a concentration of 100 PPM for chlorine sanitizer. The incorrect concentration of the sanitizer solution posed a risk of chemical cross-contamination of food. The deficiencies in food handling and sanitizer preparation had the potential to result in unsafe and unsanitary food production, which could lead to foodborne illness among the residents. The facility's failure to adhere to its own policies and procedures for food safety and sanitation was evident in the lack of proper training and monitoring of kitchen staff, as well as the incorrect preparation of sanitizer solutions.

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 adhere to the standardized recipes for the lunch menu on 11/9/2024, specifically for residents on a pureed diet. During an observation of the tray line service, it was noted that four residents on a pureed diet received 1/2 cup of pureed Salisbury steak instead of the prescribed 2/3 cup as per the food portion and serving guide. This discrepancy was due to the cook using a 4 oz. ladle instead of the required #6 scoop, which yields 5 1/3 ounces. This action was confirmed during an interview with Cook2, who acknowledged the error and its potential impact on residents' nutritional intake. The dietary supervisor (DS) emphasized the importance of following the menu and serving guide to ensure residents receive the correct amount of food. The facility's menu and spreadsheet indicated that the pureed Salisbury steak should be served using a #6 scoop, yielding 5 1/2 ounces. The facility's policy on Menu Planning states that menus are designed to meet the nutritional needs of residents in accordance with the most recent recommended dietary allowances. The failure to follow the menu and portion sizes as written had the potential to result in decreased nutritional intake and weight loss for the four residents on a pureed diet.

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 safe and sanitary food storage and preparation practices, which could potentially lead to foodborne illnesses among residents. During an observation, it was found that cut watermelon and cantaloupe stored in the reach-in refrigerator exceeded the recommended storage periods for ready-to-eat food. The fruits appeared wilted and were not discarded in a timely manner, as confirmed by Cook1, who acknowledged that the fruits were old and should have been removed. Additionally, dietary aide 1 (DA1) did not adhere to proper sanitary practices. DA1 was observed cleaning the kitchen, leaving, and then returning without washing hands before handling clean and sanitized dishes. This was confirmed during an interview with DA1 and the Dietary Supervisor (DS), where DA1 admitted to not washing hands properly, potentially contaminating the dishes. Furthermore, DA1 and DA2 were observed using a kitchen towel to dry cooking pots, pans, and utensils instead of allowing them to air dry, which is against the facility's policy and the U.S. Food and Drug Administration Food Code. The facility also failed to monitor the safe cool-down process of previously cooked roast beef. The roast pork was not cooled down within the required time frame, and the temperature was not adequately monitored. Cook1 did not document the time the roast was removed from the oven, and the temperature of the roast pork was not maintained at the required 41 degrees Fahrenheit or lower. The DS confirmed that the facility policy was not followed, and the roast pork was eventually discarded due to improper temperature control.

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 Advance Directive (ACHD) form was accurately documented in both the paper and electronic charts. This deficiency was identified for one resident, who was admitted with diagnoses including degeneration of the nervous system due to alcohol, spinal stenosis, and alcohol dependence with withdrawal. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition for daily decision-making. Despite the resident's Advance Directive Acknowledgement Form stating that an ACHD had been executed, the form also indicated that no advance directive was available or reviewed. During an interview and record review, the Social Services Director (SSD) confirmed that the resident's Advance Directive Acknowledgment Form was inaccurately completed, as the resident did not have an ACHD despite the form indicating otherwise. The SSD acknowledged the error and stated that the form should have been filled out correctly. The facility's policy and procedures require that the social services director or designee inquire about the existence of any written advance directives prior to or upon admission, ensuring that the plan of care aligns with the resident's documented treatment preferences.

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 the use of physical restraints, specifically bilateral bed siderails, without proper consent and physician's order. The resident, who was admitted with conditions including hemiplegia, hemiparesis, diabetes mellitus, and dysphagia, was observed on multiple occasions with the bed siderails raised. Despite the resident's severe cognitive impairment and dependency on staff for daily activities, there was no completed consent form or physician's order documented for the use of these siderails. During an interview, a registered nurse confirmed that the resident had been using the siderails since admission for mobility and protection, but acknowledged the lack of a physician's order and incomplete consent documentation. The facility's policy requires an interdisciplinary evaluation, informed consent, and a physician's order before using bed rails, none of which were adhered to in this case. This oversight had the potential to result in entrapment and injury, as well as a lack of respect and dignity 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 staff failed to document the reason for the discharge of a resident, identified as Resident 41, from the facility. Resident 41 was admitted with diagnoses including a nondisplaced fracture of the anterior wall of the left acetabulum and spinal stenosis. The resident was discharged to a General Acute Care Hospital (GACH 1) due to a problem with his nephrostomy tube. However, there was no documentation in the progress notes or discharge summary indicating the reason for the discharge or the destination of the resident. During an interview, the Director of Nursing (DON) confirmed that there was no documentation regarding Resident 41's discharge to GACH 1 and acknowledged that the resident did not have a proper discharge process. The facility's policy and procedures require sufficient preparation and orientation for residents prior to transfer or discharge, including documentation of the process. This deficiency resulted in incomplete information regarding the reason for Resident 41's transfer to the hospital.

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 notice of bed-hold policy and return form when a resident was transferred to a general acute care hospital (GACH). This deficiency was identified for one of the three sampled residents, who was transferred due to a problem with a nephrostomy tube. The resident's medical record did not contain documentation of a bed-hold notice being provided to the resident or their legal representative at the time of transfer. The resident involved had a history of a nondisplaced fracture of the anterior wall of the left acetabulum and spinal stenosis. The resident's cognitive skills for daily decisions were severely impaired, as indicated by the Minimum Data Set (MDS). Despite the facility's policy requiring written notice of bed-hold policies to be provided at least twice, there was no evidence that this was done for the resident during their transfer to the hospital.

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 the Minimum Data Set (MDS) for a significant change in status within the required time frame for a resident, which is a federally mandated assessment tool. The resident, who was admitted and later readmitted with diagnoses including a nondisplaced fracture of the anterior wall of the left acetabulum and spinal stenosis, was discharged from the facility without proper documentation of a significant change in condition. The resident's cognitive skills for daily decisions were noted to be severely impaired, and there was no documentation of the discharge summary or the reason for discharge in the progress notes. The Director of Nursing (DON) confirmed that the resident was transferred to a General Acute Care Hospital due to a problem with a nephrostomy tube, but there was no documentation regarding this change of condition. The facility's policy and procedures require prompt notification and documentation of changes in a resident's medical or mental condition, which was not adhered to in this case. This lack of documentation and failure to complete the MDS in a timely manner had the potential to negatively affect the provision of necessary care and services to 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 nursing staff failed to revise the care plan for a resident at risk for falls, identified as Resident 24, who experienced falls on two separate occasions. The resident, who was admitted with diagnoses including Parkinsonism, spinal stenosis, and a history of falling, was found on the floor on two occasions, once on 12/3/2023 and again on 8/9/2024. Despite these incidents, the care plan, which was initially created on 12/2/2023, was not revised after the first fall to address the resident's high risk of falls and injury. The care plan was only updated on 11/9/2024, after the second fall, indicating a lack of timely intervention to prevent further incidents. The facility's policy on managing falls and fall risk, revised in January 2024, requires staff to implement additional or different interventions if falls recur, or to document why the current approach remains relevant. However, this policy was not followed, as the care plan was not updated after the first fall. During an interview, a registered nurse acknowledged that the care plan should have been revised following the initial fall to prevent further incidents. This oversight had the potential to place the resident at increased risk for recurrent falls.

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 oral care to two residents, both of whom were dependent on staff for oral hygiene due to severe cognitive impairments and other medical conditions. Resident 20, who had Alzheimer's disease, malnutrition, and required a gastrostomy tube, was observed with a pasty yellow film on her mouth. The facility administrator acknowledged the issue, attributing it to the night shift's lack of oral care. Similarly, Resident 28, who also had Alzheimer's disease and was dependent on a gastrostomy tube, was found with a crusty buildup of yellow-brown dried secretions in his mouth. The administrator noted that the resident's mouth-breathing contributed to the buildup, which should have been addressed by the night shift CNA. During an observation, CNA 3 attempted to provide oral care to Resident 28 but was unable to remove the crusty buildup using an oral sponge and toothbrush. The CNA was unsure if the resident had been seen by a dentist. The facility's policy on mouth care, revised in January 2024, emphasizes the importance of keeping residents' oral tissues moist and preventing oral infections, which was not adhered to in these cases. This lack of proper oral care had the potential to result in infection, illness, and negatively impact the residents' self-esteem and quality of life.

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 supervise a resident, identified as Resident 147, to prevent elopement. The resident, who had a history of alcohol dependence and moderate cognitive impairment, expressed a desire to leave the facility and was observed multiple times carrying luggage and attempting to leave. Despite these clear indications of intent to leave, the facility did not adequately evaluate or analyze the risks of elopement, nor did they take appropriate measures to prevent it. On the day of the incident, the resident was not observed in her room or within the facility during scheduled checks. Interviews with another resident and staff revealed that Resident 147 had left the facility without staff knowledge and walked to a nearby hotel. The facility's administrator later contacted the resident via cellphone, and the Director of Nursing retrieved her. However, the facility did not follow its own policies and procedures for handling such incidents, as there was no documentation of the incident, no examination for injuries, and no incident report filed. The facility's policies require specific actions when a resident is missing or leaves against medical advice (AMA), including notifying relevant parties and documenting the incident. In this case, the facility did not adhere to these protocols, as the resident was not provided with an AMA discharge letter, and the incident was not reported to the state department or surveyors. This lack of adherence to established procedures contributed to the deficiency in ensuring the resident's safety and proper supervision.

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 ensure appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The deficiency was identified when the resident's catheter drainage bag was observed to be placed above the level of the bladder, tied to the moveable side rails of the bed. This placement is contrary to the facility's policy, which requires the drainage bag to be below the bladder to prevent urine backflow and potential infection. The resident involved had a medical history including hemiplegia, hemiparesis, diabetes mellitus, and dysphagia, and was severely impaired in cognition, requiring maximal assistance for daily activities. During an observation, a Licensed Vocational Nurse acknowledged the incorrect placement of the catheter bag and corrected it by tying it to a non-movable frame below the bladder. The facility's policy on catheter-associated urinary tract infections emphasizes maintaining unobstructed urine flow by keeping the drainage bag below the bladder at all times.

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 assess the pain level of a resident, identified as Resident 196, during a medication pass observation. Resident 196 was admitted with diagnoses including spinal stenosis, low back pain, and a disorder of muscle, and required moderate to maximal assistance for activities of daily living. The resident's medication orders included Oxycodone and Tylenol for pain management. During an observation, a Licensed Vocational Nurse (LVN) administered these medications without assessing the resident's pain level beforehand. The LVN admitted to forgetting to assess the pain level prior to administering the medications. A Registered Nurse (RN) confirmed that pain assessment should be conducted before giving pain medications to determine the appropriate interventions. The facility's policy on Pain Assessment and Management, revised in January 2024, outlines the importance of assessing pain, recognizing its presence, and developing appropriate interventions. The policy also emphasizes monitoring the effectiveness of pain management strategies, especially when opioids are used.

Penalty

No penalty information released

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

Summary

The facility failed to administer medications appropriately to two residents, resulting in a medication error rate of 24%. Resident 26, who has diagnoses including hemiplegia, type II diabetes mellitus, and Parkinson's disease, was observed during a medication pass where four medications were crushed and mixed together with applesauce by an LVN. This practice was against the facility's policy, which requires crushed medications to be given separately to ensure each medication is identifiable and to manage potential refusals. Resident 196, diagnosed with spinal stenosis and low back pain, was also involved in a medication administration error. The LVN administered Tylenol and Oxycodone without assessing the resident's pain level beforehand, which is a necessary step according to the facility's pain management policy. This policy outlines the importance of assessing pain to determine the appropriate medication and interventions needed for effective pain management. Interviews with the LVN and an RN confirmed the deviations from the facility's policies. The LVN admitted to not assessing the pain level of Resident 196 and to mixing medications for Resident 26, while the RN emphasized the importance of following the correct procedures for medication administration and pain assessment. The facility's policies clearly state the need for separate administration of crushed medications and thorough pain assessments to ensure proper care and medication effectiveness.

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 routine dental visit for a resident as per the physician's orders dated 9/23/24. The resident, who was admitted with diagnoses including Alzheimer's disease, a disorder of the muscles, Parkinsonism, and dysphagia, was dependent on staff for oral hygiene and other personal care needs. During an observation, the resident was found with a crusty buildup of yellow-brown dried secretions in the oral cavity, which the Certified Nursing Assistant (CNA) was unable to clear using an oral sponge and toothbrush. The CNA was unaware if the resident had been seen by a dentist. Further interviews revealed that the Registered Nurse (RN) and the Social Services Director (SSD) were also unaware of any dental evaluation for the resident, despite the facility having a dentist available to perform all dental services. The facility's policy and procedures indicated that routine and emergency dental services should be available to meet the resident's oral health needs, but this was not adhered to in the case of the resident in question.

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 resident with the correct dietary accommodations as per their documented food preferences and intolerances. Specifically, a resident with lactose intolerance was served regular milk during lunch, despite their meal ticket indicating a preference for lactose-free milk. This oversight was observed during a kitchen inspection where beverages were prepared and marked according to type and consistency. However, the milk served to the resident was not marked, indicating it was regular milk, which was confirmed by the dietary supervisor and dietary aide. The resident, who was admitted with conditions including dysphagia, prediabetes, and severe protein-calorie malnutrition, had a documented intolerance to lactose. The resident and their spouse confirmed that the milk was not consumed due to the lack of labeling, which usually indicated lactose-free milk. The dietary supervisor acknowledged the mistake and confirmed that the wrong milk was served, which could potentially cause the resident to experience stomachaches. The facility's policy on food preferences mandates adherence to residents' dietary needs, but this was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) when providing care to a resident on enhanced barrier precautions. During an observation, a Licensed Vocational Nurse (LVN) was seen entering the room of a resident without donning full PPE. The LVN only wore gloves, did not sanitize hands before putting on new gloves, and moved the resident's foley catheter without wearing a gown. After handling the catheter, the LVN exited the room without sanitizing hands and was still holding the soiled gloves. The resident involved had multiple diagnoses, including hemiplegia, hemiparesis, diabetes mellitus, and dysphagia, and was dependent on staff for activities of daily living. The resident was at high risk for complications due to the use of a foley catheter. The facility's policy on Enhanced Barrier Precautions required the use of gowns and gloves during high-contact activities, such as device care, which was not adhered to by the LVN. This oversight was confirmed by both the LVN and a Registered Nurse (RN), who acknowledged the necessity of full PPE for infection control 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 ensure that the call light was within reach for one of the sampled residents, identified as Resident 199. This deficiency was observed during a visit when Resident 199 was found lying in bed with the call light hanging off the wall behind the bed, making it inaccessible. Resident 199, who was admitted with medical diagnoses including muscle weakness, hypertension, and acute kidney failure, was capable of making decisions regarding daily care and required minimal assistance for activities such as toileting and hygiene. However, during an interview, Resident 199 expressed unawareness of the call light's location and mentioned that she would resort to yelling for help if needed. Further interviews revealed that a Certified Nurse Assistant (CNA) acknowledged the call light was not within reach but considered it acceptable due to frequent checks on residents. The Director of Nursing (DON) stated that call lights should be within easy reach of residents while in bed, and staff were expected to perform room checks to ensure safety and accessibility of call lights. The facility's policy, revised in January 2024, emphasized the importance of ensuring call lights are accessible to residents to facilitate timely responses to their 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 ensure that staff did not use expired N95 masks during a COVID-19 outbreak, which increased the risk of spreading the virus among residents, staff, and visitors. The Central Services Director (CSD) claimed that the facility had adequate PPE supplies, including N95 masks, and had not ordered new masks since the start of the pandemic, believing the existing masks were sufficient. The CSD and other staff members, including the Infection Preventionist (IP) and the Director of Nursing (DON), were aware that the masks had expired but relied on a letter from the manufacturer suggesting that the masks could be used beyond their expiration date. However, the letter explicitly warned against using expired masks. During an inspection of the facility's storage area, it was observed that the only available N95 masks were expired, with no new masks in use. The facility's policy on PPE usage clearly stated that masks should not be used beyond their expiration date, yet this policy was not adhered to. Interviews with the IP and DON revealed that they were assured by the CSD of adequate PPE supplies and were not aware of any supply chain or financial issues that would necessitate the use of expired masks. Despite the manufacturer's warning and the facility's policy, the decision was made not to purchase new masks, leading to the deficiency.

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 assess a resident for cellulitis in the left lower extremity, leading to the resident signing out against medical advice and seeking treatment at a general acute care hospital. The resident, who had a history of recurrent cellulitis, presented with bilateral leg swelling and redness. Despite expressing concerns about the condition of the left leg, the facility only ordered an ultrasound for the right leg, which delayed the diagnosis and treatment of cellulitis. The resident was admitted to the facility with multiple diagnoses, including spinal issues, diabetes, asthma, hypertension, and dysphagia. The resident required maximal assistance with daily activities and had intact cognition. On a specific date, the resident expressed concern about redness and swelling in the left leg, suspecting cellulitis. However, the facility's response was inadequate, as they only ordered a duplex doppler for the right leg, which was not performed until the resident had already decided to leave the facility. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, revealed that there was a lack of proper assessment and documentation regarding the resident's condition. The facility's policy required that any significant change in a resident's condition be assessed and communicated to a physician, but this was not done in a timely manner. The resident's decision to leave the facility and seek care elsewhere was influenced by the lack of prompt assessment and intervention for the suspected cellulitis in the left leg.

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 involve an interdisciplinary team (IDT), the resident, and/or the resident's representative in developing a discharge plan and assisting in selecting a post-acute care provider for a resident. This deficiency led to the resident and their representative being uninformed about the discharge plan, placing the resident at risk of potentially going to a facility that does not meet her needs. The resident, a [AGE] year-old female, was admitted with multiple diagnoses including non-traumatic intracerebral hemorrhage, diabetes mellitus type 2, cirrhosis of the liver, abnormal gait, pressure ulcers, hypertension, anemia, history of falls, glaucoma, and hyperlipidemia. Despite the resident's complex medical needs, the facility did not adequately coordinate her discharge planning process with the necessary parties involved. The facility's Director of Social Services (DSS) failed to follow up with the family member (FM) and other involved parties, leading to confusion and lack of a clear discharge plan. The FM reported that the DSS did not assist with finding a suitable placement for the resident and did not provide necessary information about facilities that accept the Assisted Living Waiver Program (ALWP). The DSS admitted to not being familiar with the ALWP and not following up with the FM or other agencies involved in the resident's discharge planning. The facility's Administrator acknowledged that the DSS should have exhausted all means to find a suitable placement and kept the FM informed. The facility's policy and procedures for discharge planning were not followed, resulting in inadequate discharge planning 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 follow their abuse reporting policy and procedures for one of six sampled residents. Resident 1, who had diagnoses including hypertension, heart failure, COPD, reliance on supplemental oxygen, abnormalities of gait and mobility, and dementia, was alleged to have been abused by some CNAs who reportedly slapped the resident's hand. This incident was reported by the Resident Representative (RR) to Licensed Vocational Nurse (LVN) 1, who then reported it to the Administrator (ADM), the facility's Abuse Prevention Coordinator (APC). However, the ADM did not report the alleged abuse to the state licensing/certification office or the ombudsman as required by the facility's policy and procedures. The facility's policy, dated 1/10/24, mandates that all allegations of abuse be reported immediately to the appropriate agencies, including the state licensing/certification agency, the local/state ombudsman, and local law enforcement. The policy specifies that such reports should be made within two hours of the allegation. Despite this, the ADM did not follow through with the required reporting, stating that the allegation was made out of spite by the RR due to a denied room change. This failure to report the alleged abuse incident resulted in non-compliance with the facility's abuse reporting policy and procedures.

Penalty

No penalty information released

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

Summary

The facility failed to ensure indoor and outdoor visitations for all residents without limitations on frequency and length of visits, as required by federal regulations. This deficiency affected all 33 residents in the facility. Resident 4, who was admitted with acute respiratory failure and pneumonia, reported that her family members could only visit during certain hours, needed to make an appointment, and were limited to one-hour visits. This was confirmed by posted signage and interviews with staff, including the receptionist and the Director of Nursing, who stated that visitations were restricted to between 11 a.m. and 6 p.m. and required appointments. The facility's policy on resident rights, reviewed in October 2023, indicated that residents have the right to communication and access to people and services both inside and outside the facility. However, the facility's current practice of limiting visitation hours and requiring appointments was in direct violation of these rights. The Administrator confirmed that the restricted visitation hours were in place to avoid interference with morning resident care, despite there being no current COVID-19 outbreak in the facility. A review of the Centers for Medicare & Medicaid Services (CMS) Quality, Safety & Oversight (QSO) letter QSO-20-39-NH, revised in May 2023, indicated that facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. The facility's practice of limiting the frequency and length of visits, the number of visitors, and requiring advance scheduling was no longer acceptable following the end of the Public Health Emergency (PHE). This practice violated the residents' rights to unrestricted visitation as mandated by federal 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 a resident's notice of discharge or transfer was provided to the resident and/or the resident's representative, including the right to appeal. Resident 1 was admitted with diagnoses including type II diabetes mellitus, nontraumatic intracerebral hemorrhage, and a history of falling. The Minimum Data Set indicated that Resident 1 had intact cognitive skills for daily decision-making and required moderate to maximal assistance for activities of daily living. Despite this, the Social Services Director (SSD) did not provide the Notice of Medicare Non-Coverage (NOMNC) information to Resident 1 or their family member (FM) in a timely and documented manner. The SSD received the NOMNC letter on 4/26/2024, indicating that coverage for current skilled nursing facility services would end on 4/28/2024. The SSD attempted to inform Resident 1's FM by phone on 4/26/2024 and 4/27/2024 but was unable to make direct contact and left messages instead. The SSD did not provide the NOMNC information to Resident 1 and did not document these attempts in Resident 1's Progress Notes in the Electronic Health Record (EHR). Additionally, the SSD did not send a copy of the NOMNC via mail, as required by the facility's policy and procedure. The facility's policy and procedure titled

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 refer and provide podiatry services as ordered by the physician for a resident with type II diabetes mellitus, nontraumatic intracerebral hemorrhage, and a history of falling. The resident's Minimum Data Set indicated that she required moderate to maximal assistance for activities of daily living. The physician had ordered podiatry services for the treatment of mycotic hypertrophic toenails and other foot problems related to diabetes or vascular disease. Despite this, the resident had not been seen by a podiatrist, leading to discomfort and difficulty in putting on socks due to long, thick, and sharp toenails. During an interview, the resident expressed that she had requested a podiatry appointment but had not been seen by a podiatrist. The Licensed Vocational Nurse (LVN) confirmed the resident's toenails were long and mycotic and noted that the resident also had a heel ulcer, putting her at risk of injury and discomfort. The Social Services Director (SSD) admitted that a referral to the podiatrist had not been sent because the resident's Health Maintenance Organization (HMO) insurance did not cover podiatry services, and the SSD had not inquired if the resident would like to pay for the services out-of-pocket. The Director of Nursing (DON) stated that the physician's order for podiatry services should have been followed up upon receiving the order. The facility's policy and procedures indicated that podiatry services should be provided to residents with diabetes or serious circulatory conditions to maintain mobility and good foot health and prevent complications. The failure to follow the physician's order and provide the necessary podiatry services placed the resident at risk of injury and complications.