Capital Post Acute

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 to follow infection prevention and control practices during wound care for one of three sampled residents. The resident was admitted in February 2026 with a diagnosis of aftercare following joint replacement surgery and had moderate cognitive impairment per an MDS dated 2/16/26. During an observation on 2/26/26 at 10:37 a.m., the resident was lying supine in bed with steri-strips to the left thigh while a licensed nurse performed wound care. The nurse placed wound care supplies directly on the resident’s bed without establishing a separate clean and dirty area, contrary to the facility’s wound care policy that required use of a disposable cloth or paper towel to establish a clean field. During the same observation, the licensed nurse did not perform hand hygiene between glove changes at 10:37 a.m., 10:39 a.m., and 10:41 a.m. The nurse confirmed there was no separate clean and dirty section during the procedure, which increased the potential for the resident to get infections through cross contamination. The Infection Preventionist stated that the expectation was to perform hand hygiene before and after glove changes, sanitize non-dedicated equipment after each use, and maintain separate clean and dirty areas during wound care. The DON similarly stated that staff were expected to perform hand hygiene after each glove change, sanitize equipment after use, and maintain separate clean and dirty areas during wound care, consistent with facility policies on hand hygiene and wound care.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect a resident’s right to be free from physical abuse when one resident struck another. Resident 89, who had intact memory and a history of orthopedic issues and aftercare following a surgical amputation, reported that while standing at the doorway of Resident 35’s room and talking with Resident 35, Resident 61 walked straight toward him and slapped his right hand. Resident 89 stated that Resident 61 was angry and verbally threatened to hurt him and “kick [his] butt.” A progress note documented that a CNA present at the time reported Resident 89 extended his hand outward in front of him as Resident 61 was walking down the hallway toward him, and that Resident 61 made contact with and hit Resident 89’s right hand. Resident 61’s record showed diagnoses of cerebral infarction and vascular dementia with behavioral disturbance, and an MDS indicating severe memory problems. Resident 35, who had intact memory and a diagnosis of central cord syndrome at the C4 level, corroborated the incident, stating he witnessed Resident 61 raise his right hand and slap Resident 89’s right hand while angrily yelling that he was going to hurt him and kick his butt. A signed note by CNA 6 further indicated that Resident 89 stretched out his hands and told Resident 61 to go back, after which Resident 61 became angry, started cursing, and hit Resident 89. The Administrator confirmed that residents have the right to be free from any form of abuse, and the facility’s Resident Rights policy stated residents must be free from abuse, neglect, misappropriation, exploitation, corporal punishment, involuntary seclusion, and retaliation.

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 adequate supervision and implement effective fall-prevention interventions for a cognitively impaired resident with a known history of falls. The resident was admitted with dementia, schizophrenia, and seizures, was nonverbal or minimally verbal, and required extensive assistance with ADLs, including two-person assistance for dressing, bathing, toileting hygiene, and toilet transfers, and one-person assistance for transfers and standing. An MDS dated 1/6/26 documented severely impaired decision-making and that the resident was rarely or never understood. A physician progress note on the same date described the resident as nonverbal, minimally interactive, lacking capacity for informed consent, and having a history of falls, requiring assistance for ADLs, feeding, and mobility. On 1/4/26, the resident experienced a fall in the room after staff heard the roommate yell “Man down!” and found the resident on the floor next to the bed with discoloration to the right forehead. The care plan entry for that fall stated there was an actual fall with no injury, which conflicted with the progress note documenting discoloration to the forehead. The DON acknowledged this discrepancy and stated the progress note could be expanded but reported that no staff or residents were interviewed to investigate the fall and no additional steps were taken to identify, monitor, or prevent future falls. The care plan dated 1/4/26 was updated only to include monitoring and reporting for 72 hours for signs and symptoms such as pain, bruises, or changes in mental status, and did not include any new fall-prevention interventions. An IDT fall review dated 1/6/26 listed “sent to hospital for eval” as a new intervention, which contradicted the medical record that did not show a hospital transfer on 1/4/26. On 1/10/26, the resident had another unwitnessed fall documented in a progress note as having no visible injuries. However, an IDT fall form dated 1/12/26 described a nurse witnessing the resident roll to the right side of the bed, fall out of bed, collide the head with the roommate’s bed, lose consciousness for 20 seconds, and have active bleeding from the right forehead, after which the resident was transferred to the emergency department. Prehospital and ED records from that date documented a one-inch laceration above the right eye and a small right frontal abrasion with wound irrigation and dressing. The IDT fall form dated 1/12/26 listed “fall mats and lower bed” and “transfer to acute” as new interventions, but the care plan did not reflect fall mats, and the fall-prevention interventions added to the care plan on 1/10/26 (anticipating needs, educating the resident about safety, and PT evaluation) were already present in the admission care plan dated 12/31/25. The DON stated the falls on 1/10/26 were reviewed by the IDT after the weekend and that interventions were evaluated when the resident was transferred to the hospital and upon return, but did not identify any other steps taken to identify, monitor, or prevent future falls, and stated the resident had not sustained injuries from the 1/10/26 falls, which conflicted with ED and IDT documentation. On 1/13/26, the resident sustained another fall in the shared bathroom. Staff interviews indicated that a CNA and an LN responded after hearing the roommate scream for help and found the resident on the bathroom floor, confused and with difficulty communicating. The cognitively intact roommate reported seeing the resident standing in the shared bathroom, then tripping and falling forward, hitting his head on the door, then falling backward and hitting the back of his head, followed by shaking on the floor. EMS documentation recorded that staff reported the roommate had heard a loud bang in the bathroom, found the resident on the floor, and that the resident was on blood thinners with a bump to the back of the head and an old bump above the right eye from a prior fall. Hospital trauma and orthopedic records from the subsequent admission documented an acute distal right clavicle fracture with tenderness over the fracture site and a hospitalization from 1/13/26 to 1/17/26 for a fall with a right clavicle fracture and non–weight-bearing status to the right upper extremity. The care plan revised on 1/13/26 indicated no injuries from the 1/13/26 fall, contradicting the hospital records. The DON stated there were no witnesses to the fall and that she did not investigate further or speak with any staff or residents about the fall. Throughout these events, facility policies on falls and comprehensive assessments, which required ongoing evaluation of causes of falls, documentation of appropriate interventions to prevent future falls, and monitoring and documentation of responses to interventions, were not followed as evidenced by the lack of new, implemented, and consistently documented fall-prevention measures after repeated falls and injuries.

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 Certified Nursing Assistant (CNA) physically abused a resident by striking them on the head and directing two student witnesses to physically restrain the resident during care. The incident was observed by two students who were assisting with the resident's care and later reported the abuse to their instructor and facility staff. The CNA instructed the students to hold the resident's arms and legs, claiming the resident was aggressive, and then proceeded to hit the resident on the forehead with an open hand. The resident involved had a history of traumatic hemorrhage of the cerebrum, dementia, and muscle weakness, and was assessed as having moderate cognitive impairment, requiring additional support for daily living tasks. During the incident, the resident was being changed and was unable to provide an account of the event when later interviewed. Both student witnesses confirmed that they were told by the CNA to restrain the resident, and both expressed discomfort with the situation, stating that they had received abuse prevention training and recognized the actions as inappropriate. Interviews with facility leadership, including the Director of Staff Development (DSD) and Director of Nursing (DON), confirmed that the CNA's actions were reported and that the facility does not have a policy permitting the restraint of residents. The facility's abuse prevention policy explicitly prohibits all forms of abuse, including physical abuse and the use of restraints. Documentation in the CNA's personnel file indicated an admission to restraining the resident during care.

Penalty

No penalty information released

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

Summary

Facility staff failed to protect a resident from abuse when another resident threw a dessert cup, striking the resident in the right eye during a hostile argument. Multiple staff and residents confirmed that the aggressor had a history of making verbal threats and had previously threatened to physically harm the victim. The incident occurred in a hallway while staff were attempting to separate the two residents during a verbal altercation. The resident who was struck reported feeling unsafe in the facility as a result of these ongoing threats and the physical altercation. Both residents involved had intact cognitive function as indicated by their BIMS scores. The resident who was struck had a history of major depressive disorder and bilateral below-the-knee amputation, while the aggressor had diagnoses including depression, anxiety disorder, and psychoactive substance abuse. Care plans for both residents noted potential for aggressive behavior, but the Director of Nursing and Administrator were unaware of the ongoing tension between the two residents. The facility's abuse prevention policy required staff to report any risks of abuse, but the ongoing threats and altercation were not effectively addressed prior to the incident.

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 resident with spinal cord disease and post-traumatic stress disorder, who was cognitively intact and dependent on staff for emotional, intellectual, physical, and social needs, experienced a lack of respect and dignity from a Certified Nursing Assistant (CNA). The resident, who had difficulty hearing, reported that the CNA entered her room, ignored her question, and then began yelling and waving her arms above her head. The resident expressed feeling embarrassed, afraid, and unable to understand the CNA due to her hearing impairment. Another staff member had to intervene and remove the CNA from the room. Multiple interviews corroborated the resident's account, including statements from another resident, a family member, a licensed nurse, and the Director of Nursing (DON). The family member noted that staff failed to use the available whiteboard to communicate with the resident, despite her hearing difficulties. The licensed nurse confirmed that the CNA was defensive and yelled at the resident when asked to provide assistance. The DON acknowledged awareness of the incident and admitted that the facility did not follow up on the resident's psychosocial or emotional needs. The facility's policy on communication and respect and dignity was requested but not provided.

Plan Of Correction

F557: Respect and Dignity 1. Immediate Corrective Action for the Identified Deficient Practice: The resident(s) involved in the identified incident were immediately assessed to ensure their physical and emotional well-being. Staff members involved were counseled and re-educated on residents' rights related to respect and dignity. 2. Measures to Identify Other Residents Potentially Affected: No other residents were affected by this deficient practice. 3. Systemic Changes to Prevent Recurrence: • All staff will receive in-service training on Residents' Rights, with a focus on respect, dignity, communication, and sensitivity. Ongoing education will be added to the facility's annual training schedule and orientation for all new hires. • Social Services and Department Heads will incorporate random resident interviews into weekly rounds to monitor staff-resident interactions and ensure dignity is preserved. 4. Monitoring to Ensure Sustained Compliance: • The Administrator or designee will conduct monthly audits of resident interactions on all shifts for the next 6 months using a standardized Respect & Dignity Observation Tool. • Any issues identified will be brought to the Quality Assurance and Performance Improvement (QAPI) committee for review and action planning. • Results of the audits and interviews will be tracked, trended, and reviewed at quarterly QAPI meetings. 5. Completion Date: May 18, 2025 F 557

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

Staff failed to follow infection prevention and control practices by not wearing gowns when providing high-contact care to three residents who were on Enhanced Barrier Precautions (EBP) due to multidrug-resistant organism (MDRO) colonization or infection. Observations revealed that staff, including a Certified Occupational Therapy Assistant, a Certified Nursing Assistant, and a Restorative Nursing Assistant, wore gloves but did not don gowns while performing activities such as transferring, changing briefs, and providing therapy or bed mobility assistance. These actions were in direct contradiction to posted EBP signage, physician orders, and the facility's own policy, all of which required both gloves and gowns for high-contact care activities for residents on EBP. The first resident involved had a history of MRSA colonization and was cognitively intact. Despite clear medical orders and posted EBP signage, the therapy staff assisting this resident with daily transfers and exercises consistently wore gloves but never a gown. The second resident, who was severely cognitively impaired and had a history of MDRO in the urine, was observed being transferred and having a brief changed by a CNA who also wore gloves but not a gown. The CNA acknowledged awareness of the requirement but did not comply during the observed care. The third resident, with a history of MRSA wound infection and cellulitis, was assisted by a restorative nursing assistant who transferred the resident's legs and provided bed mobility without wearing a gown, despite the resident's EBP status and relevant physician orders. Both the Infection Preventionist and the Director of Nursing confirmed during interviews that staff were expected to wear both gloves and gowns for high-contact activities with residents on EBP, as indicated by facility policy and CDC guidance. The facility's policy specifically listed activities such as transferring, changing briefs, and providing bed mobility as requiring gown and glove use for residents on EBP.

Plan Of Correction

F880 How corrective action will be accomplished for those residents found to have been affected by the deficient practice. The Infection Preventionist (IP) immediately addressed the deficient practices, including in-services and monitoring to ensure that all isolation precautions were being followed. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. The facility audit concluded that no additional employees were affected. What measures will be put into place or what systemic changes will the facility make to ensure deficient practices do not reoccur? Policy Review and Update: The facility's infection prevention and control policies were reviewed and updated to align with current CDC and CMS guidelines. Staff Education: All staff received mandatory re-education on: • Proper donning and doffing of PPE • Hand hygiene protocols • Room entry/exit infection control practices • Use of transmission-based precautions PPE Stations: All isolation rooms were checked to ensure proper PPE supply. Additional wall-mounted PPE stations were installed where needed. Infection Prevention Rounds: The IP will conduct daily infection control rounds on all shifts for 4 weeks, and weekly thereafter for 3 months. How does the facility plan to monitor its performance to make sure solutions are sustained? The IP or designee will conduct random staff observations during all shifts, using a standardized infection control audit tool. A minimum of 10 observations per week will be logged for 12 weeks. Findings will be reported to the QAPI Committee quarterly. Any deficiencies identified during observations will be addressed immediately with on-the-spot correction and re-education. A quarterly Infection Control Self-Assessment will be completed and reviewed during QAPI. Completion Date: May 8, 2025 PPE Stations: All isolation rooms were checked to ensure proper PPE supply. Additional wall-mounted PPE stations were installed where needed. Infection Prevention Rounds: The IP will conduct daily infection control rounds on all shifts for 4 weeks, and weekly thereafter for 3 months. How does the facility plan to monitor its performance to make sure solutions are sustained? The IP or designee will conduct random staff observations during all shifts, using a standardized infection control audit tool. A minimum of 10 observations per week will be logged for 12 weeks. Findings will be reported to the QAPI Committee quarterly. Any deficiencies identified during observations will be addressed immediately with on-the-spot correction and re-education. A quarterly Infection Control Self-Assessment will be completed and reviewed during QAPI. Completion Date: May 8, 2025

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 the facility failed to report an allegation of abuse involving one resident to the State Survey Agency as required by federal regulations. The incident involved a resident who reported being threatened by another resident. The resident's family member also contacted the facility, expressing concern and threatening to call emergency services if the situation was not addressed. The facility responded by moving the resident to another room for comfort and safety, and the incident was communicated to the management team and the Director of Nursing (DON). Despite the internal response, the incident was not reported to the State Survey Agency. During interviews, the Administrator acknowledged that the incident should have been reported, and the DON confirmed that the event was not escalated beyond internal management. The facility's own policy and the signed employee attestation required prompt reporting of any reasonable suspicion of abuse to the appropriate authorities, but this protocol was not followed in this case. Both residents involved were cognitively intact at the time of the incident, as indicated by their BIMS scores. The failure to report the allegation of abuse, as required by both federal regulation and facility policy, was confirmed through record review and staff interviews. The deficiency was identified during a review of documentation and interviews with facility leadership, who admitted the reporting process was not completed as required.

Plan Of Correction

How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. The facility audit concluded that no additional employees were affected. What measures will be put into place or what systemic changes will the facility make to ensure deficient practices do not reoccur? Policy Review and Training: The facility's Abuse Prevention and Reporting Policy was reviewed with a focus on the reporting timeline (within 2 hours for abuse involving serious bodily injury, and within 24 hours for all other allegations). Staff Re-Education: All staff—including licensed nurses, CNAs, and department heads—were in-serviced on mandatory reporting obligations per F609 and the internal reporting protocol. Chain of Reporting Tools: Abuse reporting binders were reviewed for accuracy. How does the facility plan to monitor its performance to make sure solutions are sustained? The Administrator or designee will audit all incident reports and grievances weekly for 12 weeks to ensure any allegation of abuse, neglect, or mistreatment is properly reported within regulatory timelines. Results of audits will be reviewed quarterly during the QAPI meeting and corrective actions taken if patterns are noted. Completion Date: May 8, 2025 F 609 F 609

Penalty

No penalty information released

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

Summary

The facility failed to ensure the security of medications for a census of 118 residents when a medication/treatment cart was found unlocked and unattended in the front lobby. During an observation, the cart was seen against the wall with prescription medications inside, posing a risk of unauthorized access. A licensed nurse confirmed the cart was unlocked and acknowledged that it should always be locked when not in use. The Director of Nursing also stated that all medication and treatment carts with prescribed medications should be locked when unattended for safety. The facility's policy and procedure on medication storage, dated March 1, 2023, mandates that all drugs and biologicals be stored in locked compartments.

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 storage, handling, labeling, and delivery of respiratory care and equipment for three residents. Resident 105's nebulizer mask and tubing set were left uncovered on the bedside drawer and were not changed after 72 hours, contrary to the facility's policy. This oversight was confirmed by a licensed nurse who acknowledged the equipment should be placed in a bag when not in use and changed every 72 hours to prevent contamination and ensure infection control. Similarly, Resident 23's nebulizer mask and tubing set were also left uncovered on the bedside drawer. The resident confirmed the equipment was last used the previous day, and a CNA admitted they were not informed about the need to store the equipment in a bag. The facility's infection preventionist and director of nursing both stated that the equipment should be stored in an antimicrobial bag and changed weekly, highlighting a discrepancy between practice and policy. For Resident 88, the physician's order for oxygen therapy was not followed, as the oxygen flow rate was set at 4 liters per minute instead of the prescribed 2 liters per minute. Additionally, the nasal cannula and humidifier bottle were not labeled with the date of first use, which is necessary for infection control and timely replacement. This was confirmed by both a licensed nurse and the infection preventionist, who emphasized the importance of labeling to ensure regular changes of the equipment.

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 pharmaceutical services for its residents, as evidenced by several deficiencies observed during a survey. Hazardous medications were stored in medication carts without appropriate warning labels, leading to unsafe handling by nursing staff. For instance, a nurse was observed crushing finasteride, a hazardous medication, with bare hands due to the absence of handling instructions on the medication label and the Medication Administration Record (MAR). Additionally, other hazardous medications like Valproic Acid and Anastrozole were found without proper hazardous labeling, which could have prompted the use of personal protective equipment (PPE) by the staff. The facility also failed to manage its Emergency Kits (Ekit) properly. Both oral and injectable medication Ekits were found opened and not replaced in a timely manner, as required by the facility's policy. The staff did not notify the pharmacy to replace the kits within the stipulated 72 hours after use, which could potentially delay urgent medication needs for residents. Furthermore, the facility did not maintain proper accountability for medication deliveries, as delivery manifests were not signed by licensed staff, and there was no clear process for verifying medication deliveries against the manifest. There were also significant issues with the documentation and destruction of medications. Non-controlled prescription drugs were not consistently co-signed by two licensed staff during destruction, and the controlled drug destruction log lacked a clear chain of custody and final destruction information. Additionally, discrepancies were found in the documentation of controlled drug use for two residents. The Controlled Drug Record (CDR) and MAR did not reconcile, indicating potential inaccuracies in medication administration records, which could lead to drug diversion. These documentation lapses were confirmed by the Director of Nursing and the Consultant Pharmacist, highlighting a lack of accountability and potential risk of medication theft.

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 dishes and utensils were cleaned in a sanitary condition, which had the potential for foodborne illnesses. During an interview with the Dietary Manager (DM), it was confirmed that the facility used a low temperature dishwasher. An observation revealed that the dishwasher had a yellow sign indicating it was a Low Temperature Dishwasher. When the Dietary Aide (DA) 1 checked the dishwasher's sanitizing solution using a chlorine test strip, it showed less than 10 parts per million (ppm), which was below the required 50 ppm. The DM confirmed that the chemical strip should have indicated a dark purple color, representing 50 ppm. Further investigation into the facility's records showed that there was no documentation of the dishwasher's chemical solution being tested and recorded at least once per shift, as required. The facility's policy and procedure titled "Dishwasher Policy" dated 3/1/23 stated that dishes and utensils must be cleaned under sanitary conditions with adequate dishwasher temperatures. For low temperature dishwashers, the sanitizing solution should be 50 ppm hypochlorite (chlorine) on the dish surface in the final rinse. The policy also required that chemical solutions be maintained at the correct concentration based on periodic testing, at least once per shift, and results should be recorded. However, these procedures were not followed, 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 maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the improper cleaning and sanitization of shared glucometers. Licensed Nurse (LN) 6 was observed using an alcohol prep pad instead of the required Medline Micro-Kill Germicidal Wipes to clean a shared glucometer after use. This practice was against the facility's policy and the manufacturer's instructions, which specified the use of germicidal wipes to prevent the transmission of blood-borne pathogens. The Infection Preventionist and the Director of Nursing (DON) both confirmed that alcohol wipes were not appropriate for disinfecting glucometers, highlighting a concern for potential cross-contamination. Another deficiency involved the cleanliness of the residents' personal items delivery cart. During an observation, the cart was found to have a thick layer of dust on its tray, which was confirmed by both the Laundry Staff and Central Supply. The Laundry Supervisor acknowledged that the cart should be cleaned daily to prevent contamination of clean clothes. The facility's policy emphasized the importance of handling and transporting clean linen in a manner that prevents contamination, yet this was not adhered to, posing a risk of exposing residents to dust and germs. Additionally, the facility did not follow safe infection prevention practices during care provided to Resident 82, who required tube feeding and medication administration in a room marked as Enhanced Barrier Precaution (EBP). LN 6 administered medication without wearing a protective gown, despite the room's EBP status requiring gown and glove use for high-contact activities. The DON confirmed that staff should adhere to guidelines for using protective equipment in such situations. These failures collectively increased the risk of cross-contamination and potential exposure to infections among residents, staff, and visitors.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the confidentiality of a resident's personal and medical records, as observed during a survey. A computer screen displaying a resident's photo, complete name, medical record number, current room and bed number, gender, date of birth, age, attending physician, and other pertinent personal and medical information was left unsecured and unattended on top of a treatment cart near the nurse's station and facility lobby. This lapse in security was witnessed by multiple staff and residents passing by, and the computer screen was facing the facility lobby, making the information easily accessible to unauthorized individuals. During an interview, a Physical Therapy Assistant confirmed the observation and acknowledged that the computer should have been closed or covered to protect the resident's confidential information. The Director of Nursing also confirmed that leaving the resident's personal and medical records unattended constituted a violation of HIPAA regulations. The facility's policy and procedure documents, dated 7/1/23 and 6/1/24, respectively, emphasize the importance of maintaining the confidentiality of residents' personal and medical records, highlighting the facility's failure to adhere to 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

The facility failed to maintain a safe, comfortable, and homelike environment for a resident when a hole was observed in the wall of the resident's room. The resident, who was admitted to the facility with diagnoses including a stroke, hemiplegia, and aphasia, was found to be cognitively intact with a Brief Interview for Mental Status score of 14 out of 15. During an observation, a six inch by 12 inch hole in the drywall with exposed plumbing was noted approximately two feet above the floor below the television in the resident's room. The resident indicated that the hole in the wall was bothersome. The facility's administrator confirmed the presence of the hole and acknowledged that it should have been repaired. The facility's policy on providing a safe and homelike environment, dated June 1, 2023, emphasizes the importance of maintaining a physical layout that does not pose a safety risk and allows residents to receive care and services safely.

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 an accurate assessment of a resident's status, leading to a deficiency in care. Resident 112, who was admitted with diagnoses including surgical aftercare and chronic obstructive pulmonary disease, was inaccurately documented in the Minimum Data Set (MDS) as having an unplanned discharge to a short-term general hospital. However, the resident had actually decided to go home against medical advice (AMA) on the same date. This discrepancy was confirmed during an interview with the MDS Coordinator Assistant, who acknowledged that the MDS should have been coded to reflect a discharge to home/community. The facility's policy on conducting accurate resident assessments emphasizes the importance of documenting the resident's status accurately at the time of assessment. Despite this policy, the MDS for Resident 112 was not updated to reflect the correct discharge status, which was confirmed by a review of the resident's progress notes and the AMA release form. This oversight had the potential to lead to inaccurate care for the resident, as the assessment did not accurately reflect the resident's decision to leave the facility against medical advice.

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 a comprehensive person-centered care plan for a resident, identified as Resident 105, specifically regarding their respiratory care and nebulizer treatment. Resident 105 was admitted in October 2024 with multiple diagnoses, including parkinsonism, asthma, dementia, and schizophrenia. The resident's Minimum Data Set (MDS) indicated moderately impaired cognition and issues with breathing when lying flat. Despite a physician's order for Ipratropium-Albuterol Solution via nebulizer four times a day for asthma, there was no corresponding care plan developed for this treatment. During an interview and record review, a Licensed Nurse confirmed the absence of a respiratory care and nebulizer treatment care plan for Resident 105, acknowledging that it should have been included in the care plan. The Director of Nursing also stated that such a care plan was expected to guide nurses in providing appropriate care. The facility's policy on care plan revisions emphasized the need for comprehensive care plans that include resident-specific interventions to maintain the resident's highest practicable well-being, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure consistent quality control for glucometer devices and proper nursing care practices for a resident with a feeding tube. The glucometer quality control records were incomplete and inconsistent, with missing documentation for several months. The Director of Nursing (DON) acknowledged that the night shift staff were responsible for performing quality control checks, and the Director of Staff Development and DON were responsible for verifying documentation. The facility's policy required calibration checks to be performed according to the manufacturer's instructions, which were not consistently followed. Additionally, during a medication administration observation, a nurse did not follow orders for checking feeding tube residuals and did not elevate the resident's head during medication administration. The resident's medical record indicated that residuals should be checked before feeding and medication administration, and the head of the bed should be elevated during these times. The nurse admitted to not following these orders, which could contribute to unsafe care. The DON confirmed that staff should adhere to the facility's policy and physician's orders.

Penalty

No penalty information released

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

Summary

The facility failed to provide treatment and care in accordance with professional standards of practice and its own policy and procedure for one resident, identified as Resident 29. Resident 29 was admitted with a diagnosis of dysphagia and had a G-Tube for nutrition and medication administration. A physician's order dated 5/10/24 required the G-Tube insertion site to be cleansed daily with normal sterile saline, patted dry, covered with gauze or an abdominal pad, and monitored for signs and symptoms of worsening. However, during an observation and interview on 11/6/24, it was noted that the G-Tube insertion site lacked the required gauze or abdominal pad, which was confirmed by Licensed Nurse 1 as a deviation from the physician's order. The facility's policy titled 'Provision of Physician Ordered Services' emphasized the importance of providing services according to professional standards of quality, which was not adhered to in this instance. Additionally, the facility's 'Care and Treatment of Feeding Tube Policy' outlined the necessity of using feeding tubes in line with current clinical standards to prevent complications. The failure to follow these policies and the physician's order had the potential to lead to an infection at the G-Tube insertion site and hinder Resident 29 from achieving their highest practicable 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 provide pressure ulcer care and treatment consistent with professional standards and its own policies for a resident with a stage 4 pressure ulcer. The resident, who was admitted in March 2023, had a diagnosis of a stage 4 pressure ulcer in the sacral region, along with severe malnutrition and muscle weakness. The resident's cognitive assessment indicated intact cognition, and the resident was at risk of developing further pressure ulcers. The resident's treatment plan included cleansing the ulcer with normal saline and Vashe, applying collagen and Opticell AG, and covering it with a foam dressing. During an observation, a treatment nurse applied the ordered treatment but failed to label the dressing with her initials and the date, which was confirmed by the nurse. Interviews with another treatment nurse, the infection preventionist, and the director of nursing revealed that labeling wound dressings with initials and dates is expected to ensure the treatment was completed and to prevent infection. The facility's policy on clean dressing changes also required securing the dressing with initials and the date, which 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 adhere to a physician's order regarding the care of a feeding tube for a resident, identified as Resident 107. The resident, who was admitted in October 2024, had medical conditions including Type 2 Diabetes and Dysphagia, and required assistance with personal care. The physician's order specified that the resident should receive a water flush of 200ml every 4 hours. However, during an observation, it was noted that the kangaroo epump was programmed to deliver 150ml every 6 hours, which did not match the physician's order. This discrepancy was confirmed by a licensed nurse during an interview, who acknowledged that the resident was receiving less fluid than prescribed. The Director of Nursing stated that the expectation was for nurses to follow the physician's orders, which should be reflected in the pump settings and water flush bag. A review of the facility's policy on feeding tube care indicated that feeding tubes should be used according to physician orders, including the volume and frequency of flushes. The failure to follow the physician's order placed Resident 107 at risk of receiving incorrect amounts of water flushes, potentially affecting their hydration and nutrition.

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 meet the medically related social services needs of a resident, identified as Resident 94, by not clarifying the date of her cranioplasty surgery with her primary physician. Resident 94, who was admitted to the facility with diagnoses including cerebral infarction, dysphagia, and depression, had a moderately impaired cognitive function as indicated by a BIMS score of 12 out of 15. After an appointment with her physician, Resident 94 and her husband returned to the facility with paperwork and a surgical kit prep, which was given to the nurse and kept in the medication room. Despite reminders from Resident 94 and her husband to the nursing and social services staff to follow up with the clinic regarding the surgery date, no action was taken. Interviews with the nursing and social services staff confirmed that they were aware of the need to follow up on the surgery date but failed to do so. The Director of Nursing expressed that the expectation was for the social services staff to clarify the surgery date and the reason for the surgical kit prep. The progress notes from August 2024 indicated that Resident 94 had a neurosurgery appointment and returned in stable condition, but no new orders were given, and the surgery was not scheduled at that time. The facility's job description for social services emphasized the responsibility to meet the medically related emotional and social needs of residents, which was not fulfilled in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 8.11%, which is above the acceptable threshold of 5%. This was observed during medication administration to two residents, where three errors occurred out of 37 opportunities. One error involved a Licensed Nurse (LN 3) administering a liquid inhalation medication, DuoNeb, to a resident after it had been removed from its foil pouch for more than two weeks, contrary to the product's labeling instructions. LN 3 admitted to not realizing the labeling requirement for the medication. Another error involved LN 3 crushing medications for a different resident without using gloves and without adhering to guidelines for medications that should not be crushed. Specifically, LN 3 crushed enteric-coated aspirin and finasteride, a hazardous drug, without realizing the risks involved. The Director of Nursing (DON) stated that staff were trained to follow computer prompts and could use online resources or drug books if unfamiliar with a medication. However, the Medication Administration Record did not provide warnings about non-crushable or hazardous drugs, contributing to the errors.

Penalty

No penalty information released

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

Summary

The facility failed to maintain safe medication storage practices in both the medication room and medication carts. In the Back Station medication room, expired, unlabeled, and undated medications were found, including an Osmolite bottle past its expiration date, an Omeprazole liquid bottle that was not discarded after 30 days as required, and an undated Aplisol Tuberculin Purified Protein vial. Additionally, an outdated influenza vaccine was found, and a staff drink bottle was improperly stored in the medication refrigerator. Two IV bags of Lactated Ringer's solution were also found without resident-specific labels. On Medication Cart #2, a pill cutter contained a pill and white powder, indicating improper cleaning and storage. A Pro-Stat AWC bottle had visible yellow/orange streaks, suggesting it was not properly wiped down after use. Hazardous medications were stored without proper labeling or instructions for safe handling on Medication Carts #1 and #4, including a bottle of Depakene and a bubble pack of Arimidex. Inhalation products like Ipratropium Bromide and Albuterol Sulfate were not dated or used within the recommended timeframe after being removed from their packaging. The Director of Nursing acknowledged these issues, stating that outdated medications should be removed from active storage and that products should be dated when opened. The facility's policy indicated that medications should be stored according to manufacturer recommendations and regularly inspected for expiration or deterioration. However, these practices were not consistently followed, leading to the deficiencies observed during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accurate documentation of a resident's diagnosis in the medical records, which may contribute to unsafe care and treatment. The deficiency was identified during interviews and record reviews involving the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The medical records of a resident, referred to as Resident 100, contained inconsistent and inaccurate documentation regarding the diagnosis for the use of the psychotropic medication olanzapine. The Discharge Summary indicated a history of dementia, heart disease, and bedsore infection, with olanzapine prescribed for dementia-related behavior. However, the Nursing Weekly Summary Review inaccurately included bipolar disorder as a diagnosis, which the ADON could not verify. Further discrepancies were noted in the Psychotropic Medication Consent document, which listed anxiety and bipolar disorder as indications for olanzapine, despite the ADON acknowledging these were incorrect. The Medical Doctor (MD 2) interviewed stated that the nursing staff should follow the documented diagnosis written by the medical provider, and the DON confirmed the use of bipolar indications was an error. The facility's policy on psychotropic medication use requires a comprehensive assessment and accurate documentation by the physician, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to protect two residents from verbal and physical abuse. Resident 1, who has schizophrenia and major depressive disorder, was known for shouting racial slurs, including the N-word, in the hallway. Despite having a care plan in place to manage his verbally aggressive behavior, the facility did not effectively intervene to prevent these outbursts. Resident 2, who also has major depressive disorder and a history of poor impulse control, became frustrated with Resident 1's repeated use of racial slurs. This frustration culminated in an incident where Resident 2 slapped Resident 1 in the face after being provoked by the racial slurs. The incident was witnessed by staff members, including a CNA who observed Resident 2 tapping Resident 1's cheek after being provoked. Interviews with other residents and staff confirmed that Resident 1's behavior was a regular occurrence and that the facility staff had not taken adequate steps to address it. The facility's policy on reporting allegations of abuse and neglect was not effectively implemented, as evidenced by the lack of intervention to prevent the verbal and physical altercation between the residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medications were stored securely, as required by their policy and professional standards. During an observation, two bags containing approximately 30-40 bottles and boxes of medications were found on top of an unlocked cabinet in the Director of Nursing's (DON) office. The office door was open and unlocked, and the DON was not present. A female staff member was seen entering the office, and other staff members were walking in the hallway nearby. Additionally, a resident's room with three residents was located in front of the DON's office. The DON confirmed that the medications should have been stored in a locked compartment or room to prevent access by residents or staff, acknowledging the risk of medication misuse or drug diversion.

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 meet professional standards of practice for a resident when the nasal cannula used for oxygen delivery was not labeled with an open date and the replacement schedule was longer than the facility's policy indicated. The resident, who had diagnoses including cirrhosis of the liver, diabetes, and chronic respiratory failure, was observed with a nasal cannula that lacked a label indicating when it was last changed. The resident mentioned that the nasal cannula was changed once every one or two months, which is inconsistent with the facility's policy of changing it every seven days. During an observation and interview, the Infection Preventionist confirmed that the nasal cannula did not have a label and that the tubing should not touch the floor. The Infection Preventionist also confirmed that the facility's policy required oxygen tubing to be changed every seven days, while the resident's order called for changes every 28 days. This discrepancy between the facility's policy and the resident's order increased the risk of bacteria buildup and infections, as timely changes were not being made.

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 alleged abuse involving a resident who had severe cognitive impairment and was non-English speaking. The resident reported to a Restorative Nursing Assistant (RNA) that he was hit twice on the chest by a Certified Nursing Assistant (CNA) the previous day. This incident was reported to the Director of Nursing (DON) and the Administrator, but the initial report was not sent to the appropriate authorities as required by the facility's policy and procedure. The facility's internal investigation initially deemed the incident as non-reportable, leading to a delay in notifying the necessary agencies. The resident reiterated the allegation two weeks later, prompting the facility to reconsider and report the incident to the Ombudsman, the California Department of Public Health (CDPH), and local law enforcement. The delay in reporting was attributed to the Administrator's decision to hold off on reporting due to inconsistencies in the resident's account of the incident. The facility's policy mandates that all allegations of abuse be reported to the state agency and other relevant authorities within two hours of obtaining knowledge of the incident, which was not adhered to in this case. Interviews with the DON and the Administrator revealed that the decision to delay reporting was based on the perceived inconsistencies in the resident's story and the belief that the incident was isolated. However, the facility's policy clearly states that all suspected abuse must be reported immediately. The failure to report the incident in a timely manner resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from harm.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision and monitoring for a resident who was at risk for elopement. The resident, who had a history of cerebral infarction, mild cognitive impairment, and other medical conditions, was documented as having moderate cognitive impairment and was identified as at risk for elopement. Despite this, the resident managed to leave the facility multiple times on the same day. The resident was found outside the facility on several occasions, including once in the back parking lot and another time near a church. On the final occasion, the resident left the facility and did not return, prompting the staff to file a police report. Interviews and record reviews revealed that the facility did not notify the resident's responsible party, physician, or the Department of the elopement incidents. The Director of Nursing confirmed that there was no documentation of any scheduled appointments or leave of absence for the resident on the day of the incidents. The facility's policy on elopement and missing residents, which requires monitoring and evaluation of residents at risk for wandering and elopement, was not followed. The policy also mandates notifying the responsible party and primary care physician, which was not done in this case.