College Vista 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 facility failed to develop and implement individualized, person-centered care plans with measurable objectives, timeframes, and interventions for four residents with diverse and significant medical needs. For one resident receiving Lovenox, an anticoagulant, there was no care plan addressing interventions and goals related to the medication, despite physician orders and administration records confirming its use. The Director of Nursing (DON) acknowledged that a care plan was necessary for anticoagulant therapy to guide staff in monitoring for adverse effects such as bleeding and to provide appropriate interventions in emergencies, but no such plan was present. Another resident with impaired immunity due to a viral infection, specifically HIV, had a care plan that included monitoring for delirium as an intervention. However, there was no evidence that staff were monitoring or documenting signs and symptoms of delirium as required. The DON confirmed that the care plan did not specify the frequency of monitoring or documentation, and that this monitoring was not being performed, despite its importance in preventing complications related to immune deficiency. A third resident with severe vision impairment due to glaucoma and diabetes had no care plan addressing their specific activity needs. The DON stated there was no coordination with the activity director to develop a plan tailored to the resident's visual impairment, which could lead to isolation or behavioral issues. Additionally, a fourth resident with diabetes and chronic kidney disease did not have a care plan addressing their nutritional needs, including interventions for monitoring food brought from outside the facility. The dietary supervisor and DON both confirmed the absence of a care plan for this resident's therapeutic diet, despite the risk of noncompliance with dietary restrictions.

Penalty

No penalty information released

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

Summary

Surveyors identified that the facility failed to properly store and discard expired medication and did not store controlled substances in accordance with facility policy and professional standards. During an observation in the medication storage room, a box of expired Microdot glucose gel was found in a cabinet. The LVN present acknowledged that the medication was expired and had not been noticed or discarded as required. The DON confirmed that expired medications were supposed to be checked and removed weekly but admitted missing the removal of the expired glucose gel at the end of the previous month. Additionally, the facility did not store Lorazepam, a controlled medication, in a separately locked compartment as required. Two vials of Lorazepam for one resident and one vial for another were found stored with non-controlled medications in a single-locked medication refrigerator. Both the LVN and DON confirmed that Lorazepam should be double locked and stored separately from non-controlled medications, in line with facility policy. The residents involved had significant cognitive impairments and required substantial assistance with daily activities.

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

Two residents were not treated with respect and dignity when their bodies were left exposed while they were asleep in bed. For one resident with dementia and alcoholic cirrhosis, observations showed that the resident's brief was visible and their gown was up, exposing the chest, arms, and lower body, with the blanket placed to the side. The resident was dependent on care and unable to make medical decisions, and the DON confirmed that the resident's lower body was exposed and identified this as a dignity issue. For another resident with a history of cerebral vascular accident and hemiplegia, who was also dependent on care and had moderately impaired cognition, observations revealed that the resident's lower body and brief were exposed, with the blanket placed to the side. A CNA present during the observation acknowledged that the resident's body was exposed and stated this was a privacy issue. A review of the facility's policy on promoting and maintaining resident dignity indicated that residents should be treated with respect and dignity, and their privacy should be maintained. The policy emphasized the importance of caring for residents in a manner that maintains or enhances their quality of life and recognizes their individuality. The observed incidents were not in accordance with this policy, as both residents were left exposed and their privacy was not maintained.

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 accuracy of the Minimum Data Set (MDS) assessment for a resident who was discharged home with home health services. The MDS was incorrectly coded to indicate that the resident had been transferred to an acute hospital, which did not reflect the actual discharge disposition. This error was identified during a review of the resident's records, which included an admission for cellulitis of the right lower limb and depression, physician orders for discharge home with home health, and progress notes confirming the resident left the facility in stable condition to go home. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the discharge status was inaccurately documented in the MDS. The MDS Coordinator acknowledged the mistake and stated that the discrepancy was not noticed until pointed out by the surveyor. The Director of Nursing also confirmed the inaccuracy in the documentation. The CMS Resident Assessment Instrument (RAI) Manual requires that MDS discharge assessments accurately reflect the resident's discharge location and care needs, which was not met 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 adequate monitoring and documentation of potential side effects for a resident who was receiving Lovenox, an anticoagulant medication. The resident, who had a history of a displaced intertrochanteric fracture of the left femur, anemia, and hyperlipidemia, was prescribed Lovenox injections for DVT prophylaxis. Despite receiving the medication as ordered, there was no documentation in the electronic medical record to indicate that the resident was monitored for signs and symptoms of bleeding, a known risk associated with anticoagulant therapy. During interviews and record reviews, the Director of Nursing confirmed that staff are expected to monitor and document any side effects of Lovenox, including bleeding, in the electronic medical record. However, a review of the resident's Medication Administration Record and electronic medical record revealed no evidence that such monitoring occurred during the period the resident received Lovenox. The facility's policy on high-risk medications, including anticoagulants, requires staff to monitor for adverse consequences and document these observations, but this was not followed in this case.

Penalty

No penalty information released

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

Summary

Facility staff failed to ensure that a resident receiving anticoagulant therapy was free from significant medication errors. The resident, who had a history of a displaced intertrochanteric fracture of the left femur, anemia, and hyperlipidemia, was prescribed Lovenox to be administered subcutaneously for deep vein thrombosis prophylaxis. The physician's orders and the facility's policies clearly indicated that Lovenox should be given via the subcutaneous route. During medication administration, a licensed vocational nurse (LVN) was observed preparing to administer Lovenox to the resident. The LVN initially stated that the medication was to be given intramuscularly and was about to proceed with this incorrect route. Upon further review and verification, the LVN realized the error and acknowledged that the medication should be administered subcutaneously, as per the physician's order. The LVN also admitted to not checking the Medication Administration Record (MAR) prior to preparing the injection, which contributed to the near-miss error. Interviews with the LVN and the Director of Nursing (DON) confirmed that administering Lovenox intramuscularly would have been a significant medication error, as the correct route is subcutaneous. The facility's policies require staff to verify the medication, dose, and route against the MAR before administration, especially for high-risk medications like anticoagulants. The failure to follow these procedures resulted in a deficiency related to medication administration practices.

Penalty

No penalty information released

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

Summary

Surveyors observed that the facility failed to maintain a safe and sanitary kitchen environment. During the initial kitchen tour, white residue was found underneath the sink by the drainage pipe, and white paint remnants were present on the kitchen floor due to a fallen tile. Additionally, there was an area of exposed drywall in the kitchen. These conditions were confirmed during interviews with both the Dietary Supervisor and the Maintenance Supervisor, who acknowledged the presence of residue, paint chips, and exposed drywall. Both supervisors stated that these unsanitary conditions had the potential to contaminate food prepared for residents. The facility's policy and procedure on food safety and storage indicated that food should be stored, prepared, distributed, and served in accordance with professional standards to prevent contamination. The policy defined contamination as the unintended presence of potentially harmful substances, including microorganisms, chemicals, or physical objects, and noted that foodborne illness could result from ingestion of contaminated food or beverages.

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 explain the Arbitration Agreement to two residents, both of whom had moderately impaired memory and cognition as documented in their Minimum Data Set assessments. One resident was asked to sign the agreement during a physical therapy session without any explanation or opportunity to read the document, and was not informed of the right to refuse or rescind the agreement. The resident later expressed concern about potentially giving up the right to present disputes in court and stated a desire to discuss the agreement with family before signing. Another resident was approached by two staff members and asked to sign the Arbitration Agreement without any explanation of its contents, being told only that it was "not something bad." The resident was unaware of the right to refuse to sign or to rescind the agreement, and the date on the form was entered by someone else without the resident's knowledge. Both residents' agreements were backdated by the Director of Admission due to missing electronic records, and the Director admitted to not providing a proper explanation or being aware of the residents' right to rescind. Interviews with staff revealed a lack of understanding regarding the Arbitration Agreement and the residents' rights associated with it. The facility's policy requires that the agreement be explained in a manner understandable to the resident or representative, explicitly inform them of their right not to sign, and grant the right to rescind within 30 days. These requirements were not met, resulting in a violation of the residents' rights to make informed decisions about their care.

Penalty

No penalty information released

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

Summary

The facility failed to revise the care plan for a resident who was at high risk for falls, following a significant event where the resident sustained a fall resulting in a humerus fracture. The resident had a history of osteoarthritis and glaucoma, with severely impaired memory and cognition, and required varying levels of assistance with daily activities. Upon admission, the resident was assessed as high risk for falls, with a fall risk score of 17, and exhibited multiple risk factors including intermittent confusion, being chair bound, balance problems, use of assistive devices, polypharmacy, and multiple predisposing diseases. Despite these risk factors and the occurrence of a fall, the facility did not complete a new fall risk assessment after the incident, nor did they update the resident's care plan to reflect the change in condition. The care plan remained unchanged after the fall, and the resident was not placed in the facility's Falling Star Program, which is intended for residents with high fall risk scores. The facility's policies required fall risk assessments upon admission, annually, and after significant changes, but these were not followed in this case. Interviews with staff revealed a lack of awareness and implementation of fall prevention protocols, such as the use of a yellow star sticker to alert staff to residents at risk for falls. The DON confirmed that the required assessments and care plan revisions were not completed as per facility policy, and that the resident should have been included in the Falling Star Program based on their risk score and fall history.

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 written grievance decision to a resident who filed a grievance, as required by their policy. The resident, who had been admitted with hepatic encephalopathy and cirrhosis of the liver, experienced a disturbance with their roommate. The grievance form indicated that a room change was made to address the issue, and it was noted that the resident and their family were satisfied. However, the form lacked signatures from the resident or their family, and verbal consent was noted without a date. Interviews with facility staff revealed that the Social Service Director (SSD) was informed of the incident and filled out the grievance form but did not document the grievance in the residents' progress notes. The SSD did not provide a grievance investigation report to the family due to previous issues with them and deferred communication to the Director of Nursing (DON) and Administrator (ADM). The facility's policy required a written summary report, but the DON admitted that no such report was prepared, and only a nursing progress note was provided to the family.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary care and interventions to prevent pressure injuries for a resident, resulting in the development of a facility-acquired Stage 2 pressure injury. The resident, who was at high risk for pressure injuries due to conditions such as hepatic encephalopathy, cirrhosis of the liver, morbid obesity, and moderate cognitive impairment, was not turned, repositioned, or offloaded every two hours while in bed. Additionally, the resident was not kept clean and dry after bowel movements or wetness from urine due to incontinence. The resident's Braden Score Assessment indicated a high risk for developing pressure injuries, and the care plan included interventions such as keeping the skin clean and dry and frequent repositioning. Despite these measures, the resident developed a Stage 2 pressure injury on the intergluteal cleft, which was noted on 2/16/25. The Treatment Nurse initially classified the injury as a pressure injury but later reclassified it as moisture-associated skin damage (MASD) due to the appearance of the skin. The facility's policy on pressure injury prevention and management emphasizes the prevention of avoidable pressure injuries and the provision of treatment to heal existing injuries. However, the facility's failure to adhere to these protocols resulted in the resident developing a pressure injury, which was confirmed upon discharge to home health services. The home health assessment noted the presence of a Stage 2 pressure injury with skin irritation, redness, and infection.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary wound care according to the physician's orders for a resident who had undergone surgery. The Treatment Nurse (TXN) did not assess or provide wound care for the resident's surgical incision at the right hip, which had staples, from a specified date. Additionally, the TXN did not assess or provide wound care for the resident's left shin and perineal area on several occasions, as required by the physician's orders. The resident was admitted with a right hip fracture and required surgical wound care. The facility's records indicated that the resident had a surgical wound on the right hip with staples and another wound on the right lateral thigh. However, the TXN failed to conduct a thorough assessment and document the resident's skin condition weekly, as required. The TXN also discontinued the wound care order prematurely, assuming that the staples had been removed during an orthopedic appointment, which was not the case. The Licensed Vocational Nurse (LVN) involved did not assess the resident's skin condition accurately and copied previous notes instead of conducting her own assessment. This lack of proper documentation and communication among the nursing staff led to the resident being discharged with staples still in place, without appropriate instructions for wound care and follow-up. The Director of Nursing acknowledged these failures, emphasizing the importance of thorough assessments and accurate documentation to prevent such deficiencies.

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 an effective discharge planning process for a resident, resulting in the resident not receiving necessary Home Healthcare services and Lovenox injections as prescribed by the physician. The resident was discharged with a bag of medications, including Lovenox syringes, without proper instructions on administration. The resident's representative expressed concerns about the lack of guidance and attempted to contact the facility for clarification but received no response. Interviews with facility staff revealed that the Registered Nurse instructed the resident's representative to contact the insurance company to set up home health services, but there was no documented evidence that the Social Service Designee coordinated these referrals. The Director of Nursing acknowledged the absence of a policy for contacting and documenting referrals for discharged residents, emphasizing the importance of ensuring residents receive required services upon discharge to prevent health decline.

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 resident was free from accident smoking hazards, leading to a serious incident. The resident, who was non-compliant with the facility's smoking policy, went to the outdoor patio to smoke a cigarette while on oxygen. This resulted in a flash fire that caused second-degree burns to the resident's face and hands. The resident was subsequently transferred to a burn center for further treatment. The facility did not implement the resident's care plan interventions, which required supervision while smoking. Despite being aware of the resident's non-compliance with the smoking schedule and policy, the facility staff failed to supervise the resident adequately. The resident was able to access smoking materials and light a cigarette while on oxygen, which was against the facility's policy. The facility's nursing staff did not maintain control of the resident's smoking materials as per the policy. Additionally, the care plan was not updated to reflect the resident's non-compliance with smoking protocols. The facility also lacked a designated staff member responsible for supervising residents while smoking, contributing to the incident.

Removal Plan

• Complete body assessment and inventory of Resident 1's personal belongings on readmission.
• Interdisciplinary team will provide education to Resident 1 on readmission regarding Resident Smoking policy, smoking information, and storage of smoking paraphernalia by nursing in a lockbox.
• All delivery/packages will be opened by the Activity Director in front of the resident to check for smoking paraphernalia.
• Daily room sweep by the assigned department manager and Manager of the Day on weekends.
• Resident 1 will be on one-on-one monitoring.
• Interdisciplinary team conducted care conference with Residents 2 and 3 that are smokers to discuss smoking safety, facility's smoking practices, and plan of care.
• Smoking safety assessment and care plans for Residents 2 and 3 were reviewed and revised by the Director of Nursing.
• Staff conducted room sweep for all residents with resident's permission to ensure there is no smoking paraphernalia stored in the rooms.
• Smoking schedule was revised by the interdisciplinary team to reflect assigned department who will oversee smoking schedule.
• Director of Staff and Development will in-service staff with various topics related to smoking safety and policy.
• Inservice to Activity Department regarding resident's package delivery.
• New hire or staff who were not able to attend the in-service will be educated prior to start of their scheduled shift.
• Interdisciplinary team created a preliminary Resident Smoking policy that reflects additional safety measure for non-compliance.
• The interdisciplinary team will obtain a written or verbal consent from the resident prior to the resident opening the package or delivery.
• The Nursing management team will oversee assigned caregivers and residents during designated smoking times.
• Interdisciplinary team will review admission and readmission to verify if resident uses tobacco.
• Activity Department or designee will deliver packages to the resident and will open the package in front of the resident.
• Department Managers or designee will conduct room rounds and Manager for the Day on weekends.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident was free from involuntary seclusion, which is defined as the separation of a resident from other residents or confinement to their room against their will. This incident involved a licensed vocational nurse (LVN) who blocked a door leading to the outdoor patio with a long table, preventing a resident from accessing the patio. The resident, who was a smoker, was upset by this action as it restricted their movement within the facility. The resident involved had a history of chronic obstructive pulmonary disease (COPD) and was using oxygen therapy. The resident's care plan included interventions for smoking safety, such as removing the oxygen tank before smoking and seeking staff supervision. Despite these interventions, the resident was non-compliant with the smoking schedule and protocols. On the night of the incident, the resident requested to smoke outside of the scheduled times, leading to a confrontation with the LVN. The LVN's actions were documented in a written statement, which indicated that the table was placed in a way that made it difficult for a wheelchair to pass. The Director of Nursing (DON) confirmed that the LVN intentionally blocked the resident's access to the patio, which was considered a form of seclusion causing psychosocial distress. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents' rights and the prevention of harm, which was not upheld in this situation.

Penalty

No penalty information released

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

Summary

The facility failed to develop a comprehensive smoking policy that ensured the safety of a resident who was noncompliant with the smoking policy. The resident, who was receiving continuous oxygen therapy, was allowed to keep a cigarette and lighter in his possession, which led to a serious incident. On the specified date, the resident was left unsupervised on the patio and lit a cigarette while still connected to an oxygen supply, resulting in a fire. The incident caused the resident to sustain second-degree burns on his face and hands, necessitating hospital transfer. The resident had a history of COPD exacerbation, respiratory failure, epilepsy, and muscle weakness, and was assessed as having moderate cognitive impairment. Despite these conditions, the facility's smoking safety assessments only recommended smoking cessation discussions and supervised smoking, without addressing the specific risks associated with oxygen therapy. Interviews with the Director of Nursing revealed that the facility's smoking policy lacked specific actions for noncompliant residents, particularly those using oxygen. The policy did not include increased monitoring or safety measures to prevent such incidents. The resident reported that staff usually removed his oxygen before smoking but failed to do so on this occasion, leading to the accident.

Penalty

Inspection fine: $15,536

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 policy and procedure regarding the notification of a resident's responsible party in the event of a change in condition. Resident 1, who was diagnosed with unspecified dementia, cognitive communication deficit, and dysphagia, experienced a change in condition due to agitation. Despite the facility's policy requiring notification of the resident's responsible party, the family member was informed nearly seven hours after the change in condition and after the resident had been transferred to a general acute care hospital. The incident began when Resident 1 exhibited signs of agitation, including stealing other residents' nasal cannulas and belongings. A Licensed Vocational Nurse (LVN) observed these behaviors and documented them in a Change in Condition Evaluation. The LVN was instructed by the Director of Nursing (DON) not to contact the family member, as the DON intended to do so herself. However, the DON became busy and did not notify the family member until much later, resulting in a significant delay in communication. The facility's policies clearly state the requirement to inform the resident's representative of any significant changes in condition, treatment alterations, or transfers. The DON acknowledged the oversight and admitted that the family member should have been informed prior to the resident's transfer to the hospital. This failure to communicate in a timely manner violated the resident's rights and the facility's own policies, potentially impacting the resident's well-being.

Penalty

Inspection fine: $28,032

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 immediate CPR to a resident, identified as Resident 41, who was found unresponsive, without a pulse, and not breathing. The Licensed Vocational Nurse (LVN 1) delayed initiating CPR because they first checked the resident's code status and called for assistance instead of starting CPR immediately. This delay occurred despite the facility's policy and procedure, which required immediate CPR initiation in such situations unless a Do Not Resuscitate (DNR) order was present. Resident 41 had a full code status, meaning they wished to be revived if their heart stopped beating or they stopped breathing. The resident was admitted with diagnoses including congestive heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. On the day of the incident, the resident was found unresponsive in bed by LVN 1, who then left the room to verify the resident's code status before starting CPR. This delay in initiating CPR was critical, as the resident was later transferred to a General Acute Care Hospital, where they were pronounced dead. Additionally, the facility's emergency cart was found to be inadequately stocked with essential items needed for CPR, such as an Ambu-bag, glucometer, and pulse oximeter. This lack of preparedness could have further contributed to the delay in providing life-saving measures. The facility's policy required that emergency carts be fully stocked and ready for use, but this was not adhered to, as evidenced by the missing items during the surveyor's inspection.

Removal Plan

• (DON) had a 1:1 in-service with the licensed nurse assigned to Resident 41 regarding Medical Emergency Response. Disciplinary action was taken with licensed nurse who delayed the CPR on the full code resident and was suspended pending investigation.
• The Medical Records Director (MRD) or designee completed a chart audit on every resident and compared the Advance Directive/Physician Orders for Life Sustaining Treatment (POLST) to the physician order for accuracy.
• The facility emergency cart checklist was revised by the DON. The glucometer, glucose strips, lancets, nebulizer, and nebulizer kit were added. The updated form will be utilized by licensed nurses. The emergency cart was checked by the DON for appropriate supplies and equipment. No issues were identified.
• The Resource Nurse Consultant (RNC) and Respiratory Therapy Consultant designee educated licensed nurses and certified nurse assistance (CNAs) on the facility's policy and procedure for Medical Emergency Response and location of code status for each resident. Licensed nurses and CNAs were not permitted to work a shift until education was completed. Nurses on leave will receive education prior to their next scheduled shift.
• The RNC and Respiratory Therapy Consultant initiated Code Blue drill to be completed on all shifts randomly by using the facility landline's paging system located at the nurse's station, hallway outside room, between rooms, activity room, rehabilitation room and office rooms (Administrator, DON, Dietary, SSD office), and announcing Code Blue to room. Licensed nurses and CNAs were in-serviced by the RNC regarding the paging system. The licensed nursing and CNAs staffs who were not scheduled to work will participate in the Code Blue drill during their scheduled shift.
• The RNC, (Director of Nursing) DON and (Director of Staff Development) DSD conducted an audit of licensed nurses and certified nurse assistants (CNAs) CPR certification. No issues were identified.
• Newly hired licensed nurses and CNAs will have their CPR certification card on file and have competency prior to their scheduled shift.
• DON or designee will audit new admissions chart to compare the resident's Advance Directives/ POLST to the physician orders for accuracy. This audit will continue for three months. Findings will be reviewed at the monthly QA (Quality Assurance) Committee meeting for discussion and recommendations.
• Licensed nurse will print the daily code status from PCC orders and will place it in the binder labeled Code Status located at the nurse's station. The SSD will oversee that the code status is available and updated daily. In the absence of SSD, the license nurse working will verify that the code status is updated.
• The POLST will be reviewed and verified by the DON and SSD immediately after admission of the resident to the facility. The RN Sup will oversee the POLST in the A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented.
• DON or designee to complete weekly mock code drills on all shifts and monitor code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Any trends will be discussed during monthly Quality Assurance meeting which will be held scheduled monthly. The DON will conduct compliance audits weekly for three months. Findings will be reported at monthly QA Committee meeting for discussion and recommendations.
• The DON will randomly audit the emergency cart on a weekly basis in addition to the daily checks from licensed nurse to ensure that the equipment and supplies are stocked as indicated on the emergency cart checklist. This audit will continue for three months. Findings will be reviewed at the monthly QAA (Quality Assurance) Committee meeting for discussion and recommendations.

Penalty

Inspection fine: $28,032

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

Summary

The facility failed to provide adequate respiratory care for a resident with respiratory failure, pneumonia, and COPD, who was receiving continuous oxygen therapy. The resident expressed feeling unwell and requested a replacement for what she believed was an empty oxygen tank. However, the Licensed Vocational Nurse (LVN) did not conduct a respiratory assessment or notify the primary physician, despite the resident's medical history and symptoms. The facility did not evaluate the need for a physician's order for oxygen therapy upon the resident's admission, nor did they notify the physician to administer oxygen at the prescribed rate. Additionally, the facility failed to develop a resident-centered care plan addressing the resident's respiratory needs and did not notify the physician of changes in the resident's condition, as required by the facility's policies. When the resident was found unresponsive, the LVN delayed initiating CPR while attempting to verify the resident's code status, contrary to the facility's emergency response policy. This delay, along with the lack of proper respiratory assessment and physician notification, contributed to the resident's transfer to a hospital where she was found pulseless and later passed away.

Removal Plan

• Administrator notified the facility Medical Director of Immediate Jeopardy incident.
• Licensed nurses identified was in-serviced by the DON regarding Physician notification when there is a change of condition focusing on respiratory system, respiratory assessment, and management of disease such as COPD, respiratory failure with hypoxia and oxygen therapy. Identified license nurse was suspended pending investigation.
• The DON and Registered Nurse (RN) Supervisor reviewed the 13 residents with oxygen therapy orders, COPD diagnosis and respiratory distress with hypoxia for signs of respiratory distress or change of condition.
• The Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) nurse reviewed in-house residents with diagnosis of COPD and respiratory failure with hypoxia for the implementation of resident centered care plans.
• Licensed nurses will check that residents are receiving the appropriate oxygen therapy as ordered at the start of their shift. When placing residents from oxygen concentrators to oxygen tanks, licensed nurses will verify the oxygen order to ensure that the liters per minute being administered matches the order.

Penalty

Inspection fine: $28,032

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 lights were within reach for four residents, as required by the facility's policy and the residents' care plans. Resident 34, who was admitted with diagnoses including unspecified dementia and Alzheimer's disease, was observed with her call light behind the bed headboard and out of reach. During an interview, Resident 34 stated she did not know where her call light was located, and a certified nursing assistant confirmed that the call light should be within reach to prevent accidents and falls. Resident 17, admitted with metabolic encephalopathy and unspecified dementia, was observed with the call light hanging off the bed and touching the floor, making it inaccessible. A certified nursing assistant confirmed that the call light should be within reach to allow the resident to alert staff for assistance and prevent accidents. The Director of Nursing also emphasized the importance of having the call light within reach to avoid distress and potential accidents. Residents 29 and 31 also experienced similar issues with their call lights. Resident 29's call light was found hanging from the bed and touching the floor, while Resident 31's call light was wrapped around a feeding pump, making it inaccessible. Staff members confirmed that the call lights should be within reach to enable residents to call for help and prevent accidents. The facility's policy on call light accessibility was not adhered to, leading to the potential for delayed care and increased risk of falls for these residents.

Penalty

Inspection fine: $28,032

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 five out of five employees had the necessary competencies and skills to provide cardiopulmonary resuscitation (CPR) for a resident, identified as Resident 41, who required life-saving measures. This deficiency was identified during a review of the incident where Resident 41 was found unresponsive in bed. Despite having a POLST indicating full code status, there was a delay in initiating CPR due to the staff's inability to immediately verify the resident's code status. Resident 41 had a history of acute on chronic systolic heart failure, acute respiratory failure with hypoxia, and chronic obstructive pulmonary disease. The resident's POLST, signed by both the resident and a physician, indicated that CPR should be attempted in the event of cardiac arrest. However, when the resident was found unresponsive, the Licensed Vocational Nurse (LVN) on duty delayed CPR to verify the code status, which was not immediately available in the electronic medical records. This delay occurred despite the facility's policy that CPR should be initiated immediately unless a Do Not Resuscitate (DNR) order is confirmed. Interviews with staff revealed that the LVN and Certified Nursing Assistants (CNAs) present did not start CPR until the LVN confirmed the code status from the paper chart. The Director of Nursing (DON) confirmed that the facility's policy required immediate CPR initiation, and any delay could result in adverse outcomes. The facility's policies emphasized the importance of high-quality CPR and immediate action in emergencies, which were not adhered to in this case, leading to a delay in life-saving measures for Resident 41.

Penalty

Inspection fine: $28,032

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 their enhanced standard precaution protocol, which is designed to prevent the transmission of multi-drug resistant organisms (MDROs) in skilled nursing facilities. This deficiency was observed when a Licensed Vocational Nurse (LVN) provided care to a resident without wearing the appropriate personal protective equipment (PPE), specifically a gown, while handling the resident's gastrostomy tube (G-tube). The resident, who had severe cognitive impairment and was on enhanced standard precautions due to long-term G-tube use, was at risk of exposure to infectious organisms due to this oversight. The incident was confirmed through interviews and record reviews. The LVN acknowledged the failure to wear a gown during the procedure, despite the presence of a blue sticker indicating the need for enhanced standard precautions. The Director of Nursing (DON) confirmed that enhanced standard precautions were necessary for residents who could expose staff to bodily fluids, such as during G-tube care, to prevent the potential spread of infections. The facility's policy on enhanced barrier precautions, revised in April 2024, mandates the use of gowns and gloves during high-contact resident care activities, including device care of feeding tubes.

Penalty

Inspection fine: $28,032

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

Summary

The facility failed to ensure that a resident was treated in a dignified and respectful manner, as evidenced by an incident involving a Certified Nursing Assistant (CNA) transporting a resident to the shower room without appropriate body coverage. During the observation, it was noted that the resident's left and right upper legs were exposed while being transported in a shower chair through the hallway. This incident was observed by the Director of Nursing (DON), who instructed the CNA to cover the resident appropriately to maintain dignity and privacy. The resident involved in the incident had been admitted to the facility with diagnoses including type 2 diabetes mellitus, hypokalemia, and hyperlipidemia. The resident was noted to have the capacity to understand and make decisions. Interviews with the CNA and the DON highlighted the importance of ensuring residents' bodies are fully covered to uphold their dignity and prevent feelings of exposure or discomfort. The facility's policy on promoting and maintaining resident dignity, dated December 19, 2022, emphasizes the responsibility of all staff members to respect resident rights and dignity.

Penalty

Inspection fine: $28,032

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 low air loss mattress was set correctly according to the resident's weight, which is crucial for the prevention of pressure ulcers. The resident, who was at risk for developing pressure ulcers, was observed lying on a mattress set at a level intended for individuals weighing over 350 pounds, while the resident's actual weight was 197.4 pounds. This incorrect setting was identified during an observation and interview with an LVN, who confirmed that the mattress should have been set at a lower level based on the resident's weight. The resident, who had severe cognitive impairment and required assistance with mobility, was at risk for pressure ulcers as indicated by their Braden Scale assessment. The facility's policy required that support surfaces be used according to physician orders and evidence-based practices, which included setting the mattress according to the resident's weight. The Director of Nursing acknowledged that incorrect settings could lead to ineffective pressure ulcer management, placing the resident at risk for developing pressure ulcers or other complications.

Penalty

Inspection fine: $28,032

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 attending physician acted upon and documented the rationale for the consultant pharmacist's recommendation regarding the use of the psychotropic medication Seroquel for a resident. The consultant pharmacist had recommended reevaluating the necessity of the medication, considering a gradual dose reduction (GDR), and documenting the rationale for continuing therapy if deemed necessary. However, the physician's response to this recommendation was not documented in the resident's clinical records. The resident involved had been admitted with diagnoses including metabolic encephalopathy and cellulitis. The resident's medication review report indicated an active order for Seroquel to manage psychosis symptoms. Despite the consultant pharmacist's recommendation, there was no documented evidence that the facility had notified the resident's primary physician or obtained a response regarding the continued use of Seroquel. The facility's policy required action on all medication regimen review recommendations, but this was not followed in this case.

Penalty

Inspection fine: $28,032

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 route of medication administration matched the label on the bubble pack, the physician's orders, and the Medication Administration Record (MAR) for a resident. This deficiency was observed during a review of the resident's medication administration process. The resident, who had diagnoses including metabolic encephalopathy, parkinsonism, and unspecified dementia, was prescribed Bromocriptine Mesylate and Divalproex Sodium to be administered via a gastrostomy tube. However, the bubble pack labels indicated oral administration, which did not align with the physician's orders. During an observation, a Licensed Vocational Nurse (LVN) verified the medications and noted discrepancies between the bubble pack labels and the MAR. The LVN acknowledged the importance of matching the physician's orders with the medication labels to prevent potential medication errors, such as choking. The facility's policy on medication administration emphasized the need for licensed nurses to administer medications as ordered by the physician and to verify the medication source with the MAR to ensure accuracy in resident name, medication name, form, dose, route, and time.