Colonial Care Center

Penalty

Fine: $22,3156 days payment denial

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

Summary

The deficiency involves a failure to ensure the environment was free from accident hazards and that adequate supervision and assistance were provided during resident repositioning. A Licensed Vocational Nurse (LVN 1) repositioned a resident who, per the Minimum Data Set (MDS), was dependent on staff and required the assistance of two or more helpers to roll from side to side. Despite knowing the resident was a two-person assist, LVN 1 proceeded to reposition the resident alone because other staff were busy. The facility’s policy on positioning and moving residents required staff to assess the resident’s physical abilities, mobility limitations, strength, awareness, and ability to follow directions, and to use maximum precautions and obtain assistance as needed, but this was not followed. The resident involved had severe cognitive impairment due to dementia and Alzheimer’s disease and was documented as dependent on staff for rolling left to right, with functional limitations in range of motion in both upper and lower extremities. On the evening of the incident, CNAs caring for the resident, who also stated the resident required a two-person assist, noticed the resident’s right knee was bending abnormally and informed LVN 1. During LVN 1’s rounds, she found the resident at the edge of the right side of the bed with the right foot hitting the bed’s footboard. To prevent a fall, LVN 1 decided to reposition the resident without waiting for assistance, using a draw sheet to pull the resident up while both legs were straight and the right leg crossed over the left. As LVN 1 turned the resident toward the left side of the bed, the resident moved her legs and the right knee struck an exposed portion of the bed frame at the bottom of the bed where the mattress did not fully cover the frame. LVN 1 observed the resident grimacing and moaning, with redness, swelling, and tenderness of the right knee. Subsequent assessment and imaging showed an acute right distal femur fracture. The resident was transferred to a general acute care hospital, where the fracture, associated swelling, deformity of the distal thigh, and need for immobilization, pain control, and monitoring for complications were documented. An orthopedic consultation later noted the injury was likely related to malunion and that surgery was not recommended due to the resident’s dementia and non-ambulatory status.

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 immediately report an allegation of physical abuse involving a resident with moderate cognitive impairment and multiple medical diagnoses, including hypertension and type 2 diabetes. The resident disclosed to an LVN that an unknown individual had pulled her hair in the hallway a few days prior, but the LVN did not report the allegation to the RN supervisor or the Administrator as required by facility policy. The RN working alongside the LVN was not informed of the incident, and the Administrator confirmed that the facility's abuse policy mandates immediate reporting to supervisors and notification to the State Agency within two hours of awareness. The failure to report the allegation promptly resulted in a delay in initiating an investigation and notifying the appropriate authorities, including the State Survey Agency and law enforcement. The facility's policy and procedure, as well as statements from the RN and Administrator, emphasized the importance of immediate reporting to ensure resident safety and compliance with regulatory requirements. The incident was not reported in accordance with these protocols, constituting a deficiency in the facility's handling of abuse allegations.

Penalty

Fine: $19,135

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 timely medical intervention and transfer for a resident who experienced a significant change in condition related to unmanaged pain and a delayed response to an acute right femoral fracture. Staff did not promptly notify the resident's physician after receiving a stat x-ray result indicating an acute proximal femoral fracture with soft tissue swelling. The x-ray result was received at 1:22 a.m., but the physician was not notified until 8:35 a.m., resulting in a delay of over seven hours before appropriate action was taken. During this period, the resident continued to experience severe pain and swelling, as documented by multiple pain assessments and nursing progress notes. The resident had a complex medical history, including chronic respiratory failure, ventilator dependence, osteoporosis with pathological fractures, quadriplegia, and contractures. On the day of the incident, staff observed the resident with facial grimacing, an unstable right hip, and increased pain during repositioning. Despite these findings and the subsequent x-ray confirming a fracture, the facility did not follow its own care plan and policy requirements for prompt physician notification and intervention. Pain management was inconsistent, with the resident receiving Tylenol and later Norco, but continued to exhibit signs of severe pain, including hyperventilation, moaning, and rigidity. The facility also failed to implement its policy on changes in a resident's condition, which requires immediate notification of the attending physician and resident representative upon significant changes. The delay in notification and transfer resulted in the resident experiencing unmanaged pain and increased swelling for approximately 10 hours before being transferred to a general acute care hospital. The resident ultimately underwent a surgical procedure involving removal of the femoral head and neck with hip disarticulation.

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 ensure that a resident assessed as high risk for falls had their bed placed in the lowest position, as required by the resident's care plan under the Falling Star Program. The resident, who had diagnoses including generalized weakness, cognitive impairment, poor balance, decreased strength, and a history of falls, was observed asleep in bed positioned close to the edge of the mattress. Measurement of the bed height revealed it was set at 16 inches from the floor, rather than the lowest possible setting of 14 inches, as specified in the care plan. In contrast, the resident's roommate's bed was observed to be almost at floor level. Interviews with facility staff, including the Registered Nurse Supervisor and the Director of Nursing Services, confirmed that interventions such as low bed positioning are discussed and expected to be implemented according to residents' care plans to reduce fall risk. The facility's policies require that care plan interventions be implemented based on ongoing assessments and that specific fall prevention measures be carried out for residents at risk. Despite these policies and the resident's documented needs, the intervention to keep the bed in the lowest position was not followed at the time of observation.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to provide immediate Cardiopulmonary Resuscitation (CPR) to a resident with a Full Code status who was in distress, significantly reducing the resident's chances of survival. The incident involved a resident who was admitted with multiple diagnoses, including Type II Diabetes, Sepsis, and Urinary Tract Infection, and had a care plan indicating CPR should be performed in case of a life-threatening emergency. On the day of the incident, the resident was found unresponsive with no palpable pulse, yet CPR was not initiated immediately by the attending Registered Nurse (RN). The RN failed to announce a Code Blue and did not provide resuscitation or basic life support immediately, despite the resident's unresponsiveness and lack of a detectable pulse. The RN relied on an oximeter reading, which still indicated a pulse, instead of manually checking for a pulse and initiating CPR as per the facility's policy and procedure. This delay in initiating CPR was contrary to the facility's policy, which required immediate CPR initiation when a resident with Full Code status is found unresponsive and not breathing normally. The facility's policy, aligned with the American Heart Association guidelines, mandates that CPR should be started immediately upon recognizing cardiac arrest symptoms, such as the absence of a palpable pulse. The RN's lack of adherence to these guidelines and the facility's procedures resulted in a delay in life-saving measures, as the paramedics had to initiate CPR upon their arrival. This deficiency highlights a critical lapse in the facility's emergency response protocol, particularly in the timely initiation of CPR for residents with Full Code status.

Removal Plan

• The Administrator and the Director of Nursing notified the facility Medical Director of the findings outlined in the IJ removal plan and developed an IJ removal plan.
• American Heart Association Instructors provided in-services to nurses on the facility's CPR policy and procedure. The training covered assessment and activation for CPR, code for cardiac/respiratory arrest-Code Blue, and CPR procedures.
• All nursing including part time and overnight shift who was unable to attend the Inservice must be given an in-service prior to returning to work.
• The DON and Registered Nurse supervisor reviewed residents who required CPR and identified one resident aside from Resident 44 with an incident of code blue with not the same deficient practice.
• The AHA instructors will repeat the in-services to nursing staff, regarding CPR policy and procedure, every month for 3 months to ensure compliance.
• The DON and/or designee will review residents who have a change in condition weekly and monthly thereafter, to ensure that any resident requiring CPR has received the CPR timely, and continually until the paramedics arrive or there are obvious signs of life.
• The DON and/or designee will review residents who have change in condition weekly and monthly thereafter, to ensure that any resident required.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to ensure adequate nutritional management for a resident receiving gastrostomy tube feeding, resulting in severe weight loss. The resident, who had a history of muscle wasting, non-Hodgkin lymphoma, and multiple pressure ulcers, experienced a significant weight loss of 25.8 pounds, equating to 21.6% of their body weight over a two-month period. Despite the resident's care plan indicating a goal to prevent weight loss exceeding 5% per month, the facility did not conduct a change of condition assessment or monitor the resident's weight and nutritional status closely. The licensed nurses did not notify the resident's physician or responsible party of the significant weight loss, nor did they inform the registered dietician in a timely manner to evaluate the resident's nutritional needs. The interdisciplinary team failed to meet to develop interventions to prevent further weight loss, and the resident's care plan was not updated with measurable goals to address the weight loss. Additionally, the facility did not document the resident's weight changes accurately or consistently, leading to a lack of timely interventions. The resident's weight loss was not addressed adequately, and the facility's staff did not follow the established protocols for monitoring and managing significant weight changes. The lack of communication and documentation among the care team contributed to the resident's continued weight loss, placing them at risk for malnutrition and dehydration. The facility's failure to implement appropriate interventions and notify relevant parties resulted in a deficiency that posed a risk to the resident's health.

Removal Plan

• A change of condition assessment, SBAR for severe weight loss was completed, which included vital signs, pain, laboratory results reviewed and obtained new physician orders for adding Liquacel and to increase GT feeding to 55cc/hr.
• The assistant director of nursing conducted another assessment, indicating the Resident 188 remained at his baseline condition with normal vital signs, and without any sign of distress.
• The IDT members, including the RD, conducted an IDT care plan meeting. During the meeting, the IDT members addressed Resident 188's overall condition with severe weight loss. The physician instructed to start weekly weight for four weeks and repeat the comprehensive metabolic panel.
• RNA 1 will receive a performance correction notice, and a one-on-one in-service by the DON regarding weight documentation, emphasizing the importance of recording the weight on the same day it was measured.
• The weights management in-service was initiated until all licensed nurses, including part-time and night shift will be completed. Any licensed nurse unable to attend the in-service due to part time status, emergency or leave of absence has been removed from the schedule and must be given an in-service prior to returning to work.
• The DON and ADON initiated review of all residents' weight records for the past 30 days to ensure that all significant or severe weight changes had proper assessments, RD recommendations, MD notifications, and updated plan of care.
• The DON and the ADON will conduct monthly in-services to licensed nurses regarding weight management for 3-months, covering the following details: Conducting a change of condition assessment for significant or severe weight change.
• The DON and/or designee will repeat a monthly in-service for three months to RNA responsible for weights documentation, to ensure all weights are recorded on the same day it is measured.
• The DON created a weight management monitoring log, including significant or severe weight loss.
• The DON/ADON will meet with the RNA weekly for four weeks, then monthly for three months to ensure timely weight documentation.
• The DON/ADON will participate in weekly weight management meeting and document the findings with corrective actions in the monitoring log.
• The DON/ADON will monitor weight variance through weekly weight meeting to ensure all residents with weight variance (significant or severe) will be addressed. The DON will discuss weight management related findings during the monthly QA meeting for three months to ensure ongoing compliance with the state and federal regulations.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to adhere to its own sanitation and infection control policy, which mandates working under sanitary conditions at all times. During an observation and interview, a Regional Registered Dietitian (RRD) was seen handling a food thermometer without performing hand hygiene or wearing gloves. The RRD used an alcohol swab to clean the thermometer before inserting it into pureed broccoli and repeated the process without washing hands or using gloves. The RRD acknowledged that hand hygiene is essential to prevent cross-contamination but justified the lack of gloves by stating that the cook had already taken the food's temperature. The facility's Policies and Procedures require hand washing before and after handling food and the use of disposable gloves when handling ready-to-eat foods, which was not followed in this instance.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to maintain proper food storage and labeling practices, which could lead to foodborne illnesses among residents. Observations revealed that frozen meats and vegetables were stored together without proper separation, and many items, including pie crusts, pepperoni, and various vegetables, were undated. Additionally, opened sausages and croissants were stored together in the produce fridge, and several items, such as thickened milkshakes and cottage cheese, lacked proper labeling and dating. Molded and expired bread and cottage cheese were also found, indicating a lack of adherence to food safety protocols. The facility also failed to maintain proper sanitation practices in the dishwashing process. Chlorine test strips, necessary for ensuring the dishwasher's effectiveness, were missing, and staff were unable to verify the chlorine levels before running the dishwasher. This oversight could result in inadequate sanitization of dishes, potentially exposing residents to harmful pathogens. Furthermore, the facility lacked a scale to ensure proper portion sizes, which could affect the nutritional intake of residents. Interviews with staff, including dietary aides, the registered dietitian, and the dietary manager, confirmed these deficiencies. Staff acknowledged the improper storage and labeling of food items and the absence of necessary equipment, such as chlorine test strips and a food scale. The facility's policies and procedures for food storage and dishwashing were not followed, contributing to the potential risk of foodborne illness among the residents.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to properly dispose of garbage and refuse by not ensuring that two out of three blue dumpsters were completely covered. This was observed during a visit to the garbage area located outside the facility near the kitchen. The Dietary Manager confirmed that the trash bin lids were not completely closed, which could attract pests. Additionally, three black trash bags were found on the floor between the dumpsters. The Maintenance Supervisor also observed one of the dumpsters open, with a black trash bag, flattened cardboard boxes, and soiled diapers in the walkway next to the dumpsters. The facility's Policies and Procedures, titled Waste Control and Disposal, require that trash bins be covered at all times and that outside garbage bins be kept closed with the surrounding area kept clean. The policy also mandates timely disposal of garbage to prevent buildup and requires that all cardboard boxes be broken down and disposed of promptly. The failure to adhere to these procedures had the potential to attract flies, insects, and other animals, posing a risk of cross-contamination for the majority of the facility's residents who receive food from the kitchen.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to offer, educate, and track COVID-19 vaccinations for staff according to its policy, potentially placing all residents at risk for coronavirus infection. During an interview with the Infection Preventionist Nurse (IPN), it was revealed that the facility did not maintain a tracking log or retain records of vaccination education, proof of vaccination, or declinations for staff. The Director of Nursing (DON) acknowledged the importance of educating and documenting staff vaccinations to protect both residents and staff. A review of the facility's COVID-19 policy indicated that the facility was required to educate residents, responsible parties, and staff about the benefits of vaccination, offer vaccinations based on health department recommendations, and keep copies of vaccination proof. Additionally, if an employee chose not to be vaccinated, they were required to provide a written declination.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to provide mandatory Effective Communications training for its direct care staff, which includes 18 Registered Nurses (RNs), 50 Licensed Vocational Nurses (LVNs), and 20 Respiratory Therapists (RTs). This deficiency was identified during interviews and record reviews conducted by surveyors. The Director of Staff Development (DSD) admitted to being unaware of the requirement for this training, and as a result, it was not provided in 2024. The facility's policy and procedure, revised in August 2022, clearly states that all staff must participate in regular in-service education, including Effective Communications, to ensure they can interact in a manner that enhances residents' quality of life and care. The Director of Nursing (DON) emphasized the importance of effective communication, particularly for non-English speaking residents and those with specific needs such as dementia, traumatic brain injury, or stroke. These residents rely on alternative communication methods, and without proper training, staff may not be able to meet their needs, potentially affecting the quality of care provided. The facility's policy requires that training be completed before staff provide services to residents, annually, and as necessary based on the facility's assessment, but this was not adhered to, leading to the deficiency.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to provide mandatory Quality Assurance and Performance Improvement (QAPI) training to its direct care staff, including 18 Registered Nurses (RNs), 50 Licensed Vocational Nurses (LVNs), and 20 Respiratory Therapists (RTs), as required by the facility's policy and procedure. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), who admitted to being unaware that QAPI training was mandatory for direct care staff and consequently did not provide the training in 2024. The facility's policy, revised in August 2022, clearly states that all staff must participate in regular in-service education, including QAPI training, to ensure they can enhance residents' quality of life and care. The Director of Nursing (DON) emphasized the importance of QAPI as an ongoing process to address issues, improve communication among staff, and ensure proper resident care. The lack of training could lead to staff being unaware of updated facility procedures, proper communication protocols, or how to assist residents effectively. The facility's policy indicates that training requirements must be met before staff provide services to residents, annually, and as necessary based on the facility's assessment. The failure to conduct this training had the potential to result in poor communication among staff, lack of awareness of facility updates, lack of collaborative work, and compromised resident care.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to involve Resident 188 and his responsible party, FM 1, in the development and implementation of a care plan addressing significant weight loss. Resident 188 was admitted with multiple health issues, including a gastrostomy tube, muscle wasting, non-Hodgkin lymphoma, a tracheostomy tube, and multiple pressure ulcers. Despite a documented weight loss of 25.8 lbs. (21.7%) over two months, there was no evidence that FM 1 was informed or involved in creating a care plan to address this issue. The Assistant Director of Nursing (ADON) confirmed the absence of a care plan for severe weight loss and acknowledged the importance of involving the resident and responsible party in the care planning process. Resident 19, who was cognitively intact and had functional range of motion limitations, was not involved in the care planning process when Restorative Nursing Aide (RNA) services for range of motion exercises to both legs were discontinued. The RNA services were discontinued due to Resident 19's refusal, which was not adequately discussed with him or documented. The ADON and RNA 2 confirmed that the plan of care should have been discussed with Resident 19, and an interdisciplinary team (IDT) meeting should have been conducted to explore alternative options and reasons for refusal. The facility's policy and procedure on resident rights emphasize the importance of involving residents in their care planning and treatment. However, in both cases, the facility failed to ensure that the residents and their responsible parties were informed and involved in their care plans, leading to deficiencies in the care provided to Residents 188 and 19.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to ensure that the medical records of four residents were updated to reflect their advance directives, which are crucial for honoring their healthcare wishes. Resident 37, who was diagnosed with dementia and other conditions, did not have a confirmed advance directive due to the unresponsiveness of the assigned public guardian. Despite multiple attempts by the Social Service Director (SSD) to contact the guardian, there was no response, leaving the resident's healthcare preferences unconfirmed. Resident 343, also diagnosed with dementia and other mental health conditions, lacked a signed advance directive upon readmission. The SSD noted that the public guardian had not signed the necessary documents, and the resident's advance directive remained incomplete. Similarly, Resident 55, who had severe cognitive impairments, did not have a confirmed advance directive due to difficulties in contacting a family member who frequently changed contact information. The resident's care was under the facility's interdisciplinary bioethics committee, but the advance directive was still pending approval from a public guardian. Resident 46, with severe cognitive impairments and multiple diagnoses, had an outdated advance directive from 2022 that was not followed up on. The resident was marked as full code by default, awaiting a response from a representative. The facility's policies and procedures require that advance directives be honored and reviewed annually, but these were not adhered to, resulting in the deficiency. The lack of updated advance directives for these residents had the potential to cause conflicts with their healthcare wishes.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to notify the physician and responsible party of a significant change in condition for Resident 188, who experienced a severe weight loss of 21.6% over 60 days. Despite the facility's policy requiring notification of significant weight changes, the physician and family member were not informed in a timely manner. The resident's weight dropped from 119 lbs. to 93.2 lbs., and the care plan goals were not met as the weight loss exceeded the 5% per month threshold. Interviews with staff revealed a lack of understanding and adherence to the facility's policy on change of condition notifications. Additionally, the facility did not report a change of condition for Resident 19, who was at high risk for contracture development and had refused restorative nursing aide services for range of motion exercises. The refusal was not communicated to the physician, and no interdisciplinary team meeting was conducted to address the change in the resident's plan of care. The facility's policy required notification of the physician and the resident's representative when there was a significant change in the resident's condition, but this was not followed. The facility's policies on weight assessment and change in resident's condition were not adhered to, resulting in a lack of timely interventions and communication with the physician and family members. The failure to notify the physician and responsible parties of significant changes in residents' conditions could potentially delay necessary care and interventions, as noted in the interviews with the facility's staff and the physician.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to adhere to its policy and procedure regarding the use of physical restraints, as evidenced by the improper application of side rails and a lap tray for two residents. For Resident 24, the facility did not explore alternative measures to prevent falls before raising all four side rails, which were considered a restraint. Despite the resident's request for side rails, there was no documented consent indicating that the resident was informed of the risks and benefits. Additionally, the facility did not conduct a pre-restraining assessment to determine if the resident could lower the side rails independently, nor did they document any attempts to use less restrictive measures. The facility also failed to hold an interdisciplinary team (IDT) meeting to discuss the appropriateness of the restraint, and there was no evidence of staff monitoring the resident's condition or the effectiveness of the restraint. Resident 161 was placed in a Geri chair with a lap tray, which acted as a restraint since the resident was unable to remove it independently. The facility did not perform a pre-assessment to determine the necessity of the lap tray or assess whether the resident could remove it. There was no documentation of alternative measures being attempted before applying the lap tray, and no IDT meeting was held to evaluate the restraint's appropriateness. The resident was observed trying to stand but was blocked by the lap tray, indicating a lack of consideration for the resident's mobility needs. The facility's policy on the use of restraints requires a pre-restraining assessment, obtaining informed consent, and ongoing evaluation of the restraint's necessity. However, these procedures were not followed for either resident. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the failures, noting that staff did not recognize the side rails and lap tray as restraints and did not implement necessary safety measures. This oversight compromised the residents' dignity and safety, creating an unsafe environment and increasing the risk of injury.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) assessments for two residents, which is crucial for determining the facility's ability to meet their special needs. Resident 16 was admitted with diagnoses including psychosis, schizoaffective disorder, and major depressive disorder. Despite these serious mental health conditions, the PASRR Level I screening inaccurately indicated that Resident 16 did not have a serious mental illness. The Assistant Director of Nursing (ADON) acknowledged that the hospital typically conducts the PASRR Level I screening and sends it to the facility, but if a Level II is required and not available, the facility would follow up. The ADON also stated that a new PASRR Level I screening would be conducted if there was a change in condition or if the initial screening was inaccurate. Similarly, Resident 55 was admitted with major depressive disorder, dementia, and psychosis, yet the PASRR Level I screening also incorrectly indicated no serious mental illness. The ADON confirmed the inaccuracies in the PASRR Level I documentation for both residents, emphasizing the importance of the PASRR process in ensuring residents' psychological and mental health needs are addressed. The facility's policy requires a new Level I PASRR to be submitted if there is any error or discrepancy in the previous screening, and designated staff are responsible for reviewing information from the PASRR Online System regularly.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to develop and implement comprehensive, person-centered care plans for nine residents, leading to unmet needs and potential negative outcomes. Resident 19, who has quadriplegia and functional range of motion limitations, refused Restorative Nursing Aide services for passive range of motion exercises. Despite the resident's refusal, the facility did not create a care plan to address these refusals, which could lead to a decline in the resident's mobility and range of motion. The Minimum Data Set Coordinator confirmed the absence of a care plan for these refusals, emphasizing the importance of having goals and interventions in place to maintain the resident's current level of function. Resident 46, diagnosed with epilepsy and experiencing seizures, did not have an updated care plan to address actual seizures and the medications prescribed for them. The resident had multiple seizure episodes, yet the care plan had not been revised since 2022 to include interventions for these occurrences. Licensed Vocational Nurse 5 and the Assistant Director of Nursing acknowledged the need for a care plan that includes interventions for actual seizures and the medications being administered. The lack of an updated care plan could result in inadequate monitoring and management of the resident's condition. Residents 55, 21, and 188 experienced significant weight loss, but the facility failed to initiate care plans to address this issue. Resident 55 had a care plan for anticipated weight loss but not for actual weight loss, and the care plan had not been revised for a year. Resident 21's care plan did not include interventions for actual weight loss, and the Registered Dietitian was unsure if a specific care plan was needed. Resident 188 experienced severe weight loss, yet no care plan was created to address this change in condition. The Assistant Director of Nursing highlighted the importance of having a care plan to prevent further weight loss and ensure staff are aware of the necessary interventions. Additionally, Residents 40, 74, and 59 required specialized services as determined by their PASRR evaluations, but the facility did not create individualized care plans based on these recommendations, potentially affecting the residents' mental health needs.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to provide appropriate treatments and services to prevent or limit a decline in range of motion (ROM) and mobility for five residents. For Resident 95, the facility did not ensure that the Restorative Nursing Aide (RNA) order for the application of a resting hand splint was written with a maximal wear time, leading to uncertainty about the appropriate duration for splint use. This oversight could potentially result in skin breakdown and discomfort, as the RNA was not qualified to determine the wear time without specific instructions. Resident 19 did not receive passive range of motion (PROM) exercises for both arms as ordered, missing several scheduled sessions over three months. This lack of adherence to the physician's orders raised concerns about the resident's ROM, as the resident expressed worry about the infrequency of arm exercises. Similarly, Resident 37 missed multiple PROM exercise sessions for both arms and legs, which were not provided as per the physician's orders, potentially placing the resident at risk for functional decline. Residents 66 and 109 also experienced deficiencies in receiving ordered ambulation exercises. Resident 66 did not receive ambulation exercises using a front-wheeled walker as frequently as prescribed, and Resident 109 missed several sessions of ambulation exercises with hand-held assistance. These omissions in care could lead to a decline in mobility and overall physical functioning, as the facility's policies emphasize the importance of maintaining residents' current levels of function and preventing declines.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to properly manage tube feedings for three residents with gastrostomy tubes, leading to potential risks of infection. For Resident 16, the tube feeding was not disconnected after administration, as observed by a Licensed Vocational Nurse (LVN). The Director of Nursing (DON) confirmed that leaving the tube connected could cause issues such as abdominal distention and restlessness. For Resident 84, the Jevity 1.5 feeding was observed to have been hanging for 48 hours, exceeding the manufacturer's recommended hang time of 24 hours. The DON acknowledged that the feeding should have been replaced the previous day to prevent gastrointestinal problems and diarrhea. Resident 37's tube feeding was also not replaced within the recommended time frame. An LVN noted that the feeding had been hanging for over 48 hours, contrary to facility policy and manufacturer guidelines. Additionally, the water bag lacked a label and should have been replaced every 24 hours. These practices were inconsistent with the facility's policy on enteral feeding safety precautions.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to ensure that the Restorative Nurse Assistant (RNA 1) and licensed nurses, including Registered Nurses (RN 2 and RN 3), were competent in documenting and reporting significant weight changes for a resident. Resident 188, who was admitted with multiple health issues including a gastrostomy tube, muscle wasting, and non-Hodgkin lymphoma, experienced significant weight loss that was not properly documented or communicated to the registered dietician (RD), physician (MD 1), or the resident's family member (FM 1). The resident's weight loss was recorded in a handwritten document but was not entered into the electronic medical record, leading to a lack of timely intervention. The report highlights that the facility's staff did not follow the policy for documenting and reporting weight changes. Despite the resident's weight dropping from 119 lbs. to 93.2 lbs. over two months, the weight loss was not addressed in the resident's care plan, and the physician and family were not informed in a timely manner. The RNA verbally informed RN 3 of the weight loss, but it was not documented, and no action was taken to notify the physician or update the care plan. The RD was only made aware of the weight loss after reviewing the monthly weight report, which delayed the assessment and intervention. Interviews with staff revealed a lack of understanding and adherence to the facility's policies regarding weight monitoring and reporting. RN 2, the subacute unit manager, acknowledged that the facility did not complete a Change of Condition (COC) for weight loss unless it was a significant amount, and RN 3 admitted to not notifying the physician due to other duties. The Assistant Director of Nursing (ADON) emphasized the importance of documenting and monitoring significant weight loss, which was not done in this case, leading to further weight loss for Resident 188.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to ensure that Resident 177's physician order for Aspirin was administered correctly. The order specified that the Aspirin 81 MG tablet should be chewable, but it was observed that the resident swallowed the tablet instead. This was confirmed during an interview with RN 4, who acknowledged that the resident swallowed the aspirin, potentially affecting its efficacy. The Director of Nursing (DON) also stated that improper administration could lead to gastrointestinal stress and an increased risk of stroke. Resident 177 had a history of hypertension and hyperlipidemia and required supervision for eating and assistance with hygiene and bathing. The facility also failed to ensure the correct medication administration route for Resident 52, who had a gastrostomy tube and was unable to swallow by mouth. The physician order incorrectly indicated that Zinc Sulfate should be given orally, but LVN 3 had been administering it via the gastrostomy tube. LVN 3 acknowledged the error and the potential risk of aspiration if the medication were given orally. The DON emphasized the importance of verifying medication administration routes against physician orders and assessing the resident's condition to ensure accuracy. The facility's policy required that medication orders include the route of administration.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to store and label medications according to manufacturer guidelines, which was observed during a survey. For Resident 152, an opened Budesonide inhalation suspension foil pack was found without an open date on the medication cart. The Registered Nurse (RN) acknowledged that the open date should have been written on the foil pack, as the medication must be used within two weeks after opening. This oversight could lead to the resident receiving expired medication, potentially affecting their treatment for shortness of breath. For Resident 1, an expired IV Tobramycin bag was found in the medication storage room refrigerator. The RN confirmed that the antibiotic was discontinued and should have been disposed of properly. Additionally, for Resident 72, an opened Ipratropium-Albuterol inhalation solution foil pack was found without an open date. The Licensed Vocational Nurse (LVN) stated that the open date should have been recorded to ensure the medication is used within the recommended timeframe, as per manufacturer guidelines. Furthermore, an opened Tuberculin Purified Protein Derivative (PPD) multi-dose vial was found with an open date, but it was not disposed of within the 30-day period as required. The Director of Nursing (DON) emphasized the importance of labeling medications and following storage guidelines to maintain potency and ensure accurate TB screening. The facility's policy and procedure documents also highlighted the need for proper medication storage and disposal, which were not adhered to in these instances.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to ensure accurate completion and documentation of Physical Therapy Joint Mobility Screenings (PT JMS) for a resident, identified as Resident 19, who was part of a sample of seven residents. The PT JMS, dated 8/19/2024 and 10/15/2024, inaccurately indicated that Resident 19 had full passive range of motion (PROM) in both hips and knees and minimal range of motion (ROM) loss in both ankles. However, the screenings were conducted based on visual observation only, as Resident 19 refused the manual PROM assessment. This discrepancy was confirmed by Physical Therapist 1 (PT 1), who acknowledged that the assessments were inaccurate and should have documented the resident's refusal more clearly. Resident 19 had a medical history that included C1-C4 quadriplegia, polyneuropathy, and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) assessment, dated 1/22/2025, indicated that Resident 19 was cognitively intact but dependent on assistance for daily activities and had functional ROM limitations in both arms and legs. The facility's policy required that joint mobility assessments be conducted upon admission, re-admission, quarterly, and upon a change of condition, with accurate documentation to ensure appropriate interventions and services. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed the importance of accurate documentation in JMS evaluations to avoid missed opportunities for detecting declines in ROM and ensuring residents receive appropriate care. The facility's policy on Joint Mobility Assessment emphasized the need for accurate documentation to assist in developing or modifying care plans. The inaccurate documentation in Resident 19's PT JMS evaluations led to confusion and potential miscommunication among staff, highlighting a deficiency in the facility's documentation practices.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility's Quality Assessment and Assurance (QAA) and Quality Assurance Performance Improvement (QAPI) committees failed to identify and address concerns related to cardio-pulmonary resuscitation (CPR) and weight loss among residents. During an interview, the administrator admitted that these issues were not part of the current QAPI plan and were not identified before the recertification survey. The administrator acknowledged that these issues should have been detected through training and follow-through but were overlooked. A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy indicated that the facility maintains an ongoing, facility-wide QAPI program focused on care outcomes and quality of life for residents. However, the program failed to measure and monitor indicators related to CPR and weight loss, which are critical for ensuring resident safety and well-being. This oversight had the potential to lead to continued weight loss and improper assessment skills for initiating CPR in full code residents.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to adhere to infection control measures for several residents, leading to potential risks of infection transmission. Restorative Nursing Aide 2 did not wear an isolation gown while providing range of motion exercises to a resident on Enhanced Barrier Precautions (EBP). The aide was unaware of the resident's EBP status due to the sign being posted behind the bed, which was not visible upon entering the room. This oversight could have facilitated the spread of infectious microorganisms. Another deficiency involved the improper wrapping of padded side rails with foam and paper tape for a resident, which hindered effective cleaning and disinfection. The infection prevention nurse confirmed that the disinfectants used in the facility were only effective on hard, non-porous surfaces, making the foam and tape inappropriate for maintaining hygiene standards. This practice could lead to the spread of infection among residents and staff. Additionally, the facility failed to post EBP signage for a resident with a gastrostomy tube, foley catheter, and nephrostomy bag, and staff did not consistently wear proper PPE when interacting with residents on EBP. Observations revealed that staff members entered rooms without PPE and handled medical devices without performing hand hygiene, increasing the risk of cross-contamination. These lapses in protocol demonstrate a lack of adherence to infection prevention measures, potentially compromising resident safety.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to implement its antibiotic stewardship program policy, resulting in the inappropriate use of antibiotics for two residents. Resident 154 was administered ceftriaxone for a urinary tract infection (UTI) despite not meeting Loeb's or McGeer's criteria for antibiotic use. The resident, who had a history of respiratory failure with hypoxia, tracheostomy, and gastrostomy, was dependent on assistance for hygiene, bathing, and dressing. The Infection Preventionist Nurse (IPN) noted that Resident 154's symptoms did not meet the criteria for antibiotic use, and there was no documentation indicating that the physician was notified of this discrepancy. Despite this, the resident completed the prescribed course of ceftriaxone. Similarly, Resident 29 was given cephalexin for a possible UTI without meeting the necessary criteria for antibiotic administration. This resident, diagnosed with dementia and hypertension, required supervision for eating and moderate assistance for hygiene, bathing, and dressing. The IPN confirmed that Resident 29's symptoms did not meet the criteria, and again, there was no documentation of physician notification. The Director of Nursing (DON) emphasized that the purpose of the antibiotic stewardship program is to ensure appropriate use of antibiotics and prevent overuse, highlighting the need for physician notification when criteria are not met.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to provide adequate oral care for a resident under hospice care, compromising the resident's dignity and health. The resident, who was admitted with diagnoses including arteriosclerotic heart disease and Wernicke's encephalopathy, was dependent on staff for oral hygiene due to severe cognitive impairment and functional limitations. Despite physician orders and care plans indicating the need for oral care for comfort, observations revealed that the resident's teeth were covered with dried, sticky brown buildup, indicating a lack of oral care. Interviews with staff, including an LVN and the DON, confirmed that oral care is essential for maintaining dignity and preventing complications such as aspiration and infection. The facility's policies emphasized the importance of maintaining dignity and providing necessary care, yet the resident's Medication Administration Record showed that oral care was not provided as required. This oversight was observed over multiple days, with staff acknowledging the buildup and the potential risks associated with inadequate oral hygiene.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for a resident, identified as Resident 55, by not following facility policy and procedure to monitor and document assessments and interventions during a change of condition. The resident, who was admitted with diagnoses including protein-calorie malnutrition, major depressive disorder, and dysphagia, experienced significant weight loss over several months. Despite various dietary interventions being added to the care plan, the facility did not adequately monitor the resident's intake or adjust the care plan to address the actual weight loss. The facility's records indicated that Resident 55 had a history of poor oral intake and significant weight fluctuations, yet the care plan was not updated to reflect the actual weight loss. The resident's weight continued to decline, leading to the necessity of a gastrostomy tube to prevent further weight loss. Interviews with staff revealed that there was a lack of communication and documentation regarding the resident's food and supplement intake, and the care plan was not revised to address the ongoing weight loss. The facility's policies required that significant weight changes be reported and addressed by the multidisciplinary team, but this was not consistently done. The resident's weight loss was not adequately monitored, and the care plan was not updated to reflect the resident's needs, resulting in a failure to provide appropriate care. The facility's failure to implement a patient-centered care plan and monitor the resident's condition contributed to the resident's continued weight loss and subsequent medical intervention.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to ensure that a resident's drug regimen was free from unnecessary antipsychotic medications. Resident 188, who was admitted with diagnoses including gastrostomy tube, muscle wasting, non-Hodgkin lymphoma, tracheostomy tube, and multiple pressure ulcers, did not have any documented mental health issues or psychosis. Despite this, the resident was prescribed Seroquel, an antipsychotic medication, without an adequate diagnosis or indication for its use. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment but no signs of psychosis or behavioral symptoms that would justify the use of antipsychotic medication. The Assistant Director of Nursing (ADON) confirmed that there was no diagnosis for psychosis or mental health issues in Resident 188's chart, and the order for Seroquel lacked a complete manifestation statement. This oversight placed the resident at risk for harmful side effects associated with antipsychotic medications, including sedation, drowsiness, dizziness, and an increased risk of death as indicated by the black box warning on Seroquel. The facility's policy on antipsychotic medication use required that medications be clinically indicated for a specific condition, which was not adhered to in this case.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to adhere to its policy and procedure regarding antipsychotic medication use, resulting in a deficiency related to the administration of psychotropic medications without complete physician orders. Specifically, the facility did not ensure that a resident, who was admitted with diagnoses of unspecified dementia with behavioral disturbance, unspecified mood disorder, and unspecified psychosis, had a specific diagnosis and indication for the use of Olanzapine, an antipsychotic medication. The resident's minimum data set indicated severe cognitive impairment but no behavioral symptoms or indicators of psychosis, yet the resident was receiving antipsychotics. The assistant director of nursing (ADON) acknowledged the oversight during an interview, noting that the facility had been cited in a recent recertification survey for unnecessary psychotropic medications. The ADON confirmed that the resident's medication orders lacked a proper diagnosis and indication for the use of Olanzapine, which is crucial to ensure the medication is clinically indicated and the resident is monitored for specific behaviors. The facility's policy, dated July 2022, mandates that residents should not receive medications without a clinical indication to treat a specific condition, and residents transferred from hospitals on antipsychotics should be evaluated for appropriateness and indications for use.

Penalty

Fine: $83,77016 days payment denial

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

Summary

The facility failed to ensure the registered dietician (RD) was competent in assessing and reassessing residents with severe weight loss, specifically for one resident who experienced significant weight loss. The resident, admitted with multiple health issues including a gastrostomy tube and non-Hodgkin lymphoma, lost 25.8 lbs. or 21.6% of their body weight within 60 days of admission. The RD did not attend interdisciplinary team meetings and failed to document or address the resident's weight loss adequately. The resident's weight was not consistently monitored as per the facility's policy, and the RD did not reassess the resident after an initial evaluation despite ongoing weight loss. The RD recommended increasing the resident's nutritional intake but did not follow through due to the resident experiencing diarrhea. The RD did not reassess the resident after the diarrhea subsided, and the resident's weight continued to decline significantly. The facility's policy required immediate notification of the RD for significant weight changes, but this was not adhered to. The RD's job description included working with other departments on resident care issues, but the RD did not participate in interdisciplinary discussions or document the resident's care plan adequately. This lack of action and documentation placed the resident at risk for continued weight loss and potential malnutrition.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the cleaning products used by housekeeping staff were effective against Candida auris, a fungus known for causing severe, multidrug-resistant infections. During an observation and interview, it was found that the cleaning agents Virex Plus and One Step Disinfectant Cleaner and Deodorizer were being used in the subacute unit, where patients require more intensive skilled nursing care. These cleaning agents were not on the approved EPA list provided by the local Health Department, which specifies products effective against C. auris. The Infection Prevention Nurse and the Housekeeper Account Manager both confirmed that the cleaning agents used were not effective against C. auris, which could lead to the spread of the organism within the facility. The Director of Nursing acknowledged that cleaning agents should be effective against organisms present in the facility to prevent their spread. A review of the facility's local Health Department guidance and the facility's policy on transmission-based precautions indicated that cleaning agents should be EPA-approved and effective against C. auris. The failure to use appropriate cleaning agents during an ongoing C. auris outbreak in the facility had the potential to allow the organism to survive on surfaces and spread to other 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 develop and implement a comprehensive care plan for a resident who was admitted with diagnoses of dementia and schizoaffective disorder. The resident was found sitting on the floor, and the facility inaccurately attributed this behavior to cultural preferences without verifying with the resident's representative. The Director of Nursing (DON) admitted to assuming the behavior was cultural based on experiences with other residents and did not investigate further or consult with the resident's representative. This lack of accurate assessment and communication led to the resident's care needs not being properly addressed. Additionally, the facility did not create a care plan for the resident's nasal fracture after a hospital readmission. The resident returned with a broken nose, but there was no documentation of a care plan addressing the fracture, pain management, or necessary monitoring. The DON acknowledged the absence of a care plan for the nasal fracture, which was contrary to the facility's policy requiring care plan updates following hospital readmissions. This oversight resulted in the resident's care needs being inadequately managed.

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 psychiatric evaluation progress notes and General Acute Care Hospital (GACH) records were available in the clinical record for a resident. The resident was admitted with diagnoses of dementia and schizoaffective disorder, and their cognition was severely impaired. A physician's order required a psychiatric evaluation, but there was no documentation of such an evaluation in the resident's clinical records. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the resident was scheduled for psychiatric evaluations after a fall, but no documentation was found until the Medical Records Director (MRD) stated that the notes were requested and received later. Additionally, the resident was transported to a GACH due to a fall resulting in a laceration. However, there was no documentation from the GACH regarding the care or treatment orders during the resident's admission. The DON acknowledged that the GACH records should have been requested when they were not sent with the resident upon return to the facility. The MRD later confirmed that the GACH records were requested and received. The facility's policy indicated that complete and accurate medical records should be maintained for each resident.

Penalty

No penalty information released

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

Summary

The facility failed to include a resident and their responsible party in an Interdisciplinary Team (IDT) Conference after the resident was found sitting on the floor. The resident, who was admitted with diagnoses of dementia and schizoaffective disorder, had severely impaired cognition and required assistance with activities of daily living. Despite these needs, the IDT assumed the resident's behavior of sitting on the floor was a cultural preference without consulting the resident or their responsible party. This assumption was made by the Director of Nursing (DON) based on her experience with other residents, rather than verified information. The responsible party was not informed about the IDT meeting or the resident's behavior, which was not part of the resident's culture or preference. The DON admitted to not investigating further into the resident's behavior to determine if additional care measures, such as fall precautions or medication adjustments, were necessary. The facility's policy on resident rights emphasizes the importance of involving residents and their representatives in care planning, 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 implement its COVID-19 policy by not conducting contact tracing testing on staff who were close contacts of residents who tested positive for COVID-19. Four residents tested positive for COVID-19 on consecutive days, and the facility did not have documented evidence that exposed staff were tested on the recommended days following exposure. The Infection Prevention Nurse (IPN) acknowledged the lack of documentation and attributed it to the increased number of staff and residents, which required more disciplined tracking during an outbreak. The Director of Nursing (DON) was aware that staff were self-testing during the outbreak but was unsure if they were following the local health department's guidelines for testing on specific days. The facility's COVID-19 policy required contact tracing and testing of employees and residents with high-risk exposure, regardless of vaccination status, on days 0, 3, and 5. The failure to track and ensure compliance with these guidelines resulted in a deficiency in the facility's infection prevention and control program.

Penalty

No penalty information released

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

Summary

The facility failed to follow up on missed laboratory tests for a resident who had lab tests ordered but not collected. The resident, diagnosed with schizoaffective disorder and having severely impaired cognition, was admitted with a physician's order for several lab tests to be completed on a specific date. However, a review of the laboratory specimen collection log showed no date or time for the collection of these tests, and the laboratory order requisition indicated that the tests were canceled on the scheduled date. Interviews with the Registered Nurse Supervisor and the Director of Nursing revealed a lack of awareness regarding the missed lab tests. The Registered Nurse Supervisor stated that if a phlebotomist is unable to draw blood, it should be reported to the charge nurse and documented, but no such documentation was found. The Director of Nursing acknowledged the importance of lab results for monitoring and managing medical conditions, especially for very ill residents, but was unsure why the tests were not completed.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the gastrostomy tube (GT) dressings for two residents were replaced when they fell off, as required by physician orders. Resident 1, who was admitted with diagnoses including acute and chronic respiratory failure, cardiac arrest, tracheostomy, and gastrostomy, had orders to cleanse the GT site with normal saline, pat dry, and cover with a dry dressing every day shift, and to change the dressing as needed (PRN) when soiled or pulled out. However, during an observation, it was noted that Resident 1's GT dressing was missing, and the Treatment Administration Records (TAR) indicated no PRN dressing changes for the month of April 2024. The resident's significant other also reported noticing the missing dressing, and the Licensed Vocational Nurse (LVN) confirmed the absence of the dressing without knowing how it came off. Similarly, Resident 2, who was admitted with chronic respiratory failure, tracheostomy, and gastrostomy, had orders to cleanse the GT site with normal saline, pat dry, and cover with a dry dressing every day shift, and to change the dressing PRN when soiled or pulled out. During an observation, it was found that Resident 2's GT dressing was missing, and the LVN stated that the dressing might have fallen off during repositioning or care. The Treatment Nurse and the Director of Nursing (DON) both emphasized the importance of replacing the GT dressing to prevent skin irritation, infection, and breakdown, in accordance with the physician's orders. The facility's policy and procedure for gastrostomy/jejunostomy site care, revised in March 2023, indicated that the purpose of the procedure was to promote cleanliness and protect the gastrostomy site from irritation, breakdown, and infection. The policy required staff to verify physician orders, review the resident's care plan, and provide for any special needs of the resident. Despite these guidelines, the facility did not ensure that the GT dressings for Residents 1 and 2 were consistently replaced when they fell off, leading to a potential decline in skin integrity for both residents.