Fountain View Subacute And Nursing Center

Penalty

No penalty information released

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

Summary

Facility staff failed to ensure a resident was free from abuse by not immediately reporting, investigating, and addressing an allegation of sexual abuse. The resident, who had heart failure, intact cognition, and required extensive assistance with ADLs including personal care and toileting, reported that about five days prior a CNA cleaned her perineal area and touched her inappropriately in her vagina. The resident stated she reported this to the social worker, but nothing was done. The resident’s MDS showed she was dependent on staff for lower body dressing, toileting, and footwear, and required maximal or partial assistance for other ADLs, indicating reliance on staff for intimate care. The Social Services Worker acknowledged that the resident reported the allegation of abuse to her on the evening of 1/26/2026 and that she was aware of the facility’s abuse reporting policy, but she did not report the allegation to the Administrator, DON, or other leadership, did not complete an SOC 341, and did not notify police or the Ombudsman. The Administrator confirmed she had not been informed of the allegation and stated it should have been reported the day it occurred. The DSD reported that several days earlier the Ombudsman had informed her that the resident said she had been touched inappropriately by a staff member, but the DSD did not seek further details and assumed the resident was referring to back rubs, and no investigation was initiated and the CNA was not suspended. The DON stated he was not made aware of the allegation when it was reported and that the failure to report prevented implementation of immediate protective interventions. Review of the facility’s abuse policy showed that all abuse allegations must be reported immediately (within two hours) to the administrator and appropriate agencies, and that any employee accused of abuse is to be placed on leave with no resident contact until the investigation is complete, which did not occur 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 abuse prevention and reporting policies when a cognitively intact resident, admitted with heart failure and requiring extensive assistance with ADLs, reported being inappropriately touched in the perineal/vaginal area by a CNA during personal care. The resident stated the incident occurred several days prior and that she informed the social services worker (SSW), but nothing was done. The resident’s MDS showed she needed maximal to total assistance for most personal care tasks, including toileting and hygiene, and setup assistance for eating, indicating reliance on staff for intimate care. On the date the allegation was reported, the SSW acknowledged that the resident directly reported the alleged abuse to her but admitted she did not notify the Administrator, DON, or other leadership, did not complete the SOC 341, and did not contact law enforcement or the Ombudsman as required by facility policy. The Administrator and DON both stated they were unaware of the allegation at the time and confirmed that such an allegation should have been immediately reported and investigated. The Director of Staff Development (DSD) reported that the Ombudsman had previously informed her that the resident said she had been touched inappropriately by a staff member, but the DSD did not seek further details, assumed the resident was referring to back rubs, and did not initiate an investigation or remove the alleged perpetrator from resident contact. Review of the facility’s abuse reporting and investigation policy showed that all abuse allegations must be reported within two hours to the Administrator and appropriate agencies, and that any employee accused of abuse must be placed on leave with no resident contact until the investigation is complete, which did not occur in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure an allegation of abuse involving one resident was immediately reported to facility administration and appropriate external authorities as required by policy and federal regulations. The resident, who had heart failure, required extensive assistance with ADLs, and had intact cognition, reported that about five days prior a CNA had cleaned her perineal area and touched her inappropriately in her vagina. The resident stated she reported this to the social worker, but nothing was done. The social services worker confirmed that the resident reported an allegation of abuse to her on the evening of 1/26/2026, acknowledged knowing the abuse reporting policy and the requirement to immediately report such allegations to administration, but did not notify the Administrator, DON, or other leadership, did not complete the SOC 341, and did not contact law enforcement or the Ombudsman as required by facility protocol. The Administrator stated she had not been informed of the allegation and confirmed that such conduct would be considered abuse and should have been reported the day it was reported to staff. The DSD reported that several days earlier, during an Ombudsman visit, the resident had also reported being touched inappropriately by a staff member, but the DSD did not seek further details and assumed the resident was referring to back rubs the resident usually requested; no investigation was initiated and the alleged perpetrator was not suspended. The DON stated he was not made aware of the allegation when it was reported and that the failure to report prevented the facility from implementing immediate protective interventions. Review of the facility’s abuse reporting and investigation policy showed that all reports of resident abuse were to be immediately reported to the administrator and appropriate agencies within two hours, and that any employee accused of abuse was to be placed on leave with no resident contact until the investigation was complete, which did not occur in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely follow-up and communication regarding a resident's request to transfer to another facility. The resident, who had diagnoses including heart failure, obesity, and reduced mobility, was cognitively intact and required significant assistance with daily activities. Despite the resident's clear request for assistance with transferring, there was no documented evidence that the facility contacted the requested receiving facility or provided the resident with updates about the status of the transfer for approximately one month. The resident expressed frustration and dissatisfaction due to the lack of communication and support for his care preferences, and even stopped participating in physical therapy sessions in anticipation of the transfer. Interviews revealed that the Social Services Worker acknowledged failing to follow up on the transfer request and not providing updates to the resident. The Director of Nursing confirmed that it was the responsibility of the Social Services Worker to assist residents with grievances and requests, including communicating updates. Review of facility policy indicated that residents have the right to be informed of and participate in care planning, and to have the facility respond to grievances. The lack of timely follow-up and communication impeded the resident's request and negatively affected his experience.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident with diagnoses including colon cancer, cognitive communication deficit, and epilepsy attended multiple scheduled physician appointments outside the facility. The resident, who had severely impaired cognition and required maximal to partial assistance with daily activities, missed several important medical appointments for colorectal surgery surveillance and neurology follow-up. The missed appointments were due to issues such as lack of available escorts, transportation staff declining responsibility, and facility staff being unaware of scheduled appointments. There was also a failure to document nursing progress notes following outside medical visits. Specifically, after the resident attended an appointment, the charge nurse did not document the resident's return, update new orders, or follow up in the resident's chart. The charge nurse acknowledged not ensuring a proper handoff to the next shift, which would have facilitated documentation and follow-up on new orders and appointments. The facility's process, as described by staff, included communication of appointments, documentation of departures and returns, and handling of new orders, but these steps were not consistently followed. Interviews with facility staff revealed gaps in communication and documentation practices. The social services worker, registered nurse supervisor, charge nurse, care coordinator, and director of nursing all described processes that were not effectively implemented, resulting in missed appointments and lack of documentation. The facility's policy required assistance with scheduling, transportation, and documentation of appointments and new orders, but these procedures were not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure timely follow-up and communication regarding a resident's request to transfer to another facility. The resident, who had diagnoses including heart failure, obesity, and reduced mobility, was cognitively intact and required maximal to total assistance with most activities of daily living. Despite the resident's request for assistance with transferring, there was no documented follow-up or communication from the Social Services Worker (SSW) for approximately one month. The resident expressed frustration and dissatisfaction due to the lack of updates and support for his care preferences, and even stopped participating in physical therapy sessions in anticipation of the transfer. Interviews revealed that the SSW acknowledged not contacting the requested receiving facility or providing the resident with updates about the status of the transfer request. Record review confirmed the absence of documentation regarding any actions taken to facilitate the transfer or communicate progress to the resident. The Director of Nursing (DON) confirmed that it was the SSW's responsibility to assist residents with grievances and requests, including providing updates. The facility's policy also indicated that social services staff are responsible for assisting with transitions of care and advocating for residents' rights.

Penalty

No penalty information released

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

Summary

Failure to develop a Comprehensive Care Plan for one sampled resident with left eye blindness was identified. The resident was admitted with diagnoses including left eye blindness and low vision in the right eye. The MDS dated 11/14/2025 indicated the resident had cognitive skills for daily decision making and required varying levels of assistance with eating, oral hygiene, bed mobility, dressing, toileting, footwear, and sit-to-stand transfers. The resident also had an order dated 11/8/2025 for Atropine Sulfate Ophthalmic Solution 0.01% to be instilled in the left eye every 12 hours for left eye blindness. Review of the resident's record found no care plan interventions addressing the left eye blindness, including no problem statement, goals, monitoring parameters, comfort measures, or physician notification requirements. During interview, the resident stated the eye medication had not been given in the morning, causing the left eye to feel dry and painful and making it difficult to keep the eyes open. The resident also stated there had been other days when the medication was not administered and expressed concern because of blindness in the left eye and low vision in the right eye. The LVN acknowledged the scheduled 6 AM dose had not been administered and was not endorsed during shift report, and also stated she did not assess the resident's pain level during her shift. The DON stated the omission should have been documented, explained, and endorsed by licensed nurses, and that a Comprehensive Care Plan should have been initiated to ensure continuity of care between shifts.

Penalty

No penalty information released

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

Summary

The facility failed to administer Resident 3’s ordered 6 AM atropine sulfate ophthalmic solution to the left eye on 11/24/2025, and the missed dose was not documented with a reason or endorsed to the oncoming licensed nurse. Resident 3 was admitted with left eye blindness and low vision in the right eye, and the MDS dated 11/14/2025 indicated cognitive skills for daily decision making along with varying levels of assistance for activities of daily living. The order summary dated 11/8/2025 directed 1 drop of atropine sulfate ophthalmic solution 0.01% in the left eye every 12 hours for left eye blindness. Review of the MAR showed the eye medication was also not given on 11/17/2025 at 6 AM and 11/22/2025 at 6 PM, and there was no documentation explaining the omissions on 11/22/2025 and 11/24/2025. During interview, Resident 3 stated the missed morning dose caused her left eye to feel dry and painful and that she had experienced other days without the medication. The LVN who was the charge nurse and medication nurse stated the medication was present in the cart but had not been administered as scheduled, that the missed 6 AM dose was not endorsed during shift report, and that she did not assess Resident 3’s pain level. The DON reviewed the care plan, order summary, and MAR and stated the omission should have been documented, explained, and endorsed by licensed nurses, and that a comprehensive care plan should have been initiated for the resident’s left eye blindness.

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 emergency tracheostomy ventilator unit box (e-kit) was properly checked and maintained monthly according to its own policy and procedure. During an observation, the e-kit was found locked without any indication of when it was last checked, and the Respiratory Therapist Supervisor (RTS) was unable to state when the last check occurred or who was responsible for maintaining the equipment inside the e-kit. A review of the e-kit order form revealed it was blank, with no documentation of when it was last opened or checked. The e-kit contained essential emergency supplies such as a tracheostomy cuffed tube, syringes, and normal saline. Interviews with the RTS and the Director of Nursing (DON) confirmed that the e-kit should be checked and maintained regularly to prevent shortages of supplies in emergencies. The facility's policy, reviewed on 3/20/2025, specified that the equipment should be checked monthly by Respiratory Therapy, be operational, locked with an appropriate tag, and have a signed equipment checklist. These requirements were not met, as evidenced by the lack of documentation and uncertainty regarding responsibility for the e-kit’s maintenance.

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 standardized recipes and menu instructions for residents on specialized diets during a lunch service. Six residents on a pureed diet received only half a cup of enchilada instead of the required one cup, as specified in the facility's portion and serving guide. The cook responsible for preparing the meal was unaware of the correct portion size and did not consult the spreadsheet, resulting in residents receiving less food than prescribed. Dietary staff responsible for reading and calling out diet orders also did not notice the discrepancy in portion size, and the registered dietitian confirmed that the meal tickets indicated the correct amount, which was not followed. For residents on a Controlled Carbohydrate (CCHO) diet, 23 individuals received four ounces of Spanish rice instead of the two ounces specified for their diet. Both the cook and dietary aide were unaware that the CCHO diet required a reduced portion of rice compared to the regular diet. The registered dietitian and dietary supervisor confirmed that the menu and spreadsheet clearly indicated the correct portion sizes, and the facility's policy emphasized the importance of adhering to these portions for blood sugar control. Additionally, six residents on a soft and bite size diet received cheese enchiladas that were not cut into the required ½ x ½ inch pieces, as per the facility's policy and IDDSI guidelines. The cook cut the enchiladas into inconsistent sizes using a spatula during service, rather than preparing them in advance to the correct specifications. The issue was identified during a tray check, and the trays were returned to the kitchen for correction. The registered dietitian and dietary supervisor confirmed that the food was not prepared to the required texture and size prior to service, as mandated by facility policy and international guidelines.

Penalty

No penalty information released

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

Summary

The facility failed to ensure safe and sanitary food storage and preparation practices by storing and serving unpasteurized shell eggs and by improperly labeling and storing previously prepared pureed desserts. Observations revealed that unpasteurized shell eggs were kept in the reach-in refrigerator and used to prepare fried eggs for residents, despite facility policy and FDA Food Code requirements that only pasteurized eggs be used for soft-cooked egg items. The dietary staff, including the cook and Dietary Supervisor, were unaware that the eggs in use were unpasteurized, and the purchase order confirmed that regular shell eggs had been received and used. The Registered Dietitian also verified that the eggs were not pasteurized and emphasized the need for checking deliveries to ensure compliance. Additionally, seven single-serving containers of brown pureed food were found in the walk-in refrigerator without proper labeling, and the Dietary Supervisor could not identify the contents or confirm the correct storage period. The facility's policy required that all refrigerated, ready-to-eat TCS foods be labeled with a prepared date and a use-by date not exceeding seven days, but the pureed desserts were labeled with a 14-day range and lacked clear identification. These failures in food storage and preparation practices had the potential to result in harmful bacteria growth and cross-contamination, affecting the majority of residents who received food from the facility.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to provide privacy to a resident during the administration of medication through a gastrostomy tube (g-tube). The LVN did not pull the privacy curtain while administering the medication, resulting in the resident's gown being pulled up and the abdomen and g-tube site exposed. During this time, the resident's roommate was present and walking around the room, further compromising the resident's privacy. The LVN later acknowledged not pulling the curtain and stated that it was necessary to do so to provide privacy and uphold the resident's dignity. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living, including feeding via a g-tube. The facility's policy required staff to promote and protect resident privacy, including bodily privacy during care and treatment procedures. Both the LVN and the Director of Nursing confirmed that the privacy curtain should have been pulled during the procedure to maintain the resident's dignity, as outlined in the facility's dignity policy.

Penalty

No penalty information released

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

Summary

The facility failed to develop a care plan addressing ventilator and tracheostomy care for one resident who was admitted with chronic respiratory failure, obesity, and encephalopathy. The resident required ongoing interventions including oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilation. Despite these needs, a review of the resident's care plans revealed that there was no care plan in place specifically for ventilator or tracheostomy care at the time of review. Interviews with the MDS Nurse and the Director of Nursing confirmed that the absence of a ventilator/tracheostomy care plan meant that essential aspects of care, such as monitoring suctioning, stoma management, and ventilator settings, were not formally addressed. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes, but this was not done for the resident in question.

Penalty

No penalty information released

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

Summary

The facility failed to review and revise the care plan quarterly for a resident who used a hand mitten as a restraint to prevent the removal of invasive tubing. The resident, admitted with diagnoses including acute respiratory failure with hypoxia and epilepsy, was noted to have significant cognitive impairment and required daily use of a limb restraint. The Minimum Data Set confirmed the use of restraints, and a physician order specified the application of a hand mitten to the resident's left hand. However, the care plan, initially created at admission, had not been updated since October of the previous year, despite facility policy requiring quarterly updates. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that the care plan was overdue for revision and that any licensed nurse could perform updates. The facility's policies on comprehensive care planning and restraint use both required quarterly review and updates by the interdisciplinary team. The lack of timely care plan revision had the potential to result in the resident not receiving appropriate nursing interventions related to restraint use.

Penalty

No penalty information released

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

Summary

The facility failed to maintain the appropriate settings on a Low Air Loss Mattress (LALM) for a resident who was re-admitted with a Stage 4 pressure ulcer of the sacral region. The physician's order specified that the LALM should be set between 250-280 lbs and checked every shift, based on the resident's weight of 250 lbs. However, during observation, the LALM was found set at 320 lbs, which was above the recommended range. The resident reported discomfort and stated that the mattress was too hard and was starting to hurt her bottom. Staff interviews confirmed that the LALM settings should match the resident's weight and that incorrect settings could impact wound healing. Further review of the operator's manual for the LALM confirmed that the pressure-adjust knob should be set according to the patient's weight. Multiple staff, including the Infection Preventionist, Treatment Nurse, and Director of Nursing, acknowledged that the settings were incorrect and that the mattress was firmer than intended, which could compromise its pressure-relieving function. The deficiency was identified through observation, interview, and record review, with direct evidence that the LALM was not set as ordered for wound management.

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

Certified Nursing Assistant 1 (CNA1) failed to follow proper infection prevention and control practices while providing care to two residents who were on enhanced barrier precautions. During an observation, CNA1 was seen emptying a urinal for one resident and then immediately assisting another resident without changing their gown or mask and without performing hand hygiene. This was confirmed by both the Infection Preventionist nurse and CNA1, who acknowledged that gloves are changed between resident care, but the gown, mask, and hand hygiene were neglected in this instance. Both residents involved had significant medical conditions requiring enhanced barrier precautions. One resident had chronic respiratory failure, a tracheostomy, and a gastrostomy tube, and was severely cognitively impaired and fully dependent on staff for care. The other resident had muscle wasting, a gastrostomy tube, dementia, and was colonized with a multidrug-resistant organism (ESBL). Both residents were always incontinent and required dependent assistance for personal hygiene, increasing their vulnerability to infection. Facility policies and care plans for both residents specified that staff must perform hand hygiene and change PPE, including gowns and gloves, before and after providing care, especially when moving between residents. The facility's own infection control policy and staff interviews confirmed these requirements. However, CNA1 did not adhere to these protocols during the observed care, which was recognized as an infection control issue by the Infection Preventionist nurse and the Director of Nursing.

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 the required minimum of 80 square feet per resident in multiple occupancy rooms for 12 out of 36 resident rooms, as determined through observation, interviews, and record review. During an initial tour, nursing staff were observed to have enough space to provide care in each room, and residents attending a council meeting reported no concerns regarding room size. However, a review of the facility's Client Accommodation Analysis confirmed that rooms 2, 4, 6, 8, 14, 18, 20, 22, 24, 28, 30, and 37 did not meet the minimum square footage requirement, with each resident in these rooms having less than 80 square feet of space.

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 care plan interventions were followed for a resident with multiple medical conditions, including end-stage renal disease, hemiplegia, and diabetes mellitus type two. The resident's care plan for a mouth lesion with a possible infection required vital signs to be taken and recorded, and an antibiotic, Amoxicillin, to be administered twice daily for five days. However, the Medication Administration Record indicated that a dose was missed on one day, and the Director of Nursing confirmed that vital signs were not consistently documented during the specified period. The facility's policies and procedures for nursing documentation and medication administration were not adhered to, as evidenced by the lack of timely and accurate documentation of vital signs and the missed administration of medication. The Director of Nursing acknowledged the documentation gaps and attributed them to the presence of many new nurses, indicating a need for reinforcement of proper documentation practices. This deficiency had the potential to negatively impact the delivery of care and services to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accurate and complete medical records for two residents, leading to deficiencies in documentation. For Resident 1, inaccuracies were found in the ventilator administration record, where various procedures and checks were marked as completed with checkmarks, despite the resident being discharged to a General Acute Care Hospital. The Director of Nursing (DON) confirmed that the documentation should have indicated the resident was away or in the hospital, and acknowledged that the respiratory therapist responsible for the documentation had not been working at the facility for over eight months. Resident 1 had a complex medical history, including ventilator-dependent respiratory failure, tracheostomy, gastrostomy, chronic atrial fibrillation, and functional quadriplegia. The resident was dependent on staff for various activities of daily living and had severe memory problems. The inaccuracies in the ventilator administration record included daily and weekly procedures such as changing the inner cannula, checking the heat moisture exchanger, and monitoring ventilator settings, which were incorrectly documented as completed. For Resident 3, the facility failed to maintain accurate vital sign summaries and nurse progress notes. The DON verified that the temperature summary was incomplete, with missing entries for several days. Additionally, there was an error in the nursing progress note, which inaccurately recorded the resident's date of death. Resident 3 had a medical history of end-stage renal disease, dependence on renal dialysis, hemiplegia, and diabetes mellitus type two. The resident required varying levels of assistance for daily activities and was cognitively intact. The inaccuracies in documentation were attributed to new nursing staff and the need for reinforcement of proper documentation 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

The facility failed to comply with professional standards of care by not implementing and following its policy and procedure regarding staff meal-breaks. Interviews with three Licensed Vocational Nurses (LVNs) revealed that they were scheduled to work 12-hour shifts as full-time employees. However, when the census in the sub-acute area was low, their hours were flexed, resulting in them either taking an unpaid one-hour lunch break or going home early, which led to them working less than their scheduled 12-hour shifts. This practice was inconsistent with the facility's Employee Acknowledgement agreement, which allowed employees to waive a second 30-minute meal break only if they worked more than 10 hours but less than 12 hours in a day. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the licensed nurses' hours were adjusted based on census levels, requiring them to take unpaid lunch breaks or leave early, thus not completing their 12-hour shifts. This was contrary to the signed meal waiver agreement, which was not being adhered to. A review of the facility's policy titled 'California Meal and Rest Periods' indicated that employees working over 10 hours but less than 12 hours must start their second 30-minute meal break by the end of the 10th hour unless they choose to waive it. The facility's failure to follow this policy infringed upon the employees' agreement and acknowledgment.

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 actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift were posted for two sampled days. On both 10/15/2024 and 10/16/2024, observations revealed that only the projected hours were posted on the Direct Care Services Hours Per Patient Day (DHPPD) board, with no actual hours displayed. Interviews with the Director of Nursing (DON) and Administration (ADM) confirmed that the actual hours for the previous day should have been posted alongside the current day's projected hours, but this was not done. The facility's policy and procedure, reviewed on 3/21/2024, mandates the daily posting of nurse staffing data, including actual hours worked for each shift, which was not adhered to in this instance.

Penalty

Inspection fine: $24,53116 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 effective infection prevention and control measures for scabies, a highly contagious skin condition, as per their policy and procedure titled 'Scabies Identification, Treatment and Environmental Cleaning.' This deficiency was identified during a recertification survey and involved four residents who were sampled. The facility did not identify and detect symptoms of scabies in a timely manner for a resident who had a skin rash upon readmission. The resident was not placed on contact precautions when treatment with Elimite and Ivermectin began, and the diagnosis of scabies was confirmed days later. The facility also failed to maintain contact precautions as per the physician's order, which was issued after the scabies diagnosis. The resident was not isolated from roommates, and contact precautions were not implemented promptly, increasing the risk of transmission to other residents, staff, and visitors. The infection preventionist acknowledged that contact isolation precautions were initiated late and should have been in place when scabies was suspected. The deficiency resulted in a potential risk of scabies transmission to 86 in-house residents, staff, and the community. The facility's failure to adhere to its scabies policy and procedure led to an Immediate Jeopardy situation, as identified by surveyors, due to the threat posed to the health and safety of residents, staff, and family members.

Removal Plan

• Licensed Nurses completed skin assessments for Residents 1, 2, 3, and 4.
• Resident 1: Noted to have a generalized body rash secondary to diagnosis of eczematous dermatitis and will be re-assessed by a dermatologist after final treatment.
• Resident 2: Noted to have body rash on chest, abdomen, arms, back and thighs secondary to dermatitis.
• Resident 3: Noted to have a body rash on bilateral arm secondary to dermatitis.
• Resident 4: Noted to have body rash extending from back to abdomen secondary to dermatitis.
• Treatment Plan for Residents 1, 2, 3 and 4 included:
• Resident 1: Clobetasol Propionate External Cream 0.05% to generalize body topically daily, Permethrin External Cream 5% to neck and toes topically at bedtime every Thursday and Ivermectin 9 mg via GT every Wednesday.
• Resident 2: Refused treatment and was educated regarding risks of refusing treatment and the importance of receiving treatment. Resident 2 was subsequently placed in contact isolation pending test results.
• Resident 3: Clobetasol Propionate External Cream 0.05% to arms twice daily.
• Resident 4: Hydrocortisone Cream 0.1% and Clindamycin Phosphate External Gel I% to abdomen and back.
• Residents 2, 3, and 4 had skin scraping completed, pending results.
• Environmental Service completed a deep cleaning of the room for Residents 1, 2, 3, and housekeeping department will continue with deep clean schedule for all resident care areas. Work areas were also deep cleaned.
• The Infection Control committee, including the Medical Director held an ad hoc QAA meeting to review the IJ Removal Plan for further review and recommendations.
• The Infection Control Nurse and/or designee connected with the Public Health Nurse for further recommendations and validation to confirm that the facility took all necessary steps for Residents 1, 2, 3, and 4.

Penalty

Inspection fine: $24,53116 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 Infection Preventionist Nurse (IP) completed the required specialized training related to infection control on an annual basis. This deficiency was identified during an interview and record review, where it was revealed that the IP had not completed the necessary continuing education units (CEUs) for 2023. The IP acknowledged the importance of continuous training to stay updated on changes and guidelines in infection control, which is crucial for preventing the spread of infections within the facility. The deficiency led to a failure in maintaining contact precautions for a resident diagnosed with scabies, a highly contagious skin condition. The resident was readmitted to the facility with multiple diagnoses, including chronic respiratory failure, pneumonia, and heart failure. Upon readmission, the resident was found to have a generalized body rash, which was later confirmed as scabies through a positive skin scraping. Despite the diagnosis, the facility did not implement the necessary contact precautions in a timely manner, as indicated by the lack of appropriate signage and protective measures for staff and visitors. The Director of Nursing (DON) admitted uncertainty about the CEU requirements for the IP but emphasized the importance of the IP being up-to-date with infection control issues. The DON also acknowledged that contact precautions should have been initiated earlier for the resident and their roommates to prevent the spread of scabies. The facility's policy on infection prevention and control, which aims to maintain a safe and sanitary environment, was not adequately followed, contributing to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the certification requirements for one of its certified nurse assistants (CNA 2) were up to date. CNA 2's certificate had expired, yet the CNA continued to work for over a month with an expired certificate. The Director of Staff Development (DSD) acknowledged that it was her responsibility to ensure that all CNAs were certified and that their credentials were current. Despite this, CNA 2 was hired with an expired certificate and continued to provide patient care without an active certificate. The Assistant Director of Nursing (ADON) confirmed that CNAs should not work with expired credentials as it could lead to inadequate nursing care. A review of the facility's policy and procedure on licensure, certification, and registration of personnel indicated that recertifications must be presented to the human resources director or designee before the expiration of current certifications. This policy was not followed in the case of CNA 2, leading to a potential knowledge, training, and certification deficit among the CNA, which could result in inadequate resident care. The facility's failure to adhere to its own policy and ensure that CNA 2's certification was up to date represents a significant deficiency in maintaining proper staff qualifications.

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 care plan for four residents, leading to several deficiencies. For Resident 31, the care plan did not include measurable goals for monitoring cerebrovascular accidents (CVA) and the use of aspirin for CVA prophylaxis. This oversight was confirmed by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the absence of monitoring for aspirin side effects such as bleeding and bruising. The Minimum Data Set Coordinator (MDSC) also admitted that the verification of the care plan was overlooked, resulting in a lack of patient-centered care for Resident 31. Resident 70's care plan was deficient in monitoring the adverse effects of the psychotropic medication Lexapro. Despite the resident's diagnosis of depression and the prescription of Lexapro, there was no individualized plan to monitor for potential adverse effects. This was confirmed by LVN 6 and the DON, who both acknowledged the importance of monitoring for adverse effects to ensure the resident's health was not negatively impacted. Resident 188's care plan did not include transmission-based precautions (TBP) despite the resident's history of carbapenem-resistant Enterobacterales (CRE) and immunocompromisation. The DON confirmed that the absence of a care plan for TBP increased the risk of spreading infections to other residents. Similarly, Resident 25's care plan failed to address a skin disorder, which was confirmed by the DON. The facility's policies and procedures were not followed, resulting in the lack of comprehensive care plans for these residents, which should have included measurable objectives and timetables to meet their medical, physical, mental, and psychosocial needs.

Penalty

No penalty information released

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

Summary

The facility failed to provide complete Restorative Nursing Assistant (RNA) treatments as per physician's orders for three residents, leading to increased risk for contractures and decline in physical function. Resident 2, who had severe cognitive impairment and was dependent on staff for various activities, did not receive passive range of motion (PROM) exercises to the lower extremities on multiple occasions. The Restorative Administration Record and Weekly/Monthly Progress Report for Resident 2 were incomplete, with no documentation of treatment provided or refused on specific dates. Resident 53, who had diagnoses including neuropathy and hemiplegia, also did not receive PROM exercises to the left upper extremity and both lower extremities as ordered. The resident's records indicated that the RNA did not perform the exercises on several dates, and the Weekly/Monthly Progress Report lacked documentation for a specific week. Resident 53 confirmed that RNA services were not provided as frequently as ordered. Resident 71, who had reduced mobility and muscle weakness, did not receive ambulation using a platform walker and active range of motion (AROM) exercises to the upper extremities as ordered. The Restorative Administration Record and Weekly/Monthly Progress Report for Resident 71 were incomplete, with blank spaces indicating that the treatment was not documented. Interviews with staff confirmed that the documentation was not properly maintained, and the treatments were not consistently provided, putting the residents at risk for functional 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 account for controlled substances (CS) for several residents, leading to discrepancies in medication counts and documentation. During an observation, it was found that one dose of lorazepam was missing for a resident, and one dose of phenobarbital was missing for another resident. The Licensed Vocational Nurse (LVN) responsible admitted to administering the medications but failing to document the administration, which is against the facility's policy. This failure in documentation could lead to medication errors and potential harm to the residents involved. In another observation, it was found that there were extra doses of hydrocodone-acetaminophen and oxycodone in the medication bubble packs for two other residents. The LVN responsible had documented the preparation of these medications but did not administer them, again failing to follow the facility's policy. This inconsistency in documentation could lead to untreated pain and discomfort for the residents. Additionally, the facility's Director of Nursing (DON) failed to include verifying signatures on the Controlled or Antibiotic Drug Record accountability logs for two sampled months. This lack of verification could lead to inaccuracies in medication records and potential diversion of controlled substances. The DON acknowledged the failure to follow the facility's policy and the need for a consistent process to ensure accountability and prevent harm to residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a medication error rate of less than five percent during medication administration, resulting in an overall error rate of 7.69%. Specifically, Resident 43 received vitamin D3 5000 iu instead of the prescribed vitamin D2 50000 iu, and Resident 83 received folic acid 400 mcg instead of the prescribed folic acid 1 mg. These errors were observed during medication administration and confirmed through interviews with the involved licensed vocational nurses (LVNs) and a review of the residents' Medication Administration Records (MARs). The LVNs acknowledged their mistakes and recognized that administering incorrect medications could lead to adverse effects for the residents. The Director of Nursing (DON) confirmed that the LVNs failed to verify the correct form and dosage of the medications before administration, which is a violation of the facility's policies and procedures. The facility's policy requires medications to be administered as prescribed and for the administering individual to check the medication label three times to ensure the right resident, medication, dosage, time, and route. The errors were attributed to the LVNs not adhering to these protocols, leading to the administration of incorrect medications to Residents 43 and 83.

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 medications were safely stored as per their policy and procedures. During a medication administration observation, an LVN placed four medication cups on a resident's bedside table. After administering one medication, the LVN left the room to grab gloves, leaving the remaining three medication cups unattended. Upon returning, the LVN administered the remaining medications. This action was confirmed by the LVN, who acknowledged that medications should always be supervised and stored safely to prevent unauthorized access and potential harm. The Director of Nursing confirmed that the LVN failed to safely store and supervise the medications, emphasizing the risk of other residents gaining unauthorized access and potential harm. The facility's policy on medication storage requires all drugs and biologicals to be stored in a safe, secure, and orderly manner, with only authorized personnel having access. The policy also mandates that nursing staff maintain medication storage and preparation areas in a clean, safe, and sanitary manner.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper infection control procedures for two residents. For one resident, a Licensed Vocational Nurse (LVN) did not disinfect a nightstand before placing a syringe cap on it, and did not clean or disinfect a water tray after it was contaminated with residual droplets from a gastrostomy tube (G-tube) procedure. The LVN admitted to these lapses in infection control, acknowledging that these actions could lead to contamination and potential infections for the resident. The Director of Nursing (DON) confirmed that these actions were indeed infection control issues that could harm the resident by causing G-tube infections. For another resident, the facility failed to post the correct transmission-based precautions sign for contact isolation, despite the resident having a history of carbapenem-resistant Enterobacterales (CRE) and being immunocompromised. The Infection Preventionist (IP) confirmed the absence of the required contact isolation sign, and the DON stated that the lack of such a sign posed a risk of spreading microorganisms to staff and other residents. The facility's policies and procedures were reviewed and found to require proper cleaning, disinfection, and posting of isolation signs to prevent the spread of infections. The facility's policies on cleaning and disinfection of resident-care items and equipment, as well as standard precautions, were not followed in these instances. The failure to adhere to these policies increased the risk of infection for the residents and potentially for other residents and staff in the facility. The DON and IP both acknowledged the deficiencies and the potential for harm due to these lapses in infection control 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

The facility failed to ensure that the call light was within reach for Resident 7, who was dependent on staff for various activities of daily living. Resident 7 had significant medical conditions, including acute respiratory failure with hypoxia, COPD, epilepsy, and a tracheostomy, and used a ventilator to breathe. Despite the care plan indicating that the call light should always be within reach, an observation on 4/15/2024 revealed that the call light was hanging on the right side of the bed and was not accessible to the resident. Registered Nurse 1 confirmed that Resident 7 could not reach the call light. Further interviews and record reviews supported this finding. The Director of Nursing acknowledged that if the call light is not within the resident's reach, the resident would not have access to assistance when needed. The facility's policy and procedures, dated 9/2022, also stipulated that the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor. This failure had the potential to delay services and not address the needs of Resident 7.

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 one of three sampled residents had an Advance Directive on file as part of the resident's medical record, as required by the facility's policy and procedures. Resident 67, who was admitted with severe cognitive impairment and multiple serious diagnoses, including traumatic brain injury, cerebral infarction, and quadriplegia, did not have a copy of their Advance Directive in their medical record. This oversight was identified during a review of the resident's records and confirmed through interviews with the Case Manager/Social Services and the Director of Nursing, who both acknowledged the importance of having the Advance Directive in the chart to ensure proper care and adherence to the resident's wishes in case of an emergency. The absence of the Advance Directive in Resident 67's medical record was noted despite the resident's representative having signed an Advance Healthcare Directive Acknowledgement Form. The facility's policy, dated 3/23/2022, mandates that a copy or scan of the Advance Directive be placed in the resident's medical record by the Admission Staff or designee. The failure to comply with this policy could potentially affect the resident's care and psychosocial well-being, as the facility staff would not have the necessary information to carry out the resident's healthcare wishes accurately.

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 accurately complete the Minimum Data Set (MDS) assessment Section I for a resident by omitting a diagnosis of cerebrovascular accidents (CVA). This omission was identified during a review of the resident's clinical records, which indicated a history of CVA and a prescription for aspirin as a prophylactic measure. The resident's Admission Record and General Acute Community Hospital discharge records both documented the CVA diagnosis, but it was not included in the MDS assessment initiated on 03/10/2024. During an interview, the Director of Nursing (DON) confirmed that the CVA diagnosis was missed and overlooked in the MDS assessment. The DON acknowledged the importance of accurately reflecting residents' needs in the MDS and comprehensive assessments to maintain their highest level of functionality and quality of life. The failure to include the CVA diagnosis in the MDS assessment had the potential to negatively affect the resident's plan of care and delivery of necessary services.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper assessment and documentation for a resident with a diagnosis of schizophrenia, leading to an inaccurate PASARR Level I screening. The resident was initially admitted and later readmitted with diagnoses including schizophrenia, chronic obstructive pulmonary disease, and dysphagia. However, the PASARR Level I screening incorrectly indicated that the resident did not have a serious diagnosed mental disorder. This error was acknowledged by the Director of Nursing (DON) during a review and interview, who confirmed that the schizophrenia diagnosis was missed, resulting in the resident not receiving a PASARR Level II assessment and subsequent follow-up for their mental condition. The facility's policy and procedures require all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders as part of the PASARR process. The admission coordinator was responsible for completing the PASARR forms, but the DON confirmed that the form was filled out inaccurately. This oversight could affect the resident's treatment and generalized care while in the facility. The facility's policy also states that the admitting nurse should notify the social services department when a resident is identified as having a possible or evident mental disorder, intellectual disability, or related disorder, which did not occur 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 provide skin and pressure ulcer preventative care consistent with professional standards of practice and per physician's orders for one resident. The resident, who was at risk for skin breakdown, developed a left heel pressure injury while residing in the facility. The facility did not complete weekly skin assessments, did not document the initial wound assessment upon discovery, and failed to obtain and document physician's orders for treatment of the pressure ulcer from the time it was discovered until several days later. This resulted in the resident not receiving the necessary daily treatment and care for the pressure injury during this period. The resident was admitted with diagnoses including adult failure to thrive, muscle wasting and atrophy, and depression. The resident's Braden Scale assessment indicated a moderate risk for pressure ulcers, and the care plan included interventions such as weekly skin assessments and preventative skin care. However, there were no documented skin assessments or progress reports for the month of February, and the resident's care plan was not updated to reflect the new pressure injury until after it was discovered. Interviews with facility staff revealed that the treatment nurse did not document the weekly skin assessments and failed to transcribe the physician's order for wound treatment. The Director of Nursing confirmed that physician orders should have been transcribed and carried out, and that weekly wound assessments were required to monitor the wound's progress. The facility's policies and procedures for pressure ulcer care and the treatment nurse's job description were not followed, leading to the resident's pressure injury going untreated for several days.

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 respiratory care services for two residents by not administering oxygen therapy as per the physician's orders. Resident 238, who had severe cognitive impairment and multiple diagnoses including metabolic encephalopathy and dementia, was observed with an oxygen concentrator set incorrectly at 3 liters per minute (lpm) instead of the ordered 2 lpm. The concentrator's red status indicator light was illuminated, indicating a malfunction, and the resident was receiving less than 0.5 lpm of oxygen. Licensed Vocational Nurse 1 (LVN 1) confirmed the malfunction and replaced the concentrator with an oxygen tank. The Director of Nursing (DON) acknowledged that staff should have identified the issue and taken appropriate action sooner to prevent the resident from not receiving the correct amount of oxygen, which could lead to severe health risks. Maintenance Supervisor stated that it was the nurse's responsibility to notify the respiratory therapist for servicing the concentrator when it failed. The facility's policy and procedures for oxygen administration were not followed correctly in this instance, leading to the deficiency in care for Resident 238. Resident 5, who had diagnoses including schizophrenia, chronic obstructive pulmonary disease (COPD), and dysphagia, was observed receiving oxygen therapy at 4 lpm instead of the ordered 2 lpm. Licensed Vocational Nurse 2 (LVN 2) confirmed the incorrect oxygen flow rate and acknowledged that the resident should have been on 2 lpm. The DON verified the physician's order and stated that licensed nurses were responsible for ensuring the correct oxygen therapy. The facility's policy and procedures for oxygen administration were not adhered to, resulting in the resident receiving an incorrect oxygen flow rate, which could lead to adverse health effects. The facility's policies and procedures for oxygen administration, including verifying the physician's order, setting the correct flow rate, and ensuring the equipment is functioning properly, were not followed in both cases. This led to deficiencies in the respiratory care provided to Resident 238 and Resident 5, putting them at risk for serious health complications. The DON emphasized the importance of following the physician's orders for oxygen administration to prevent such deficiencies in 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 post the federally required daily actual hours worked by the staff in an area accessible to the public for two out of 17 days in April 2024. On 4/17/2024, it was observed that the Census and Direct Care Service Hours Per Patient Day (DHPPD) for the skilled nursing facility (SNF) and Sub-Acute unit were dated for 4/15/2024, not the current date. The Director of Nursing (DON) confirmed that the DHPPD should have been updated daily to reflect the most current hours worked by the staff, which was not done on the day of observation. The Director of Staff Development (DSD) also confirmed that the DHPPD was supposed to be posted by 9 AM each day, but the actual hours for 4/17/2024 had not yet been posted at the time of the surveyor's visit. The facility's policy and procedures, revised in August 2022, indicated that nurse staffing data should be posted daily for each shift within two hours of the beginning of each shift. This data should include the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care. The DSD mentioned that the facility had a new process of posting the actual hours from the previous day instead of projections and actual hours together. However, this process was not followed correctly, leading to the deficiency noted by the surveyors.

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 appropriate monitoring to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, Resident 31 was prescribed aspirin to prevent cerebrovascular accidents but did not have monitoring for signs and symptoms of bleeding for 36 days. This oversight was identified through interviews and record reviews, which revealed that the resident's clinical record lacked documentation for monitoring the side effects of aspirin, such as bleeding and bruising. Additionally, there was no care plan with measurable goals for the use of aspirin and the prevention of cerebrovascular accidents. During interviews, both the Licensed Vocational Nurse and the Director of Nursing confirmed the absence of necessary monitoring and care planning for Resident 31. The Pharmacy Consultant also corroborated that monitoring for side effects should have started when the aspirin was prescribed. The facility's policy and procedures for Medication Regimen Review were not followed, as they require thorough reviews to prevent and resolve medication-related problems, including inadequate monitoring for adverse consequences.

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 necessary care was provided consistently for a resident receiving hospice services. Specifically, the facility did not provide the required hospice licensed nurse and hospice aide visits twice a week as per the integrated hospice and facility plan of care. Additionally, the hospice agency did not provide a calendar of visits for the month of April 2024. These deficiencies were identified for Resident 27, who had diagnoses including senile degeneration of the brain, kidney failure, and encephalopathy. The resident was admitted to hospice care with a physician's certification effective from April 6, 2024, to June 4, 2024, and the plan of care required twice-weekly visits from both a hospice nurse and aide for patient assessment and personal care, respectively. Upon review, it was found that there was no calendar for April in Resident 27's hospice binder, and no documented visits from the hospice nurse or aide from April 6 to April 17, 2024. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), confirmed the absence of the required documentation and visits. The facility's policy and procedures indicated that it was the facility's responsibility to coordinate with the hospice provider to meet the resident's needs, including maintaining communication and documentation. The lack of adherence to these protocols had the potential to lead to Resident 27 experiencing unnecessary pain and discomfort due to the missed hospice services.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a working call light system for Resident 69, who had severe cognitive impairment and was dependent on staff for various activities of daily living. During an observation, it was noted that the call light in Resident 69's room did not illuminate when pressed, requiring multiple attempts by a Certified Nursing Assistant (CNA) to activate it. Additionally, the call light panel at the nurses' station did not indicate that the call light was on, as confirmed by the Maintenance Supervisor (MS). This malfunction was corroborated by the Director of Nursing (DON), who acknowledged that the faulty call light system posed a risk of delayed care and falls for Resident 69. Resident 69's medical history included congestive heart failure, anoxic brain injury, repeated falls, and asthma. The resident's care plan specifically included interventions to prevent falls, such as placing the call light within reach and reminding the resident to use it. However, the malfunctioning call light system compromised these preventive measures. The facility's policy on the call system, revised in September 2022, emphasized the importance of timely responses to residents' needs, 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 meet the required 80 square feet per resident in multiple residents' bedrooms for 12 out of 36 resident rooms. Specifically, rooms 2, 4, 6, 8, 14, 18, 20, 22, 24, 28, 30, and 37 did not meet the minimum space requirement, providing less than 80 square feet per resident. This deficiency was identified during an initial tour of the facility and confirmed through a review of the facility's Client Accommodation Analysis. Despite the space constraints, nursing staff were observed to have enough space to provide care, and no concerns were raised by residents during a council meeting regarding the room sizes. Additionally, individual interviews with residents and staff indicated that they did not experience difficulties in moving around or providing care within the rooms, even those that were undersized according to the regulations. The facility had submitted a room waiver letter requesting an exemption for the identified rooms, stating that there were no obstructions interfering with the free movement of wheelchairs and other devices. The letter also indicated that the rooms provided adequate space for each resident's care, dignity, and privacy, and would not adversely affect the residents' health and safety. Observations confirmed that the rooms had privacy curtains and direct access to corridors, and staff were able to maneuver medical equipment and assist residents without difficulty. However, the deficiency remains due to the rooms not meeting the specified square footage requirements.