Gladstone Sub-acute And Rehab 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

The facility failed to ensure a safe, comfortable, and homelike environment for one resident when it did not address a malfunctioning television over an extended period. The resident, who had diagnoses including acute and chronic respiratory failure, COPD, and Type 2 diabetes mellitus, was cognitively intact and required substantial to maximal assistance with activities of daily living such as bathing, dressing, toileting hygiene, personal hygiene, and oral hygiene. The resident reported that the television, which was the main source of entertainment, would shut off approximately every 20 minutes, requiring the resident to repeatedly turn it back on with the remote. The resident stated having previously informed both the Maintenance Supervisor and the Social Service Director about the problem and reported feeling frustrated by the ongoing issue. Surveyors directly observed the television malfunction when the screen went black while the audio continued, necessitating the resident to use the remote to restore the picture. During interviews, the Maintenance Supervisor acknowledged that the television screen had been turning off for the past six months and attributed the issue to a weak TV signal. The Social Service Director reported being informed by the resident about the faulty television about one month prior and stated that this concern had been relayed to the Maintenance Supervisor. Despite facility policies stating that the Maintenance Department is responsible for maintaining equipment in a safe and operable manner at all times and that residents are to be provided with a safe, clean, comfortable, and homelike environment, the television remained unrepaired, resulting in the identified 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 provide timely notices of discharge to the ombudsman for three sampled residents who were transferred to a general acute care hospital. For one resident with severe cognitive impairment and total dependence on staff, the Notice of Proposed Transfer/Discharge (NPTD) was not faxed to the ombudsman until several days after the transfer, despite the facility's policy requiring immediate notification. The responsible party received the notice on the day of transfer, but the ombudsman was notified late, as confirmed by the Registered Nurse Supervisor during record review and interview. Another resident, who had intact cognition but required varying levels of assistance with daily activities, was transferred due to difficulty swallowing. The NPTD was provided to the resident on the day of transfer, but the ombudsman was not notified until the following day. Similarly, a third resident with metabolic encephalopathy and respiratory failure was transferred for medical treatment, and while the resident received the NPTD on the day of transfer, the ombudsman was notified two days later. In both cases, the facility's transmission logs confirmed the delays in notification to the ombudsman. Interviews with facility staff, including the DON and Medical Record Director, revealed that the facility's policy required the ombudsman to be notified at the same time as the resident or their representative, but the policy language was unclear and not consistently followed. The Medical Record Director acknowledged being responsible for faxing the NPTD but cited being busy as the reason for the delays. The facility's own policy and procedure documents confirmed that notification to the ombudsman should occur concurrently with notification to the resident or representative, and that temporary transfers to acute care are considered facility-initiated discharges.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the timely readmission of a resident who was transferred to a general acute care hospital for further evaluation due to medical needs. The resident, who had severe cognitive impairment, hemiplegia, and bipolar disorder, was dependent on staff for all activities of daily living and lacked capacity to make decisions. After the transfer, the facility's records indicated a seven-day bed hold was in place, and the resident had the right to be readmitted to the first available bed even if the hospitalization exceeded the bed-hold period. Despite this, the facility did not readmit the resident for seven days after the resident was ready for discharge from the hospital. Documentation and interviews revealed that a bed was available during this period, but the facility's admission team delayed the readmission process due to concerns about verifying the resident's insurance eligibility, specifically related to a Medi-Cal M1 code. The admissions coordinator, DON, and administrator were all involved in the decision-making process, with instructions given to hold the readmission until insurance eligibility was confirmed, even though the resident was Medi-Cal eligible and the facility's policy did not require third-party payment guarantees for readmission. Observations confirmed that the bed previously occupied by the resident remained vacant and unassigned to any other resident during the delay. The facility's own policies and procedures indicated that residents should be readmitted to their previous room or the next available bed, regardless of insurance status, but this was not followed. The delay resulted in the resident remaining unnecessarily in the hospital, contrary to the facility's stated policies and the resident's rights.

Penalty

No penalty information released

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

Summary

The facility failed to provide activities of daily living (ADLs) related to hygiene and bathing in accordance with residents' needs and preferences for four out of five sampled residents. Multiple residents with significant physical impairments, including paraplegia, hemiplegia, quadriplegia, morbid obesity, and Parkinson's disease, were dependent on staff for transfers, personal hygiene, and dressing. These residents had intact cognitive skills and were able to express their preferences for showers over bed baths, stating that showers made them feel cleaner and more dignified. Residents reported that they were unable to receive showers as preferred due to the unavailability of a Hoyer lift, which was required for safe transfers. Staff interviews confirmed that only one Hoyer lift was operational across three nursing units during the past week, resulting in delays in morning care routines, substitution of bed baths for showers, and residents getting out of bed later than usual. This equipment shortage led to residents arriving late to scheduled activities and, in some cases, missing the start of these activities. The facility's policy required that residents be offered showers at least once weekly and upon request. However, due to the limited availability of functioning lifts, staff were unable to meet these preferences and needs, directly impacting residents' hygiene routines and psychosocial well-being. Maintenance staff confirmed that the shortage was due to a malfunctioning remote and a new lift awaiting calibration, which further contributed to the delays and substitution of 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 maintain an adequate supply of heat and moisture exchange (HME) devices for all 14 residents with tracheostomy tubes who were dependent on mechanical ventilators. On 6/29/2025, there were only 8 HMEs available for 14 residents, and this shortage persisted until the supply was replenished on 7/2/2025. According to the facility's policy and procedure, HMEs are required to be changed every 24 hours or when soiled, but due to the insufficient supply, this standard was not met for any of the affected residents during the shortage period. All 14 residents involved had diagnoses including respiratory failure and were dependent on others for most activities of daily living, as well as on oxygen therapy, suctioning, tracheostomy care, and ventilator support. The Respiratory Therapist Lead and Assistant Director of Nursing both confirmed that the available supply was inadequate to meet the needs of the residents, and that the facility's policy regarding HME changes could not be followed during the shortage. The shortage was attributed to a delay in delivery from the respiratory supply vendor, despite timely ordering by facility staff.

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 public health nurse (PHN) guidance and its own policies for infection prevention and control during a Covid-19 outbreak. Specifically, the facility did not ensure that proper signage for novel respiratory precautions was displayed outside the rooms of residents presumed to be infected with Covid-19. Observations revealed that only one resident's room had the correct signage, while others had signage for enhanced barrier precautions (EBP), which require less stringent use of personal protective equipment (PPE). Interviews with the Infection Preventionist Nurse (IPN) and review of facility policy confirmed that novel respiratory precautions, including full PPE, were required for these residents, but were not implemented until after the surveyor's inquiry. Additionally, the facility did not adhere to the PHN's instructions to test all newly admitted and re-admitted residents for Covid-19 on days 0, 3, and 5. Instead, residents were tested only twice weekly, regardless of their admission or readmission status. This was confirmed through interviews with the Assistant Director of Nursing (ADON) and review of the facility's Covid-19 Mitigation Plan, which also specified the need for serial testing on the specified days. The PHN stated that the facility was expected to follow these serial testing instructions, but this was not done for the sampled residents. The facility also failed to ensure that staff completed Covid-19 rapid antigen tests (RAT) and confirmed negative results before entering patient care areas. An observation showed that a Licensed Vocational Nurse (LVN) began their shift and entered patient care areas before their RAT result was fully developed and confirmed negative. The LVN acknowledged that the test result was unclear and that they should have waited for a definitive result before starting work. Facility policy and PHN instructions required staff to test before each shift and restrict work until a negative result was confirmed.

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 adequately monitor a resident's use of the psychotropic medication Ativan, prescribed for anxiety. The resident, who had chronic respiratory failure and quadriplegia, was admitted with intact cognition and was dependent on staff for bathing and toileting. From 5/9/2025 to 5/23/2025, the resident received thirteen 1 mg doses of Ativan for anxiety manifested by screaming and yelling due to concerns about their health condition. However, during this period, the Medication Administration Record (MAR) did not indicate that the resident was monitored for side effects of Ativan or for the presence of anxious behaviors. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed that monitoring for both side effects and target behaviors was not documented after a new order for Ativan was written. The previous monitoring orders had expired, and staff failed to renew them with the new prescription. The facility's policy required daily monitoring of psychotropic drug use for adverse effects and target behaviors, but this was not followed during the specified timeframe.

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 document a resident's diagnosis of mood disorder in the admission record, despite evidence from multiple sources indicating the presence of this condition. The resident was admitted with several diagnoses, including chronic respiratory failure and quadriplegia, but the admission record did not reflect a mood disorder. However, the Minimum Data Set assessment and medical professional progress notes indicated the resident had intact cognition and was dependent on staff for certain activities, and a psychiatrist had planned to initiate Depakote for mood disorder. The order summary report showed an active physician order for Depakote, but the order did not specify the diagnosis of mood disorder, only referencing poor impulse control manifested by screaming and yelling. During an interview, the DON confirmed that Depakote was prescribed for a mood disorder and acknowledged that the admission record should have been updated to include this diagnosis. The facility's policy required that psychotherapeutic medication orders include the diagnosis and indications for the medication, which was not followed in this case. This omission meant that the resident's current condition and the justification for the medication were not clearly documented or communicated to staff.

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 care plan interventions for two residents as required by its own policies and procedures. For one resident with a history of osteoporosis, osteoarthritis, and dementia, the care plan specified the use of a left heel splint and required assessment of pedal pulses every shift following a documented left calcaneus fracture. However, there was no physician order for the splint in the resident's active orders, and staff interviews revealed confusion about who was responsible for applying and removing the splint. Additionally, there was no documentation that pedal pulses were being checked as required by the care plan. For another resident with diagnoses including abnormalities of gait and mobility and dementia, the care plan and physician orders required restorative nursing services (RNS) for ambulation with a front wheel walker three times per week. Despite these orders, the resident did not receive any RNS for an entire month. Staff interviews and record reviews confirmed that the missed services were due to miscommunication between nursing, restorative nursing aides, and rehabilitation staff, resulting in the resident not being ambulated as ordered. The facility's policy on care planning states that residents have the right to receive the services and items included in their plan of care. In both cases, the facility did not follow its own care planning procedures, leading to failures in providing ordered treatments and monitoring as specified in the residents' care plans.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate care and services to prevent the development of new pressure injuries for one resident with significant risk factors. The resident was admitted with diagnoses including morbid obesity, quadriplegia, and chronic respiratory failure, and was assessed as being at risk for impaired skin integrity due to factors such as immobility, incontinence, and fragile skin. The care plan specified that the resident should be kept dry and clean and repositioned at least every two hours to prevent pressure injuries. Observations and interviews revealed that staff did not consistently reposition the resident as required. On one occasion, the resident was observed lying on their back in a high Fowler's position, and after being assisted by staff, was not repositioned to either side to relieve pressure. Staff interviews confirmed that the resident was not repositioned as per protocol, and that repositioning is necessary to prevent pressure injuries, especially for residents who are dependent for mobility and incontinent. Additionally, the resident was found to be double briefed, with the inner brief saturated with urine, contrary to facility policy and staff knowledge. Both nursing and administrative staff acknowledged that double briefing is not permitted as it increases heat and moisture, contributing to skin breakdown. Facility policies reviewed did not support double briefing and emphasized the importance of regular repositioning and perineal care to maintain skin integrity.

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 document and provide restorative nursing services (RNS) as required for several residents, resulting in incomplete or falsified records. For one resident with orders for ambulation using a front wheel walker three times per week, the RNS was not provided for an entire month despite physician orders and care plan directives. The restorative nursing assistant (RNA) later signed the resident's record for that month at the direction of the Director of Nursing (DON), even though the services had not been rendered. The RNA stated that the DON instructed them to sign the record to correct the mistake, and the RNA complied due to the DON's authority, not realizing this constituted falsification of records. Additionally, the facility failed to ensure that RNAs only documented services they actually provided. For two other residents, the RNS records were signed by an RNA on a date when the RNA was not clocked in for work, indicating that the services were not actually performed. The RNA admitted to accidentally signing and initialing the records for those dates. Similarly, for another resident, three different RNAs signed the RNS record on dates when none of them were present at work, and each acknowledged during interviews that they had made mistakes in documentation or were unsure if the services were provided. The facility's policy required accurate and timely documentation of restorative nursing services, with staff expected to document and communicate any significant resident problems or changes. However, the review of timecards, interviews with staff, and examination of medical records revealed that the facility did not follow its own procedures, resulting in inaccurate records and a lack of required restorative care for multiple residents. The DON and Assistant DON were aware of discrepancies but did not ensure that the records accurately reflected the care provided.

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 document and provide restorative nursing services (RNS) as ordered for several residents, resulting in incomplete and inaccurate medical records. For one resident with diagnoses including gait abnormalities and dementia, there was a physician's order for ambulation assistance three times per week, but the resident did not receive any RNS for the entire month as required. Despite this, the Restorative Nursing Assistant (RNA) was instructed by the Director of Nursing (DON) to sign the treatment record for the month, resulting in documentation that falsely indicated services were provided. The RNA later stated that the DON directed them to 'fix the mistake' by signing the record, and the DON acknowledged a miscommunication between nursing, RNA, and rehabilitation staff regarding the new order. Additionally, the facility failed to ensure that documentation on the Restorative Nursing Record (RNR) accurately reflected the provision of services for other residents. One RNA signed and initialed the RNR for two residents on a date when the RNA was not clocked in for work, and two other RNAs signed for services provided to another resident on dates when they were not present in the facility. These inaccuracies were confirmed through timecard reviews and staff interviews, where the involved RNAs admitted to signing for services they did not provide, either by accident or as directed. The facility's policy required accurate and timely documentation of restorative nursing services to ensure residents received appropriate care based on their assessments and physician orders. The failures in communication, documentation, and oversight led to medical records containing false information for multiple residents, which could affect their care and outcomes. The facility's own policy emphasized the importance of accurate documentation and prompt communication of significant changes or problems to the charge nurse.

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 all staff had up-to-date N95 respirator fit tests, as required by CDC and NIOSH guidelines. A review of the facility's Fit Test Log (FTL) revealed that 101 staff members had expired N95 fit tests, with 37 of those staff actively working during a specific shift while wearing N95 masks with expired fit tests. The Director of Nursing (DON) confirmed that they themselves had not been fit tested for the current year, and the last update to the FTL was provided to the Public Health Nurse due to a COVID-19 outbreak. The Assistant Director of Nursing (ADON) corroborated that 37 staff on duty were wearing N95 masks with expired fit tests. The Infection Prevention Nurse (IPN) stated that annual fit testing is necessary to ensure proper mask fit, especially in light of changes to staff members' facial structure or weight, and that expired fit tests could result in staff inhaling infectious particles during an ongoing outbreak. The facility was unable to provide a policy and procedure for annual N95 mask fit testing. Review of CDC and OSHA guidelines confirmed the requirement for annual fit testing for tight-fitting respirators, and the need for re-testing if there are changes in mask brand, model, or the employee's facial characteristics. The lack of current fit testing and absence of a policy contributed to the deficiency identified during the survey.

Penalty

No penalty information released

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

Summary

Certified nursing assistant (CNA) 3 failed to work within their scope of practice by turning off a gastrostomy tube (G-tube) feed pump for a resident who had been admitted with quadriplegia and required enteral feeding via G-tube. The resident's medical records indicated intact cognition and a physician's order for continuous enteral feeding at a specified rate using a pump. During an observation, CNA 3 was seen turning off the G-tube feed pump and admitted to doing so, despite acknowledging that this task was supposed to be performed by a nurse. Interviews with licensed vocational nurses (LVN 3 and LVN 4) and the Director of Nursing (DON) confirmed that CNAs were not permitted to stop G-tube feeds or operate the pump, as it was outside their scope of practice and could lead to complications such as pump malfunction or G-tube dislodgement. The facility's failure to ensure that CNA 3 worked within their legal and ethical boundaries placed the resident at risk for adverse outcomes related to improper handling of the G-tube and feeding equipment.

Penalty

No penalty information released

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

Summary

The facility failed to designate a qualified infection preventionist nurse (IPN) to oversee the Infection Prevention and Control program during a period when a COVID-19 outbreak was occurring. According to the facility's records, the last day the former IPN worked was 5/20/2025, and as of 5/21/2025, there was no designated IPN present. The Director of Nursing (DON) reported covering the IPN role despite not having IPN certification. The COVID-19 outbreak had been declared on 5/12/2025, and at least three COVID-19 positive cases were identified among residents and/or staff within a seven-day period. Interviews with the DON confirmed that the facility did not have a certified IPN during the outbreak, and the DON acknowledged the need for a certified IPN to monitor and prevent infections. Review of the facility's job description for the Infection Control Coordinator (ICC), also known as the IPN, indicated that this role is responsible for promoting and maintaining infection control guidelines and ensuring all infection control documentation is maintained according to federal and state requirements. The absence of a designated and qualified IPN during an active outbreak constituted a failure to implement the facility's Infection Prevention and Control program as required.

Penalty

No penalty information released

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

Summary

Licensed nurses failed to follow physician orders and care plan interventions for a resident who was admitted with multiple diagnoses, including COPD, heart failure, and type II diabetes mellitus. The resident had significant bilateral lower extremity pitting edema, with a care plan and physician order in place for the application of Thrombo-Embolic Deterrent (TED) hose stockings to manage the edema. Despite these orders, staff did not consistently apply the TED hose, and there was no documentation in the medication administration record (MAR) indicating that the TED hose were being used as prescribed. Interviews and observations revealed that the resident was not wearing TED hose at the time of surveyor visits, and both the resident and staff were unable to recall when the TED hose were last applied. The resident reported that staff were not putting the TED hose on and expressed frustration that their needs and physician's orders were not being followed. Staff interviews indicated confusion regarding documentation requirements and assessment of edema, with some staff unsure how to properly assess or document the resident's condition. The care plan and physician order specifically required the use of TED hose, but this intervention was not implemented or monitored as directed. The facility's policies and procedures required that physician orders be accurately transcribed, implemented, and documented, and that care plans be person-centered and based on assessed needs. However, the lack of application, monitoring, and documentation of the TED hose for this resident resulted in the resident experiencing ongoing significant edema and pain, with staff unable to provide evidence of compliance with the prescribed interventions. The Director of Nursing confirmed the importance of following such orders and acknowledged that staff had not been recently in-serviced on edema assessment.

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 implement and follow the care plan for a resident with a history of chronic obstructive pulmonary disease, heart failure, and type II diabetes mellitus, who was admitted with significant pitting edema in both lower extremities and the left upper extremity. The care plan, initiated in June 2024, specified that the resident should wear TED hose stockings to address the risk of fluid volume overload and reduce edema, as ordered by the physician. However, observations and interviews revealed that the resident was not wearing the prescribed TED hose, and staff were unable to confirm when they were last applied. Record reviews, including the medication administration record, did not show documentation that TED hose were being applied as ordered. Multiple staff interviews confirmed that the resident was not wearing the TED hose and that licensed nurses were not consistently assessing or documenting the resident's pitting edema. The resident reported not understanding why the TED hose were not being applied, and staff acknowledged the importance of this intervention for managing edema. The facility's policy and procedure on care planning required that comprehensive, person-centered care plans be developed and implemented based on assessed needs, and that residents receive the services and items included in their care plans. The failure to apply TED hose as ordered and to assess and document edema as required by the care plan constituted a failure to follow both physician orders and facility policy, resulting in the identified 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 provide documentation of a resident's status and care related to the application of Thrombo-Embolic Deterrent (TED) hose stockings, as required by the facility's policy and procedure for nursing documentation. Despite a physician's order for the resident to wear TED hose on both lower extremities for leg swelling/edema, nursing staff did not document when the TED hose were applied or removed. Review of the resident's medication and treatment administration records showed no indication that the TED hose were being applied as ordered. Interviews with licensed nurses and the Director of Nursing confirmed that the lack of documentation was due to the way the order was transcribed, and staff were not monitoring or recording the use of TED hose or the resident's edema status. The resident involved had a history of chronic obstructive pulmonary disease, heart failure, and type II diabetes mellitus, and required substantial assistance with dressing. Observations confirmed that the resident was not wearing TED hose at the time of the survey, and staff were unable to state when the TED hose were last applied. The facility's policy required concise, clear, and accurate documentation of treatments completed as per physician orders, but this was not followed in the case of the resident's TED hose application.

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 physician's orders were carried out or noted in a timely manner for three residents. In one case, an optometrist ordered antibiotic eye ointment for a resident with blepharitis, but due to a delay in clarifying the order and obtaining an alternative medication from the pharmacy, the first dose was not administered until several days after the initial order. Documentation shows that the pharmacy notified the facility that the originally ordered medication was unavailable, but the process to obtain a new order and administer the medication was not completed promptly. Another resident had a physician's order for ropinirole to treat restless leg syndrome and for laboratory tests to check magnesium, Vitamin D, and iron levels. The medication order was not carried out until the day after it was written, and the laboratory tests were not performed until three days after the order. There was no documentation that the physician was informed of the delay in laboratory testing. Interviews with nursing staff revealed a lack of follow-up and communication regarding the flagged orders, and an assumption that another nurse or LVN would complete the tasks. A third resident had multiple medication orders written, but only some were carried out on the day the order was written. The order for methocarbamol, a muscle relaxant, was not carried out until the following day. Nursing staff interviews indicated that the missed order was due to incomplete follow-through by the assigned LVN, and a lack of verification by the supervising RN. Facility policy requires timely transcription and implementation of physician orders, as well as prompt laboratory services, but these were not adhered to in the cited cases.

Penalty

No penalty information released

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

Summary

Staff failed to perform appropriate hand hygiene when providing care and assistance to four of six sampled residents. Specifically, a CNA prepared and assisted with lunch trays and feeding for two residents without washing hands or using alcohol-based hand rub (ABHR). Additionally, an LVN patted the backs of two residents without performing hand hygiene before or after the interaction, and another LVN handled a resident's wheelchair and assisted another resident out of the dining area without handwashing or using ABHR. These actions were observed during routine care and resident interactions in the dining room. Interviews with the involved staff confirmed their awareness of the facility's hand hygiene policy, which requires handwashing or use of ABHR before and after resident contact. The Director of Nursing also confirmed that the expectation is for staff to sanitize hands between resident contacts and that ABHR is available throughout the facility. A review of the facility's policy indicated that hand hygiene is required before and after assisting residents with dining and when moving between residents, regardless of glove 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

Surveyors observed that the Sub-Acute unit medication room refrigerator contained unauthorized and unlabeled items, including a can of Coca-Cola, a pint-sized Oatmeal Extra Thick, and an eight-ounce Ensure, none of which were labeled with a name or date. Additionally, a Licensed Vocational Nurse (LVN) was seen retrieving a bag of food from the medication room and admitted to storing personal food there due to previous incidents of food loss in the employee refrigerator. The LVN acknowledged that staff are not permitted to place their food in the resident-designated refrigerator. The facility administrator confirmed the presence of the unauthorized and unlabeled items in the medication room refrigerator and stated that only properly labeled resident food, with name and date, is allowed in that refrigerator for up to three days. The facility's infection prevention and control policy requires maintaining a safe, sanitary environment to prevent the transmission of diseases and infections, which was not followed in this instance.

Plan Of Correction

F 880 Infection Prevention & Control How corrective actions will be accomplished for these residents found to have been affected by the deficient practice: On 4/4/25, RN Supervisor immediately removed the Coca-Cola can, one pint sized Oatmeal Extra Thick, one eight ounce ensure, and bag of food from LVN 1 from the Sub-Acute medication room refrigerator designated for resident food. On 4/4/25, RN Supervisor immediately conducted a 1:1 education for LVN 1 regarding "No Employee Food in Resident's Refrigerator." How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: On 4/4/25, RN Supervisor made observed SNF Medication Room Resident food refrigerator to identify if the same deficient practice occurred. No deficient practice identified and was reported to the Administrator. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: Beginning 4/4/25, RN Supervisor(s) provided in-service to licensed nurses and CNAs regarding resident food refrigerator use and no employee food should be placed in resident food refrigerator. In-services regarding resident food refrigerator and no employee food refrigerator completed on 4/25/25. On 4/25/25, Administrator revised "Form A of Policy No. - DS 53, Refrigerator / Freezer Temperature Log" to include DAILY checking of RESIDENT ONLY FOOD STORED IN REFRIGERATOR to be completed by licensed nurses. If deficient practice is identified, it will be corrected immediately. How the facility plans to monitor its F 880 performance to make sure that solutions are sustained: ICP will review revised Form A of Policy DS - 53 - Refrigerator / Freezer Temperature Log" monthly and report findings to the DON and/or Administrator. Findings will be brought to the attention of the QAPI Committee monthly x 3 months for further recommendations.

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 notify the physician of a resident's missed hemodialysis sessions on two consecutive days, which was a significant oversight given the resident's medical condition. The resident, who was admitted to the facility with diagnoses including congestive heart failure and end-stage renal disease, required hemodialysis. On the first day, transportation for the resident's hemodialysis did not arrive, leading to the cancellation and rescheduling of the session. The responsible party was informed, but there was no documentation indicating that the resident's physician was notified of the missed session. The following day, the resident's hemodialysis was again rescheduled due to transportation issues, and once more, the responsible party was informed, but the physician was not notified. The facility's policy requires prompt consultation with the attending physician in the event of significant changes in a resident's condition, such as a missed treatment. The Assistant Director of Nursing confirmed the oversight during a review of the resident's progress notes, which lacked documentation of physician notification for the missed hemodialysis sessions.

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 adequately monitor a resident's condition following an acute change of condition (ACOC). The resident, who was admitted with diagnoses including congestive heart failure and end-stage renal disease requiring hemodialysis, experienced episodes of low oxygen saturation, congestion, nausea, and vomiting. Despite these symptoms, the facility staff did not consistently monitor or document the resident's vital signs, particularly oxygen saturation levels, as required by the facility's policy. On the night of the incident, the resident's oxygen saturation dropped to 85%, prompting an increase in oxygen delivery, which temporarily improved the saturation level. However, the resident's condition deteriorated overnight, leading to a transfer to the hospital the following morning due to low oxygen saturation, low blood pressure, and altered consciousness. The responsible party was informed of the resident's condition and subsequent hospital transfer, but the facility staff failed to document the necessary monitoring during the night shift. Interviews with the nursing staff revealed a lack of understanding and adherence to the facility's policy on monitoring and documenting changes in a resident's condition. The Licensed Vocational Nurse (LVN) assigned to the resident did not document the monitoring of the resident's oxygen saturation, and the Assistant Director of Nursing confirmed that the required alert charting was not completed. The facility's policy mandates documentation of a resident's condition every shift for at least 72 hours following an ACOC, which was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a chest X-ray was completed for a resident as ordered by the resident's physician. The resident, who was admitted on January 7, 2025, had diagnoses including congestive heart failure and end-stage renal disease, requiring hemodialysis. On January 16, 2025, the resident's physician ordered a STAT chest X-ray due to increased congestion and low oxygen saturation levels. Despite the urgency of the order, the X-ray was not completed as the contracted radiology company did not arrive to perform the procedure. The facility's policy required that STAT orders be followed up on during the same shift, but the registered nurse on duty reported calling the radiology company three times without success. The failure to obtain the X-ray as ordered had the potential to impact the resident's medical needs. The facility's policy and procedure for laboratory, diagnostic, and radiology services indicated that such services should be coordinated and results received timely, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to accurately assess a resident's health status according to its policy and procedure for the Resident Assessment Instrument (RAI) Process. Specifically, the Minimum Data Sets (MDS) for a resident dated 2/28/2022, 7/7/2023, and 10/7/2024 incorrectly included a diagnosis of seizure disorder or epilepsy, which was not supported by the resident's medical records. This discrepancy was identified during a review of the resident's admission records, discharge summaries, and various medical history documents, none of which indicated a diagnosis of seizure disorder or epilepsy. The resident was initially admitted with diagnoses including epilepsy, chronic respiratory failure, and COPD. However, subsequent reviews of the resident's medical records from a general acute care hospital and long-term care skilled admission history did not support the presence of a seizure disorder or epilepsy. Despite this, the MDS continued to list these conditions as active diagnoses, which could lead to unnecessary medication and services. Interviews with facility staff, including a Licensed Vocational Nurse and the Director of Nursing, confirmed the absence of documentation supporting a seizure disorder or epilepsy diagnosis. The resident had been prescribed Keppra, a medication for seizures, but it was discontinued after a short period. The Director of Nursing emphasized the importance of accurate documentation to prevent potential risks associated with incorrect diagnoses. The facility's policy on the RAI Process and nursing documentation requires that all information recorded within the MDS must accurately reflect the resident's status at the time of assessment.

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 resident-centered comprehensive care plan for a resident, as required by their policy and procedure titled 'Care Planning.' The deficiency was identified when the facility did not provide a timely care plan for the administration of Trazodone, an antidepressant medication, to a resident. The resident was admitted with multiple diagnoses, including an infection of an internal right knee prosthesis, type 2 diabetes mellitus, diabetic chronic kidney disease, and chronic kidney disease stage 3. Despite having the capacity to understand and make decisions, the resident's care plan for antidepressant medication was not initiated until two days after the physician's order was written. The facility's policy required that a care plan be created when there is a change in doctor orders or resident condition. However, the care plan for the resident was not updated on the day the physician's order was written, as confirmed by the Director of Staff Development. The care plan was only created two days later, which was not in compliance with the facility's policy. This oversight was confirmed during interviews with the registered nurse and the Director of Staff Development, who acknowledged that the care plan should have been updated promptly according to the facility's 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 complete and accurate documentation for a resident, which had the potential to impact the resident's care and treatment. The resident was admitted with several diagnoses, including an infection of an internal right knee prosthesis, type 2 diabetes mellitus, diabetic chronic kidney disease, and chronic kidney disease stage 3. During a review of the resident's records, inconsistencies were found in the documentation of the resident's care, specifically in the Shower and Care Sheet Observations (SCSO). The records did not consistently include the resident's name, details of the care provided, or the presence of a cast or immobilizer on the right lower extremity. Interviews with facility staff, including a registered nurse, the administrator, and the director of staff development, revealed that the documentation did not adhere to the facility's policy and procedure, which requires nursing documentation to be concise, clear, pertinent, and accurate. The staff acknowledged that the documentation was inconsistent and did not meet the facility's standards. The facility's policy indicated that certified nursing assistants (CNAs) are responsible for documenting the care provided, either manually or electronically, but this was not consistently followed in the case of the resident in question.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a comfortable temperature level in the room of a resident, resulting in discomfort and potential health risks. During an observation and interview, the Maintenance Supervisor noted that the room temperature was 87 degrees Fahrenheit, which is above the normal range of 71 to 75 degrees Fahrenheit. The air conditioning was not functioning, and fans were placed in the rooms as a temporary measure, but the temperatures remained outside the acceptable range. The Director of Nursing was aware of the air conditioning issue but not of the residents' discomfort. The affected resident, who has a history of acute respiratory failure with hypoxia, dependence on a respiratory ventilator, and a tracheostomy, reported feeling hot and uncomfortable for the past two weeks. The resident stated that the ventilator exacerbated the heat, causing sweating and difficulty sleeping. The facility's policy emphasizes providing a safe, clean, comfortable, and homelike environment, which includes maintaining comfortable temperatures. However, the failure to address the air conditioning issue led to a breach of this 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 maintain a sanitary environment to prevent the spread of infections among residents. Hospitality Aide 1 did not perform hand hygiene as per the facility's policy when entering and exiting the rooms of Residents 3, 7, and 8. This aide also failed to sanitize hands after touching Resident 3's bed control. During an interview, HA 1 acknowledged the importance of hand hygiene to prevent contamination and infection spread. Certified Nursing Assistant 5 did not remove soiled gloves or perform hand hygiene between residents and before handling clean linens. Resident 6 reported observing CNA 5 touching clean linens with soiled gloves after caring for another resident. This lack of proper glove use and hand hygiene could contribute to cross-contamination and infection spread among residents. The facility also failed to prevent flies and mosquitoes from entering the rooms of Residents 2, 5, and 6. Resident 5 reported seeing flies in the room during breakfast, and Resident 6 noted flies entering through open doors. CNA 4 confirmed seeing flies enter the facility and expressed concerns about their presence, especially for residents with wounds and tubes. The Infection Prevention Nurse and Director of Nursing acknowledged the importance of pest control as part of infection prevention, noting that a ripped window screen in Resident 2's room allowed mosquitoes to enter.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate care and services to prevent a fall for a resident who required contact guard assistance (CGA) with ambulation. The resident, who had been admitted with diagnoses including hemiplegia, gout, difficulty in walking, generalized muscle weakness, and epilepsy, was assessed by a physical therapist as needing CGA for safety during ambulation. However, the staff assigned to care for the resident, including CNAs and LVNs, were not made aware of this requirement by the physical therapist. On the night of the incident, the resident fell while walking from the closet to the bed, resulting in a severe injury. The resident experienced extreme pain in the right groin area and was subsequently transferred to a hospital where a fracture in the right femoral neck was diagnosed. The resident underwent a partial right hip arthroplasty and was hospitalized for 20 days. Interviews with staff revealed that they were unaware of the resident's need for assistance and had observed the resident walking independently, which was contrary to the physical therapist's assessment. The facility's failure to communicate the resident's need for CGA and to update the care plan with this information contributed to the fall. The care plan did not reflect the physical therapist's assessment, and staff did not refer to the physical therapy notes. The facility's policy on fall management emphasized the importance of implementing interventions based on assessments, but this was not followed in the case of the resident, leading to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident 1, which addressed their individual assessed needs. The care plan did not incorporate the assessments and recommendations from Physical Therapy 1 (PT 1) and did not address the resident's behavior of getting up without calling for assistance, as required by the facility's Policy and Procedure on Care Planning. This oversight had the potential to result in unmet individualized needs and inconsistent provision of treatment and services for the resident. Resident 1 was admitted with diagnoses including hemiplegia, gout, difficulty in walking, generalized muscle weakness, and epilepsy. The Physical Therapy Evaluation indicated that Resident 1 felt unsteady when standing or walking and was at risk for falls, requiring contact guard assistance (CGA) with transfers and gait on level surfaces. Despite these assessments, the care plan only included general interventions such as explaining the call system and maintaining a hazard-free environment, without specific measures to address the resident's refusal to use the call light and their need for CGA. Interviews with facility staff, including a Licensed Vocational Nurse, a Certified Nursing Assistant, and the Director of Rehabilitation, confirmed that Resident 1 was independent and did not use the call light, often getting up independently. The care plan was not updated to reflect the PT assessment or the resident's behavior, and staff acknowledged the need for additional interventions such as education on the risks and benefits of calling for assistance, involving the resident's family, and implementing a toileting program. The Director of Nursing also confirmed the need for these interventions and a possible room change closer to the nurse's station.

Penalty

No penalty information released

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

Summary

The facility failed to protect the rights of four residents by not informing them or their representatives about the right to formulate an advance directive (AD). For Resident 18, the Social Service Director (SSD) did not provide the resident's responsible party (RP) with information about making an AD, despite the resident being severely impaired in cognitive skills and dependent on staff for daily activities. Similarly, Resident 29's SSD did not document discussions with the resident's RP about the right to formulate an AD, even though the resident had no cognitive impairments and required supervision for personal care. Resident 36, who was severely impaired in cognitive skills and dependent on staff, also did not receive information about formulating an AD from the SSD. The SSD admitted that the information pamphlet provided to residents did not include details about the facility's policies on implementing ADs. Additionally, Resident 49's AD was not included in their medical chart, despite the SSD acknowledging the existence of the AD and the facility's policy requiring it to be part of the medical record. The facility's policy and procedure on advance directives, revised in September 2023, mandates that residents be informed of their rights to make medical decisions and formulate ADs upon admission. However, the SSD failed to ensure that this information was communicated and documented for the residents involved, leading to potential issues in decision-making for care and treatment.

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 notify the physician of a change in condition for two residents, leading to potential physical declines. For Resident 19, who had chronic respiratory failure and was dependent on a respiratory ventilator, the facility did not inform the physician when the resident exhibited mild work of breathing, with vital signs indicating a change in condition. The resident's oxygen saturation was below the normal range, and the heart rate was elevated, yet there was no documentation of physician notification, which was required by the facility's policy. Resident 40 experienced a significant weight loss of 12.06% over six months, which was not communicated to the physician in a timely manner. The resident had multiple diagnoses, including type 2 diabetes and heart failure, and required supervision with eating. Despite the interdisciplinary team's recommendation for a physician review of pancreatic enzyme replacement therapy due to inadequate energy intake, the physician was only informed after the survey team highlighted the issue. The facility's policy required timely notification of the physician for significant changes in a resident's condition, including weight loss of five pounds or more within 30 days. However, the facility did not adhere to this policy for both residents, failing to ensure that the physician was informed of critical changes that could impact the residents' health and well-being.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that four residents did not receive unnecessary psychotropic medications. For Resident 90, the facility did not limit the PRN Alprazolam order to 14 days as per the facility's policy. The Assistant Director of Nursing (ADON) acknowledged that the physician did not document a rationale for extending the PRN order beyond 14 days. This oversight could lead to the unnecessary administration of psychotropic medication. Resident 49's case involved a failure to document a personalized rationale for not attempting a Gradual Dose Reduction (GDR) of Trazodone. The prescriber disagreed with the pharmacist's recommendation for a GDR, citing a generic reason that was not specific to Resident 49's condition. The ADON confirmed that the documented reason was not applicable to Resident 49, who was not a danger to himself or others. For Resident 84, the facility did not attempt a GDR for Risperdal or try non-pharmacological interventions for hallucinations. The ADON admitted that the facility should have attempted these interventions. Similarly, for Resident 69, the facility did not attempt GDRs for Depakote and Seroquel, despite the absence of documented behaviors that would contraindicate such attempts. The ADON stated that the facility was transitioning to a new psychiatrist, which delayed the GDR attempts, contrary to the facility's policy.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its policy and procedures regarding the dietary preferences of a resident, identified as Resident 40, which led to significant weight loss and potential physical decline. Resident 40, who was admitted with multiple diagnoses including type 2 diabetes mellitus, heart failure, and gastro-esophageal reflux disease, had specific dietary preferences and restrictions due to the absence of a gallbladder. These preferences included avoiding greasy foods and consuming meals with little to no oil, as greasy foods caused diarrhea and discomfort for the resident. Despite these documented preferences, the facility did not consistently provide meals that met Resident 40's needs. The resident's dietary records indicated a preference for hamburgers cooked without oil and fried eggs prepared in a non-stick pan without grease. However, the facility's kitchen staff continued to prepare meals using oil, and the resident's requests for alternative cooking methods were not accommodated. Interviews with the resident revealed frustration and a sense of being unheard, as the resident repeatedly communicated these preferences to the staff without resolution. The facility's failure to accommodate Resident 40's dietary needs was further compounded by the lack of documentation and follow-through by the registered dietician and dietary staff. The resident experienced a weight loss of 12.6% over six months, falling below the goal weight range. The dietary staff, including the cook and dietary supervisor, acknowledged the resident's requests but did not implement the necessary changes to the meal preparation process. This oversight was a direct violation of the facility's policies on resident rights and nutritional care, which emphasize the importance of respecting and accommodating individual dietary preferences.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to proper food storage and handling protocols, as evidenced by the presence of expired food items in the walk-in refrigerator. During an inspection, a Dietary Services Supervisor (DSS) identified 22 red apples that had been stored beyond the recommended one-month period according to the facility's Suggested Refrigerated Storage Guideline. Although the apples appeared visually acceptable, the DSS acknowledged the potential risk of internal spoilage and the possibility of causing illness if consumed by residents. Additionally, the inspection revealed an unopened gallon of whole milk that had expired. The DSS confirmed that the milk should not have been in the refrigerator and recognized the risk of illness if it were accidentally served to residents. The facility's policy on food receiving and storage emphasized the importance of rotating perishable foods using the first in-first out method, which was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the right to a dignified existence for Resident 95 by not accommodating their needs for timely incontinence care. On June 10, 2024, Resident 95 requested assistance for incontinence care, but the Certified Nursing Assistant (CNA) 1 did not attend to the request promptly. The delay was due to CNA 1 waiting for Resident 95's roommate to finish their meal before providing care, which was not communicated to Resident 95, leaving them confused and uninformed. Resident 95, who was admitted with multiple diagnoses including heart failure, morbid obesity, and anxiety disorder, was dependent on assistance for toileting and bathing. The care plan for Resident 95 indicated the need for timely incontinence care to prevent discomfort and potential urinary tract infections. However, during the observation, CNA 1 left the room to gather supplies and did not return promptly, leading to a second call light activation by Resident 95. Licensed Vocational Nurse 2 (LVN 2) had to intervene and call CNA 1 back to the room. Interviews with CNA 1, CNA 2, and the Director of Staff Development (DSD) revealed that the facility had a practice of avoiding incontinence care during mealtimes to maintain infection control and protect the dignity of other residents. However, it was acknowledged that urine incontinence care could be provided sooner and should be communicated to the resident. The facility's policy emphasized the importance of explaining procedures to residents and promptly responding to requests for toileting assistance, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to develop a comprehensive care plan for a resident, identified as Resident 40, who experienced progressive weight loss. Despite having multiple diagnoses, including type 2 diabetes mellitus with diabetic neuropathy, heart failure, and gastro-esophageal reflux disease, the resident did not have a care plan addressing their weight loss. The resident's Minimum Data Set indicated intact cognitive skills and a need for supervision with eating. However, the facility did not create a care plan to address the resident's dietary needs and preferences, which included a controlled carbohydrate, no added salt, low-fat diet with chopped meats and double protein. Interviews and observations revealed that the resident expressed dissatisfaction with the food provided, stating that greasy foods caused diarrhea and that staff were not attentive to their food preferences. The resident's weight records showed a significant decline over six months, yet the Assistant Director of Nursing confirmed the absence of a care plan to address this issue. The facility's policy required a person-centered care plan developed by an interdisciplinary team, but this was not implemented for Resident 40, leading to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate interventions for a resident with edema, as outlined in the resident's care plan. The care plan specified that the resident's arms and legs should be elevated to reduce swelling, but during an observation, the resident was found lying in bed with their arms flat on the mattress and not elevated. The resident's fingers and forearms were noted to be swollen, indicating that the care plan was not being followed. Interviews with facility staff, including a Licensed Vocational Nurse and a Treatment Nurse, confirmed that the resident had edema and that the standard intervention was to keep the resident's arms and legs elevated with pillows. The staff acknowledged that failing to do so increased the risk of blood clots and skin breakdown. The facility's policy and procedure on care standards emphasized the necessity of providing care in accordance with a comprehensive assessment and plan of care, which was not adhered to in this case.