Golden Harbor Healthcare 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 provide RN coverage eight hours a day, seven days a week. During a concurrent interview and record review on 8/27/25 at 11:06 a.m. with the Staffing Coordinator, the facility’s licensed staffing schedules for January 2024 through March 2024 were reviewed and showed no RN scheduled to work eight hours a day on 1/10/24, 1/11/24, 1/16/24, 1/25/24, 2/8/24, 2/9/24, and 2/13/24. A later review of the staffing schedules for April 2024 through June 2024 showed no RN scheduled to work eight hours a day on 4/29/24. During an interview on 8/28/2025 at 9:26 a.m., the DON stated the facility should have an RN eight hours in a day per facility policy and that residents needed an RN to assess them if there were any changes in condition. A review of the facility’s PBJ Staffing Data Report submitted to CMS for January 2024 through June 2024 also showed days when no RN was scheduled to work eight hours a day. The facility policy titled Staffing, revised October 2017, stated that direct care staffing information per day, including agency and contract staff, is submitted to the CMS PBJ system.

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

Controlled substance accountability was not maintained for three residents. For one resident, the physician ordered oxycodone IR 10 mg every 6 hours as needed for severe pain, but the Controlled Drug Record showed the medication was removed from the medication cart on two occasions without the administrations being documented on the MAR. For another resident, tramadol 50 mg every 6 hours as needed for pain was removed from the cart and not documented on the MAR. For a third resident, hydrocodone/APAP 5/325 mg every 6 hours as needed for pain management was removed from the cart and also not documented on the MAR. The DON reviewed the records and confirmed the discrepancies, and the facility policy required that the MAR be signed after administration and that controlled substances also be signed in the narcotic book. Emergency medication kits and supplies were not replaced after use according to facility policy. In one medication storage room, an opened IV supplies e-kit contained documentation showing that normal saline and flushes had been removed several days earlier, and the kit had not been replaced. In another storage room, an opened narcotic e-kit showed that hydromorphone tablets had been removed, and an opened IM e-kit showed that cefazolin, sterile water, and lidocaine had been removed; both kits remained opened and unreplaced. The DON stated that when nursing staff opened an e-kit, the re-order sticker was removed and faxed to the pharmacy for replacement, and the facility policy stated that medications and supplies used from the emergency medication kit must be replaced upon the next routine drug order. Routine medications were also not available for administration for one resident. During a medication pass, lactulose ordered three times daily for chronic kidney disease was not available, and the LVN stated it would need to be ordered from the pharmacy. The resident’s MAR showed all three scheduled doses were missed that day. In a separate medication pass, another resident’s Stiolto Respimat inhaler was attempted to be administered, but the inhaler was empty and locked because the dose indicator had reached the end of the red scale. The DON stated staff were expected to reorder routine medications when the bubble pack or inhaler indicated supply was running low. In addition, the facility used red sharps containers in medication carts to dispose of refused or dropped doses of medication whole, including narcotics, and the DON confirmed this method did not render the medications unusable and irretrievable and did not limit unwanted exposure to staff. The facility policy stated drugs must be destroyed in a manner that renders them unfit for human consumption and disposed of in compliance with applicable requirements.

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

Medications and biologicals were not consistently stored in locked, orderly conditions during medication pass observations and cart inspections. During an observation with an LVN, insulin lispro was removed from a medication cart, the dose was drawn up, and the vial was left on top of the cart while the nurse walked into a resident’s room to administer the medication without locking the cart. The cart was angled toward the hallway and accessible to staff and residents passing by. In interview, the LVN confirmed the insulin had been left unattended on top of the cart and that the cart had not been locked. Additional cart inspections found loose tablets and capsules in drawers, an opened and undated vial of blood glucose test strips, and ipratropium bromide/albuterol vials outside of their manufacturer’s foil packaging without an opened date. Staff confirmed loose pills should have been disposed of, the test strip vial should have been dated when opened, and the inhalation vials had a shortened use period once removed from the pouch but had no date showing when they were opened. Another cart contained loose tablets and capsules along with nicotine and scopolamine patches stored underneath bottles of oral medication. The DON stated internal medications were to be stored separately from external medications and that medications were to be kept securely in locked medication carts.

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

Infection prevention and control measures were not maintained for multiple residents during observations, interviews, and record reviews. A Central Supply staff member was observed entering and exiting Contact Precaution rooms without sanitizing hands, and the same staff member was also observed taking half-empty glove boxes from those rooms and refilling them with clean gloves using bare hands. The Contact Precaution signs on the doors instructed staff to clean hands before entering and when leaving the room and to use dedicated or disposable equipment, but the staff member stated he did not know he needed to gel his hands and did not know the glove-box handling was an infection control issue. Reusable medical equipment was not disinfected as required. During a wound care observation for a resident with an open left lower leg wound, pneumonia, and a BIMS score of 14/15, scissors used during negative pressure wound therapy were handled inconsistently after use. The scissors were washed in the resident’s bathroom, wrapped in paper towels, carried out of the room, placed on a desk, and later wrapped again before being offered to the wound care nurse. The treatment nurse stated the scissors should have been disinfected with germicidal wipes before leaving the room, while other staff gave different descriptions of how the scissors should be cleaned. The facility’s policy stated reusable items are to be cleaned and disinfected or sterilized between residents. Additional infection control failures were observed with shared equipment, medication preparation, laundry processes, and hand hygiene. A CNA stated Super Sani-Cloth wipes were used for shared non-critical equipment and identified an incorrect dwell time, while the Infection Preventionist stated the wipes require 2 minutes and air drying between residents. A blood pressure cuff used on a resident was returned to a rolling cart without being sanitized or disinfected. During medication preparation, an LPN with long artificial nails attached a needle to an insulin aspart pen without wiping the rubber stopper with alcohol first, despite manufacturer instructions requiring it. In another observation, a nurse performing wound care on a resident with stage 4 pressure injuries repeatedly changed gloves without performing hand hygiene between glove changes. A laundry assistant also did not clean the dryer lint trap at the scheduled time and the lint log was completed with initials entered for times before the work was observed.

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 residents' medical records were updated to show that advance directives were discussed with residents and/or their responsible parties for 14 of 51 sampled residents. The report states that this involved residents with a range of conditions and cognitive statuses, including adult failure to thrive, kidney failure, dementia, respiratory failure, end stage renal disease, Alzheimer’s disease, osteomyelitis, congestive heart failure, quadriplegia, diabetes mellitus, cerebral infarction, and hypertensive heart disease with chronic kidney disease and heart failure. In multiple records, the POLST forms indicated that the resident did not have an advance directive, but the chart did not show documentation that the option had been discussed or offered. For Resident 1, the admission record showed admission with adult failure to thrive, and the MDS indicated impaired short- and long-term memory with moderately impaired decision-making capacity. The POLST form dated 6/5/25 stated the resident did not have an advance directive, but there was no documentation that advance directives were discussed with the resident or responsible party. For Resident 4, the admission record showed kidney failure and the MDS showed a BIMS of 10, indicating moderate cognitive impairment; the POLST dated 7/14/25 stated no advance directive, and the record lacked documentation that the advance directive was discussed or offered to the resident or representative. For Resident 28, the record showed dementia and impaired memory with moderately impaired decision-making capacity, and the POLST dated 7/16/24 stated no advance directive, but there was no documentation that the advance directive was discussed or offered. The report also identified missing documentation for Resident 53, whose MDS showed a BIMS of 14 and cognitive intactness, and whose POLST dated 1/11/23 stated no advance directive; there was no documentation that the advance directive was discussed or offered to the resident or representative. Similar findings were noted for Resident 77, whose record showed end stage renal disease and a BIMS of 11, with a POLST dated 2/22/25 showing no information on the presence of an advance directive and no documentation of discussion or offer. For Residents 11, 33, 8, 10, 57, and 6, the records showed diagnoses including ESRD, Alzheimer’s disease, osteomyelitis, CHF, diabetes mellitus, and quadriplegia, and their MDS/POLST records indicated no advance directive, but there was no documentation that the option was provided or discussed with the residents or their representatives. For Residents 2, 7, and 12, the records showed severe or moderate cognitive impairment or stated capacity to make decisions, but the EHR still lacked documentation that advance directives were discussed or offered. During interviews, the SSD stated advance directives were offered and documented in the residents' records, but after reviewing the charts, the SSD acknowledged that the records for several residents did not contain documentation that advance directives were discussed and followed up with the residents and their responsible parties. The DON stated that advance directives are important to help ensure the resident's wishes for medical care are carried out if the resident becomes incapacitated.

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 keep resident health data and records secure and confidential when not in use for a census of 94. During a medication pass observation on 8/25/25 at 12:19 p.m., LVN 1 was observed leaving a computer screen unlocked and accessible to residents and staff passing by while he went to administer medications to Resident 40. In an interview later that day, LVN 1 confirmed he had left the computer unlocked and unattended when he went to administer medication to Resident 40. During an interview on 8/26/25, the DON stated nursing staff were to sign out from the computer system or lock the computer every time they walked away so resident information would not be exposed. The facility policy titled Electronic Medical Records stated only authorized persons with a password and user ID code were permitted access to the electronic medical records system and that the facility would make reasonable efforts to limit the use or disclosure of protected health information.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, clean, comfortable, and homelike environment for multiple residents by not providing wall clocks in several rooms and by leaving room surfaces in disrepair. Resident 33 and Resident 14 shared a room that did not have a wall clock, and both residents stated they were bothered by not being able to tell the time. Resident 33 said he had repeatedly asked multiple staff members for a wall clock since admission and felt singled out because it was missing. The Maintenance Director stated he was aware of the repeated requests but had overlooked them due to being busy, and he acknowledged that a wall clock was important for residents to tell time and avoid confusion. Similar concerns were observed in other rooms. Resident 74’s room did not have a wall clock, and the resident stated he could not tell the time and that it would be better to have one. Resident 81’s room also did not have a wall clock, and the resident stated it was important to have one so he could tell the time of day. The Director of Nursing stated that it was essential for residents to have wall clocks in their rooms so they could tell the time. The facility also failed to maintain room conditions for Residents 36, 46, and 90. Resident 36’s room had baseboards removed below the window with white patchwork exposed and unpainted, and the resident stated the room was unfinished on admission and asked whether the facility would neglect his needs. Resident 46’s room had removed baseboards, exposed white patchwork, brown areas under yellow paint, cracked plaster, unfinished patchwork, and peeling paint. Resident 90’s room had peeling green paint above the baseboard area, removed baseboards, brown patches, and exposed patchwork, and the resident stated he had informed staff about the wall disrepair. The Maintenance Director stated that repair requests should be logged and reviewed daily, but the cited rooms were not logged for repair, and he stated he knew about the rooms needing repair because of ongoing renovations.

Penalty

No penalty information released

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

Summary

The facility failed to ensure safe medication use for three residents when multiple PRN pain medication orders were incomplete or unclear and were not clarified before administration. For Resident 20, the record showed PRN orders for tramadol 50 mg every 6 hours as needed for pain and Tylenol Extra Strength 500 mg every 6 hours as needed for pain. During interview, the DON confirmed both medications were ordered as needed and stated nursing staff should have clarified with the physician when it was appropriate to administer each medication. For Resident 11, the record showed PRN orders for hydrocodone/APAP 5/325 mg every 6 hours as needed for pain management and Tylenol 325 mg, 2 tablets every 4 hours as needed for mild pain, and the DON confirmed the hydrocodone/APAP order did not indicate what pain level should trigger administration and should have been clarified to include parameters. The facility also failed to administer insulin in accordance with manufacturer specifications and the facility's policy for Resident 104. During a medication pass observation, an LVN prepared and administered Lantus SoloStar and NovoLog FlexPen after priming the pens, injected both into the right middle abdomen at a 45-degree angle, and did not pinch or grasp a fold of skin before injection. During interview, the LVN stated insulin could be injected at either a 90-degree or 45-degree angle for all residents and said she usually used the 45-degree angle because residents reported it was less painful. The manufacturer's labeling for Lantus SoloStar stated to keep the pen straight and insert the needle into the skin, and the facility's insulin administration policy stated to lightly grasp a fold of skin and insert the needle at a 90-degree angle, using 45 degrees only for very thin residents to avoid intramuscular injection.

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 four sampled residents were free from unnecessary drugs when narcotic pain medications were administered outside of physician orders. Resident 20 had an order for tramadol 50 mg every 6 hours as needed for pain, but the MAR showed the medication was given on 8/16/25 and 8/17/25 when the documented pain score was 0. The DON reviewed the record and confirmed there was no documentation that Resident 20 was in pain on those days. Resident 101 had an order for oxycodone 10 mg every 6 hours as needed for severe pain 8-10/10, but the MAR showed oxycodone was administered multiple times when the pain score was below 8. Resident 11 had orders for hydrocodone/APAP 5/325 mg every 6 hours as needed for pain management and Tylenol 325 mg, 2 tablets every 4 hours as needed for mild pain 1-3, but Tylenol was administered on several dates when the pain level was above 3, and the DON confirmed there was no documentation that the resident preferred Tylenol instead of hydrocodone/APAP. Resident 10 had an order for oxycodone 10 mg every 6 hours as needed for moderate to severe pain 4-10, but the MAR showed oxycodone was given when the pain level was below 4. The DON confirmed these medications were not administered in accordance with the physician orders.

Penalty

No penalty information released

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

Summary

The facility had a medication error rate of 11.63%, with five medication errors identified out of 43 opportunities during a medication pass observation involving four residents. The errors were observed during surveyor review of medication administration and record review, and the report states the failure resulted in medications not being given in accordance with the manufacturer's specifications. For one resident with chronic kidney disease stage 2, the LVN prepared multiple medications but did not administer the ordered lactulose because it was not available. During the concurrent interview and record review, the LVN confirmed the medication was not given because it had not been delivered from the pharmacy. The resident's MAR showed all three scheduled lactulose doses were missed that day. The DON stated nursing staff were expected to reorder routine medications when the reorder sticker appeared and to monitor inhaler dose counters and liquid levels so refills could be requested in time. For another resident with diabetes, an LVN checked a blood sugar of 326 mg/dl and prepared insulin aspart. The LVN attached a needle to the insulin pen without first sanitizing and disinfecting the pen, then primed it by dialing to eight units and pushing the button until the dial reached six units while holding the pen needle facing down. The LVN stated the facility did not train staff to sanitize and disinfect the pen before attaching a needle. The DON stated staff were expected to prime insulin pens first and then dial the ordered dose, and that it was not acceptable to dial two units higher than the dose and dispense the excess first. During another medication pass, an LVN attempted to administer Stiolto Respimat to a resident with COPD but found the inhaler empty and locked after trying to give the dose. The LVN stated he was not aware of the meter indicating the number of doses left before that day. In the same pass, the LVN administered only one drop of Refresh Tears into each eye even though the order was for two drops in both eyes. In a separate observation, an LVN prepared amlodipine for one resident from a bubble pack labeled with another resident's name and confirmed it was the wrong resident's medication. The DON stated staff were expected to compare the pharmacy label with the order in the computer, including the resident name, drug name, and dose, and to follow the most current physician order.

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 policy for self-administration of medications and did not ensure safety for one resident who self-administered insulin lispro without a physician's order, an interdisciplinary team evaluation, or care plan documentation. During a medication pass observation, an LVN prepared insulin lispro for the resident, stated that the resident usually self-administered his insulin, drew up seven units in a syringe, and then handed the syringe to the resident after wiping the resident's abdomen with an alcohol pad, allowing the resident to inject the medication himself. The resident's record showed physician orders for insulin lispro, including a scheduled 3-unit dose before meals and a sliding-scale order before meals and at bedtime. In interviews and record review, the LVN confirmed there was no IDT evaluation or physician order approving self-administration, and the DON confirmed there were no orders or documentation showing the resident could safely self-administer medication. The facility policy stated that residents may self-administer medications only if the IDT determines it is clinically appropriate and safe, and that this decision must be documented in the medical record and care plan.

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 two sampled residents were free from unnecessary psychotropic medication use. For one resident admitted with depression, diabetes, and high blood pressure, the record showed an order for Cymbalta 20 mg daily for depression manifested by verbalization of sadness. During a concurrent interview and record review, the DON stated that non-pharmacological interventions had been implemented for pain but not for depression, and that non-drug interventions were used unless contraindicated. The facility policy stated that non-pharmacological approaches would be attempted unless clinically contraindicated to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medication. For another resident admitted with Alzheimer's disease, the record showed an order for Seroquel 37.5 mg at bedtime for increased agitation, with behaviors listed as easily getting frustrated, constant talking to the point of exhaustion causing distress, and trying to get out of bed. The resident's MDS showed severely impaired cognition and no behavior episodes of physical or verbal symptoms directed toward others. During review of the behavioral care plan, the MDSC could not find documentation of a referral to a mental health professional, although that referral was listed as an intervention. The MDSC stated the only behavioral symptom was yelling. During interviews, the LVN stated the resident's only behavioral problem was yelling, and the consultant pharmacist stated Alzheimer's disease was not an adequate diagnosis for prescribing Seroquel for the resident. The pharmacist also stated yelling was not an appropriate behavior to prescribe Seroquel and that the risk of prescribing Seroquel to residents with dementia was death. The DON stated the resident should have been referred to a mental health professional or psychiatrist so the use of Seroquel was evaluated. The facility policy stated psychotropic medications should only be used when other nonpharmacological interventions are clinically contraindicated and only to treat the resident's medical symptoms, not for discipline or staff convenience.

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 effective communication for a resident whose primary language was Chinese and who had a hearing deficit and moderate cognitive impairment. Resident 50 was admitted with diagnoses including metabolic and toxic encephalopathy, delirium, and depression. The resident stated during interview that she had difficulty communicating with and understanding staff, that staff spoke quickly and not always in her direction, and that she felt frustrated. She also stated she understood some English but could not understand all English words and requested that staff write questions on paper and show them to her. Record review showed the resident had a communication binder with health care pictures and Chinese translations that allowed her to express needs and ask questions, but during observation and interview the binder could not be located in the resident's room or clothes cabinet. CNA 2 stated they did not know how long the binder had been missing. RN 1 stated she had not seen the binder in several weeks, did not know the resident's primary language, and did not know the resident's interventions for the communication deficit or the process to ensure care plan interventions were carried out and evaluated. The care plan identified the resident as Chinese speaking and included interventions such as allowing time to respond, using simple words, using alternative tools, and providing a translator as necessary.

Penalty

No penalty information released

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

Summary

The facility failed to provide treatment and care consistent with professional standards of practice when Resident 14 was provided a wheelchair that was not appropriate for the resident's size. Resident 14 was admitted in November 2024 with diagnoses including diabetes mellitus, dementia, and muscle weakness. The 7/28/25 MDS indicated the resident could understand others and be understood, had a BIMS score of 10, used a wheelchair for mobility, and required supervision or touching assistance for chair/bed-to-chair transfers. The care plan for ADL self-care performance deficit, initiated on 11/27/24, stated the resident would maintain current level of function in bed mobility and transfers and that the resident's choices and preferences should be honored whenever possible. During observation on 8/25/25, Resident 14 was up in a wheelchair with a wide seat and at least four inches of space on both sides between the resident and the armrests, and the resident stated he had been using that wide-seat wheelchair for a few months because the facility had not provided the appropriate-sized wheelchair he had been promised. On 8/27/25, the Maintenance Director stated the resident was using a bariatric wheelchair that was inappropriate for the resident's size and could be a safety hazard because the wheelchair was too wide and could allow slipping. The Physical Therapist stated the Director of Rehabilitation identifies a resident's body size and provides an appropriate wheelchair, and the Director of Rehabilitation stated she had no knowledge the resident was using an inappropriate-fitting wheelchair and confirmed the wide-seat wheelchair was not the appropriate size for 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 a safe environment for one resident after an unwitnessed fall in the resident’s room. The resident was admitted in July 2025 with diagnoses including alcohol dependence with alcohol-induced disorder, diabetes mellitus, and muscle weakness. The resident’s MDS dated 7/22/25 showed intact cognition with a BIMS score of 15 and indicated the resident required supervision or touching assistance for chair/bed-to-chair transfers. The resident was also identified as high risk for falls on the nursing admission/readmission assessment dated 7/17/25. During the fall event, CNA 1 found the resident on the floor next to the bed and assisted the resident back to a chair before the licensed nurse had been notified or had assessed the resident. CNA 1 stated he assessed the resident and then rushed to inform LVN 4, but also acknowledged he was a new CNA and knew he should have reported the fall to the nurse right away. The DSD stated CNAs are to keep the resident safe and inform the charge nurse immediately, and that CNAs are not to move the resident after a fall but instead report it immediately for a thorough assessment. LVN 4 did not assess the resident immediately after being informed of the incident. LVN 4 stated she was unaware of the fall at first and believed CNA 1 had asked her to see the resident for pain medication. The SBAR completed by LVN 4 documented the unwitnessed fall, pain to the right arm and shoulder, swelling to the right hand, and a small elevated area on the back of the head. The DON stated a charge nurse should have attended to the situation right away, completed a head-to-toe assessment, and initiated a neurological check. Record review showed the neurological assessment flow sheet was started an hour after the fall occurred, and LVN 4 stated the neurological check began at 11 a.m. even though the form was mistakenly marked with a 10 a.m. start time.

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 sampled resident's call light was answered promptly. During an initial tour, the resident stated that she had waited a long time for her call light to be answered and had also waited a long time for her incontinent briefs to be changed. When call light response time was tested, the resident pressed the call light at 10:25 a.m., and the Assistant Director of Nursing answered it at 10:48 a.m., 23 minutes later. The ADON stated that it was not acceptable for the resident to wait that long for staff to attend to her needs and stated that call lights should be answered promptly due to the risk of unattended needs. Record review showed that the resident's MDS dated 5/28/25 indicated she was able to make herself understood and understand others, and that she was dependent on staff for toileting hygiene. The facility's undated policy titled "Call Lights: Accessibility and Timely Response" stated that the purpose of the policy was to assure the facility was adequately equipped with a call light to allow residents to call for assistance.

Penalty

No penalty information released

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

Summary

The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who did not receive a prescribed medication, albuterol sulfate inhalation, as ordered by the physician. The resident, who was admitted with multiple diagnoses including osteomyelitis, type II diabetes mellitus, and lobar pneumonia, was experiencing hypoxia, wheezing, and shortness of breath. Despite the physician's order for albuterol sulfate inhalation to be administered every six hours, the medication was not given on multiple occasions due to it not being available at the facility. The Director of Nursing (DON) confirmed that the licensed nurses did not follow up with the pharmacy or inform the physician about the missing medication to seek an alternative. Additionally, the resident's oxygen saturation levels were not monitored from January 27 to January 29, despite the resident's complaints of shortness of breath and wheezing. The DON acknowledged that the licensed nurses and/or certified nurse assistants should have monitored and documented the resident's vital signs daily, including oxygen saturation levels, to assess the resident's condition. The lack of monitoring and administration of the prescribed medication potentially worsened the resident's respiratory condition, as indicated by the DON.

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 pharmaceutical services and procedures that ensured the accurate dispensing and administration of medication for a resident. The resident, who was admitted with multiple diagnoses including osteomyelitis, type II diabetes mellitus, and lobar pneumonia, had an order for albuterol sulfate inhalation to be administered every six hours for wheezing. However, the medication was not available and was not administered on several occasions as per the physician's order. The Director of Nursing (DON) confirmed that the licensed nurses documented the absence of the medication in the progress notes, stating that the pharmacy did not deliver the inhaler as expected. The DON acknowledged that the pharmacy should have delivered the medication the same day it was ordered and that the licensed nurses should have followed up with the pharmacy and informed the physician about the missing medication. The facility's policy and procedure indicated that medications should be administered as ordered by the physician and in accordance with professional standards of practice, 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 identify and address a potential accident hazard when an Activity Assistant (AA) did not take appropriate action after a resident inquired about purchasing a firearm. The resident, who had a BIMS score indicating intact cognitive status, asked the AA if they knew where or from whom a gun could be obtained. The AA initially thought the resident was joking and did not report the interaction until two days later. This delay in reporting allowed the resident to have a gun and ammunition in their room, which was discovered by the laundry staff. The Social Services Director (SSD) was informed of the situation after the bullets were found, and the sheriff was called to search the resident's room, where a gun and bullets were confiscated. Interviews with the Director of Staff Development (DSD) and the Interim Activity Director (IAD) revealed that the AA should have reported the incident immediately, as it posed a significant safety risk to all residents and staff. The facility's policies on investigating and reporting accidents and unusual occurrences were not followed, contributing to the deficiency.

Penalty

Inspection fine: $22,777

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

Summary

The facility failed to provide adequate supervision and safety measures for two residents, leading to significant deficiencies. Resident 52, who was at high risk for elopement due to severe cognitive impairment and a history of attempting to leave the facility, managed to elope from the facility unattended. Despite having a care plan that included the use of a WanderGuard system and ensuring exit alarms were functional, these measures were not implemented. The resident was found outside the facility in a street intersection, highlighting a lapse in supervision and monitoring by the staff. Additionally, Resident 43, who had a history of frequent seizures and was at high risk for falls, was not monitored for 50 minutes. The resident expressed concerns about the lack of staff awareness regarding his seizures, which had led to falls from his wheelchair. Despite the facility's policy requiring monitoring every 15 to 30 minutes, this was not adhered to, and there was no documentation of the monitoring that was supposed to occur. Interviews with staff revealed a lack of awareness and adherence to the facility's policies and procedures regarding the safety and supervision of residents at risk. The Director of Nursing acknowledged the deficiencies in monitoring and the failure to follow the care plans designed to prevent such incidents. The facility's policies on wandering, elopement, and seizure management were not effectively implemented, resulting in these serious lapses in resident care.

Removal Plan

• Monitoring/updating residents in the elopement binder
• Activated all the exit door alarms
• All exit door alarms will be activated
• The front door will be disarmed and be monitored by the receptionist and/or designated staff
• The maintenance department will conduct weekly inspection of the exit door alarms

Penalty

Inspection fine: $22,777

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 Registered Nurse (RN) was on duty for eight hours a day, seven days a week, as required. This deficiency was identified during an interview and record review conducted on May 17, 2024, at 11:20 a.m., with the payroll department. The review of payroll data from the first quarter of 2023 to the first quarter of 2024 revealed that there was no RN scheduled for eight specific dates across July, August, and October 2023. During a subsequent interview on the same day at 11:59 a.m., the Director of Nursing confirmed the requirement for RN presence in the facility for eight hours daily. The absence of RN coverage on these dates has the potential to endanger the health and safety of residents and prevent them from reaching their highest practicable level of well-being.

Penalty

Inspection fine: $22,777

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 a comprehensive person-centered care plan to address the risk of elopement for two residents, resulting in a significant deficiency. Resident 52, who was admitted with diagnoses of alcoholic cirrhosis of the liver and was receiving palliative care, was identified as a high risk for elopement. Despite this, the care plan interventions, including the use of a Wanderguard system, were not implemented. An observation revealed that Resident 52 did not have a Wanderguard bracelet, leading to the resident eloping from the facility for almost an hour without staff knowledge. Similarly, Resident 4, diagnosed with dementia and also identified as a high risk for elopement, did not have the necessary Wanderguard interventions in place. The facility's administrator admitted that the alarms on the side exits were not activated and was unsure if the Wanderguard system was operational, as it had not been in use. The maintenance assistant confirmed that the side exit doors were only recently alarmed during the night shift, indicating a lapse in ensuring the safety measures were consistently applied. These oversights had the potential to result in serious harm to the residents.

Penalty

Inspection fine: $22,777

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 proper system of records for controlled drugs, specifically in the Narcotics Destruction Log (NDL). During a review, it was found that three pages of the Controlled Drug Logbook (CDL) were incomplete. These pages, which listed a total of 43 medications, lacked essential information such as the date of receipt by the Director of Nursing Services (DNS), co-signatures by the licensed nurse and DNS upon exchange of controlled medications, and page numbers. The absence of these details could hinder accurate accounting and prompt identification of any loss or diversion of controlled medications. The Director of Nursing (DON) acknowledged the missing information on the CDL pages, including the date column, staff co-signatures, and page numeration. During an interview, the DON admitted that there was no existing policy for maintaining CDL records for controlled drugs disposition and that the facility followed the instructions written on the CDL record. The DON emphasized the importance of maintaining consistent narcotic logs to prevent diversion and discrepancies, highlighting the facility's failure to adhere to proper documentation procedures for controlled substances.

Penalty

Inspection fine: $22,777

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 three residents were free from unnecessary psychotropic drugs. Resident 33 had a PRN order for Olanzapine, an anti-psychotic medication, without an end date, contrary to the facility's policy that requires PRN orders for antipsychotic medications to not be renewed beyond 14 days without a healthcare practitioner's evaluation. Resident 33's medical history included diabetes and dementia, and the medication was prescribed for agitation. Residents 23 and 28 were prescribed PRN Ativan for anxiety, but their orders also lacked a stop date, exceeding the 14-day limit set by the facility's policy. Both residents had diagnoses of dementia and anxiety, with impaired memory and decision-making capacity. Interviews with the RN and DON confirmed the absence of stop dates and acknowledged the need for reevaluation of the medication's appropriateness beyond 14 days. The Pharmacy Consultant also confirmed the policy requirement for reevaluation after 14 days.

Penalty

Inspection fine: $22,777

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 monitoring and storage of medications in one of its medication rooms. Specifically, the temperature of the medication refrigerator was not monitored daily for nine days in May 2024, as required by the facility's policy. The acceptable temperature range for the medication refrigerator is between 36°F and 46°F, and the absence of temperature records for these days could lead to medications being stored at improper temperatures, potentially affecting their efficacy. This was confirmed during an interview with the Infection Preventionist (IP), who acknowledged the importance of monitoring refrigerator temperatures to prevent medications from becoming ineffective. Additionally, the facility did not label two multiple dose vials of Tuberculin Purified Protein Derivative (PPD) with the date they were opened. These vials were found in the medication refrigerator without any indication of when they were first accessed, which is against the facility's policy that requires vials to be dated upon opening. The IP confirmed that the vials should be discarded 28 days after opening, but without the date, it is unclear if they were still effective. This oversight could result in the use of ineffective medications for residents, as the vials were stored in an unsealed manufacturer's box with the vial stoppers uncovered.