Majestic Mountain Care 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 deficiency involves the facility’s failure to provide adequate supervision and prevent accidents when a resident with bilateral above‑knee amputations was left unattended in bed during wound care. The resident, who required substantial/maximal assistance for functional abilities and had orders for a left-side quarter bed rail for functional mobility, was receiving wound care to the bilateral medial buttocks from an LVN and a wound doctor. During the treatment, the LVN observed blood on the resident’s brief and asked a CNA to obtain a clean brief. The LVN then left the resident lying on his right side without placing a new brief, with no bed rail on the right side of the bed, and assumed a CNA would complete the brief change. The LVN went to another resident’s room and did not return to complete the care. Subsequently, staff and the resident’s roommate reported that the resident fell from the right side of the bed. The resident stated he had fallen asleep while waiting for staff, rolled onto his back, and then off the bed, after the LVN and wound doctor left the room. The roommate reported that a woman had been with the resident and then left, and shortly afterward he heard a shaking motion from the resident’s bed followed by the sound of the resident falling to the floor on the right side of the bed. CNA 1, who was across the hall, heard a faint cry for help, entered the room, and found the resident on the floor, noting it was not normal for this resident to be out of bed due to his condition. CNA 1 called an RN for assistance, and multiple staff, including CNA 2, used a mechanical lift and sling to return the resident to bed. Interviews and record review confirmed that the resident’s fall was unwitnessed and occurred after the LVN left him on his right side during wound care. CNA 3 reported that the resident said he was waiting for the LVN to return with a brief when he fell and that he complained of left hip pain afterward. The ADON stated that the resident was a two-person assist prior to the fall and expressed surprise that he had been considered a one-person assist, adding that the LVN should never have left the resident in the middle of providing care and that it was standard practice not to leave any resident alone during care. The Administrator reported that the IDT fall review determined the LVN left the resident unattended during wound care and that the fall was potentially avoidable. Progress notes and radiology results documented that the resident sustained a fracture of the left femoral trochanter and experienced mild pain, for which acetaminophen was administered as needed. The facility’s policy on Provision of Quality Care stated that residents are to receive treatment and care in accordance with professional standards of practice, which was not followed in this incident. The Director of Nursing, who had recently started in the role, stated she was informed that the resident had an unwitnessed fall from the right side of the bed and that he initially did not complain of pain but later reported left-sided pain and refused transfer to the hospital. The resident’s care plan and MDS indicated he required assistance of one to two persons for most ADLs and substantial/maximal assistance for functional abilities, and he had a BIMS score of 14, indicating minimal to no cognitive impairment. The fall IDT review documented that the resident had bilateral above-knee amputations, preferred his bed at a high level, and that the treatment nurse stepped away from the room, leaving the resident on his right side while awaiting her return, and that she did not return. These facts collectively show that the resident, with significant physical limitations and identified assistance needs, was left unattended in a vulnerable position during care, without appropriate supervision or protective measures on the right side of the bed, resulting in a fall and left hip fracture.

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 deficiency involves the facility’s failure to follow its Abuse Prevention and Response Policy in response to an allegation of sexual abuse made by one resident against another, and in a separate incident, failure to supervise a resident at high risk for elopement during a smoking break. One resident, admitted with moderate cognitive impairment as evidenced by a BIMS score of 12, reported that another resident with severe cognitive impairment (BIMS score of 4) had inappropriately touched her breasts during what began as a mutual hug in a hallway. The resident stated she felt violated and only felt safe after she personally informed staff of the incident. Staff interviews confirmed that the allegation was reported to social services on a specific date, but no internal investigation or documentation of the allegation or subsequent actions was found in the resident’s electronic medical record. The administrator and social services staff acknowledged that the incident was not reported per facility policy because the resident requested that it not be reported, and that the only external contact made was to local law enforcement, which did not take action. Social services stated that nothing else was done for the allegation beyond that call, and there were no social services visits or documented monitoring for psychosocial harm or behavioral changes after the report. Multiple staff members, including LVNs and the clinical coach, stated that the facility process for any abuse allegation was to ensure resident safety, separate involved residents, report the allegation immediately, conduct an investigation, document all findings, and monitor for emotional distress. Review of the alleged perpetrator’s care plan showed a prior history of inappropriate behavior toward a female resident, including grabbing a female resident’s breast in the social dining room, with interventions such as 15‑minute checks and monitoring during mealtimes to keep him away from female residents. Despite this history and the new allegation, staff reported there were no new interventions documented for the alleged victim, and no investigation or documentation of the March incident in the medical record. In a separate incident, the facility failed to provide adequate supervision to a resident identified as high risk for elopement. This resident, admitted with dementia, schizophrenia, and muscle weakness, had an elopement risk assessment score of 20, which staff stated represented high risk. The resident reported leaving the facility through the front door during a smoke break, hitchhiking with an unfamiliar female to her home, receiving money, and then being driven to a casino several miles away, where the resident remained until local law enforcement arrived. Facility records and staff interviews indicated that an LVN left the resident sitting on a bench outside the front door, which was not a designated smoking area, and returned inside to complete an admission, leaving the resident unsupervised for approximately 10–15 minutes. The progress note documented that the front door alarm sounded, the nurse found the resident outside smoking, turned off the alarm, reminded the resident to come inside after smoking, and then, after 10–15 minutes, discovered the resident was gone, prompting a search of the building and surrounding area. Multiple staff, including social services, the clinical coach, the activities director, and another LVN, confirmed that facility process required staff to remain with and monitor residents during outings and smoking breaks, especially those at high risk for elopement, and that the resident should not have been left unattended outside the front entrance.

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 deficiency involves the facility’s failure to report an allegation of sexual abuse to the state agency as required by policy and mandated reporter standards. Resident 1, who had a BIMS score of 12/15 indicating moderate cognitive impairment, reported that another resident (Resident 2) inappropriately touched her breasts without consent during a hug in a hallway. Resident 1 described that Resident 2 blocked her path, requested a hug, and as she pulled away, Resident 2 slid his hand over both of her breasts. She stated she immediately yelled at Resident 2, told him the action was inappropriate, felt violated, and later reported the incident to staff herself, after which she felt safe in the facility. The administrator stated that on 3/12/26 he was informed by staff that Resident 1 had reported the incident involving Resident 2 inappropriately touching her breast, and that an investigation was initiated. He further stated that Resident 1 requested the incident not be reported to any authorities, and based on that request, the incident was not reported to the state agency and was only reported to law enforcement. The social services director confirmed that Resident 1 reported that Resident 2 had touched her breast without consent and that Resident 1 requested the incident not be reported outside the facility. The social services director acknowledged that the incident was not reported as per facility policy, and stated that all staff were mandated reporters and the allegation should have been reported immediately. Interviews with facility staff and review of facility documents showed that the facility had a process and policy requiring immediate reporting of suspected abuse. The CNA stated it was facility process to report and investigate sexual abuse or any abuse allegation immediately to ensure resident safety. LVN 1 referenced the facility’s “Report of Suspected Dependent Adult/Elder Abuse” form, which stated that any mandated reporter who has knowledge of, is told of, or reasonably suspects abuse or neglect shall complete the form immediately or as soon as practicably possible for each known or suspected instance of abuse, including sexual abuse. LVN 1 stated that Resident 1’s report that Resident 2 touched both of her breasts without consent should have been reported immediately to ensure separation and safety. The clinical coach and administrator both stated that the facility process for an allegation of abuse was to ensure safety, separate residents, and report the incident immediately, and the facility’s “Unusual Occurrence Reporting” policy required reporting allegations of abuse to appropriate agencies. Despite these policies and staff understanding, the allegation of sexual abuse involving Resident 1 and Resident 2 was not reported to the state agency.

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 deficiency involves the facility’s failure to ensure nursing services met professional standards of quality and to follow its policy titled “Nursing Assessment and Management of Residents Following a Fall” for one sampled resident. The resident was admitted with a history of falling, anxiety disorder, dementia, and a cognitive communication deficit, and had a BIMS score of 5/15 indicating severe cognitive impairment. On the day in question, CNAs observed that the resident was restless, anxious, exit seeking, self‑propelling in her wheelchair through the halls, and attempting to get into other residents’ beds, which both CNAs identified as behavior that was out of her normal pattern. Despite this change in behavior, LVN 1 did not perform an assessment to determine the cause of the behavior and did not notify the physician for guidance. Instead, LVN 1 instructed CNA 1 and CNA 2 to assist the resident to bed, even after both CNAs expressed concern that putting the restless resident in bed could lead to a fall. After the CNAs assisted the resident to bed, they observed her awake and fidgeting with the bed remote and call light. Approximately 15–30 minutes later, CNA 1 and CNA 2 found the resident sitting on the hallway floor outside her room. Both CNAs reported that LVN 1, who was in the hallway, directed them to pick the resident up from the floor and assist her back to bed before LVN 1 completed an assessment for injuries. CNA 1 and CNA 2 stated that the facility process required the nurse to assess a resident for injuries before the resident was moved or transferred after a fall. LVN 1 later acknowledged that the resident’s behavior had been different that day, that no assessment was completed to identify the cause of the behavior before the fall, and that she did not assess the resident while the resident was still on the floor following the unwitnessed fall. Documentation reviewed by surveyors showed that the progress note for that day recorded the resident as being found on the ground in her room, sitting upright near the foot of her bed, and noted that she had been self‑propelling through the halls and attempting to lie in other residents’ beds. An SBAR form documented an unwitnessed fall with no injuries noted and described the resident as anxious and requiring redirection throughout the shift. LVN 1 stated she only completed a quick, limited assessment after the resident was already back in bed, focusing on visible skin, vital signs, and observation of extremity movement, and did not perform a thorough head‑to‑toe assessment as required by facility policy. The facility’s fall policy required an immediate, comprehensive post‑fall assessment, including a head‑to‑toe physical and neurological assessment, and specified that residents should not be moved until assessed unless remaining in place posed immediate risk. The DON and DSD both confirmed that the facility’s expectation was for the nurse to assess residents when there was a change in behavior and immediately after a fall, and that the nurse should assess the resident on the floor before any transfer. On the following day, a progress note documented that the resident was observed in a wheelchair in the lobby with a bruise on the top of the left outer palm and top of the left hand, which had not been identified on the day of the fall. An x‑ray order was obtained for the left hand and wrist related to the unwitnessed fall, and the radiology report showed a fracture of the 5th metacarpal shaft with associated soft tissue swelling. A subsequent SBAR documented that the radiology company reported a fracture to the left hand and that this injury was a delayed finding after the unwitnessed fall. The hospital emergency department record noted bruising and purple discoloration to the left hand and referenced the ground‑level fall the previous day. These findings demonstrated that the resident sustained an injury that was not identified at the time of the fall due to the lack of timely, thorough assessment in accordance with professional standards and the facility’s post‑fall 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 follow its transfer and discharge policy and procedure for a resident who was admitted with multiple complex medical conditions, including cervical spine fusion, functional quadriplegia, inflammatory spondylopathy, chronic pain syndrome, and cervical spinal stenosis. The resident was cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status. Despite a court order requiring the facility to readmit the resident after a hospitalization, the facility did not comply and refused readmission. The facility did not provide the required written notice to the resident regarding the transfer or discharge, nor did it document a legally permissible reason for the discharge in the medical record. The facility also failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals. Interviews with facility staff revealed that although preparations were made for the resident's return, concerns about the resident's behavior led to a decision not to readmit, despite the court order and the resident's expressed preference to return. Documentation from the hospital indicated that the resident was ultimately discharged to another skilled nursing facility after the family was unable to provide care at home. The facility's own policy required that residents be permitted to return after hospitalization unless a proper discharge process was followed, including timely notice and coordination with the resident and their representative. In this case, the facility did not meet these requirements, resulting in the resident being transferred without proper notice or planning.

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 treatment and services to maintain or improve range of motion (ROM) for a resident who had undergone left knee surgery. The resident was admitted with a knee brace in place, but the facility did not obtain a physician order for the use of the knee brace, nor did they develop an individualized care plan addressing its use. Additionally, the facility did not schedule a follow-up orthopedic appointment within the recommended timeframe, resulting in the knee brace being left on continuously for an extended period. Observations and interviews revealed that the resident experienced significant pain and immobility in the left leg, with a pain score of 10/10 upon movement. The resident's medical history included a left tibial shaft fracture, muscle weakness, abnormal gait, and muscle atrophy. Despite recommendations from the orthopedic surgeon for weight-bearing as tolerated and physical therapy, the resident's care plan did not address the knee brace, and there was no documented follow-up with the orthopedic specialist as required. The physical therapy department provided ROM exercises, but the resident was often unable to participate fully due to pain, and the knee brace remained on during all therapy sessions without a physician's directive for its continued use. Multiple staff interviews confirmed that there was a lack of communication and coordination regarding the resident's post-operative care, including the absence of a care plan for the knee brace and failure to clarify or obtain necessary physician orders. The attending physician, DON, and orthopedic physician all acknowledged that prolonged use of the knee brace without proper follow-up could lead to joint stiffness and contractures. Ultimately, the resident developed an equinus contracture of the left ankle and decreased knee mobility, resulting in immobility and pain. The deficiency was attributed to failures in communication, care planning, and timely follow-up with the orthopedic specialist.

Penalty

No penalty information released

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

Summary

A deficiency occurred when facility staff failed to ensure a resident's environment was free from accident hazards and did not provide adequate supervision or assistive devices to prevent accidents. Staff were aware that certified nursing assistants (CNAs) used a regular wheelchair to transport a resident with significant mobility limitations, including functional quadriplegia and a history of cervical spine fusion, over an elevated threshold to access the smoking area. The CNAs pulled the resident backwards in the wheelchair and tilted it to navigate the threshold, which resulted in the wheelchair tipping over and the resident falling backwards, striking his head and neck on the concrete floor. Nursing staff did not evaluate the hazardous nature of the travel path or the unsafe technique used to tilt the wheelchair. There was no consideration for a physical therapy evaluation for a new wheelchair with anti-tilt bars prior to the incident, despite the resident's complaints about the safety of the original wheelchair. Documentation following the fall was incomplete, with discrepancies in the location of the fall and lack of follow-up on radiology results. The resident experienced increased pain following the fall, and staff failed to ensure timely and complete assessment and documentation of the incident and its aftermath. Interviews and record reviews revealed that the path used for transporting the resident was not assessed for safety, and staff were not consistently informed or trained on safe transport practices. The facility's policies required identification and mitigation of accident hazards, but these were not followed in this case. The resident continued to use an unsafe path and wheelchair until after the incident, and staff did not adequately communicate or document the risks or interventions related to the resident's fall.

Penalty

No penalty information released

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

Summary

A resident with a history of cervical spine fusion, functional quadriplegia, inflammatory spondylopathy, chronic pain syndrome, and cervical spinal stenosis experienced a fall when staff tilted the resident's wheelchair backward to transport him, resulting in the resident striking his head and neck on the concrete ground. Following the incident, the resident reported increased and persistent pain in the neck and back, radiating to the arms, with pain levels escalating from a pre-fall 8/10 to 9/10 post-fall. Despite these complaints, nursing staff did not conduct a thorough pain assessment or effectively manage the resident's pain in accordance with professional standards and the facility's pain management policy. The resident's medical records and interviews revealed that pain medication, including oxycodone-acetaminophen, was administered as needed, but the resident consistently reported that the medication was ineffective in controlling his pain. Documentation showed repeated high pain scores (averaging 8/10) over several weeks, and staff notes indicated the resident verbalized the ineffectiveness of the prescribed pain regimen. However, there was no evidence that staff reassessed the pain management plan, notified the physician of the ongoing uncontrolled pain, or revised the care plan as required by facility policy. Additionally, the facility failed to follow up on incomplete cervical spine x-ray results, which were necessary to rule out injury after the fall. The lack of follow-up on diagnostic results and the absence of a systematic approach to pain assessment and management led to the resident experiencing avoidable, uncontrolled pain. Staff interviews confirmed that the expected process of assessment, documentation, and physician notification was not followed, resulting in unmanaged pain for the resident after the fall.

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 follow their policy and procedure on charting and documentation in accordance with professional standards of practice for one resident. After a fall occurred when the resident's wheelchair was tilted backwards by staff, resulting in the resident falling and hitting the back of his head and neck, staff did not complete thorough documentation of the incident or possible injuries. The initial progress notes and SBAR post-fall documentation were incomplete, lacking detailed descriptions of the event, assessments, and interventions performed. The resident refused vital signs at the time, but the documentation did not reflect a comprehensive assessment or follow-up. Additionally, although x-rays were ordered immediately after the fall, the cervical spine x-ray results were not followed up for three weeks. The radiology report was incomplete, and there was no indication in the medical record that staff obtained or reviewed the final results for the cervical x-ray. Interviews with nursing staff and the DON confirmed that the documentation was incomplete and that the process for following up on diagnostic results was not adhered to, leaving the possibility of an undiagnosed injury. The resident, who had a history of cervical spine fusion, functional quadriplegia, chronic pain syndrome, and spinal stenosis, reported increased pain following the fall, which was not adequately addressed in the documentation. The facility's policy required complete, objective, and accurate documentation of all services, changes in condition, and incidents, but this was not met in the handling of the resident's fall and subsequent care.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to ensure acceptable nutritional status was maintained for one resident who had dysphagia, type 2 DM, Alzheimer’s disease, anxiety, and unspecified protein-caloric malnutrition. The resident’s weight declined from 176 pounds on 2/1/25 to 170 pounds on 3/1/25, then to 169 pounds on 5/1/25, 160 pounds on 6/1/25, 156 pounds on 6/23/25, 153 pounds on 7/7/25, and 151 pounds on 7/14/25. The record reflected unplanned weight loss of 6 pounds (3.4%) in one month, 9 pounds (5.3%) in one month, and 23 pounds (13.7%) over five months. The resident’s assessments showed increasing dependence with eating, progressing from partial/moderate assistance on the 3/2/25 MDS to substantial/maximum assistance on the 5/29/25 MDS. During the survey, the resident was observed lying in bed, dressed in a gown, and unable to state her name or be interviewed. The RD stated the resident had a six-pound weight loss in one month and that the facility should have had an IDT meeting in March 2025, with weekly weight checks recommended at that time. The RD also stated the resident had a nine-pound weight loss on 6/1/25, that an IDT meeting occurred on 6/12/25, and that the resident was later started on Prostat on 7/21/25. Staff interviews and record review showed delays and omissions in response to the weight loss. The LVN stated she was not aware she had to notify the physician of the resident’s weight loss on 6/1/25 and 7/7/25. The RD stated the physician should have been notified of the weight loss on 6/1/25 and that additional supplement interventions should have been implemented earlier. The DON stated the nurses should have contacted the physician and RP right away, that an IDT meeting should have been held in March 2025 and weekly thereafter, and that the facility did not follow its weight management policy and procedure. The chart also showed no supplement recommendations and no documentation of physician or RP notification in the March and June nutrition risk reviews and the 6/12/25 progress note.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to have qualified, full-time oversight of Food and Nutrition Services. The deficiency was identified after interview and document review showed that the Dietary Supervisor had been supervising the kitchen since December 2024 but had only started school in January 2025 to become a Certified Dietary Manager (CDM), and was therefore not yet qualified for the role. The Registered Dietitian stated she worked at the facility only one to two days a week, and later clarified she usually worked there on Thursdays only. During interview, the Dietary Supervisor Mentor stated he was a CDM at another facility and provided mentoring to the Dietary Supervisor, but that the mentoring was usually done by phone rather than on site. The Administrator in Training stated he had reviewed the California Health and Safety Code and understood the plan was for the Dietary Supervisor to become qualified through CDM training, but acknowledged she was not currently qualified to be the full-time person supervising Food and Nutrition Services. Review of the job description for Manager of Dining Services showed the position was responsible for managing dietary operations, including staffing, food ordering and preparation, food delivery, and clean-up.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to ensure kitchen staff had the appropriate competencies to carry out food and nutrition services. During observation in the kitchen, an employee who was helping out from housekeeping demonstrated limited knowledge of the low-temperature dish machine and how to test sanitizer strength. He initially reached for Quat test strips even though chlorine was the sanitizer used in the machine, and after being given chlorine test strips, he tested the machine and stated the sanitizer strength was acceptable even though the strip indicated less than 10 ppm and the Dietary Supervisor confirmed there was no sanitizer in the dish machine. The manufacturer label on the machine indicated a minimum wash temperature of 120 F and minimum chlorine of 50 ppm, and the Dietary Supervisor stated the sanitizer strength should be checked before use and the machine should reach 120 F before use. Record review showed the dish machine log was maintained for breakfast, lunch, and dinner from July 1 through July 20, but the July 21 lunch wash temperature and rinse ppm were not documented. The Dietary Supervisor also confirmed that the employee had not participated in the dish machine in-service training dated 12/19/24 and stated she was not able to provide dish machine in-service training for him. The facility policy for dishwashing machine operation stated machines should be operated according to manufacturer recommendations and should not be used if the final rinse temperature or chemical sanitizing concentration was out of range. The facility also failed to ensure competency in preparing pureed food and using the three-compartment sink. While pureeing chicken for residents on a pureed diet, an employee added 3 1/2 cups of chicken broth to the chicken and blended it, producing a runny consistency before adding thickener. She stated the pureed chicken should have a pudding-like consistency and should hold shape on a spoon, but the Dietary Supervisor and Registered Dietitian stated she should not have added the entire amount of broth and that liquid should be added gradually to achieve the proper formed consistency. The employee had attended an in-service on proper pureeing, but the observed preparation did not match the recipe guidance. During another observation, the same employee stated she knew the three-compartment sink was used for washing, rinsing, and sanitizing, but she did not know how long items had to be submerged in the sanitizing solution or the temperatures required for the wash and rinse compartments. The Dietary Supervisor stated the posted instructions should be followed, and record review showed no documentation of training on the three-compartment sink for any staff. The facility's emergency dishwashing policy described a three-step manual washing process with 120 F water in the first and second sinks and a chemical sanitizing solution in the third sink.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to ensure food was palatable, attractive, and served at a safe and appetizing temperature when lunch items on both a regular diet tray and a pureed diet tray were observed below the facility’s preferred hot-food temperature. During a concurrent observation and interview with the Dietary Supervisor and Registered Dietitian, the regular tray items of honey glazed ham, cauliflower, and sweet potato wedges were measured at 109.3°F, 108.4°F, and 104.8°F, respectively. The pureed tray items were measured at 100.6°F for ham, 101°F for cauliflower, and 104°F for sweet potato wedges. The Registered Dietitian stated food should be at least 110°F when served and stated she did not conduct test trays or assess trays as they were delivered to residents. The pureed ham, cauliflower, and sweet potato wedges on the test tray were also observed to have a thin, runny consistency and were spread flat on the plate. During interview, the Registered Dietitian stated the pureed food was too thin and should have been a mashed potato consistency. She stated that if pureed food is too thin, residents could choke if they could not tolerate thinner liquids, and that the thin appearance and texture were not appealing and may cause residents to eat less. Review of the facility’s diet manual showed pureed foods should have a pudding-like or smooth mashed potato consistency. The pureed sweet potato wedges were additionally found to be bland. When tasted during the observation, the regular sweet potatoes were flavorful, but the pureed sweet potatoes had little flavor. A cook stated she did not follow a recipe for the sweet potatoes because they came prepared in a box, added milk and thickener, and did not add extra seasoning. She also stated she did not taste the sweet potatoes before they were served. The Registered Dietitian stated cooks should follow recipes and taste food, and that pureed foods should have the same desirable flavor as the menu item. The deficiency affected 55 residents who received food from the kitchen out of a census of 56.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

Food was not stored, prepared, distributed, and served in a safe and sanitary environment in multiple areas of the kitchen and food storage areas. During observation, the dish machine was in use while the wash and sanitizing temperatures were 110 degrees Fahrenheit, and chlorine sanitizer did not register on test strips. The sanitizer tubing was pinched, and the Dietary Supervisor Mentor confirmed sanitizer was not reaching the machine while utensils were being washed. The dish machine manufacturer label indicated a minimum wash temperature of 120 degrees Fahrenheit and minimum chlorine of 50 PPM, and the Dietary Supervisor stated the sanitizer strength should be checked before use and the machine should reach 120 degrees Fahrenheit before use. The ice machine was observed with yellow residue along the evaporator plate frame and a rough texture on the frame surface. The Maintenance Supervisor stated the ice machine was cleaned monthly and described a cleaning process that ended with spraying nickel-safe cleaner, while the manufacturer instructions reviewed during the survey indicated sanitization was the last step of the cleaning process. The three-compartment sink had pink residue around the drain opening, a brownish-yellow film on the sink surfaces, and hard gray patches with brown and black residue. Staff stated the sink was used to wash produce, and one staff member stated she sprayed the inside with water only and did not scrub it with cleaner. The Dietary Supervisor confirmed the cleaning schedule did not consistently show the sink being cleaned twice a day as required by the facility’s schedule. The kitchen environment and equipment were also not maintained in clean condition. Floors had cracks, broken tiles, gaps, and uneven surfaces; baseboards and wall transitions were pulled away from the wall; ceiling panels were warped with gaps; and a ceiling panel above the tray line had black residue around the vent and perimeter. The back door near the kitchen entrance was cracked, did not fit snugly, and had gaps, and the screen door had multiple tears. Under the three-compartment sink, there was yellow and brown residue on the floor, gray dust-like substance on the pipes, and thick yellow buildup in an upright pipe. A counter-mounted can opener had sticky gray residue on the blade and brown and black residue on the base, and plastic serving trays had black, pink, and brown discoloration. In the walk-in refrigerator, opened pastrami deli meat and canned mushrooms were observed past their use-by dates, and the Dietary Supervisor stated both items should have been discarded.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to ensure arbitration agreements were explained to residents in a manner they could understand for 57 of 57 residents. During an interview, the Admissions Coordinator stated she gave residents the arbitration agreement upon admission but did not explain what arbitration was to any newly admitted resident. She stated residents were left to review the agreement on their own with the rest of the admission packet and that she did not know what arbitration was, so she had never explained it to any resident. During an interview, the Administrator in Training stated the Admissions Coordinator needed to be familiar with what arbitration was and with the facility's arbitration agreement. The Administrator in Training stated residents had the right to understand what arbitration was and to know their rights regarding the process, and that some residents may not want to sign the agreement if it was not thoroughly explained to them. The facility policy titled Arbitration stated the facility asks residents to enter into binding arbitration but does not require it as a condition of admission or continued care, and that the facility shall explicitly inform the resident or representative of the right not to sign, explain the agreement in a form and manner understood by the resident or representative, and ensure acknowledgment of understanding.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to implement adequate infection prevention and control measures and did not have a comprehensive water management plan to minimize the risk of Legionella and other pathogens in the building's water system. During a concurrent interview and record review, the Maintenance Supervisor reviewed the undated Facilities Water Management plan and found that the sections titled Description of the Building Water System, Identification of Potential Growth Areas, and Control Measures and Monitoring were empty and incomplete. The Maintenance Supervisor stated that no Legionella testing was done in 2024 and that the facility did not currently have a complete Water Management plan. During interviews, the Infection Preventionist stated the facility needed a complete Legionella and water management plan and that Legionella had the potential to infect everyone in the facility. The Administrator in Training stated the facility should have been aware that the water management plan was incomplete and that proper water management documentation should have been included in the Water Management binder. The DON also stated the Water Management plan should have been complete and that it was important because it helped ensure Legionella did not spread to residents. The facility policy titled Legionella Water Management Program stated the program includes a detailed description and diagram of the water system, identification of areas that could encourage the growth and spread of Legionella or other waterborne bacteria, identification of situations that can lead to Legionella growth, and documentation of the program.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to keep the three-compartment sink in safe operating condition when it was used for food preparation and ware washing. During observation in the kitchen, the sink was being used to wash kitchen utensils and other equipment if the dish machine was not working, and staff also stated it was used to wash produce. When the Maintenance Supervisor removed the drain plug from the first compartment, the water drained slowly and he stated there was something wrong with the drains and that the drains were bad. When the Maintenance Supervisor removed the drain plug from the third compartment, water and black and brown debris backed up into the second compartment. He then replaced the drain plug in the first compartment and left the third compartment unplugged to drain, but the drain plug in the first compartment popped out and water and debris backed up into the second and third compartments. The report also noted that the drain from the three-compartment sink was plumbed directly into the wall and there was no air gap under the sink. The Dietary Supervisor stated the facility did not have drain plugs to plug the sink compartments so they could be filled for manual dishwashing. Facility procedures posted above the sink and in the dishwashing policy described use of the three compartments for washing, rinsing, and sanitizing pots and pans, and the manual dishwashing procedure stated the sink would be used if the dish machine was not functioning. The report also cited the Federal Food Code and facility policy regarding maintenance of equipment, plumbing, and air gaps.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents. Resident 12 stated his mattress was too small, worn down in the middle, and allowed him to feel the springs and metal from the bed frame. He reported that he was 6 feet 7 inches tall and weighed 350 pounds, and that the mattress did not provide a comfortable night's rest. Staff members, including an LVN, the Maintenance Supervisor, a CNA, the AIT, and the DON, acknowledged that Resident 12 needed a larger or better-supported bed and that the current mattress was older and did not provide the support he required. Resident 31 and Resident 38 shared a room that had two white painted patches on the wall next to the door, which staff and a family member described as unfinished, tacky, depressing, and not homelike. In the shared restroom, a brown substance was observed on the toilet seat, along with a bag of adult briefs, a urinal hat, a commode bucket, wipes, lotion, and an unlined trash bin. The LCNA stated none of the items should have been there and that the toilet should have been cleaned. The Infection Preventionist and DON both stated the restroom was unsanitary, not homelike, and created an infection control concern. Resident 31 had dementia and a BIMS score of 4, indicating severe cognitive impairment, while Resident 38 had diagnoses including anxiety, lower back pain, dysphagia, heart failure, and anemia, with a BIMS score of 15. Resident 16’s bathroom had a strong odor of urine, yellow liquid on the floor around the toilet, and trash on the floor. Resident 16 stated the bathroom had not been cleaned for a long time and had always smelled of urine. An LVN stated the resident should not have to get used to the smell of urine and that the bathroom should be clean and odor-free. Resident 54 was observed lying directly on the mattress without sheets, a pillowcase, or blankets after staff removed the bedding because she had been pulling at it and putting it over her face. The CNA stated she left the bed bare because she was following prior instruction, while the LVN, DSD, and AIT stated the resident should not have been left on the bare mattress. Resident 54 had Alzheimer’s disease, dementia, major depressive disorder, osteoarthritis, and a BIMS score of 0, indicating severe cognitive impairment.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to ensure that LVN 2 had the annual nursing skills training competency completed in accordance with the facility's Nursing Skills Training and Competency Policy. During interview and record review, the Director of Staff Development stated that LVN 2 did not have her annual nursing skills competency check-off list in her personnel file, that it should have been completed annually, and that it was due in 5/2025. The Director of Staff Development also stated she was not sure why it had not been done and that the facility was working on obtaining the competency check-off list for LVN 2. During interview, the Director of Nursing stated LVN 2 should have had the nursing skills competency check-off list evaluation during the first 90 days and then annually. The DON stated that LVN 2's lack of competency could not have been identified and the facility could not have helped her improve on areas of concern. The DON also stated that resident care could be affected by the lack of competency check and acknowledged, "We did not follow our policy and procedure." The facility policy stated that all nursing staff must demonstrate competency in required nursing skills upon hire and annually thereafter through hands-on demonstration, written evaluations, and direct observation.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to ensure fortified diets were prepared according to the fortified menu for 6 residents who were ordered fortified diets: Residents 2, 3, 18, 24, 26, and 56. During a concurrent observation and interview in the kitchen, tray line service was observed as food was plated. A scoop of cooked cauliflower was placed on resident plates, and the meal ticket for Resident 1 was reviewed as an example of a fortified diet order. The staff member stated residents on a fortified diet were supposed to receive extra calories on their food, and that extra butter was provided on the cauliflower for extra calories that day. When the fortified meals were plated for the residents on fortified diets, extra butter was not placed on the vegetables. The staff member explained that more butter had been used during cooking than the recipe called for, but no extra scoop of butter was added at tray line. The staff member stated all residents received the same cauliflower and there was no difference between the cauliflower served to a resident on a regular diet and a fortified diet. The RD stated fortified diets were to receive extra calories by adding extra butter, dressing, or gravy, and that for lunch that day fortified diets should have received extra gravy on the meat and butter on the vegetables. The RD also stated the extra butter and gravy had to be added during tray line, not during cooking, to ensure the correct portion. Record review showed the six residents had active fortified diet orders with start dates documented in their OSRs.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to ensure the rights of one resident were honored when the call light in her former room was not working and she was unable to return to that room. Resident 22 was observed in her current room with the curtains drawn and stated she did not like her current room or her roommate. She said her roommate was going through her items, giving them away, and made her nervous. Resident 22 stated she had been in the current room for about two months, liked her old room, and wanted to go back. Her record showed she was admitted with multiple sclerosis and had a BIMS score of 14, indicating she was cognitively intact. Staff interviews confirmed the call light in Resident 22’s old room was not working and had been out of service for about two months. CNA 3 stated the resident had mentioned not liking her roommate and that the resident had the right to return to her room and keep her items from being moved or taken. LVN 1 stated the resident had been asking to return to her old room and that the room should have been changed when the roommate went through her items. The DON observed exposed wires at the call light system in the old room and stated the call light was not working. The SSD and AIT also stated the call light should have been fixed and that the resident had the right to return to her old room and be comfortable in her room.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to complete a performance review for one of two sampled CNAs at least once every 12 months. During a concurrent interview and record review on 7/24/25 at 10:02 a.m. with the DSD, CNA 2's personal file was reviewed and the DSD stated she could not find CNA 2's annual evaluation in the file. The DSD stated CNA 2 was hired on 5/1/24 and her annual evaluation should have been completed in 5/2025. The DSD also stated she was the interim DSD and was in a position to perform CNA 2's annual evaluation. During an interview on 7/24/25 at 3:32 p.m., the DON stated the annual evaluation should have been done by the DSD and that staff should be getting annual evaluations for job performance and competency. The DON stated, "We did not follow our policy and procedure." Review of the facility's policy and procedure titled, Certified Nursing Assistant Annual In-Services Training policy, indicated each CNA must complete a minimum of 12 hours of in-service training annually based on the hire date or recertification renewal date.

Penalty

Inspection fine: $160,666102 days payment denial

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

Summary

The facility failed to ensure that Resident 20’s food preferences were honored because the resident’s meal card did not list any dislikes, including a known dislike of fish. During a concurrent observation and interview in the dining room, Resident 20 stated he did not like fish and had been served fish in the facility. He also stated he had been in the facility for one year and that his meal card had not been updated to reflect his dislikes, and that staff did not listen to him. The Dietary Supervisor stated she and the RD were responsible for updating resident food preferences and acknowledged that Resident 20’s likes and dislikes should have been on the meal card. She stated she was aware Resident 20 did not like fish and should have updated the food preferences. The RD stated meal cards were expected to be updated quarterly and as needed, and that residents’ food preferences should have been updated so likes and dislikes could be identified. The RD stated the kitchen staff should have been honoring residents’ food preferences and said, “We did not follow our policy and procedure.” Resident 20’s record showed diagnoses including muscle wasting, COPD, bipolar disease, dysphagia, pain, and adult failure to thrive, and the MDS indicated a BIMS score of 15, showing he was cognitively intact.

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 medications were administered according to professional standards of practice for one resident, resulting in missed doses of prescribed medications due to unavailability. Specifically, the resident was not given metformin, enoxaparin, and nystatin powder as ordered by the physician. The Medication Administration Record (MAR) showed that enoxaparin was not administered on two occasions, nystatin powder was not given on one occasion, and metformin was missed for two doses, all due to the medications not being available in the facility at the required times. Interviews with nursing staff and the Director of Nursing (DON) revealed that the facility's process required nurses to reorder medications when there were two to three days of doses remaining. However, the missed doses occurred because staff did not reorder the medications in a timely manner, leading to a disruption in the resident's medication regimen. Both the DON and a Licensed Vocational Nurse (LVN) confirmed that it was not acceptable to wait until medications were depleted before reordering, and that the expectation was to maintain an adequate supply to avoid missed doses. The resident involved had a history of cerebral infarction, diabetes, seizures, and aphasia, and was assessed as cognitively intact. The facility's policy required medications to be administered as ordered and within a specific time frame, and professional references emphasized the importance of timely administration to maintain therapeutic effectiveness. The failure to follow these procedures resulted in the resident not receiving critical medications as prescribed.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including dementia, cerebrovascular disease, diabetes, and osteoporosis, was able to leave the facility unsupervised. The resident had a documented history of wandering and previous elopement attempts, and was identified as being at high risk for elopement based on assessment tools and care plans. Despite these known risks, the resident was last seen in the facility approximately 30 minutes before being found by law enforcement at a grocery store half a mile away. The facility's monitoring systems and supervision protocols were inadequate to prevent the elopement. Staff interviews revealed that the facility previously used a monitoring system with bracelets for at-risk residents, but this system had been removed and not replaced. The front entrance door, through which the resident exited, only had an active alarm during nighttime hours and was not monitored by an alarm during the day. Additionally, the back door of the dining room was found to be unlocked and without an alarm unless specifically set up, and staff were not consistently monitoring these exits. Staff also reported that only one resident was assigned 1:1 supervision, despite multiple residents being at risk for elopement. Facility policy required adequate supervision and the use of door alarms for residents at risk of wandering or elopement, but these measures were not effectively implemented. Staff interviews confirmed that the lack of a functioning monitoring system and insufficient supervision allowed the resident to leave the facility undetected. The deficiency was further compounded by a lack of awareness among leadership regarding the status of door alarms and the absence of consistent monitoring protocols for all at-risk residents.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of abuse according to its policy and procedure, as evidenced by an incident involving a resident-to-resident verbal altercation. On February 9, 2025, a resident reported to an LVN that another resident had verbally assaulted him, using profanity and derogatory language. Despite the facility's policy requiring documentation and reporting of such incidents, the LVN did not report the altercation, resulting in a delay of three days before the incident was addressed. The affected resident, who was cognitively intact and had a history of cerebral infarction, ADHD, bipolar disorder, anxiety, adult failure to thrive, and suicidal behavior, experienced distress due to the altercation. The resident reported feeling uncomfortable and emotionally upset when encountering the other resident during smoking breaks, as there was no monitoring or separation by the facility staff. The lack of immediate action exposed the resident to further verbal altercations and emotional distress. Interviews with facility staff, including the assistant director of nurses, confirmed that the incident was not reported or documented as required. The facility's policy mandates immediate reporting and monitoring of resident-to-resident altercations to ensure resident safety and protection. The failure to adhere to these procedures placed the resident at risk for further distress and highlighted a deficiency in the facility's handling of abuse allegations.

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 a resident from emotional abuse when a certified nursing assistant (CNA) deliberately cut the resident's hair without permission, disregarding the resident's personal preference to grow and donate her hair to charity. This incident involved a resident who was cognitively intact and had been growing her hair since her admission in 2018. The resident expressed feelings of anger, sadness, and betrayal, and reported being cautious and scared of retaliation following the incident. The incident was discovered when another CNA noticed the resident's hair was significantly shorter than before. The resident confirmed that she had not consented to a haircut and was visibly upset by the unauthorized action. Interviews with facility staff, including licensed vocational nurses and social services directors, revealed that the resident's preference to keep her hair long was well-known among the staff. The facility's policy on abuse, neglect, and exploitation was not followed, as the CNA's actions were identified as a form of emotional abuse and a violation of the resident's rights. The facility's policy and procedure documents emphasize the importance of respecting residents' rights to personal preferences and self-determination. Despite this, the CNA proceeded to cut the resident's hair, causing emotional distress and mental trauma. The incident was witnessed by another CNA, who initially did not question the action due to unfamiliarity with the resident. The facility staff acknowledged the emotional harm caused to the resident and recognized the need to respect and follow residents' personal preferences and beliefs.

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 person-centered care plan for a resident, which included measurable objectives and timeframes to meet her psychosocial needs. The resident, who was cognitively intact, had expressed her preference to grow her hair for donation to charity since her admission in 2018. However, this preference was not documented in her care plan, leading to a significant oversight in her care. The deficiency was highlighted when a certified nursing assistant (CNA) cut the resident's hair without her consent, reducing it from hip length to shoulder length. This action caused the resident to feel betrayed, angry, and sad, resulting in psychosocial and emotional harm. The incident was discovered when another CNA noticed the change in the resident's hair length and inquired about it, leading to the realization that the resident's preference had not been respected or documented. Interviews with various staff members, including a Licensed Vocational Nurse (LVN), the social services director, and the director of nursing, confirmed that the facility's process required documenting all residents' personal preferences in their care plans. The staff acknowledged the importance of respecting the resident's choices and the failure to do so in this case. The facility's policy and procedure for comprehensive person-centered care plans emphasized the need to include residents' preferences and rights, which was not adhered to in this situation.

Penalty

No penalty information released

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

Summary

The facility failed to meet professional standards of quality for a resident who experienced an unwitnessed fall. On the date of the incident, the resident was found lying on the floor outside the therapy room with no injuries reported. However, the facility staff did not complete the necessary change of condition assessment, skin assessment, and post-fall assessment as required by the facility's protocol. The resident, who was admitted with diagnoses including Alzheimer's disease, muscle weakness, altered mental status, and unspecified dementia, was severely cognitively impaired with a BIMS score of 0 out of 15. Despite the resident's vulnerable condition, the charge nurse did not follow the facility's established process for documenting and assessing the resident's condition after the fall. This lack of documentation was acknowledged by the LVN, DON, and the administrator, who all confirmed that the assessments were not completed as expected. The facility's policy and procedure, as well as professional nursing standards, emphasize the importance of documenting changes in condition and conducting thorough assessments following a fall. The failure to adhere to these protocols resulted in incomplete documentation for the resident, potentially putting them at risk for further falls and delayed care. The facility's post-fall checklist and clinical protocol were not followed, highlighting a deviation from the expected standard of care.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to maintain an effective infection prevention and control program, leading to the transmission of COVID-19 among staff and residents. The Maintenance Director worked while symptomatic and was not immediately tested for COVID-19, resulting in a positive test the following day. Despite this, outbreak testing was not initiated. Similarly, a Nursing Assistant worked while symptomatic and later tested positive, having cared for a resident who subsequently tested positive and was hospitalized. This lack of timely testing and response contributed to a significant outbreak within the facility. The facility also failed to ensure that staff wore proper Personal Protective Equipment (PPE) and that appropriate signage was posted to indicate the required PPE for rooms with COVID-19 positive residents. Observations revealed that staff entered rooms without the necessary PPE, such as gowns and face shields, despite signage indicating the need for full PPE. This oversight increased the risk of COVID-19 transmission among staff and residents. Additionally, the facility did not ensure that staff were fit tested for N-95 respirator masks, which are crucial for protecting against airborne transmission of the virus. The Infection Preventionist acknowledged that not all staff had been fit tested, and the Administrator confirmed this gap in compliance. These deficiencies in infection control practices had the potential to affect all residents in the facility, as evidenced by the widespread outbreak.

Removal Plan

• Residents who were found to be COVID-19 Positive had their physician notified, obtained appropriate orders to treat their symptoms, and were placed on alert monitoring.
• The Infection Preventionist (IP) and designee initiated COVID-19 testing for all 53 Resident in house and staff members.
• All Residents and staff will be tested on the first day, third day, and fifth day. If there are new cases, the testing will continue every three to seven days until there are no new cases for fourteen days.
• New COVID-positive Residents were identified and placed on close monitoring by following COVID 19 protocol and monitoring for any change of condition pertaining to COVID 19.
• One additional employee tested positive for COVID-19 and was removed from the schedule.
• The Interim Director of Nursing (DON) reeducated the IP and staff with an in-service on the following: COVID-19 testing guidelines and the importance of compliance with testing and ensuring adequate supplies of testing kits to prevent the spread of COVID 19, Donning and doffing with proper personal protective equipment (PPE), N-95 fit-testing protocols.
• The IP/Designee will post a schedule of staff required to COVID 19 test at least one day prior to the testing date. The staff posting will be next to the time clock. This will also be followed up with a group text message.
• Any staff reporting back on duty will need to be tested for COVID-19 prior to the beginning of their next shift.
• The DON and designee educated the staff with an in-service about the signs and symptoms of COVID-19. If staff identifies any symptoms from residents or themselves, they must report it to the IP or designee as soon as possible. Any reported symptoms from residents or staff must result in the immediate administration of a COVID test.
• The IP/Designee will report the COVID-19 testing results at the next daily stand-up meeting. They will then follow-up the announcement with the appropriate corrective action.
• The DON will audit the IP/Designee testing process on day one, day three, and day five to ensure that the residents and staff were tested for COVID-19. Any deficiencies will be corrected immediately, and the Administrator will be notified.
• The Administrator will review the plan of correction and submit all findings of non-compliance to the Quality Assessment and Assurance (QAA) committee.
• The QAA Committee shall review and monitor the effectiveness of this Plan of Correction monthly.
• An IP from one of our sister facilities provided an in-service training to 40 out of 84 active staff on the following: The guidelines for COVID-19 testing and the importance of compliance, including ensuring the adequacy of testing kit supplies to prevent the spread of COVID-19, Donning and doffing with proper PPEs, N-95 fit testing protocols.
• Any staff out on leave of absence (LOA) will be educated by the IP or designee prior to the start of their next shift.
• The IP or designee will provide an in-service to the remaining staff that were not in-serviced.
• The Administrator/DON will verify that the remainder of the staff are educated with an in-service training.
• The DON/Designee shall conduct random observations of at least three staff members each week to validate proper donning and doffing of appropriate PPE for four weeks or until substantial compliance is achieved.
• Annual competency-tests for doffing and donning are to be completed by all staff.
• The IP from our sister facility initiated the skills competency validation for all active staff, ensuring the proper donning and doffing of PPE.
• The IP from our sister facility will complete the skills competency validation for all active staff, ensuring the proper donning and doffing of PPE.
• The IP/Designee will complete a skills competency validation for newly hired staff on the proper donning and doffing of appropriate PPE during orientation.
• The DON/Designee will conduct random observations of at least three staff members per week to validate proper donning and doffing of appropriate PPE for four weeks or until substantial compliance is achieved.
• Any findings will be corrected immediately, and the administrator will be notified. The administrator will submit all non-compliance findings related to the plan of correction to the Quality Assessment and Assurance (QAA) Committee.
• The QAA Committee will review and monitor the effectiveness of this plan of correction monthly.
• The IP updated the signage for the five rooms of residents with COVID-19.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to provide adequate pressure ulcer care for three residents, resulting in delayed healing and deterioration of their conditions. The facility did not consistently assess and document the appearance, stage, and measurements of pressure ulcers weekly, which is crucial for tracking healing progress and identifying deterioration. This failure was observed in the cases of three residents, where the facility did not consult with physicians to obtain appropriate treatment orders when a decline in the condition of pressure ulcers was noted or when new ulcers developed. One resident, who had a history of type 2 diabetes mellitus, obesity, and bilateral above-the-knee amputations, was admitted with Stage III pressure ulcers on the buttocks. The facility did not update the care plan to include a focus area for a newly identified Stage III pressure ulcer until during the survey. Additionally, the facility failed to notify the registered dietitian to obtain nutritional recommendations to facilitate wound healing for two residents. The lack of consistent wound treatment and documentation further contributed to the deterioration of the residents' pressure ulcers. The facility's noncompliance with professional standards of practice led to the worsening of pressure ulcers, as evidenced by the increase in size and severity of the wounds. The facility's failure to ensure the availability of necessary treatment supplies, such as Calmoseptine cream, and the lack of physician notification regarding unavailable supplies and wound deterioration, were significant factors in the delayed healing and deterioration of the residents' conditions.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to provide timely responses and resolutions for resident grievances, as evidenced by the lack of documented investigations or follow-up information in nine out of eleven grievance reports reviewed from January to July 2024. The facility's policy required that grievances be resolved promptly, with written decisions provided to residents or their representatives. However, the Resident Council Minutes revealed repeated grievances regarding call light response times, meal setup assistance, noisy staff, and call lights needing to be within reach, all of which lacked documented resolutions over several months. Resident #5, who had moderate cognitive impairment, reported that their complaints about staff not responding to call lights and being loud at night were not addressed or communicated back to them. Interviews with facility staff, including the Social Services Director (SSD), Activities Director (AD), Interim Director of Nursing (IDON), and the Administrator, highlighted a lack of clarity and accountability in the grievance process. The SSD, who was also the Grievance Officer, stated that grievances resolved immediately were not documented, and the AD admitted to not following up with residents after grievances were raised in meetings. The IDON and Administrator both emphasized the expectation for grievances to be documented, investigated, and resolved in a timely manner, with follow-up communication to residents, which was not consistently happening.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to provide a means for residents to file anonymous grievances, which is a violation of residents' rights to voice grievances without discrimination or reprisal. The facility's policy indicated that residents should be able to file grievances anonymously, but interviews with residents and staff revealed that this was not the case. Residents were unaware of how to file anonymous complaints, and the grievance forms were only available at the nurses' station, requiring staff assistance to access them, thus compromising anonymity. Interviews with the Social Services Director, Activities Director, Interim Director of Nursing, and the Administrator confirmed the lack of an anonymous grievance filing system. The Social Services Director acknowledged that residents typically approached her directly, and the forms' location at the nurses' station did not support anonymity. The Activities Director and Interim Director of Nursing also confirmed the absence of a system for anonymous grievances, and the Administrator recognized this as an issue, expecting residents to have the ability to file grievances anonymously.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to implement pharmacy recommendations for three residents, leading to deficiencies in medication management. Resident #29, who had a history of hypertension and cognitive impairment, was prescribed metoprolol without the recommended hold parameters for systolic blood pressure and heart rate. Despite the Consultant Pharmacist's recommendation on 05/30/2024, these parameters were not included in the resident's orders as of 08/04/2024. The Interim Director of Nursing acknowledged the oversight and stated that the physician should have been notified of the medication regimen review. Resident #42, with severe cognitive impairment and a history of diabetes and hypokalemia, was prescribed metformin and potassium supplements without the recommended special instructions. The Consultant Pharmacist had advised that metformin be given with meals and potassium supplements with food and a full glass of fluid, without crushing or chewing. These instructions were not included in the resident's orders, as confirmed by the Interim Director of Nursing on 08/04/2024. Resident #50, who had intact cognition and a history of cerebral infarction, was prescribed several medications without the recommended special instructions. The Consultant Pharmacist recommended hold parameters for spironolactone and carvedilol, and specific administration instructions for Flomax and Colace. These recommendations were not reflected in the resident's Medication Administration Record as of early August 2024. The facility's staff, including the Interim Director of Nursing and the Administrator, acknowledged the need for follow-up on pharmacy recommendations, which was not adequately performed in these cases.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to maintain a medication error rate below 5%, resulting in a rate of 14.28% with 4 errors out of 28 opportunities. This affected two residents during medication administration. For Resident #61, the Licensed Vocational Nurse (LVN) administered an incorrect dosage of ascorbic acid, giving 500 mg instead of the prescribed 250 mg. Additionally, the LVN held all of the resident's blood pressure medications, including Valsartan, despite the absence of hold parameters for Valsartan in the physician's order. Resident #61 had a medical history of congestive heart failure, hypertensive heart disease, and unspecified atrial fibrillation. For Resident #43, the LVN administered calcium carbonate with vitamin D at an incorrect dosage of 800 units instead of the prescribed 200 units. Furthermore, the LVN administered ferrous sulfate and calcium carbonate with vitamin D simultaneously, contrary to the physician's order to separate the administration by one to two hours. The Consultant Pharmacist confirmed that administering calcium and iron together inhibits iron absorption, reducing its effectiveness. The Interim Director of Nursing and the Administrator emphasized the importance of following physician orders and verifying medication details before administration.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to notify the physician when new pressure ulcers were identified and when there was a decline in the condition of existing pressure ulcers for two residents. Resident #15, who had a history of type 2 diabetes mellitus, obesity, and bilateral above-the-knee amputations, developed multiple Stage III pressure ulcers on the buttocks. Despite changes in the size and condition of these ulcers, there was no documented evidence that the physician was notified. The facility's policy required prompt notification of the physician for significant changes in a resident's condition, but this was not adhered to, as evidenced by the incomplete physician notification sections in the wound review forms. Resident #46, who had a complex medical history including paraplegia and dementia, also experienced a deterioration in the condition of a Stage III pressure ulcer on the coccyx. The wound, initially showing signs of healing, lost epithelial tissue and was comprised entirely of granulation tissue, indicating a decline. Again, there was no documentation that the physician was informed of this change, contrary to the facility's policy. Interviews with staff revealed a lack of consistent communication with the physician regarding changes in wound status. The report highlights that the facility's nursing staff, including LVNs, did not consistently notify the physician of changes in wound conditions, as required by the facility's policy. Interviews with the Interim Director of Nursing and the Administrator confirmed that physician notification should occur with any change in a wound's condition, yet this was not documented in the residents' medical records. The physician for Resident #15 was unaware of the current status of the resident's pressure ulcers, indicating a breakdown in communication and documentation within the facility.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to complete the Minimum Data Set (MDS) assessments in a timely manner for a resident, as required by the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual. The manual specifies that a quarterly assessment must be completed at least every 92 days following the previous assessment. In this case, the resident's most recent MDS assessment had an Assessment Reference Date (ARD) of 04/21/2024, indicating that the next assessment should have an ARD no later than 07/22/2024. However, the electronic medical record flagged the MDS as one day overdue, indicating a failure to meet the required timeframe. The deficiency was identified during an interview and record review, where the MDS Director acknowledged that the assessment was not completed on time. The Director cited being new to the position and time management issues as reasons for the delay. The Interim Director of Nursing and the Administrator both emphasized the importance of completing MDS assessments within the allotted timeframes. The Administrator also mentioned that the MDS Consultant was responsible for monitoring the completion of these assessments, suggesting a lapse in oversight or communication within the facility's processes.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to ensure that a Minimum Data Set (MDS) assessment accurately reflected the presence of a serious mental illness for a resident as required by the state Level II Preadmission Screening and Resident Review (PASRR) process. The resident, who was admitted with a medical history of paranoid schizophrenia and anxiety disorder, had a positive Level I PASRR screening indicating a need for a Level II assessment. The subsequent Level II PASRR report confirmed the need for specialized services due to the resident's mental health condition. However, the annual MDS assessment inaccurately coded the resident as not having a serious mental illness, despite the presence of an active diagnosis of schizophrenia and a Level II PASRR determination. Interviews with facility staff, including the MDS Director, Interim Director of Nursing, and the Administrator, revealed that the MDS assessments were not accurately coded to reflect the resident's Level II PASRR findings. The MDS Director acknowledged the error, stating that the resident's Level II PASRR should have been coded on the MDS. The Interim Director of Nursing and the Administrator also confirmed the oversight, emphasizing the responsibility of the MDS staff to ensure the accuracy of these assessments. This inaccuracy in the MDS assessment was identified as a deficiency in the facility's compliance with PASRR requirements.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to complete a Level I Preadmission Screening and Resident Review (PASRR) assessment for a resident who was reviewed for PASRR. The resident was admitted to the facility with a medical history that included unspecified dementia and mixed anxiety disorders. A psychologist consultation later revealed symptoms of delusions, agitation, and inappropriate behaviors, leading to a diagnosis of dementia with behaviors and schizoaffective disorder. Despite these new diagnoses, the facility did not resubmit a Level I PASRR for the resident. Interviews with facility staff revealed a lack of awareness and adherence to PASRR requirements. The Social Services Director (SSD) admitted she was unaware of the need to conduct a new PASRR following a new qualifying diagnosis, citing that the previous facility owner did not require it. Additionally, the SSD was managing dual roles, which led to tasks falling behind. The Interim Director of Nursing and the Administrator both expressed expectations that the PASRR process should be completed correctly and timely, indicating a disconnect between expectations and actual practice.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level I screening was resubmitted for a resident who was reviewed for PASRR. The resident, who had a medical history of schizophrenia and unspecified psychosis, was admitted to the facility and had a positive Level I screening due to suspected mental illness. A Level II mental health evaluation was required but could not be completed because the resident was temporarily transferred to an acute care hospital. Consequently, the case was closed, and a new Level I screening was needed to reopen the case. Interviews with facility staff, including the Social Service Director, Interim Director of Nursing, and the Administrator, revealed that the facility did not resubmit the Level I screening upon the resident's readmission from the hospital. The Social Service Director acknowledged that a new PASRR should have been completed when the resident was readmitted. The Interim Director of Nursing and the Administrator also confirmed that the Level I screening should have been resubmitted, indicating a lapse in following the required PASRR process.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to update the care plan with fall interventions for a resident, leading to a deficiency in care. The resident, who was admitted with a history of Parkinson's disease, rheumatoid arthritis, muscle weakness, and a history of falling, experienced multiple falls during their stay. Despite having a care plan that identified the resident as at risk for falls, the plan was not updated with new interventions following significant fall incidents. The resident's care plan initially included interventions such as keeping the call light within reach and following the facility's fall protocol. However, after a witnessed fall on May 12, 2024, where the resident attempted to self-transfer without assistance, the care plan was not updated with the recommended interventions from the interdisciplinary team (IDT). These recommendations included checking the resident every two hours and placing them in a wheelchair in front of the nursing station. Another fall occurred on June 29, 2024, resulting in injuries, yet the care plan still lacked updates with the necessary interventions. Interviews with facility staff, including the MDS Director and Interim Director of Nursing, revealed that the responsibility for updating the care plan was not fulfilled, leading to the deficiency. The MDS Director was unsure why the interventions were not added, and the Interim Director of Nursing acknowledged that the care plan should have been updated to reflect the actual interventions being used.

Penalty

Inspection fine: $92,01738 days payment denial

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

Summary

The facility failed to ensure an environment free of accidents and hazards for a resident, identified as Resident #39, who experienced repeat falls. The resident, admitted on 04/17/2024, had a medical history including Parkinson's disease, rheumatoid arthritis, muscle weakness, and a history of falling. The resident's care plan, initiated and revised in 2024, identified them as at risk for falls due to generalized weakness, gait/balance problems, severe cognitive impairment, and a history of non-compliance with safety measures. Despite these identified risks, the facility did not effectively prevent the resident from falling multiple times. The resident experienced a fall on 05/12/2024, resulting in a skin tear, and another fall on 06/29/2024, which led to a head injury and severe pain. The facility's interventions, such as keeping the bed in the lowest position and encouraging the use of a call light, were not consistently implemented or effective. The resident's cognitive impairment made it difficult for them to remember to ask for assistance, yet the facility did not adequately adjust their interventions to address this issue. Interviews with staff revealed that the bed was not always kept in the lowest position, and there was a lack of thorough investigation and documentation following the falls. The facility's policy on managing falls required staff to implement resident-centered fall prevention plans and to re-evaluate interventions if falls continued. However, the facility did not conduct comprehensive investigations or root cause analyses for the falls in May and June 2024. The Interim Director of Nursing and the Administrator acknowledged the lack of thorough investigation and the need for more effective interventions. The failure to implement and monitor appropriate interventions contributed to the repeated falls and injuries sustained by 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 uphold resident rights by not responding to call lights in a timely manner, as observed in the cases of three residents. Resident 1 reported being left in soiled bed sheets for two to three hours without assistance, despite using the call light. The staff informed her they could not assist during mealtimes, leaving her feeling degraded and demeaned. Resident 1 was admitted with diagnoses including difficulty in walking and morbid obesity, and her care plan required extensive assistance with mobility and transfers. Resident 2 experienced similar neglect, with staff turning off his call light without providing the requested assistance to use the restroom. He expressed feeling ignored and unsafe, leading him to request briefs due to the delay in assistance. Resident 2, who has Parkinson's disease and a history of falls, was at risk for skin breakdown, as indicated by his Braden Scale score. The facility's interdisciplinary team noted his complaints about untimely changes, yet the issue persisted. Resident 3 also faced delays in receiving help for changing soiled briefs, observing staff using cellphones instead of responding to call lights. This resident, with severe cognitive impairment and a high risk for skin integrity issues, was left waiting for assistance for up to two hours. Interviews with staff, including CNAs and LVNs, revealed a pattern of ignoring call lights and using cellphones during care times, with no disciplinary action taken by the administration. The facility's policies on call light response and resident dignity were not followed, contributing to the residents' feelings of neglect and potential health risks.

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 report a sexual abuse allegation in accordance with its policy and state regulations. Resident 1, who had moderate cognitive deficits due to dementia and Parkinson's Disease, reported to an LVN that two male staff members attempted to rape her. The LVN informed another LVN, but neither reported the allegation to the Administrator or Director of Nursing immediately, as required by law and facility policy. This resulted in a delayed investigation and placed Resident 1 at risk for harm. The Director of Nursing was not made aware of the alleged abuse until three days after the incident. During interviews, both LVNs admitted to not reporting the allegation to the appropriate authorities. The facility's policy mandates that all abuse allegations be reported immediately to the Administrator and other officials, including the state licensing agency, local and state ombudsman, law enforcement, and the resident's representative. The failure to report the allegation immediately was confirmed through interviews and record reviews. The facility's policy clearly states that any suspicion of abuse must be reported within two hours. The delay in reporting the allegation compromised the safety and well-being of Resident 1 and potentially other residents in the facility.