Monterey Healthcare & Wellness Centre, Lp

Penalty

No penalty information released

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

Summary

The facility failed to implement its infection prevention and control program by not maintaining the water system in accordance with its Water Management Plan for the Prevention of Waterborne Pathogens. During observation and interview, Water Heater 1 behind the laundry room was found with a broken mercury temperature gauge, and the Maintenance Supervisor stated he did not know how long it had been broken. Water Heater 2 behind the kitchen was also observed, and the Maintenance Supervisor stated its mercury temperature gauge should be at 110 F. The facility’s Water Management Plan, reviewed with the Infectious Preventionist Nurse, stated the water heater temperature should be 145 F. The Maintenance Supervisor checked sink temperatures at Nursing Station A and Nursing Station B and found Nursing Station A ranged from 86 F to 105 F, which he stated was too low, and Nursing Station B ranged from 116 F to 120 F, which he stated was too high. He stated the water temperature at sinks should be 110 F. He also stated he performed visual checks of the water heaters by draining them and inspecting the initial drained water for crystal-like structures, but there was no log documenting the visual monitoring of the drained water appearance for biofilm, rust, sediment, or contamination.

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 develop and implement comprehensive, person-centered care plans for three residents with identified needs. For one resident with acquired hemolytic anemia, the care plan initiated at readmission included detailed interventions to educate the resident and caregivers about expected stool changes and to monitor, document, and report specific signs and symptoms of anemia such as pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, feelings of cold, low HGB/HCT, shortness of breath on activity, sore tongue, chest pain, tinnitus, and changes in condition. The resident’s MDS showed intact cognition and active diagnoses including anemia, heart failure, HTN, and renal insufficiency. A change of condition evaluation documented abnormal vital signs and a critical lab result that led to transfer to a GACH, and the care plan was later revised to note very low HGB and HCT values. However, there was no evidence that new or updated interventions were added after the hospitalization and readmission, and interviews with the ADON and nursing staff confirmed that, although routine labs were ordered every three months, there was no documented monitoring for the physical signs and symptoms of anemia as specified in the care plan. For a second resident with schizophrenia, depression, and auditory hallucinations, the MDS indicated moderately impaired cognition and a need for supervision or touch assistance with most cares, and it documented that the resident did not exhibit verbal behavioral symptoms directed toward others at that time. The existing care plan addressed a mood disorder with interventions to monitor and report risks of harming others, such as increased anger, labile mood, agitation, feeling threatened, or thoughts of harming someone. Progress notes from a provider visit indicated no suicidal or homicidal ideations and no violent behavior. According to an LVN, about a month after admission the resident began expressing frustration by saying "I want to hit you" to staff, which was described as a new behavior. The LVN acknowledged there was no documentation of these verbal threats in progress notes, no change in condition form was completed, and the care plan was not updated to reflect the new threatening behavior or to prompt physician notification, despite facility protocol that residents expressing intent to harm themselves or others should be placed on one-to-one supervision and have a CIC completed. A later CIC documented that during a coffee social activity the resident stood up, spoke loudly, and threw a cup of coffee toward another resident, leading to notification of the NP and transfer to a GACH on a 5150 hold. For a third resident admitted with schizophrenia, lack of coordination, depression, and anxiety, the MDS documented intact cognition and impaired vision, with the ability to see large print but not regular print. Observations during a karaoke activity showed the resident sitting close to the TV, holding a microphone, looking down, not singing, and stating to activity staff that he wanted to hear the song but could not sing along because he could not read the words on the TV; he was also observed squinting at the TV and at staff. In interviews, the resident reported being partially blind, having difficulty seeing, wanting to participate in more activities but being unable to due to impaired vision, and feeling that staff did not listen to his concerns. Activity staff reported that the resident often complained about not being able to see well, did not participate in some activities because of poor vision, and would not attend group activities that could not accommodate his visual impairment. The activities director stated that one-to-one activity visits were needed because the resident was not actively participating in group activities and presented with low self-esteem, expressing that he felt like a burden. During a record review, the DON confirmed there was no care plan addressing the resident’s poor vision, despite the facility’s policy requiring development and implementation of a comprehensive person-centered care plan to support residents in attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Penalty

No penalty information released

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

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in its kitchen used by 66 residents because the dishwasher machine thermometer was not functioning properly. During observation with the Dietary Supervisor, the low-temperature dishwasher was run three times, and the wash and rinse temperatures remained below the stated minimum goal of 120 degrees Fahrenheit on each run, with readings of 100/102 F, 110/112 F, and 110/112 F. The Dietary Supervisor stated that the dishwasher temperatures should have reached at least 120 F to properly clean the dishware. During interview, the Dietary Supervisor stated that if the dishwasher did not reach the goal temperatures, staff would need to use the three-compartment sinks to handwash dishes while the machine was out of order. The Dietitian stated that if the dishwasher did not reach the goal temperatures of 120 F to 150 F, the dishes would not be cleaned and pathogens from dirty dishes could transfer to residents. On the following day, the Dietary Supervisor stated that a repair person assessed the machine and found that the dishwasher thermometer was not reading accurately, and she did not know how long it had not been working. The facility policy stated that the dish machine would be routinely monitored during use to ensure appropriate temperatures.

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 notify a physician of a resident’s new behavior of making verbal threats toward staff, as required by the resident’s care plan and the facility’s change in condition policy. The resident was admitted with schizophrenia, depression, and auditory hallucinations, and had a care plan initiated in January that directed staff to monitor, record, and report to the physician any risk of the resident harming others, including increased anger, labile mood, agitation, or thoughts of harming someone. The resident’s MDS from late January indicated moderately impaired cognition and no verbal behavioral symptoms directed toward others. However, according to an LVN, beginning about one month after admission, the resident began verbalizing “I want to hit you” to staff when he did not get what he wanted. The LVN acknowledged that this was a new threatening behavior that started in February, but there was no documentation of these verbal threats in the progress notes, no Change in Condition (CIC) form was completed, and the care plan was not updated to reflect this new behavior. The DON stated she was not aware that the resident was making verbal threats and confirmed that facility protocol required staff to create a CIC, update the care plan, and notify the physician when a resident expressed verbal threats such as “I want to hit you.” The facility’s written Change in Condition policy required the licensed nurse to notify the resident’s physician and legal representative when there is an incident involving the resident or a significant change in the resident’s mental or psychosocial status. On a later date, a CIC was completed after the resident threw coffee toward another resident during an activity, and the NP was notified and ordered transfer to a general acute care hospital for evaluation. Prior to this incident, however, the new pattern of verbal threats toward staff was not reported to the physician or documented as a change in condition, constituting the cited failure to immediately notify the physician of a significant change in the resident’s behavior.

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 implement effective interventions and supervision for a resident with escalating verbal aggression and delusions, which resulted in that resident physically striking another resident. Resident 54 was admitted with schizophrenia, anxiety disorder, bipolar disorder, depression, psychotic disorder, and documented delusions, and had a conservatorship order stating she was gravely disabled and unable to provide for basic personal needs. Her care plan, initiated on 2/13/2026, identified potential for verbal and physical aggression related to ineffective coping skills, mental and emotional illness, and poor impulse control, with goals that she not harm herself or others. Interventions listed included analyzing triggers and circumstances, assessing coping skills and support systems, anticipating and assessing needs, and identifying and addressing contributing sensory deficits. In the days leading up to the incident, multiple records documented a clear increase in Resident 54’s verbal aggression and delusional thinking. A Change of Condition (CoC) evaluation on 3/9/2026 at 5:30 PM recorded that she was verbally aggressive, cursing, yelling, and shouting at staff and other residents, with staff attempting redirection and close monitoring for safety. Nursing progress notes from 3/9/2026 through 3/12/2026 described multiple episodes of increased verbal aggression toward staff and residents, with staff sometimes able to redirect her and sometimes unable to do so. The Medication Administration Record for March 2026 documented 13–16 episodes of increased delusions and aggression toward staff and residents between 3/9/2026 and 3/15/2026. Staff interviews confirmed that for approximately one to three weeks before the physical incident, Resident 54 had increased verbal aggression, increased delusions, and periods of withdrawal and staying in bed, and that she sometimes did not comply with redirection. Despite these documented changes, the facility did not implement additional or modified interventions beyond redirection and monitoring, nor did it effectively escalate concerns for timely psychiatric evaluation. The Assistant Director of Nursing (ADON) spoke with the psychiatrist (Physician 5) on 3/10/2026 about possible medication adjustments, and the psychiatrist stated he would conduct an in‑person evaluation before making changes, but he did not come to the facility between 3/10/2026 and 3/13/2026. A nursing note on 3/13/2026 documented that the ADON attempted to call the psychiatrist and was unable to reach him, and the ADON acknowledged he did not notify the psychiatrist’s nurse practitioner or the psychiatric medical director, even though existing interventions were not effective and the resident had the potential to harm others. On 3/16/2026 at 7:00 AM, a CoC record documented that a CNA witnessed Resident 54 elbow Resident 25 in the right cheek while Resident 25 was quietly reading her Bible in her wheelchair in an alcove. Statements from staff and residents indicated that Resident 54 approached Resident 25, used a racial slur, and then struck her with an elbow to the right side of the face. The facility’s Resident Safety policy required evaluation when there is a change of condition to identify circumstances that pose a risk for safety and well‑being, but the documented escalation in aggression and delusions was not met with effective interventions to prevent the physical assault.

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 staff assisted a resident with dining in a manner that promoted dignity when a CNA was observed feeding the resident while standing rather than sitting at eye level. The resident had diagnoses including schizophrenia, anxiety disorder, and adult failure to thrive, and the H&P indicated the resident did not have the capacity to understand and make decisions. The MDS dated 3/17/2026 indicated severe cognitive impairment and active diagnoses of schizophrenia, anxiety disorder, and depression. The resident’s diet order included a regular standard portion diet with level 6 soft and bite-sized texture and thin liquids. During observation in the dining room, the resident was seated at a dining table while the CNA stood over the resident and spoon-fed the resident twice. Another staff member whispered into the CNA’s ear, after which the CNA stopped spoon-feeding and instead prompted the resident to eat items on the meal tray, but remained standing the entire time while staying with the resident until the meal was finished. The CNA stated she should have been sitting down with the resident and not standing over her. The LVN and DON both stated staff should be seated with residents at eye level during feeding and should not stand over them, and the facility’s feeding procedure and resident rights policy both stated staff should assist residents in a comfortable seated position and treat residents with kindness, respect, and dignity.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that one of three sampled residents, Resident 75, was provided written information regarding Advance Directive rights upon admission. Resident 75 was admitted on [DATE] with diagnoses including schizophrenia, depression, and cannabis use. The resident's H&P dated 3/22/2026 indicated the resident did not have the capacity to understand and make decisions. During interview and record review, the Social Services Director stated the Advance Directive pamphlet was provided on 3/26/2026, six days after admission, and acknowledged it should have been given upon admission on 3/20/2026. Facility staff also stated the facility was not following its Advance Directive policy, which required written information to be provided upon admission. The DON stated the pamphlet should have been provided when the resident was admitted so the resident would be aware of their rights and medical wishes could be followed.

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 revise or update the care plan for Resident 72 after the resident was readmitted following hospitalization and experienced increased hallucinations and delusions. Resident 72’s record showed diagnoses including paranoid schizophrenia, schizophrenia, and diabetes mellitus with diabetic chronic kidney disease. The resident’s H&P dated 3/25/2026 indicated the resident did not have the capacity to understand and make decisions. A physician order dated 3/16/2026 directed transfer to a GACH for psych evaluation with a 7-day bed hold. A change in condition evaluation dated 3/11/2026 documented complaints of lower back pain after the resident alleged a fall from a 50-foot elevator, but the resident was able to ambulate and move the lower extremities without difficulty, denied numbness, and denied head injury. The same evaluation noted increased hallucinations and delusions with a recommendation from the physician for transfer to the hospital for psych evaluation. Review of the care plans showed no revision for the transfer to the hospital on 3/11/2026, and the DON confirmed during interview that there was no care plan for the transfer and that a revised care plan should have been in place to follow the resident’s plan of care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two residents were informed of the name and purpose of each medication at the time of administration. During medication passes, LVN 4 was observed preparing and handing medications to both residents after verifying their names and dates of birth, but without explaining what the medications were or why they were being given. In both observations, the nurse checked the residents’ mouths after administration to confirm the medications were swallowed. Resident 9 had diagnoses including schizophrenia, depression, and anxiety disorder. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, while the MDS indicated cognition was intact and that the resident was receiving antipsychotic, antianxiety, and antidepressant medications. The resident also had physician orders for benztropine mesylate, Depakote, Keppra, vitamin B12, Lasix, metoprolol tartrate, folic acid, multivitamin-minerals, and potassium chloride. On the observed medication pass, the resident received the morning medications without any explanation from LVN 4 about the medications or their purposes. Resident 16 had diagnoses including schizoaffective disorder, bipolar disorder, and major depressive disorder. The resident’s H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated moderate cognitive impairment and antipsychotic medication use. The resident had physician orders for divalproex sodium, polyethylene glycol 3350 powder, gabapentin, multivitamin-minerals, loxapine succinate, and Artane. During the observed medication pass, LVN 4 again administered the medications without telling the resident what each medication was or why it was being given. LVN 4 stated she normally informs residents of each medication and why they are receiving it, but forgot that morning. The DON stated staff should inform residents of their medications and roughly explain what each medication was, and also stated residents have the right to know what medications they are receiving.

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

Provide appropriate treatment and care according to orders, resident preferences, and goals was deficient for a resident with acquired hemolytic anemia, hypertension, and schizophrenia. The resident’s care plan, initiated on 11/17/2025, directed staff to educate the resident and caregivers about stool color changes and to monitor and document/report signs and symptoms of anemia, including pallor, fatigue, dizziness, syncope, headache, palpitations, weakness, feeling cold, low HGB and HCT, shortness of breath on activity, sore tongue, chest pain, tinnitus, and changes in condition. On 2/18/2026, the resident’s lab results showed critically low RBC, HGB, and HCT values, and a change-of-condition evaluation documented abnormal BP of 94/43, HR 99, RR 16, and temperature 98.8 F, with a critical lab result and blood pressure prompting the PCP to recommend transfer to the GACH via 911. The report states the facility failed to assess and monitor the resident for signs and symptoms of hemolytic anemia and failed to follow up with the Hematology Clinic regarding the after-visit care plan. The resident was transferred to the GACH, where additional labs showed even lower RBC, HGB, and HCT values, and the resident received a total of four units of packed RBC during the hospitalization from 2/18/2026 to 2/23/2026.

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 drugs and biologicals stored in Medication Cart A were labeled in accordance with accepted professional principles for one sampled resident. Resident 46 was admitted with diagnoses including bipolar disorder, schizophrenia, and bipolar type schizoaffective disorder, and the record also showed a conservatorship finding that the resident was gravely disabled due to a mental health disorder. The resident’s MDS indicated intact cognitive skills, hallucinations, and active diagnoses that included anxiety disorder, depression, bipolar disorder, psychotic disorder, and schizophrenia. A review of the resident’s active order summary showed Clozaril (clozapine) 37.5 mg by mouth once daily for schizophrenia. During concurrent review of the medication cart and interview with an LVN, the current Clozaril bubble pack label was observed to state 37.5 mg twice daily, which did not match the active order’s dose and frequency. The LVN stated the active order and the bubble pack label were not the same and did not know why the old bubble pack had not been properly disposed of and replaced with a new one with the correct medication, dose, and frequency. The facility policy stated that prescription labels must include the resident’s name, route, medication name, strength, and specific directions for use, and that improperly or inaccurately labeled medications are rejected and returned to the dispensing pharmacy.

Penalty

No penalty information released

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

Summary

The facility failed to accurately document the administration of pioglitazone for one sampled resident with diagnoses including metabolic encephalopathy, schizophrenia, and DM. The resident’s order required pioglitazone 45 mg by mouth daily for DM, with the medication to be held if blood sugar was less than 120 mg/dL. Review of the February and March 2026 MAR showed entries indicating the medication was administered on multiple dates when the resident’s blood sugar was documented below the ordered parameter, including 89 mg/dL, 110 mg/dL, 77 mg/dL, 84 mg/dL, and 114 mg/dL. During interview, an LVN stated the MAR check mark on 3/10/2026 indicated administration, but said there was no way the medication was actually given and that the entry was a charting error. The LVN confirmed awareness of the order to hold pioglitazone if blood sugar was less than 120 and stated the documented blood sugar value for that date was accurate. The facility’s policy required medical records to be complete and correct, and its medication administration policy required medications to be administered according to physician orders and federal and state regulations.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that four resident rooms accommodated no more than four residents each. During the survey, rooms 1, 5, 20, and 26 were identified as having more than four residents per room, including two 12-bed rooms, one 7-bed room, and one 6-bed room. The Administrator stated during the entrance conference that the facility had a waiver in place for the rooms and wanted to request an additional waiver that year. A review of the facility’s Client Accommodations Analysis form and request for an additional room waiver confirmed that the rooms exceeded the standard room occupancy limits. The waiver request stated that the rooms provided adequate space for nursing care and wheelchair access and that the multiple beds did not adversely affect resident health and safety. During the survey, residents in the affected rooms were observed to have enough space to move freely, with beds and lockers in place and room for wheelchairs, walkers, and canes. Resident 4 stated the room size was okay and that wheelchairs and other equipment were used by other residents without restrictions. CNA 5 stated residents did not complain about room size or having multiple roommates. The resident census review showed that the residents occupying rooms 1, 5, 20, and 26 during this survey were not the same residents who occupied those rooms during the prior recertification survey.

Penalty

No penalty information released

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

Summary

The facility failed to provide a minimum of 80 square feet per resident in 12 of 22 resident rooms, including rooms 1, 2, 3, 4, 6, 9, 21, 26, 27, 28, 30, and 31. The affected rooms included one 12-bed room, one 7-bed room, two 4-bed rooms, two 3-bed rooms, and six 2-bed rooms. The facility's Client Accommodations Analysis and room waiver request documented that several of these rooms measured less than the required square footage per resident, with examples including a 12-bed room at 79.1 square feet per resident, 2-bed rooms at 63, 66.5, 70, and 75 square feet per resident, 4-bed rooms at 67 and 72 square feet per resident, 7-bed room at 79.8 square feet per resident, and 3-bed rooms at 78 square feet per resident. During the survey, the Administrator stated that multiple rooms did not have the required space per resident but that a room waiver was in place and an additional waiver would be requested. Residents and staff interviewed stated they had no concerns with the room size, and observations showed residents in the affected rooms had enough space to move freely, with beds and lockers present and room for wheelchairs, walkers, and canes. The survey also noted that there were no observed adverse effects related to the adequacy of space, nursing care, comfort, or privacy, and that the residents occupying the affected rooms during this survey were not the same residents who occupied those rooms during the prior recertification survey.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to notify a resident’s physician at the time of an accident that resulted in a head injury. The resident had paranoid schizophrenia, lack of coordination, and gait and mobility abnormalities, and an MDS dated 1/29/26 documented severe cognitive impairment and a need for supervision with most activities of daily living. On 3/7/26 around 3 AM, a CNA observed the resident turn a corner in the hallway and bump his face into the edge of an open door that protruded into the hallway, resulting in a cut above the right eye with bleeding. The CNA brought the resident to the nurses’ station, where an LVN and an RN assessed the cut and provided first aid. Despite the observed accident and visible injury, the LVN and RN on the night shift did not initiate a Change in Condition Evaluation (CIC) form and did not notify the resident’s physician of the incident. There was no documentation in the resident’s progress notes or CIC records related to the 3 AM accident. As a result, the day shift staff initially considered the injury to be of unknown origin because they were unaware of how the resident sustained the right eye injury. The facility’s later investigation confirmed that the injury occurred when the resident walked into the door during the night shift. Later that morning, at 8:45 AM, a CIC was completed when the resident was seen in the shower room rubbing his right eyebrow, with bleeding noted and a 1.2 cm cut on the right eyebrow and discoloration of the right upper eyelid. The CIC documented that the skin change and a neurological assessment were relevant to the change in condition, and the physician was notified at 9 AM and recommended transfer to a general acute care hospital for medical clearance. The facility’s policy titled “Change in Condition” required licensed nurses to notify the physician and the resident’s representative when there is an incident or accident involving the resident, or an accident resulting in injury with potential need for physician intervention. The failure of the night-shift licensed nurses to initiate a CIC and notify the physician at the time of the accident constituted the cited deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that licensed staff verified a resident's admission orders by reviewing the resident's medical history and discharge orders from a general acute care hospital (GACH) upon readmission. The resident, who had diagnoses including schizophrenia and bipolar disorder, was readmitted to the facility with specific medication orders from the hospital. However, the nurse responsible for the admission did not review the complete discharge documents and only relied on a clinical summary report and previous medication records to input the resident's readmission orders. The nurse communicated the orders to the physician via SMS, assuming agreement if the message was read, without verbal confirmation. The Director of Nursing (DON) indicated that the facility's protocol required licensed nurses to discuss discharge summaries with the admitting physician to confirm medication orders. The facility's policy also stated that the attending physician should provide medication orders upon admission. The failure to follow these procedures resulted in a potential risk of the resident not receiving the correct medications and care needed for their diagnosis.

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 its nursing staff had the appropriate competencies to care for a resident diagnosed with PTSD, as identified through resident assessments. Resident 11, who was admitted and readmitted with multiple mental health diagnoses including PTSD, did not receive care from staff trained in trauma-informed care. The facility's Director of Staff Development (DSD) admitted that there were no in-services related to trauma or PTSD provided to the staff, and the topic was not brought up to the Administrator or Director of Nursing. Interviews with Certified Nurse Assistants (CNAs) revealed a lack of awareness and training regarding trauma or PTSD. CNA 2, CNA 3, and CNA 4 all stated they had not received specific training on how to care for residents with PTSD, and they were not aware of any residents diagnosed with PTSD in the facility. This lack of training and awareness among the staff resulted in Resident 11 not receiving the appropriate care needed for their condition. The facility's policy and procedures on Trauma-Informed Care indicated that staff should be educated on the specific needs of residents who have experienced trauma, including PTSD. However, the facility's failure to implement these policies and provide necessary training led to a deficiency in care for Resident 11, as the staff did not have the competencies required to manage the resident's PTSD and related behaviors effectively.

Penalty

No penalty information released

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

Summary

The facility failed to post daily nurse staffing information in a prominent location that was readily accessible to both residents and visitors, as required by their policy and procedure titled 'Nursing Department - Staffing, Scheduling & Postings.' During an observation and interview with the Assistant Director of Nurses (ADON), it was noted that there was no visible daily nurse staffing information posted. The ADON acknowledged that the postings should be accessible and visible for residents and visitors. The Director of Staff Development (DSD) admitted to posting the nurse staffing information on the visiting window, which was only accessible to visitors and not to residents. The DSD was unaware that residents should have access to this information. The Administrator confirmed that it was a resident's right to be informed about nurse staffing, and the postings should be accessible in the residents' area. The facility's policy, revised in 2018, indicated that nurse staffing postings must be in a prominent place readily accessible to residents and visitors.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to proper sanitation and food handling practices, specifically in ensuring that all hair was properly secured within a hairnet during meal preparation. During a dining observation, a Dietary Aide (DA 1) was seen with hair exposed outside of the hairnet while assisting in the preparation of meal trays for all 69 residents in the facility. This observation was confirmed during an interview with DA 1, who acknowledged the importance of securing all hair to prevent contamination and the associated risks of infection or illness. Further interviews revealed that the kitchen staff, including the cook, were aware of the risks associated with exposed hair in food preparation areas. The Assistant Director of Nursing (ADON) also emphasized the requirement for anyone entering the kitchen to wear a hairnet and ensure no hair is exposed. A review of the facility's policy and procedures, revised in 2024, confirmed the requirement for effective hair restraints in kitchen and food storage areas, highlighting a lapse in adherence to these standards.

Penalty

No penalty information released

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

Summary

The facility failed to implement proper infection control practices by not ensuring its Water Management Program adhered to national, state, and local measures to prevent and monitor the growth of Legionella. During an interview, the Infection Preventionist (IP) revealed that the facility only tested for Legionella if there were 10 or more pneumonia cases, citing cost concerns. The facility had five water heaters, which were reportedly flushed monthly, but there was no documented evidence of flushing for February 2025. The IP was unaware of the meaning of terms like 'good' or 'bad' in the Water Heater Legionella Management Plan and did not know if the plan was based on a national standard. The facility's Water Management Plan, revised in February 2024, lacked specific measures for Legionella management, and the IP was unfamiliar with the risk assessment process outlined in the facility's policy and procedure. The policy indicated the need for a risk assessment to determine Legionella growth risk and the use of national guidelines to develop control measures. However, the IP was unaware of these requirements. The facility's policy also referenced the American Association of Heating Refrigeration and Air-Conditioning Engineers (ASRAE) guidelines for Legionella prevention, which included quarterly water quality measurements and maintenance of chemical levels, but there was no evidence these measures were implemented. The State Operational Manual required a documented water management program based on national standards, but the facility failed to demonstrate compliance with these requirements.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe and sanitary environment for all 69 residents, staff, and the public by not ensuring that the lint screens in the laundry machines were cleaned as per the established schedule. The Lint Cleaning Log for the dates 2/12/2025 and 2/13/2025 was incomplete, lacking documentation that the lint screens were cleaned for two out of three dryer machines on 2/12/2025 and for all three machines on 2/13/2025. This oversight was confirmed during interviews with the Laundry Services (LS) and the Infection Preventionist (IP), who both acknowledged the absence of documented evidence for the cleaning of lint screens. The facility's policy, titled 'Laundry - Safety' and revised on 1/1/2012, mandates that all machines and appliances be checked daily to ensure they are clean and free of defects. However, the failure to document the cleaning of lint screens as per the schedule posed a potential fire hazard, as acknowledged by both the LS and the IP. The LS emphasized the importance of regular lint screen cleaning to prevent fires, while the IP noted the uncertainty of whether the last scheduled person on 2/12/2025 had completed the task due to the lack of documentation.

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 promote respect and dignity for a resident who was observed wearing jeans that were too loose and held up with an elastic glove tied to the belt loops. This resulted in the resident's jeans frequently falling down, exposing his buttocks and groin area in front of other residents, staff, and visitors. The resident expressed a desire for properly fitting pants, indicating awareness and discomfort with the situation. The resident, who has diagnoses of paranoid schizophrenia and hyperlipidemia, was noted to have intact cognition and was independent in various activities of daily living. Despite this, the staff, including a CNA, acknowledged the issue with the resident's clothing but did not take appropriate measures to ensure the resident's dignity was maintained. The facility's policy emphasizes the importance of providing care that promotes dignity and respect, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident, identified as Resident 56, was fully informed and understood their health status, care, and treatments. Despite the resident's documented lack of mental capacity to make medical decisions, as indicated in multiple assessments including the Health & Physical assessment, psychiatric notes, and a neuropsychological evaluation, the facility allowed the resident to sign informed consent for psychotropic medications without the involvement of a surrogate decision-maker or an interdisciplinary team meeting. This oversight occurred even though the resident's medical records consistently highlighted cognitive impairments such as loose associations, distractibility, and hallucinations. The Social Service Director acknowledged that the mental status assessment was not verified by the physician before obtaining informed consent, which placed the resident at risk of making uninformed medical decisions. The facility's policy required a clear determination of the resident's capacity and the identification of a decision-maker, which was not adhered to in this case. The failure to conduct an interdisciplinary team meeting or arrange for a surrogate decision-maker when the resident lacked capacity violated the resident's rights and potentially exposed them to inappropriate medical care.

Penalty

No penalty information released

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

Summary

The facility failed to accommodate the needs of a resident by not ensuring that the call light was within reach in the shower room. This deficiency was identified during an observation and interview with a Certified Nursing Assistant (CNA) who was unable to reach the call light switch lever, which was positioned too high on the wall. The Maintenance Staff confirmed that a string or cord should have been attached to the call light switch lever to make it accessible for residents. The facility's policy required that call alert devices be placed within the resident's reach, but this was not adhered to in the shower room. The resident involved, who had been admitted with diagnoses including schizophrenia and hypertension, had intact cognition and required assistance with various activities of daily living. During an interview, the resident expressed that having the call light within reach would make them feel safer in the shower room. The Assistant Director of Nursing (ADON) acknowledged that all call lights should be accessible to ensure residents' needs and safety, especially during emergencies. The facility's failure to comply with its policy and procedure on the communication-call system resulted in a deficiency that could potentially impact resident safety.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the privacy of two residents, identified as Resident 41 and Resident 119, when using common restroom and shower facilities. The deficiency was observed in the [NAME] Wing's shower room and the East Wing's restroom, where the stained-glass window films were peeling off, allowing visibility from the front patio. This issue was noted during observations on February 11, 2025, and confirmed through interviews with staff, including a Certified Nursing Assistant (CNA) and the Maintenance personnel, who acknowledged the problem but were unsure of how long the films had been in disrepair. Resident 41, admitted with schizoaffective disorder and hyperlipidemia, was found to have intact cognition and required assistance with personal care tasks. During an interview, Resident 41 expressed concern about privacy, stating she would not shower if she knew others could see through the window. Similarly, Resident 119, who had schizophrenia and hypertension, also had intact cognition and required assistance with personal care. He expressed discomfort with the possibility of being seen while using the restroom. The facility's policy on resident rights, which includes privacy and confidentiality, was not adhered to, as confirmed by the Assistant Director of Nursing (ADON) and the Housekeeper (HSKP). The HSKP mentioned that addressing the peeling window films was an ongoing project since a previous survey identified the issue. Despite this, the problem persisted, compromising the residents' right to privacy as guaranteed by state and federal laws.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive care plan for Resident 68, who was admitted with schizophrenia and depression. Although the resident was discharged to a transition care facility, the staff did not create a detailed care plan addressing discharge planning. The Assistant Director of Nursing (ADON) acknowledged that the Social Services Director (SSD) was responsible for initiating the discharge care plan, which was not done. This oversight could lead to confusion in the resident's care and discharge process, as the interdisciplinary team did not have a structured plan to follow. For Resident 11, the facility did not develop a specific care plan to address the management and triggers of Post-Traumatic Stress Syndrome (PTSD). Resident 11, who had a history of childhood trauma and PTSD, was admitted with multiple mental health diagnoses, including schizophrenia, schizoaffective disorder, and bipolar disorder. The care plan included interventions for behavioral problems but did not specifically address PTSD. The ADON stated that a separate care plan for PTSD was expected to guide staff in managing the resident's care and identifying potential triggers. The facility's policy on Comprehensive Person-Centered Care Planning required that all goals and interventions from the baseline care plan be included in the comprehensive care plan. However, the facility did not adhere to this policy for both residents. The lack of specific care plans for discharge planning and PTSD management indicates a failure to provide resident-specific care, which is essential for maintaining continuity of care and communication among staff.

Penalty

No penalty information released

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

Summary

The facility failed to provide trauma-informed and culturally competent care to a resident diagnosed with PTSD, schizoaffective disorder, schizophrenia, and bipolar disorder. The resident experienced re-traumatization and increased hallucinations and delusions, leading to multiple hospitalizations. The facility did not adequately assess or document the resident's trauma history or triggers, despite the resident's history of childhood trauma and PTSD being known to family members. The resident's care plans and assessments lacked documentation of trauma triggers, and staff members were unaware of the resident's PTSD diagnosis and potential triggers. Interviews with staff revealed a lack of awareness and training regarding trauma-informed care, with staff unable to identify residents with PTSD or their specific needs. The facility's policy on trauma-informed care was not effectively implemented, as staff did not assess the resident's trauma history or engage with family members to understand the resident's triggers. Observations and interviews indicated that the resident exhibited aggressive and homophobic behavior, which was not adequately addressed by the facility. The facility's failure to provide appropriate care and interventions for the resident's PTSD and trauma history resulted in the resident experiencing distress and behavioral issues. The facility's policies on trauma-informed care were not followed, leading to a deficiency in providing culturally competent and trauma-informed care to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary behavioral health care and services for a resident diagnosed with multiple mental health disorders, including PTSD, schizoaffective disorder, schizophrenia, and bipolar disorder. The resident, who had a history of recent trauma, exhibited behaviors such as agitation, yelling, and attempts to hit staff members. Despite these behaviors, there was no documented evidence of the resident's triggers, which are crucial for managing PTSD and preventing re-traumatization. The resident's care plans, initiated upon readmission, included interventions such as anticipating needs, assisting in developing coping skills, and monitoring behavior episodes. However, these plans did not adequately address the resident's PTSD triggers or involve the family in understanding the resident's history of trauma. Interviews with family members and staff revealed that the facility did not inquire about the resident's PTSD history or address the deep trauma and homophobia that the resident experienced. Observations of the resident's behavior included arguing, talking to himself, and making homophobic comments towards staff members. Interviews with facility staff, including the ADON and the Administrator, highlighted the importance of identifying PTSD triggers to prevent re-traumatization and potential harm. The facility's policy on behavior management indicated that assessments should be conducted to address mood or behavior problems, but the implementation of these assessments and interventions was insufficient for this resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Bactrim, an antibiotic. The resident, who was admitted with diagnoses including heart failure, asthma, schizophrenia, and depression, was prescribed Bactrim for HIV without a specified stop date. This oversight led to the resident receiving the antibiotic for nearly a year, far exceeding the recommended 14-day course. The Infection Preventionist Nurse was unaware of the prolonged administration due to the lack of a documented end date. The facility's policy on Antibiotic Stewardship, which aims to optimize antibiotic use and reduce resistance, was not adhered to in this case. The prolonged use of Bactrim without reassessment or a stop date posed a risk of developing antibiotic resistance. The deficiency was identified during a review of the resident's records and an interview with the Infection Preventionist Nurse, who acknowledged the oversight and the potential for adverse health outcomes due to the extended use of the antibiotic.

Penalty

No penalty information released

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

Summary

The facility failed to comply with the regulation that limits the number of residents per room to a maximum of four. During the survey, it was observed that four rooms in the facility exceeded this limit, with two rooms accommodating twelve residents each, one room with seven residents, and another with six residents. The facility's administrator acknowledged the situation and mentioned that a waiver was in place, with plans to request an additional waiver. Despite the non-compliance, the administrator claimed that the number of residents per room did not impact the care provided. Interviews with residents in the affected rooms revealed that they did not have concerns about the number of residents sharing their space. Observations during the survey indicated that the rooms provided adequate space for movement and the use of mobility aids, such as wheelchairs and walkers. The survey did not find any adverse effects on the residents' care, comfort, or privacy due to the room arrangements. The facility's request for a waiver highlighted that the room sizes allowed for adequate nursing care and accessibility, and the survey confirmed that the care and services provided were not compromised.

Penalty

No penalty information released

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

Summary

The facility failed to provide the required minimum of 80 square feet per resident in twelve out of twenty-two resident rooms. These rooms included a variety of bed capacities, ranging from two to twelve beds per room. The Administrator acknowledged the deficiency, stating that the facility had a room waiver in place and intended to request an additional waiver. Despite the deficiency, the Administrator claimed that the room size did not impact the care provided to residents. Observations and interviews with residents in the affected rooms revealed that they did not express concerns about the space available to them. Residents were able to move freely with assistive devices such as wheelchairs and walkers. The facility's Client Accommodations Analysis confirmed that the rooms did not meet the required square footage per resident. However, during the survey, no adverse effects related to the inadequate room size were observed, and residents were seen to have enough space to move freely and receive care without restrictions.

Penalty

No penalty information released

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

Summary

The facility failed to implement its policy and procedure on resident safety by not providing adequate supervision to a resident at high risk for falls. This resulted in the resident suffering an acute subdural hematoma after falling while attempting to stand up from a sitting position on the facility's patio without staff supervision. The incident occurred when a staff member observed the resident sitting on the patio's brick seating area and later saw the resident fall on his right side after standing up using a front-wheeled walker. The resident was subsequently sent to a general acute care hospital for further evaluation. The resident had a history of falls and was known to have severely impaired cognition, requiring supervision or touching assistance when standing from a sitting position. Previous assessments, including a Minimum Data Set and a Physical Therapy Evaluation, indicated the need for supervision due to the resident's balance issues and decreased muscular coordination. Despite these documented needs, the resident was left unsupervised, leading to the fall and subsequent injury. Interviews with staff confirmed that they were not in close proximity to the resident at the time of the fall, which was contrary to the facility's policy on resident safety that required a person-centered observation system to address identified risk factors.

Penalty

Inspection fine: $8,021

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 prevent two residents, both assessed at high risk for elopement, from leaving the facility unsupervised. Resident 1, who had fluctuating capacity to understand and make decisions and was diagnosed with suicidal ideation, eloped from the facility during a shift change. The resident climbed the roof from the facility's main patio, jumped into the parking lot, and climbed over the fence. This incident occurred despite the resident's care plan indicating a need for monitoring and supervision to prevent elopement. Resident 2, who had no capacity to understand and make decisions and was also diagnosed with suicidal ideations, eloped from the same location a week later. The resident used water pipes attached to the building to climb to the roof and escape. The facility's lack of dedicated staff to monitor the patio during the night shift contributed to this incident. The patio doors remained unlocked 24 hours a day, allowing residents to access the area freely, which further facilitated the elopement. The facility did not thoroughly investigate the first elopement incident to prevent a recurrence. Staff monitoring the breezeway and patio areas did not have a full view of the patio, and there was no dedicated staff assigned to monitor the patio during the night shift. Additionally, the facility's closed-circuit television did not cover the area where the residents climbed to the roof, and there was a lack of communication among staff regarding the residents' elopement risks.

Removal Plan

• Residents were monitored and supervised when in Patio 1 at all times, in all three shifts.
• Heightened awareness on security and oversight of all facility exit doors for all three shifts.
• Residents at risk for elopement are frequently monitored and their whereabouts are always accounted for.
• Staff were in-serviced on how to care for residents at risk for elopement.
• Measures are in place to prevent residents from leaving the facility unsupervised for 22 residents at risk for elopement.
• Police notified and missing person's report filed.
• Facility contacted local hospitals during every shift to locate the resident.
• Maintenance Staff removed clutter/items in Patio 1 that may potentially be used by the residents to gain access to climbing over the roof.
• Patio 1 was assigned 24-hour monitoring to ensure residents are monitored and supervised and for staff to be on the outer perimeter of Patio 1 on all three shifts when in Patio 1.
• Outgoing staff monitoring patio stays in Patio 1 until incoming staff to patio monitor arrives.
• During shift change, incoming and outgoing staff that monitors patio are to position themselves in a spot where they have clear vision of Patio 1 while they are endorsing to other staff.
• When the staff monitoring patio goes on break, a staff is assigned to relieve them prior to leaving Patio 1.
• Administrator contacted security agency to secure a contract for unarmed security to provide heightened awareness for security oversight of all facility exit doors and facility egress for all three shifts including supervision and monitoring of resident areas.
• Administrator secured a quote for fencing. The contractor is arriving to evaluate the area of concern on the identified area of fencing. A work order will be completed.
• Corporate policy committee will be consulted regarding a more updated Elopement policy.
• DON/Designees conducted an audit of the Elopement Binder to ensure that current residents that are at risk for elopement were included and had a photo identifier unless they refused to have their photo taken.
• Administrator/designee conducted an observation of the patio area (Patio 1) during the shift change to ensure that the patio is monitored, and residents were always supervised by the staff.
• Administrator and DON initiated an in-service education to RNs, Licensed Vocational Nurses (LVNs), CNAs, Rehabilitation and Activity staffs, Activities, Business Office, Dietary, Housekeeping, Laundry, Maintenance, Receptionist, Social Services, Medical Records staff regarding the facility's policy and procedures for Wandering and Elopement, with emphasis on the importance of having the patio area always supervised in all three shifts, caring for residents at risk for elopement, and recognizing changes in condition that may potentially increase the risk of residents leaving the facility unsupervised.
• DON initiated an in-service to the nursing staff regarding hourly monitoring of residents who are at risk for elopement. This will be documented on the 'Residents who are at Risk for Elopement Monitoring' form.
• CNAs will conduct room rounds hourly every shift to ascertain all residents are accounted for.
• The Elopement Binder is placed at each Nurses Station and are reviewed with staff during shift change for any concerns, changes, or new admissions. These binders are updated by the DON/Designee as needed.
• The ADM will be responsible for monitoring and sustaining compliance.

Penalty

No penalty information released

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

Summary

The facility failed to develop a comprehensive care plan for a resident with a history of drug abuse and who was permitted to go out on pass. Despite the resident's history of schizophrenia, depression, and drug abuse, the facility did not include specific interventions in the care plan to monitor the resident's behaviors when going out on pass. The Director of Nursing (DON) acknowledged the absence of a documented care plan addressing the resident's history of drug use and the out on pass situation, stating that the facility had not initiated care plans for such scenarios. The resident's medical records indicated a history of schizophrenia, hypertension, hyperthyroidism, depression, and drug abuse, with a social history of smoking, alcohol, and methamphetamine use. The DON admitted that while there was verbal communication among staff regarding interventions for residents returning from out on pass, there was no written policy or care plan. The facility's policy on comprehensive person-centered care planning emphasized the need for interdisciplinary care to meet residents' health, safety, psychosocial, behavioral, and environmental needs, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to investigate and locate a resident who was at risk for elopement and had a history of suicidal ideations. The resident, who had fluctuating capacity to understand and make decisions, was transferred to a General Acute Care Hospital (GACH 2) for evaluation due to claims of abuse and pain. However, upon arrival at the hospital, the resident eloped from the ambulance and was not admitted to the hospital. The facility did not take immediate action to locate the resident after being informed that the resident was not admitted to GACH 2. The facility's Administrator (ADM) and Admission Coordinator (AC) were aware of the situation but did not follow up with the hospital or the ambulance company promptly. The ADM believed that the responsibility for the resident's whereabouts lay with the hospital since the resident had been discharged from the facility's care. The facility's Medical Records Director (MRD) was involved in a group text message with the physician and hospital liaison, where it was confirmed that the resident had eloped from the hospital. Despite this information, the facility did not report the incident to law enforcement or take further steps to locate the resident. The facility lacked a policy on ensuring a safe discharge or transfer of residents to other facilities. The existing policy on resident safety did not address the procedures for handling such situations. This deficiency in policy and the failure to act promptly upon learning of the resident's elopement contributed to the resident remaining missing, with potential risks to their safety.

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 monitor and supervise a resident who was identified and assessed at risk for elopement. The resident, who had diagnoses of unspecified psychosis, major depressive disorder, and dementia, eloped from the facility and was missing for an extended period. The resident was last seen in the facility's breezeway area and was later found at a nearby school football field the following day. The facility's staff did not have a scheduled monitor for the breezeway area, and the surveillance cameras were not continuously monitored during the day and evening shifts, contributing to the resident's ability to leave the facility undetected. The resident's elopement was discovered during a medication pass when the Licensed Vocational Nurse (LVN) could not locate the resident. A Code [NAME] was initiated, and local law enforcement was called for assistance. The facility staff conducted a search of the premises and the surrounding neighborhood but did not find the resident until the next morning. The resident was compliant and returned to the facility without injuries, stating that he left because he was hungry and did not know why he had left initially. Interviews with the facility's Administrator (ADM) and staff revealed that the breezeway area did not have assigned staff for monitoring, and the surveillance cameras were only continuously monitored during the night shift. The facility's policy on wandering and elopement indicated that residents at risk for elopement should be identified and measures taken to minimize injury, but these protocols were not effectively implemented in this case. The resident demonstrated how he had kicked open a locked door and climbed onto the roof to leave the facility, highlighting gaps in the facility's security and supervision measures.