North Bay Post Acute

Penalty

No penalty information released

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

Summary

Licensed nurses failed to follow physician orders for a resident who was prescribed a scopolamine transdermal patch to be applied every three days for secretion control. During observation, the resident was found to have two identical scopolamine patches in place—one near each ear—despite the physician's order and manufacturer instructions specifying that only one patch should be worn at any time. The patch near the right ear was dated two days prior, while the writing on the patch near the left ear was smudged and unreadable. Interviews with nursing staff confirmed that the resident was not supposed to have two patches applied simultaneously, and the Director of Nursing acknowledged that the physician's orders were not followed. Facility policy also required medications to be administered according to written physician orders. The failure to remove the old patch before applying a new one resulted in the resident wearing two patches at once, contrary to both medical orders and manufacturer guidelines.

Penalty

Fine: $45,920

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 physical abuse when another resident punched him in the eye, resulting in a bruise. Resident 2, who had a history of angry outbursts and physical aggression and was prescribed multiple psychotropic medications, engaged in a verbal argument with Resident 1 after being asked to turn off the light. The argument escalated, and Resident 2 physically struck Resident 1. Documentation and interviews confirmed that Resident 1 sustained a bruise under the left eye as a result of the altercation. Resident 1, who had a history of alcoholic cirrhosis and type 2 diabetes with mild cognitive impairment, reported tolerable pain and emotional distress following the incident. Staff observed the injury and offered medical assistance, which was declined by the resident. The incident was witnessed by staff, and the police were involved, resulting in Resident 2 being removed from the facility. The facility's policy states that each resident has the right to be free from abuse, but this right was not upheld 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 maintain a sanitary environment and adhere to infection prevention protocols for one resident with a Foley catheter. During an observation, a staff member was seen allowing the resident's Foley catheter drainage bag to touch the floor. The staff member acknowledged that the drainage bag should not be on the floor due to infection control concerns, a sentiment echoed by both a licensed nurse and the Director of Nursing, who confirmed that such practice increases the risk of infection. Review of the facility's policy also indicated that catheter tubing and drainage bags must be kept off the floor. Additionally, staff did not follow Enhanced Barrier Precautions (EBP) when handling the resident's Foley catheter. Despite signage indicating the resident was on EBP, a staff member handled the catheter drainage bag without wearing a gown, contrary to CDC guidelines and facility policy. Both the staff member and licensed nurse confirmed that gloves and gowns are required for such care activities to prevent cross-contamination. The Director of Nursing verified that the facility follows CDC EBP guidelines, which mandate the use of gloves and gowns during high-contact care activities involving urinary catheters.

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 was identified when a resident's call light was found tangled with a red string by the wall, near the foot of the bed, and not within the resident's reach. During observation and interview, the resident confirmed that the call light was too far away to be used when assistance was needed. Unlicensed staff verified the call light's position and acknowledged that it should have been clipped to the resident's clothing or pillowcase to ensure accessibility, as per facility policy. Further interviews with a licensed nurse and the Director of Nursing confirmed that the facility's policy requires call lights to be within reach of residents at all times. Review of the facility's policy and procedure also indicated that call lights must be placed within reach. The deficiency was based on direct observation, staff interviews, and review of facility policy, all confirming that the call light was not accessible to the resident as required.

Penalty

No penalty information released

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

Summary

The facility failed to follow its abuse policy by allowing a Certified Nursing Assistant (CNA) to return to work after allegations of physical and sexual abuse were made against him, before the completion of the facility's abuse investigation. The administrator initially stated that the CNA was suspended immediately after the allegations were reported, but time records showed that the CNA worked over the weekend while the investigation was still ongoing. The facility's policy requires suspension of staff involved in abuse allegations pending the outcome of the investigation to protect residents from harm or retaliation. A resident, who was cognitively intact according to her BIMS score, reported that the CNA had pushed her and had been on top of her roommate in bed, and expressed feeling unsafe if the CNA returned to work. The social worker confirmed that the resident had made multiple allegations, including physical and sexual abuse, and that the CNA was supposed to be suspended. Despite this, the CNA was observed by the resident in the facility during the investigation period, and time records confirmed the CNA worked shifts before the investigation was completed.

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 multiple medical conditions, including syncope, muscle weakness, gait abnormalities, bilateral knee replacements, and schizophrenia, did not receive nursing assessments related to changes in skin integrity documented in the medical record. The resident was at risk for pressure ulcers, required substantial assistance for mobility and transfers, was always incontinent, and used a wheelchair independently. Orders were received for a low-air loss mattress and barrier cream due to observed redness and open areas on the resident's coccyx and left buttocks, as noted on a shower sheet completed by a CNA and a nurse. Despite the CNA documenting the presence of two open areas on the resident's body map and reporting these findings, there was no corresponding nursing assessment or documentation in the resident's medical record regarding these skin changes. Interviews with staff confirmed that while the CNA reported the findings to the treatment nurse, and the DON expected a change in condition form and further assessment, no such documentation or assessment was completed. The only documentation present was related to the application of barrier cream and dressing, not a full nursing assessment of the wounds. Facility policies required licensed nurses to conduct and document pressure injury risk assessments and full skin assessments whenever a resident's condition changed or a new skin issue was identified. The lack of documentation and assessment by licensed nursing staff following the identification of new open areas on the resident's skin constituted a failure to meet professional standards of quality care, as required by facility policy and procedure.

Penalty

Fine: $35,880

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 COPD and metastatic lung cancer experienced a medical emergency involving severe respiratory distress and critical hypoxia. During this event, licensed nursing staff failed to perform a physical assessment by not listening to the resident's lung sounds or assessing for the use of accessory muscles. The staff did not administer oxygen appropriately, attempting to decrease the oxygen flow despite the resident's low oxygen saturation levels, and failed to provide Albuterol as ordered by the physician. Additionally, the staff did not document the resident's oxygen saturation levels throughout the emergency, nor did they ensure prompt transfer to the hospital, with a delay of approximately 50 minutes from the discovery of the resident's critical condition to contacting emergency services. The nursing staff also did not immediately notify the resident's physician upon discovering the critical condition, with documentation showing a delay of about 50 minutes before the physician was contacted. There was a lack of documentation regarding the nursing interventions implemented during the emergency. The facility's policies and job descriptions required timely assessment, intervention, and documentation, including monitoring and reporting changes in condition, administering medications as ordered, and documenting all care and resident responses. These requirements were not met during the incident. Interviews with facility staff, the DON, and the resident's physician confirmed that the actions taken were inconsistent with professional standards of nursing care and the resident's individualized care plan. The resident was ultimately transferred to the hospital in critical condition, where she required intensive interventions, including intubation and ICU admission. The failure to follow established protocols and provide care consistent with professional standards directly contributed to the severity of the resident's condition during the emergency.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a sanitary, safe, and comfortable environment for its residents, as evidenced by the disrepair of all 21 residents' bathrooms. Observations revealed multiple issues, including uneven surfaces, large cracks, and grimy substances on the bathroom floors, which residents described as mold-like. Residents expressed dissatisfaction with the cleanliness and safety of the bathrooms, with some resorting to using personal disinfectants and towels to avoid direct contact with the floors. The Housekeeping Manager acknowledged the presence of mold-like substances that could not be removed despite deep cleaning efforts, and it was noted that previous maintenance reports were not addressed by the former Director of Maintenance. In addition to the bathroom conditions, Resident 54's privacy curtain was found to be unsanitary, with a dark brown substance smeared on it, resembling feces. The Licensed Vocational Nurse confirmed the curtain's dirty condition and mentioned that maintenance only replaced curtains upon request, which had not been made in this instance. This lack of proactive maintenance contributed to the unsanitary environment. Furthermore, the facility failed to maintain comfortable water temperatures in the bathrooms of five residents' rooms. Observations and interviews revealed that the water temperatures were significantly below the required levels, with showers being described as cold. The Maintenance staff confirmed the inadequacy of the water temperatures and admitted the absence of temperature logs, indicating a lack of regular monitoring and maintenance of water temperature controls. These deficiencies collectively violated the residents' rights to a safe, clean, and comfortable living environment.

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's abuse prevention program failed to protect residents in several instances. Resident 54 was involved in a resident-to-resident altercation and expressed a desire to transfer to another facility due to feeling unsafe. Despite this, the Social Services Director did not follow up on the transfer request after initial contact with other facilities, leaving Resident 54 feeling unsafe and depressed. The Director of Nursing acknowledged the importance of addressing residents' psychosocial needs, but no further action was taken to ensure Resident 54's safety and well-being. Additionally, the facility's Quality Assurance and Performance Improvement (QAPI) program did not review or analyze reports of abuse, contrary to the facility's policy. The Administrator, who also served as the abuse coordinator, failed to track trends in abuse allegations, stating it was not QAPI's responsibility. Furthermore, the facility lacked a policy to prevent retaliation against residents, families, or visitors who reported abuse, with the Administrator dismissing the possibility of such retaliation occurring against residents. These deficiencies compromised the safety and protection of residents, staff, 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 ensure that five licensed nurses, including four Registered Nurses and one Licensed Vocational Nurse, were competent in medication administration. This deficiency was identified through observations, interviews, and record reviews, revealing a medication error rate of 24%. The errors were observed during medication administration to six residents, indicating a significant lapse in the nurses' ability to administer medications correctly. The Director of Nursing stated that competency evaluations were conducted upon hire and during medication administration audits, which were supposed to be completed by the Pharmacist. However, the Pharmacist clarified that conducting medication administration audits was not part of his responsibilities. The facility's job descriptions for the involved nurses outlined their duties, including the preparation and administration of medications as ordered by physicians. The facility's assessment and policy indicated that competency evaluations were to be conducted upon hire and reviewed annually, with performance evaluations ensuring adherence to facility standards. Despite these protocols, the failure to conduct proper audits and ensure competency led to a high medication error rate, posing potential risks to the 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 maintain a medication error rate below 5%, resulting in a 24% error rate during the survey. This was observed when five licensed nurses made medication errors involving six different incidents. These errors included incorrect administration of medications, failure to follow physician orders, and not adhering to manufacturer guidelines. One of the errors involved a resident with chronic kidney disease who was administered potassium with insufficient water, contrary to the physician's order. Another resident with hypokalemia was not instructed to remain upright after receiving potassium-phosphate, as per the manufacturer's guidelines, and was later found lying down. Additionally, the same resident was given twice the prescribed dose of cholecalciferol. Further errors included the incorrect preparation of polyethylene glycol for a resident with metabolic encephalopathy, administering insulin after meals instead of before as ordered for a resident with diabetes, and an attempted administration of an incorrect insulin dose due to a documentation error. These incidents highlight the facility's failure to ensure medications were administered according to physician orders and manufacturer instructions.

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's QAPI committee failed to maintain documentation and demonstrate evidence that the QAPI program was sustained during transitions in leadership. Specifically, there were no follow-ups for medication administration audits that were supposed to be conducted by the Pharmacy. This failure resulted in a medication error rate of 24%, including one significant error, which had the potential to result in severe adverse effects for all residents. The facility census was 94. During a review of the facility's QAPI Minutes from January to December 2024, it was noted that medication administration audits by the Pharmacist were planned to be completed monthly and reported to QAPI. However, the audits were not completed for February. Interviews with the Director of Nursing and the Pharmacist revealed a lack of clarity regarding responsibility for these audits. The Administrator, who started employment in June 2024, was unaware of the audits and declined to discuss issues identified by QAPI prior to his employment. The facility was unable to provide documentation that the audits were conducted from February to December 2024.

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's Quality Assurance and Performance Improvement (QAPI) program failed to identify, address, and evaluate several systemic quality deficiencies, including nursing medication administration competency, infection control, abuse program, incomplete resident records, and social services. These deficiencies were not recognized or addressed in the QAPI minutes from January to December 2024, indicating a lack of oversight and potential negative impact on resident safety and care quality. The facility census was 94, and the issues were confirmed by the Administrator during interviews, who acknowledged that no Performance Improvement Projects (PIPs) were conducted for the identified issues. Further review of the facility's QAPI agendas and minutes from June to October 2024 revealed that while some PIPs were initiated, such as for baseline care plans, handwashing, COVID vaccines, call lights, care conferences, and falls, there was no discussion or evaluation of these projects. The facility's QAPI policy and procedure outlined a comprehensive approach to identifying and addressing quality deficiencies, but the lack of implementation and evaluation of PIPs suggests a disconnect between policy and practice. The Administrator was also unaware of the existence of the Quality Assessment and Assurance Log, further highlighting the deficiencies in the facility's QAPI program.

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 adequate infection prevention and control measures, as evidenced by several deficiencies observed during the survey. Firstly, the maintenance staff did not conduct monthly water testing for Legionella bacteria from January 2024 through January 2025, which is a critical component of the facility's Legionella Water Management Program. The facility's policies and procedures, which were last updated in 2001, were not revised annually as required, contributing to outdated practices. Additionally, toilet plungers were improperly stored on the floor next to toilets in multiple rooms, and urinals were found unlabeled and improperly placed, increasing the risk of cross-contamination. In another instance, a used urinal without a lid was observed on a resident's bedside table for approximately one hour, posing a potential infection control issue. The Certified Nursing Assistant (CNA) acknowledged the oversight and stated that the urinal should have been emptied, cleaned, and stored properly. The facility's policy on urinal management, last updated in 2018, was not adhered to, as the urinal was not placed in a bag within the resident's reach, nor was it removed from the bedside table. Furthermore, staff failed to follow Enhanced Barrier Precautions (EBP) and other transmission-based precautions for residents requiring such measures. A CNA did not wear a gown while providing perianal hygiene care to a resident on EBP, and an Occupational Therapist did not use PPE while providing care to a resident with a foley catheter. Additionally, a nurse did not wear a gown when entering a room with a resident on contact precautions, and a droplet precaution sign was missing for a resident with influenza. These lapses in following established protocols increased the risk of spreading infections within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate procedures for reporting incidents of abuse and training for seven staff members, including the Social Services Director, a Registered Nurse, a Licensed Vocational Nurse, and several Certified Nurse Assistants. This deficiency was identified through interviews and record reviews, revealing that staff members were unable to effectively identify the facility's procedure for reporting abuse incidents. A resident reported hearing verbal abuse directed at his roommate, but no action was taken after he reported the incident. Interviews with staff members indicated a lack of understanding of the immediate reporting requirements, with some staff stating they would report incidents to the Director of Nursing during the next shift rather than immediately. Record reviews showed that several staff members selected incorrect answers on abuse training post-tests, indicating a misunderstanding of the mandated reporting requirements according to California law. Some employee files were missing the abuse training post-test altogether, and the Director of Staff Development confirmed that there was no tracking system for staff struggling with the training information. The facility's policy and procedure on abuse prevention required staff orientation and training on reporting abuse, but the lack of effective training and understanding among staff members compromised the safety of residents, staff, 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 ensure the accuracy of the Minimum Data Sets (MDS) for two residents, which could potentially affect their care. For Resident 391, the MDS inaccurately indicated that the resident was discharged to a Short-Term General Hospital, while records and interviews confirmed that the resident was actually discharged home. This discrepancy was identified during a review of the resident's discharge summary and nursing progress notes, which clearly stated the resident's discharge to home. The MDS Coordinator acknowledged the inaccuracy during an interview and record review. For Resident 25, the MDS inaccurately reflected the resident's significant weight loss. The resident experienced a 22.22% weight loss since admission, as confirmed by the Director of Nursing and the Registered Dietitian. However, the MDS was coded incorrectly, indicating no significant weight loss. This error was confirmed by the MDS Coordinator, who acknowledged the importance of accurate MDS coding as it triggers the resident's plan of care. The facility's policy and procedure on resident assessments emphasize the need for comprehensive and accurate assessments, which was not adhered to in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to proper medication storage and labeling protocols, leading to several deficiencies. In one instance, a yellow-colored tablet was found on the floor under a resident's bed, and the Licensed Vocational Nurse (LVN) present could not identify the medication. This indicates a lapse in ensuring medications are securely stored and accounted for, as per the facility's policy that mandates all medications be stored in locked compartments. Additionally, the facility was observed to have left treatment and medication carts unlocked and unattended on multiple occasions. One treatment cart was left unlocked near the nurses' station, and a medication cart was found unattended with an unidentified pill in the top drawer. Both LVN and Registered Nurse (RN) staff acknowledged these oversights, which contravene the facility's policy requiring carts to be locked when not in use to prevent unauthorized access. Furthermore, the facility failed to properly label insulin pens for two residents, as the pens were missing the date they were opened. This is critical because insulin pens are only viable for 28 days after opening, and without proper labeling, there is a risk of administering expired medication. The facility's policy clearly states that multi-dose vials should be dated when opened, highlighting a significant oversight in medication management for residents with diabetes.

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 effective monitoring of antibiotic use for a resident diagnosed with a urinary tract infection (UTI). The resident was prescribed Amoxicillin-Pot Clavulanate to be taken twice daily for 14 days. However, during a review of the facility's records, it was found that there was no documentation of antibiotic stewardship monitoring for the months of October and November 2024. The Infection Preventionist confirmed the absence of documentation and acknowledged that the monitoring should have been conducted monthly. The facility's policy on antibiotic stewardship, dated 2001, states that the purpose of the program is to monitor antibiotic use among 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 provide adequate living space for residents in 24 rooms, each housing three residents. This deficiency was identified through observations, interviews, and record reviews. Specifically, Resident 54, who used a walker, was residing in a room where Bed C's living space was significantly smaller than the spaces for Beds A and B. The living space for Bed C was measured at 74.75 square feet, which is below the required 80 square feet per resident in multiple occupancy rooms. This inadequate space was confirmed by both the Maintenance Director and the Administrator during their assessments. Further investigation revealed that all 24 rooms with a Bed C had individual living spaces below the required 80 square feet. The facility was unable to provide a policy or procedure that ensured adequate resident living space, indicating a systemic issue affecting 23 residents. The lack of sufficient space had the potential to compromise the safety of residents, particularly those requiring assistive devices like walkers, due to the limited maneuverability within their living quarters.

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 essential information in the preferred languages of two residents, leading to a deficiency in ensuring that residents were fully informed about their health status, care, and treatments. Resident 342, who only spoke and read Spanish, had important documents such as the weekly menu, activity calendar, and instructions for accessing interpreter services posted in English. This oversight was confirmed through interviews with facility staff, including a registered nurse and a registered dietician, who acknowledged the absence of translated materials and the importance of providing information in residents' primary languages. The facility's policy on language access, which mandates meaningful access to information for individuals with limited English proficiency, was not adhered to in this case. Similarly, Resident 8, whose primary language was Mandarin, also had essential information posted in English only. Interviews with a licensed vocational nurse and a certified nurse assistant confirmed that Resident 8 spoke only Mandarin and had not received translated materials. The facility's assessment indicated the capability to accommodate language preferences, yet this was not reflected in practice. The failure to provide translated materials for these residents resulted in them being uninformed about menu options, activities, and how to obtain translation services, contrary to the facility's stated policies and procedures.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the call light was within reach for a resident, resulting in the resident being unable to contact staff for assistance. The resident, who was admitted with diagnoses of hemiplegia following a cerebral infarction affecting the right dominant side, aphasia, and weakness, was observed in a geriatric chair in the middle of the room without access to a call light. The resident attempted to gain attention by throwing a pillowcase and waving, while grunting and pointing at the call light on the floor. Interviews and record reviews revealed that the resident was non-verbal and required maximum assistance for all activities of daily living. The Certified Nursing Assistant confirmed that the call light was not within the resident's reach. The Director of Nursing acknowledged that the call light should have been accessible to the resident at all times. The resident's care plans and the facility's policy emphasized the importance of having the call light within reach to ensure a safe environment, 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 83, or their legal representative was informed and provided with written information about Advance Directives (AD). This deficiency was identified during a review of Resident 83's records, which showed that the resident was admitted with multiple diagnoses, including hypertension and muscle weakness. The Minimum Data Set (MDS) assessment indicated that Resident 83 had moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 12. Despite this, there was no documented evidence that the resident's Responsible Party 1 (RP 1) was provided with information regarding AD or that they signed the Advance Directive Acknowledgment form. During interviews and record reviews, it was revealed that the facility's policy required the determination of whether a resident had executed an advance directive upon admission and to provide information if they had not. The Director of Nursing (DON) stated that it was the responsibility of the physician and nurses to ensure that information regarding the advanced directive was discussed and documented. However, the review of Resident 83's Physician Orders for Life-Sustaining Treatment (POLST) showed that the section for information and signatures was incomplete, indicating a failure to comply with the facility's policy and procedure regarding residents' rights and advance directives.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper screening and follow-up for a Registered Nurse (RN) who had been found guilty of neglect by a court of law. The RN had an administrative disciplinary action against their license, which was not investigated or addressed by the facility. The RN's employee file indicated a disciplinary action posted on their license, and a public court document confirmed a conviction for child endangerment. Despite this, the facility did not provide documentation of any investigation into the disciplinary action. The facility's policy and procedure on abuse, neglect, exploitation, and misappropriation prevention required conducting employee background checks and not employing individuals with findings of abuse, neglect, or disciplinary actions against their professional license. However, the facility did not adhere to this policy, as evidenced by the RN's continued employment despite the disciplinary action. This oversight had the potential to compromise the safety of residents, staff, and visitors, given the RN's history of neglect.

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 send a copy of the transfer notification to the Office of the State Long-Term Care Ombudsman for two residents, resulting in the Ombudsman not being informed of their transfers to a General Acute Care Hospital (GACH). Resident 77, who was admitted with chronic obstructive pulmonary disease, was transferred to the hospital on 11/10/24 due to a high temperature and irregular heart rate. The Medical Records Director confirmed that the Notice of Transfer or Discharge was not sent to the Ombudsman, as required by the facility's policy. Similarly, Resident 84 was transferred to the hospital on 11/15/24 for osteomyelitis of the great left toe. The Medical Records Director also confirmed that the Notice of Transfer or Discharge was not present in Resident 84's medical record. The facility's policy, which mandates that a copy of the notice be sent to the Ombudsman at the same time it is provided to the resident and their representative, was not followed in these instances.

Penalty

No penalty information released

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

Summary

The facility failed to identify a mental illness in one of the residents, referred to as Resident 71, and did not refer her for a Level II PASRR screening. This oversight resulted in Resident 71 not receiving the specialized mental health services she required. The PASRR screening dated 7/14/23 indicated a negative Level 1 screening, suggesting that Resident 71 was not diagnosed with a mental disorder and was not prescribed psychotropic medications. However, a subsequent review of Resident 71's Minimum Data Set (MDS) dated 7/20/23 revealed active diagnoses of anxiety disorder and post-traumatic stress disorder (PTSD), which were not reflected in the PASRR conditions. Further investigation through the Care Area Assessment (CAA) Worksheet dated 7/20/23 indicated that Resident 71 had severe depression, thoughts of self-harm, and was on medication for PTSD and psychosis. Despite these findings, the Social Services Director (SSD) acknowledged that it was her responsibility to arrange the referral for a PASRR evaluation, which was not done. The facility's policy on PASRR, dated July 2016, mandates the completion and submission of a PASRR screening, especially when there is a significant change in a resident's mental condition. This policy was not adhered to, leading to the deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to implement necessary interventions to reduce the risk of falls for a resident diagnosed with a malignant neoplasm of the temporal lobe. The resident was admitted to the facility with a care plan that included the use of a fall mat at the bedside due to a history of crawling out of bed. However, during multiple observations, no fall mat was present at the resident's bedside. Interviews with staff, including a CNA, RN, and the Director of Nursing, confirmed the absence of the fall mat, which was a required intervention according to the resident's care plan. The deficiency was highlighted when the resident rolled out of bed, as reported by the resident's responsible party. Staff interviews revealed that the resident was prone to agitation and movement in bed, necessitating the use of a fall mat to prevent injuries. Despite this, the fall mat was not consistently in place, and staff suggested it might have been removed for cleaning. The facility's policy on managing falls and fall risks emphasized the importance of identifying and implementing interventions based on the resident's specific risks, 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 revise and implement a person-centered comprehensive care plan for a resident who experienced a fall. The resident, who was admitted with diagnoses including repeated falls, muscle weakness, and dementia, had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3. Despite an unwitnessed fall on January 12, 2025, which resulted in a skin tear on the resident's left elbow, the care plan was not updated with new interventions to address the fall risk. During interviews and record reviews, it was revealed that the care plan, dated September 7, 2024, did not include updated interventions following the fall. A Licensed Vocational Nurse (LVN) acknowledged that the care plan should have been updated post-fall to implement and measure effective interventions. The Director of Nursing (DON) confirmed that the facility's policy required care plans to be updated after falls to prevent serious injuries, but this was not done, placing the resident's health and safety at risk.

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 medication administration met professional standards of practice when a Licensed Vocational Nurse (LVN) prepared medications for two unsampled residents, Resident 39 and Resident 193, without observing them ingest the medications. During an observation, LVN 2 was seen preparing medications for both residents simultaneously, labeling the medicine cups with black marker, and then walking approximately 65 feet to the residents' room. The LVN placed the medicine cups on the bedside tables of the respective residents without observing them take the medications or informing them of the contents of the cups. In an interview, LVN 2 acknowledged that she did not follow the expected procedure, which required her to push the medication cart to each resident's room and prepare medications for one resident at a time. The Director of Nursing (DON) confirmed that the facility's policy was to administer medications at the time they are prepared and to observe residents ingesting their medications to ensure the dose was completely taken. The failure to adhere to these procedures had the potential to result in medication errors for the residents involved.

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 290, received an assistive device for his vision needs. Resident 290, who was admitted with a diagnosis of diabetic retinopathy, reported that he had been without eyeglasses for more than two weeks, which hindered his ability to engage in his favorite hobby of solving crossword puzzles. During an observation and interview, Resident 290 expressed his difficulty in performing this activity due to the absence of his eyeglasses, which he had reported missing to the Social Services Director (SSD). The SSD acknowledged having a conversation with Resident 290 about the need for a consultation to obtain new eyeglasses but admitted to not documenting the interaction or following up on the matter. The SSD also mentioned that if residents approached her outside of her office, she sometimes forgot to record their concerns. The facility was unable to provide a policy or procedure to ensure residents received necessary assistive devices like eyeglasses. This oversight negatively impacted Resident 290's quality of life, as confirmed by the SSD.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that physician visits were conducted once every thirty days for a resident, identified as Resident 25. This deficiency was identified through interviews and record reviews. Resident 25 was admitted with several diagnoses, including a malignant neoplasm of the temporal lobe, iron deficiency anemia, type 2 diabetes mellitus, and dysphasia. During an interview, the Medical Director (MD) stated that she visited the facility daily and attempted to see all residents monthly, but was unaware of the specific requirements for physician visits. She mentioned that she sometimes visited residents without documenting these visits unless an examination was performed. A review of Resident 25's medical records, conducted with the Director of Nursing (DON), revealed a lack of documentation indicating that the MD had seen Resident 25 between September 20 and November 28, a span of 58 days. The DON confirmed the absence of documentation and acknowledged that the MD likely did not visit Resident 25 during this period. The facility's policy and procedure on physician visits, dated April 2013, required attending physicians to visit patients at least once every thirty days for the first ninety days, with appropriate documentation of the resident's care program.

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 mental health services to a resident diagnosed with depression, panic disorder, generalized anxiety disorder, and chronic post-traumatic stress disorder. The resident, who was admitted with these diagnoses, was observed to be isolated and lying in bed most of the day. Despite expressing a desire for counseling to the Social Services Director, the resident had not been evaluated or seen by any mental health professional since admission. Interviews with staff, including a registered nurse and the medical director, confirmed the resident's ongoing depression and occasional aggression. A review of the resident's Care Area Assessment Worksheet indicated severe depression and recommended a referral to a psychologist, which was not acted upon. The facility's policy on behavioral health services stated that residents would receive such services, yet the resident did not receive any mental health support. The administrator acknowledged the oversight, expressing surprise that the resident had not received the necessary help. This lack of action had the potential to negatively affect the resident's 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 follow up on a transfer request for a resident who did not feel safe after a resident-to-resident altercation. The resident expressed a desire to transfer to another facility, but the Social Services Director did not follow up with potential facilities after initial contact attempts. The resident continued to feel unsafe and expressed feelings of depression related to the facility environment, as noted in a psychiatric progress report. Another deficiency involved the improper screening for Preadmission Screening and Resident Review (PASARR) for a resident with mental health diagnoses. The resident's PASARR screening was negative, despite having active diagnoses of anxiety disorder and post-traumatic stress disorder, and being on medications for these conditions. The Social Services Director acknowledged that the resident should have been referred for PASARR clarification but was not. Additionally, the facility failed to arrange and provide mental/psychosocial counseling services for the same resident. Despite the resident's expressed need for counseling and a history of severe depression, no mental health services were provided. The resident remained isolated in her room, and the facility's policy on behavioral health services was not followed, as confirmed by the facility's administrator.

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 Monthly Medication Reviews (MMR) were conducted for a resident, identified as Resident 61, which resulted in the potential for the resident to receive unnecessary medications. Resident 61 was admitted with diagnoses including Lewy body dementia and major depressive disorder. During an interview, the pharmacist stated that he is responsible for conducting MMRs every month to identify any medication concerns and communicate the results to the Director of Nursing (DON). However, a review of Resident 61's medical records revealed that MMRs were not documented for January and August 2024. The DON confirmed that these reviews were not conducted. The facility's policy, dated December 2016, requires the consultant pharmacist to perform a comprehensive medication regimen review at least monthly and document the findings within 72 hours.

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 attempt a Gradual Dose Reduction (GDR) for a resident who was receiving psychotropic medications, specifically escitalopram and quetiapine, despite the absence of documented behaviors that would necessitate such medications. The resident, diagnosed with Lewy body dementia and major depressive disorder, was noted to have no aggressive behaviors, striking out, depression, or excessive pacing over a period of 9 1/2 months. Despite recommendations from the Executive Mental Health Doctor and the facility's pharmacist to reduce or discontinue these medications, the Medical Director did not attempt a GDR or discuss it with the resident's responsible party. The facility's policy requires a GDR to be attempted within the first year of admission on psychotropic medication or after initiation, in two separate quarters, unless clinically contraindicated. However, there was no documentation of a GDR attempt for the resident from the time of admission to the time of the survey. The Medical Director acknowledged awareness of the recommendations but confirmed no GDR was attempted. The facility's failure to adhere to its policy and the recommendations of healthcare professionals resulted in the potential for the resident to receive unnecessary and excessive doses of psychotropic medications.

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 correct dosage of insulin was administered to a resident, identified as Resident 291, who was diagnosed with diabetes mellitus type 2. During an observation and interview, a registered nurse (RN) checked the resident's blood sugar level using a glucometer, which showed a result of 205 mg/dL. However, the RN documented an incorrect blood sugar level of 305 mg/dL in the resident's Medication Administration Record (MAR) and prepared to administer 8 units of insulin based on this incorrect reading. Upon reviewing the glucometer history, the RN realized the actual blood sugar level was 205 mg/dL, which required only 4 units of insulin according to the physician's sliding scale order. The physician's order specified different insulin dosages based on blood sugar ranges, and the incorrect documentation and preparation of insulin could have led to a significant medication error. The Medical Director confirmed that administering too much insulin is life-threatening, and the pharmacist noted that doubling the insulin dose could cause significant harm to the resident. The facility's policy on medication administration, dated October 2017, requires medications to be administered according to written orders, which was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to provide routine dental services for a resident, identified as Resident 71, for a period of 16 months. This deficiency was identified through observation, interview, and record review. During an observation and interview, Resident 71, who had multiple missing teeth, reported having seen a dentist only once since admission and had verbally requested dental visits multiple times. The Social Services Director confirmed that Resident 71 was admitted on an unspecified date and was not seen by a dentist until November 14, 2024, despite the requirement for dental visits every six months and as needed. A review of Resident 71's Minimum Data Set (MDS) dated December 26, 2024, indicated that the resident was edentulous and had triggered the Care Area for Dental Care. The facility was unable to provide a policy and procedure regarding dental services.

Penalty

No penalty information released

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

Summary

The facility failed to maintain cleanliness of kitchen equipment, specifically the dishwasher, which was observed to have a white powdery substance on top and a thick greasy buildup on the bar across the bottom. This observation was made during a concurrent interview with the Dietary Supervisor, who acknowledged the equipment's dirty condition. The facility's policy and procedure for cleaning surfaces, including those used for food preparation, requires the removal of large debris, washing with a warm detergent solution, rinsing with clear water, and drying with a clean cloth. The failure to adhere to these procedures posed a risk for foodborne illness among the 98 medically fragile residents who received food prepared in the kitchen.

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 designated refrigerator for storing personal, perishable food items for three of five sampled residents. This deficiency was observed when Resident 56 was seen storing perishable food items, such as butter and pickled beets, in her bedside drawer, acknowledging the need for refrigeration but citing the lack of an available refrigerator. Interviews with the Dietary Manager and Registered Nurse confirmed the absence of a refrigerator for resident use, despite the facility's policy allowing food brought by family or visitors to be stored safely. Residents 54 and 341 also expressed a desire for a refrigerator to store their personal food items, with Resident 54 recalling that the facility previously had a refrigerator for resident use. The Social Services Director and Director of Nursing Services were unaware of why the refrigerator was removed, but the Director of Nursing Services acknowledged the residents' right to store food brought from outside. The facility's policy, dated March 2022, indicated that food brought by visitors should be stored in a distinguishable manner and discarded if left unrefrigerated for more than two hours.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Physician's Progress Notes were documented in the medical records for three sampled residents, leading to potential communication delays and coordination of care issues. Resident 25, who was admitted with a malignant neoplasm of the temporal lobe and a urinary tract infection, had no documented Physician's Progress Notes in their medical record. The Director of Nursing (DON) confirmed the absence of these notes and stated that the Medical Director (MD) documented from home and faxed the notes later, which were not readily available in the facility. Similarly, Resident 61, diagnosed with Lewy body dementia, also lacked documented Physician's Progress Notes in their medical record. The DON acknowledged the absence of these notes and mentioned that the MD was expected to document progress notes during visits but instead faxed them later. The MD confirmed that the notes were not in the medical record and that she did not have remote access to them. Resident 75, admitted with type 2 diabetes mellitus, also had no documented Physician's Progress Notes in their medical record. The DON reiterated the issue of the MD faxing notes later and not documenting them during visits. The Administrator confirmed that the facility did not have access to the progress notes for multiple residents, which could hinder staff's ability to review them when needed. The facility's policy and procedure required the attending physician to perform all relevant tasks, including appropriate documentation, at the time of each visit.

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 within the required 2-hour timeframe. The incident involved an unlicensed staff member, ULS B, and a resident who reported inappropriate texts and interactions to another staff member, ULS D. ULS D was assigned to care for the resident on the day the incident was reported to him, but he delayed reporting the allegation to the facility administrator until the following day. This delay resulted in the abuse allegation being reported late to the state, contrary to the facility's policy. Interviews with staff, including the Interim Director of Nursing and the facility administrator, revealed a lack of understanding and adherence to the mandated reporting timeframe. The facility's policy required immediate reporting, no later than 2 hours, to local law enforcement and licensing agencies. However, the administrator mistakenly believed the timeframe was 24 hours. This misunderstanding contributed to the failure to report the abuse allegation promptly, as required by the facility's policy 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 follow a physician's order to obtain a Keppra blood level for a resident, identified as Resident 10, who was admitted with a history of Parkinson's, epileptic seizures, muscle weakness, and dysphagia. The physician had ordered a Keppra level test every four months, but the facility did not ensure the laboratory company came to obtain the sample, and the nursing department did not follow up on this missed opportunity for four months. This oversight was discovered during a review of Resident 10's records, which showed the last Keppra level was taken on 4/4/24, with no subsequent tests performed as ordered. As a result of the missed Keppra level tests, Resident 10 experienced seizures in October and November 2024, with the latter incident requiring a transfer to a higher level of care. During an interview, Licensed Staff A, who was covering for the Director of Nursing, confirmed the absence of additional Keppra test results and acknowledged that there was no documentation of the resident refusing the test. The facility's policy on diagnostic services, which mandates providing such services as ordered by a physician, 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 uphold residents' rights to self-determination by enforcing a smoking policy without considering the preferences and input of residents who were smokers at the time of their admission. The policy change restricted residents' ability to choose their smoking schedules, and residents were not provided with guidance on managing these restrictions or offered alternatives to smoking. This affected nine out of thirteen residents identified as smokers, including those who were assessed as safe to smoke with or without supervision. The residents expressed dissatisfaction with the policy, stating it infringed on their rights and freedom. Interviews with residents revealed that they were not adequately informed or involved in the decision-making process regarding the smoking policy changes. Some residents, like Resident 3, expressed a desire to exit the facility for fresh air, while others, like Resident 11, preferred to smoke during specific times for personal reasons. Staff interviews indicated that the smoking policy had not been enforced in the past, leading to resistance from both residents and staff when the policy was suddenly implemented. The facility's administration cited safety concerns as the reason for enforcing the policy, but the lack of resident involvement and consideration of their rights led to dissatisfaction and non-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 adhere to transfer and discharge requirements when it issued a Notice of Transfer and Discharge to nine residents identified as smokers, citing non-compliance with the smoking policy as the reason. The facility did not provide adequate documentation to support that these residents' smoking behavior posed a safety risk to others or that they were non-compliant with the smoking policy. This lack of documentation could lead to unfair and unsafe discharges. The clinical records of several residents, including Residents 2, 3, 4, 5, 7, 9, 11, 12, and 13, were reviewed. Each resident had been assessed for their ability to smoke safely, with some requiring supervision and others not. Despite this, all were given a 30-day discharge notice for alleged non-compliance with the smoking policy. However, there was no documentation in their medical records to show they had been given the smoking policy prior to the notice or evidence of their non-compliance. Interviews with residents and staff revealed that the Social Services Director was instructed to issue the discharge notices on the same day, and the Administrator acknowledged that the notices were intended to encourage compliance with the smoking policy. The facility's policy on transfer and discharge requires that any grounds for such actions be documented in the medical record, which was not done in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to implement necessary interventions to prevent the elopement of a resident diagnosed with unspecified dementia and behavioral disturbances. The resident, who was identified as a high risk for wandering, left the facility undetected and was found on a busy street. This incident was reported by a bystander who stayed with the resident until emergency responders arrived. The facility's records indicated that the resident had a history of wanting to leave the facility and exhibited impulsive behavior, making it difficult to redirect him. Upon readmission to the facility, the resident was assessed using the Wandering Risk Scale and was found to be at high risk for wandering. Despite this assessment, the care plan to address the resident's elopement risk was not initiated. The facility's policy required that residents identified as at risk for elopement have a care plan written to address this risk, but this was not done in a timely manner. The resident's care plan was only updated after the elopement incident occurred. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's elopement risk. The licensed nurse assigned to the resident on the day of the incident did not recall the elopement and was unaware of the specific resident involved. The facility administrator acknowledged that the care plan and preventive measures were not implemented as expected, which contributed to the resident's ability to leave the facility undetected.

Penalty

No penalty information released

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

Summary

The facility failed to notify the responsible party of a resident's transfer to the hospital, violating the requirement to inform and involve the resident's representative in care decisions. The resident, a veteran with dementia, diabetes, hypertension, and an unspecified mood disorder, was transferred to the hospital without the responsible party's knowledge. The responsible party only learned of the transfer when the resident called from the hospital with assistance from the hospital staff. The facility's records show that a voicemail was left for the responsible party indicating the facility could not meet the resident's needs and that a subsequent message was left about the impending transfer. However, the responsible party stated she did not receive any calls or messages from the facility and was unaware of the transfer until contacted by the hospital. The facility's failure to provide timely written notification of the transfer disregarded the rights of the resident and the responsible party to be informed and participate in care decisions.

Penalty

Fine: $119,192

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

Summary

The facility failed to maintain a sanitary environment for food storage and preparation, resulting in a rat infestation in the kitchen where residents' food was stored and prepared. Observations revealed rat droppings and gnawed food items in various areas of the kitchen, including under the ware washing area, the two-compartment sink, the steam table, the ice machine, and the dry storage area. Kitchen staff confirmed the presence of rat droppings and gnawed food, and it was noted that these issues had been ongoing for at least two months. Interviews with facility staff, including the Administrator, Director of Nursing (DON), Maintenance Director, and Infection Preventionist (IP), revealed a lack of timely and effective response to the rat infestation. The Administrator acknowledged that the pest control company had been called multiple times for reports of rodents, but the last visit was over two weeks prior to the survey. The Maintenance Director admitted to receiving daily complaints about rat droppings and gnawed food since the last pest control visit but had not contacted the pest control company again. The IP confirmed that rats carried diseases and could expose residents to harm, yet no immediate action was taken to address the infestation. Further investigation showed that the facility's pest control measures were inadequate, with the Pest Control Service Specialist confirming the presence of rats and setting additional traps only after the surveyor's findings. The County Health Inspector verified the rat infestation and noted that the kitchen could not be used for food preparation or distribution. The Registered Dietitian and Dietary Manager were unaware of the extent of the rat activity, indicating a lack of oversight and communication among staff responsible for food safety.

Removal Plan

• discarded contaminated food
• food for residents to be prepared off site and delivered to the facility
• pest control service and increased rat bait stations until no more activity
• hired additional pest control company for rat exclusion work

Penalty

Fine: $119,192

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 garbage in a manner that made it inaccessible to pests, potentially contributing to a rat infestation in the kitchen. During an observation, a dumpster located approximately 20 feet from the kitchen door was found with its lid propped open by a stick, surrounded by overgrown English ivy. The pest control company confirmed multiple reports of rat activity in the kitchen over several months, with sightings of gnawed food and rat droppings in dry storage. A pest control specialist identified holes and droppings in various areas of the kitchen, verifying the presence of rats. Further observations revealed the dumpster was frequently overfilled, causing the lid to remain open, and the surrounding ivy was not trimmed back, which could facilitate rodent access. Interviews with staff, including a registered dietitian and the dietary manager, confirmed the improper handling of the dumpster and the need to keep it closed to prevent rodent entry. The FDA Food Code mandates that refuse be stored in a manner that is inaccessible to pests, with receptacles kept covered with tight-fitting lids, which the facility failed to comply with.

Penalty

Fine: $119,192

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 administrator failed to effectively manage pest control issues in the kitchen, leading to a significant infestation of rats. Observations revealed rat droppings and gnawed food items in various areas of the kitchen, including under the ware washing area, the steam table, and in the dry storage area. Despite being aware of the problem, the administrator did not ensure regular follow-ups with the pest control company, resulting in a lapse of 15 days without a visit. The administrator also lacked a copy of the pest control contract and was unaware of multiple reports of rat activity made in the preceding months. Additionally, the administrator did not respond to requests from the county health department to address code compliance issues in the kitchen. The facility's kitchen permit was suspended due to major violations, including rodent presence, contaminated food, and improper food handling practices. The county health department had previously notified the facility of these issues, but the administrator failed to submit the required architectural plans and other documentation necessary for compliance. The facility also experienced staffing issues, with nurses working 24-hour shifts due to the failure of a staffing agency to provide coverage. The Director of Nursing confirmed that nurses worked extended hours when registry nurses did not report for their shifts. The administrator did not review the staffing contract or involve himself in resolving the staffing shortages, leaving the responsibility to the DON and staffing coordinator. This lack of oversight contributed to unsafe working conditions for the nursing staff.

Penalty

Fine: $119,192

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 pest control program, resulting in a rat infestation in the kitchen. Observations revealed rat droppings under various kitchen areas, including the ware washing area, two-compartment sink, steam table, ice machine, and dry storage. Food items such as bananas, bread, and spaghetti were found gnawed, and droppings were present on food and kitchen surfaces. The Director of Nursing and kitchen staff confirmed the presence of droppings and gnawed food, indicating the issue had persisted for at least two months. The Administrator acknowledged that the pest control company had been contacted multiple times, with the last visit occurring on 3/19/24. However, the Maintenance Director admitted to receiving complaints about rats for two weeks and had attempted to address the issue by placing poison baits and sealing entry points with steel wool and spray foam. Despite these efforts, the problem persisted, and the Maintenance Director had not contacted the pest control company again. The Pest Control Service Specialist confirmed the presence of rats and initiated an escalation plan for more frequent visits. The County Health Inspector verified the rat infestation, finding droppings and gnawed food throughout the kitchen. The inspection led to the suspension of the facility's permit to operate the kitchen, requiring food to be sourced externally. The Dietary Manager, who had been on vacation, was unaware of the ongoing pest issues and stated that staff should have reported any signs of rodents to the Administrator. The facility's pest control policy, last revised in 2008, was not effectively implemented, contributing to the deficiency.

Penalty

Fine: $119,192

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

Summary

The facility failed to adequately staff the Noc shift for three consecutive nights, resulting in three nurses working triple shifts, each lasting 24 hours. This staffing issue arose when registry nurses scheduled for the Noc shift did not report to work. The Director of Nursing (DON) was unaware of the situation until after it occurred, as her phone was on sleep mode, preventing her from receiving calls from the staff. The Staffing Coordinator also did not respond to notifications due to being asleep and lacked access to the registry portal from home to arrange backup staff. Licensed Nurses E, F, and G each worked 24-hour shifts on different days due to the absence of scheduled registry nurses. These nurses reported that they stayed to cover the shifts because they did not want to leave their colleagues alone with over 90 patients. They acknowledged that working such long hours was unsafe for both staff and patients, as it increased the risk of medication errors and delayed care. Despite attempts to contact facility leadership, the nurses received no response, and the situation persisted for three nights. The facility's policy on staffing, revised in August 2022, mandates sufficient and competent nursing staff to meet resident needs. However, the failure to ensure adequate staffing during the Noc shift led to a breach of this policy. The Medical Director and Administrator were not initially aware of the 24-hour shifts worked by the nurses, and a root cause analysis had not been conducted to address the issue. The Administrator suggested that the DON should have covered the shift, indicating a lack of clear communication and contingency planning within the facility.