North Valley Nursing Center

Penalty

Fine: $96,46820 days payment denial

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

Summary

The facility failed to honor a resident's documented Do Not Resuscitate (DNR) order as indicated in the Physician Orders for Life-Sustaining Treatment (POLST) and other medical records. When the resident was found not breathing, multiple nursing staff, including RNs and LVNs, initiated and continued cardiopulmonary resuscitation (CPR) for seven minutes without verifying the resident's code status. The decision to start CPR was based solely on an unidentified person shouting that the resident was a full code, rather than checking the resident's POLST, Admission Record, or electronic health record, all of which clearly indicated a DNR order. The involved staff, including those who performed CPR and those who assisted, admitted during interviews that they did not check the resident's code status and instead relied on the verbal assertion from an unidentified individual. The resident's POLST, Admission Record, and care plan all indicated DNR status, and the resident had previously expressed his wish for DNR due to his medical condition, including a cancer diagnosis. Despite these clear directives, the staff proceeded with resuscitation efforts until paramedics arrived and identified the DNR order in the resident's documentation. Facility policy and procedures required staff to verify code status and honor residents' rights to refuse life-sustaining treatment. However, these procedures were not followed during the emergency. The Director of Nursing and other staff acknowledged that the resident's wishes were not respected and that the failure to verify code status before initiating CPR was a violation of both facility policy and the resident's rights.

Removal Plan

• The Social Services Director (SSD), the DON, and the Assistant DON (ADON) conducted an in-house audit of each resident's POLST, Advance Directive, and History & Physical (H&P) exam to determine if the resident had the capacity to make decisions and to verify the resident's responsible party if the resident did not have the capacity to make decisions.
• The Interdisciplinary Team (IDT) reviewed the medical record of all residents and verified which residents were Full Code, which were DNR, and which had advanced directives.
• RNC 2 provided reinforcement training to LVN 1, RN 1, RN 2, and RNC 1 on Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response.
• The SSD and the DON met with residents who had the capacity to make their own decisions and verified that their POLST was current.
• The SSD and the DON spoke with the resident representative of each resident who did not have the capacity to make decisions, to verify if their POLST is current. All the resident representatives stated that the POLST is current and there are no changes.
• The Medical Records Director (MRD) printed current Admission Record (face sheets) of each resident reflecting the verified POLST.
• The ADON printed out the list of all residents with their Code Status Orders Report (based on the POLST) and visibly posted the list at each nurses' stations, emergency cart, and in a binder at the medication carts. The Code Status Order Report will be updated daily by the 11pm to 7am licensed nurses and checked for accuracy. The 7am to 3pm licensed nurses will update any report not completed during the prior 11pm to 7am shift.
• The DON placed DNR stickers on the outside of the confirmed DNR residents' medical records to clearly display their DNR status. The 11pm to 7am licensed nurses were tasked to reconcile the Code Status Order Report daily with the DNR stickers and update as necessary. The MRD will audit the DNR stickers on the medical records and reconcile it with the Code Status Order Report weekly to ensure accuracy. The audit will be documented utilizing a Code Status audit form. Any inaccurate findings will be immediately corrected by MRD. The Code Status audit form will be available in the facility's binder with all documents related to the IJ Situation (IJ Binder).
• The licensed nurse assigned to the desk work will discuss resident code status during huddle for all three shifts. During the huddle the nursing supervisor will assign a licensed nurse as the Shift Code Leader should any incident occur.
• The SSD placed red wristbands (to visually identify DNR status) on the wrists of residents with DNR orders with their consent. Residents with DNR status agreed to wear the red wristbands. The IDT updated the Care Plans of the residents with DNR orders. All licensed nurses are tasked to print the code status report and visually verify that red wristbands are worn by the residents with orders for DNR and document it on the DNR Form list. The MRD will audit residents' care plans weekly utilizing the Code Status audit form to ensure compliance and accuracy.
• The ADM updated the Person-Centered Interview and Rounding Worksheet to reflect the wristband section for department managers to visually verify that the wristband is intact on their assigned residents on Monday through Friday basis. Registered Nurse (RN) supervisor will conduct the audit on weekends utilizing Weekend Room Round form. Department Managers and RN supervisor will utilize the Code Status Order Report to ensure accuracy during rounds. The Person-Centered Interview and Rounding Worksheet and Weekend Room Round forms will be available the Room Rounds binder.
• A mandatory facility-wide in-service training was conducted to reinforce the facility's P&P including Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response. 100% of the staff received the in-service training. New hires will be educated prior to the start of their first scheduled shift.
• The ADM or the DON will interview employees from different shifts on weekly basis to validate understanding of the in-service training on Resident Rights, POLST, Communication of Code Status, CPR, DNR, Advance Directive, and Medical Emergency Response. Employee response will be recorded utilizing an Employee Validation form. The form will be available in the IJ Binder.
• Regular audits during IDT meetings will include verification of the residents' clinical record for the current code status. Newly admitted residents' code status will be reviewed during IDT meetings. The audit will be done upon admission and readmission of residents, weekly for current residents or when where there is a change in residents' code status. The audits will be documented utilizing the Code Status audit form and will be reported by the MRD during Monday through Friday operations meeting for appropriate follow up.
• The IDT conducted Root Cause Analysis (RCA) and identified the following: a. Code status was not immediately visible during an emergency requiring life-saving measures if appropriate. b. There was a lack of visual cues such as DNR sticker or resident identifier such as red wristbands.
• A QAPI (Quality Assurance & Performance Improvement) was implemented to track and report on above audit findings. The findings will be presented at the monthly QA Committee meeting for a minimum of three months for review and recommendations. After the initial three months, the QA Committee will decide regarding the continued frequency of audits and subsequent reporting, with audits continuing at least monthly to sustain compliance.

Penalty

Fine: $96,46820 days payment denial

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

Summary

A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to inform a resident of the names and indications of medications prior to administration. During a medication pass, the LVN administered docusate, bisacodyl, and a multivitamin with mineral tablets to a resident with moderate cognitive impairment, without providing information about each medication or its purpose. The resident was observed swallowing the medications without being told what they were, and later received a cranberry tablet, also without explanation until prompted by a surveyor. The resident expressed a desire to know what medications were being given. The LVN acknowledged during an interview that it was facility policy to inform residents of the names and indications of medications before administration, and admitted to forgetting to do so in this instance. The Director of Nursing confirmed that the process was not followed, emphasizing the importance of informing residents to support their right to participate in care decisions. The facility's policy states that residents have the right to be informed of and participate in their treatment, including the right to request or discontinue treatment.

Penalty

Fine: $96,46820 days payment denial

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

Summary

The facility failed to include required witness signatures on Medication Disposition Record/Pass Logs for multiple non-controlled medication disposals on three separate dates. During review, it was found that seven, thirteen, and eight non-controlled medication disposals, respectively, lacked the necessary witness signatures. Licensed nursing staff, including the nurse present during the review, confirmed that they did not follow facility policy, which requires a witness signature when disposing of medications to ensure accountability and prevent diversion. Additionally, there was a failure to account for one dose of a controlled substance, pregabalin 25 mg, for a resident with polyneuropathy. The controlled drug record indicated that there should have been nine capsules remaining after the last documented administration, but only eight were present in the medication bubble pack. The nurse responsible for administering the medication admitted to giving the dose but failing to sign the accountability log as required by facility policy. The facility also did not reconcile a medication emergency kit containing controlled medications at every shift change for the month reviewed. The emergency kit in one medication cart lacked an accountability log for shift-by-shift reconciliation, contrary to facility policy and staff statements. These failures in documentation and reconciliation were confirmed by both nursing staff and the Director of Nursing during interviews and record reviews.

Penalty

Fine: $96,46820 days payment denial

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

Summary

The facility failed to maintain a medication error rate below five percent, as required, resulting in a calculated error rate of 10.72%. This was based on three medication errors out of 28 observed opportunities, affecting two residents. One resident did not receive the correct form of vitamin B complex as ordered by their physician, instead receiving a tablet that also contained vitamin C. The nurse responsible acknowledged not following the physician's order and failing to adhere to the five rights of medication administration. Another resident received docusate and cyanocobalamin at a time different from what was ordered by their physician. The nurse administered these medications earlier than the facility's policy-allowed window and documented the administration at an incorrect time. The nurse admitted to not following the five rights of medication administration and failing to document the correct time, both of which were considered medication errors. Record reviews confirmed that the residents had specific physician orders for the medications in question, including the correct dosage and administration times. Facility policies required medications to be administered as prescribed, within a 60-minute window of the scheduled time, and for documentation to occur immediately after administration. The observed failures to follow these procedures directly contributed to the medication errors identified during the survey.

Penalty

Fine: $96,46820 days payment denial

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

Summary

Surveyors observed that an open and used Humulin N Kwikpen insulin pen, prescribed for a resident, was stored at room temperature in a medication cart without a label indicating the date it was first opened. The pharmacy label on the pen specified that it should be discarded 14 days after opening, in accordance with the manufacturer's requirements. During interviews, the LVN confirmed that the pen was in use and stored at room temperature but was not labeled with the date of opening, making it impossible to determine when it would expire. The LVN acknowledged that the pen should be removed to prevent administration of potentially expired insulin. The Director of Nursing (DON) also confirmed that the insulin pen was not labeled with the date of first use and that several LVNs had failed to label the pen as required. The facility's policy and procedures require that multi-use vials be labeled with the date of initial opening and discarded according to manufacturer specifications. The lack of labeling meant that the expiration date of the insulin pen was unknown, which could result in the administration of expired medication to the resident.

Penalty

Fine: $96,46820 days payment denial

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

Summary

The facility failed to maintain a copy of a resident's advance directive in the medical record, as required by policy. Upon review, it was found that although the resident had executed an advance directive and provided a copy to the facility at admission, there was no copy filed in either the physical chart or the electronic record. The Minimum Data Set Coordinator confirmed that the advance directive was acknowledged and should have been placed in the resident's record, but it was not accessible. The resident involved had diagnoses including dementia and hypertension, was totally dependent on staff for most activities of daily living, and was able to make himself understood and understand others. The facility's policy stated that advance directives should be placed on the chart and communicated to staff upon admission if provided. The absence of the advance directive in the resident's record was confirmed during interviews and record reviews, and the staff acknowledged the importance of having this document accessible to honor the resident's healthcare wishes.

Penalty

Fine: $96,46820 days payment denial

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

Summary

The facility failed to update a resident's care plan to accurately reflect the resident's current nutrition status. Specifically, a resident with quadriplegia and a gastrostomy was readmitted with physician's orders for a nothing by mouth (NPO) diet and enteral tube feeding. However, the resident's care plan still included an intervention to provide 4 ounces of puree three times daily for oral gratification, which was inconsistent with the NPO order. The Minimum Data Set Coordinator confirmed that the care plan should have been updated to reflect the resident's NPO status. Interviews with facility staff, including the Director of Nursing, confirmed the importance of updating care plans to ensure staff provide care consistent with current physician orders. The facility's policy required that care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, but this was not done in this case, resulting in the potential for staff to follow outdated interventions.

Penalty

Fine: $96,46820 days payment denial

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

Summary

A deficiency was identified when a resident with dementia and hypertension, who was totally dependent on staff for most activities of daily living and at risk for pressure ulcer development, was found to have a Low Air Loss Mattress (LALM) set incorrectly. The resident's physician had ordered the use of a LALM for skin management, and the care plan included monitoring the mattress for proper functioning. However, during observations and interviews, it was found that the LALM was set for a weight range of 174-210 lbs, while the resident's actual weight was 133 lbs. Staff confirmed that the LALM should be checked every shift to ensure it is set according to the resident's current weight, and that an incorrect setting could increase the risk of skin impairment. Facility policy required support surfaces to be used in accordance with evidence-based practice for residents at risk for pressure injuries. The failure to set the LALM according to the resident's weight represented a lapse in following both physician orders and facility policy.

Penalty

Fine: $96,46820 days payment denial

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

Summary

Licensed nurses failed to attempt or document nonpharmacological interventions before administering PRN hydrocodone-acetaminophen for pain management to a resident. The resident, who was admitted with diagnoses including a stage 3 pressure ulcer, history of falls, right hip pain, intervertebral disc degeneration, and a history of opioid poisoning, had physician orders specifying the use of hydrocodone-acetaminophen for moderate to severe pain. Despite these orders and the facility's pain management policy, the MAR showed multiple instances where the medication was given without any documentation of nonpharmacological pain relief measures being tried first. The resident's Minimum Data Set indicated intact cognition and a need for moderate assistance with ADLs. The facility's policy required the use of various nonpharmacological interventions, such as environmental comfort measures, physical modalities, and cognitive/behavioral techniques, prior to administering opioid medications. The DON confirmed the importance of these interventions and acknowledged that they were not attempted or documented before PRN opioid administration on several occasions.

Penalty

Fine: $96,46820 days payment denial

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

Summary

A resident with end stage renal disease, dependent on dialysis, was admitted and readmitted to the facility with a care plan that included scheduled dialysis treatments. The resident was cognitively intact and required moderate to substantial assistance with activities of daily living. On a specified date, the facility failed to document and communicate the resident's pre-dialysis assessment, including vital signs, to the dialysis center prior to the resident's scheduled treatment. The Director of Nursing confirmed that the pre-dialysis assessment was not completed or communicated as required, and the responsible nurse could not provide a reason for the omission. Facility policy required monitoring for complications before and after dialysis and ongoing communication with the dialysis provider, but this was not followed in this instance.

Penalty

Fine: $96,46820 days payment denial

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

Summary

The facility failed to ensure that a resident's code status was accurately documented across all sections of the medical record. Specifically, the resident's Physician Orders for Life-Sustaining Treatment (POLST), which was signed by a physician, indicated a Do Not Resuscitate (DNR) order and the resident's wish to allow for a natural death. However, the Admission Record in the resident's medical binder and the Interdisciplinary Care Conference meeting notes both incorrectly documented the resident as a full code, indicating that all life-saving measures should be provided in the event of cardiac or respiratory arrest. The resident in question had diagnoses including psychosis, schizophrenia, and hypotension, and was assessed as having moderately impaired cognition but retained the capacity to understand and make decisions. The discrepancy was identified during a review of the medical record with the DON and Administrator, who acknowledged that the Admission Record and POLST should match. The facility's policy required accurate communication and documentation of code status, but this was not followed, resulting in inconsistent records regarding the resident's end-of-life care preferences.

Penalty

Fine: $96,46820 days payment denial

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

Summary

The facility failed to ensure that 36 out of 38 resident rooms met the required minimum square footage per resident, as specified by federal regulations. Specifically, multiple resident rooms were found to be below the 80 square feet per resident requirement for shared rooms and below the 100 square feet requirement for single rooms. During the recertification survey, it was observed that these rooms, despite being under the required size, allowed residents to move freely and accommodated the use of mobility aids such as wheelchairs, walkers, or canes. The facility had submitted an application for a Room Variance Waiver for these rooms, acknowledging that the rooms did not meet the federal size requirements. A review of the facility's policy and procedure confirmed that resident bedrooms are expected to be designed and equipped for adequate nursing care, comfort, and privacy, and should meet the minimum square footage requirements. The room waiver letter submitted by the facility indicated that the rooms did not have obstructions that would interfere with resident mobility and asserted that the space was sufficient for care, dignity, and privacy. However, the documented square footage for the affected rooms did not meet the regulatory minimums, resulting in a deficiency finding during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for five of six sampled residents by not maintaining a clean bathroom. Residents 2, 3, 4, 5, and 6 shared a bathroom that was observed to be soiled with dried stool and had a malodor. Certified Nursing Assistant 2 did not notice the soiled condition of the bathroom when retrieving a basin for Resident 3 earlier in the morning. Resident 5, who is mostly continent, reported that the bathroom was often soiled and smelled, and that it took a long time for it to be cleaned when requested. Housekeeping staff, represented by Housekeeping 1, admitted to not checking the shared bathroom until later in the morning, as they prioritized cleaning the entrance area first. The Director of Nursing and Maintenance Supervisor confirmed the unclean state of the bathroom, noting the dried feces and unpleasant smell. The facility's policy on maintaining a safe and homelike environment was not adhered to, as housekeeping services were not provided promptly to maintain a sanitary and comfortable environment. The facility's maintenance schedule indicated that housekeeping staff were available from 7 a.m. to 3 p.m., with emergency cleaning handled by laundry or janitor staff until 8:30 p.m. However, if a room or bathroom became soiled after these hours, nursing staff were expected to clean it with disinfectant wipes. The facility's policy emphasized minimizing odors and promptly addressing soiled conditions, which was not followed in this instance, 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 maintain proper infection control practices by not ensuring the cleanliness of a shared bathroom used by five residents. The bathroom was observed to be soiled with dried feces on the floor and toilet bowl, emitting a malodor. This situation was discovered during an observation and interview with a Certified Nursing Assistant (CNA), who admitted not noticing the soiled condition earlier in the morning. The CNA stated that if they had noticed, they would have informed housekeeping immediately. Interviews with residents and housekeeping staff revealed further issues with the facility's cleaning schedule. One resident mentioned that the bathroom was often soiled and not cleaned until later in the morning, sometimes taking more than an hour to be addressed after a request. The housekeeping staff confirmed that they had not checked the bathroom until after breakfast, as their routine involved cleaning the entrance area first and waiting until residents finished breakfast to clean the bathrooms. The Director of Nursing (DON) acknowledged the unclean state of the bathroom and the potential for infection spread due to the conditions. The facility's policy on infection prevention and control, which was last reviewed earlier in the year, emphasizes maintaining a safe and sanitary environment to prevent the transmission of infections. However, the observed practices did not align with these guidelines, leading to the deficiency noted in the report.

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 the proper use of a low air loss (LAL) mattress for a resident with pressure-induced deep tissue damage. The resident, who was admitted with type 2 diabetes mellitus and pressure injuries on the left buttock, was observed lying on a LAL mattress with multiple layers of linen, including a fitted sheet, a disposable incontinence pad, and an adult incontinence brief. This setup exceeded the recommended two layers of linen, which is crucial for the LAL mattress to function effectively in promoting wound healing. Interviews with facility staff, including CNAs, a treatment nurse, an RN, and the Director of Nursing, confirmed that the facility's policy and procedure, as well as the manufacturer's recommendations, were not followed. The staff acknowledged that using more than two layers of linen with a LAL mattress could impede the mattress's ability to promote wound healing. The facility's policy explicitly stated to limit the amount of linen and pads placed on the bed to ensure the effectiveness of support surfaces like the LAL mattress.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate foot care for a resident with long, thick, and curved toenails, which were observed to be in poor condition. The resident, who had been admitted and readmitted to the facility with diagnoses including type 2 diabetes mellitus and pressure-induced deep tissue damage, required maximum assistance with mobility and had moderately impaired cognition. Despite an order for the resident to see a podiatrist, there was no documentation of podiatrist consult notes from the time of admission to the time of the survey. The resident expressed concern about when their toenails would be trimmed, and staff confirmed the need for trimming. The Director of Nursing acknowledged that the resident had missed regular podiatrist visits since their initial admission. The facility's policy indicated that toenails should be trimmed by qualified personnel, especially for residents with diabetes. However, the facility did not ensure that the resident received the necessary foot care, leading to the deficiency. The lack of timely podiatric care had the potential to result in complications for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to arrange a timely nephrology consult for a resident who was admitted with a follow-up order for a nephrology appointment within one week. The resident, who had diagnoses including a thoracic compression fracture, rheumatoid arthritis, and acute kidney failure, was admitted on 8/10/2023. However, the facility did not arrange the nephrology appointment until 9/21/2023, significantly later than the one-week timeframe specified in the discharge instructions from the general acute care hospital. During interviews, it was revealed that the facility did not notify the resident's attending physician about the delayed nephrology appointment. The Director of Nursing acknowledged that arrangements should have been made within the specified timeframe and that the attending physician should have been informed of any delays. The facility's policies indicated that consulting physician orders should be followed in a timely manner, but this 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 ensure that Physician Progress Notes were completed as required for a resident, leading to a deficiency in care coordination. The resident, who was admitted with diagnoses including a thoracic compression fracture, rheumatoid arthritis, and acute kidney failure, had moderately impaired cognition and required varying levels of assistance for daily activities. A physician's order indicated that the resident had an appointment with a spine specialist, but the consultation notes from this appointment were missing from the resident's electronic medical records and clinical records. During interviews, both the Medical Records Director and the Director of Nursing confirmed the absence of the consultation notes from the spine specialist appointment. The Director of Nursing acknowledged the importance of maintaining physician consultation progress notes in the resident's chart to communicate treatment plans and care needs. The facility's policy, in accordance with OBRA regulations, requires that physician orders and progress notes be maintained, highlighting the deficiency 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 timely radiology services for a resident who had a physician's order for an MRI due to lumbar and thoracic compression fractures. The order was placed on 9/27/2023, but the facility did not arrange the MRI until 10/10/2023, after a family member intervened. The MRI was scheduled for 10/31/2023, indicating a significant delay in obtaining necessary diagnostic services. The resident, admitted on 8/10/2023, had a medical history including thoracic compression fracture, rheumatoid arthritis, and acute kidney failure. The resident required varying levels of assistance for daily activities and had moderately impaired cognition. The delay in arranging the MRI was acknowledged by the Director of Nursing, who stated that arrangements should have been made promptly upon receiving the physician's orders, and any delays should have been communicated to the attending physician.

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 permit a resident to return after hospitalization, resulting in an unnecessary prolonged hospitalization. The resident, who had diagnoses including basal cell carcinoma, tachycardia, and orthostatic hypotension, was originally admitted to the facility and later transferred to a general acute care hospital. Despite having two available male beds, the facility rejected the resident's readmission, citing an inability to meet the resident's needs. The facility's census indicated that there were two available male beds, but these were reserved for potential new admissions who ultimately did not take the beds. The resident remained hospitalized until the state surveyor intervened. Interviews with the Director of Nursing (DON), Admission Director, and Administrator revealed that the facility's procedure prioritizes readmission for residents with an active bed hold and those who were most recently admitted but exceeded their bed hold period. Despite this policy, the facility did not inform the hospital social worker about the available beds, leading to the resident's delayed readmission. The facility's policy mandates that residents should be readmitted to the first available bed, but this was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's personal belongings were returned to the resident's representative upon discharge. Resident 1, who had diagnoses including chronic myeloid leukemia, Alzheimer's disease, dysphagia, dementia, and benign prostatic hyperplasia, was totally dependent on staff for daily activities. The facility's Social Services Director (SSD) stated that residents' belongings are inventoried upon admission and yearly, and should be collected and kept for 30 days upon discharge or death. However, there was no documented evidence that Resident 1's belongings were picked up or that attempts were made to contact the resident's responsible party to return the belongings. During interviews, the SSD and a Licensed Vocational Nurse (LVN) confirmed that Resident 1's family member came to the facility but refused to sign the Resident's Clothing and Possessions document and did not take the belongings. The SSD acknowledged that the licensed nurse should have documented in the progress notes if the belongings were picked up, and that attempts to contact the responsible party should have been documented. The facility's policy requires that personal items be given to the designated resident representative and that inventories be reviewed and signed off by the recipient, but this procedure was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to develop a comprehensive person-centered care plan for a resident who had an indwelling catheter. The resident, who had diagnoses including chronic myeloid leukemia, Alzheimer's disease, dysphagia, dementia, and benign prostatic hyperplasia with lower urinary symptoms, was readmitted with an indwelling catheter due to urine retention. Despite this, there was no documented evidence of a care plan addressing the indwelling catheter from the time of readmission on 1/30/2023 to 3/7/2023. During an interview and record review, a registered nurse confirmed the absence of a care plan specific to the resident's indwelling catheter. The facility's policy requires the development and implementation of a comprehensive care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs. The lack of a care plan for the indwelling catheter was identified as a deficiency that could negatively affect the delivery of care and services 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 administer Acetaminophen as prescribed to a resident who reported severe pain rated at ten out of ten. Despite the resident's complaint of severe pain in the right shoulder and arm, the medication was not administered as per the physician's order. The Medication Administration Record (MAR) did not indicate that the Acetaminophen was given, and the nurse confirmed that the pain medication should have been offered and documented. Additionally, there was no reassessment of the resident's pain after the medication was supposed to be administered, which is a standard practice to evaluate the effectiveness of the pain management intervention. Furthermore, the facility did not complete a pain risk assessment when the resident reported a new onset of pain, nor was a quarterly pain risk assessment conducted as required by the facility's policy. The resident's medical history included chronic myeloid leukemia, Alzheimer's disease, dysphagia, dementia, and benign prostatic hyperplasia. The lack of a pain risk assessment and the failure to administer prescribed pain medication resulted in the resident experiencing severe untreated pain. The facility's policy on pain management emphasizes the importance of recognizing, evaluating, and managing pain to help residents attain their highest practicable level of 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 implement its medication administration policy by not ensuring that a licensed nurse signed the Medication Administration Record (MAR) after administering Albuterol Sulfate to a resident on 3/7/2023. This oversight was identified during an interview and record review, where it was found that the medication was documented in the progress notes but not in the MAR, as required by the facility's policy. The resident involved had multiple diagnoses, including chronic myeloid leukemia, Alzheimer's disease, dysphagia, dementia, and benign prostatic hyperplasia, and was totally dependent on staff for daily activities. The resident's physician had ordered Albuterol Sulfate Inhalation Nebulization Solution to be administered every four hours as needed for shortness of breath or wheezing. On 3/7/2023, the resident received the medication at around 1:00 p.m., but the administration was not recorded in the MAR. Instead, it was noted in the progress notes at 5:20 p.m. The facility's policy, reviewed on 1/10/2024, clearly stated that medications should be documented in the MAR immediately after administration, which was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that orientation was provided to hospice staff as per facility policy for two residents. Resident 1, who was admitted with diagnoses including chronic myeloid leukemia, Alzheimer's disease, dysphagia, dementia, and benign prostatic hyperplasia, was admitted to hospice care. Similarly, Resident 2, who had Alzheimer's disease, dysphagia, and weakness, was also admitted to hospice care. Both residents had severely impaired cognitive skills and were totally dependent on staff for daily activities. Despite these conditions, the facility did not provide a thorough orientation to hospice staff as required by their policy, which includes familiarizing them with facility policies, resident rights, appropriate forms, and record-keeping requirements. During interviews, the Director of Staff Development (DSD) and the Administrator (ADM) confirmed that hospice staff only received a verbal orientation about the facility layout and not the detailed orientation required by the facility's policy. The DSD admitted that no documentation of the orientation was maintained, and the ADM stated that he did not believe additional orientation was necessary. This lack of proper orientation had the potential to delay the coordination and delivery of hospice services 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 ensure that licensed nurses signed the Medication Administration Record (MAR) for several residents after administering controlled medications. Specifically, for Resident 49, there was no documentation in the MAR for the administration of Norco and Alprazolam on multiple dates in March 2024, despite the medications being removed from the Controlled Drug Record (CDR). Licensed Vocational Nurse 1 (LVN 1) confirmed the absence of documentation during a review with the Director of Nurses (DON), who emphasized the importance of signing the MAR to prevent drug diversion. Similarly, for Resident 65, the MAR lacked documentation for the administration of Lorazepam on several dates in March 2024, even though the medication was removed from the CDR. Licensed Vocational Nurse 2 (LVN 2) and the DON both acknowledged the missing documentation and reiterated the procedure for administering and documenting controlled drugs. For Resident 139, the MAR did not reflect the administration of Zolpidem on specific dates, despite the medication being removed from the CDR. LVN 2 and the DON confirmed the discrepancy and stressed the need for accurate documentation. Additionally, the facility failed to properly dispose of a controlled medication for Resident 84. A dose of Norco was removed from the bubble pack and then secured back with tape instead of being discarded. LVN 1 and the DON both stated that once a medication is removed, it should be either administered or disposed of with a witness. For Resident 70, the administration of Oxycodone HCL was documented two hours late, which the DON noted could lead to discrepancies. The facility's policies and procedures for controlled substance administration and medication administration were not followed, leading to potential risks for drug diversion and inaccurate medication records.

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 Medication Regimen Review (MRR) recommendations made by the consulting pharmacist were acted upon for two residents. For Resident 51, the pharmacist recommended verifying the duration of therapy for Lovenox and considering an oral replacement. This recommendation was not discussed with the provider, and there was no documented rationale for continuing Lovenox until it was discontinued months later. This oversight placed the resident at risk of adverse side effects such as bleeding and pain at the injection site during medication administration. For Resident 12, the pharmacist recommended a dose reduction of Ambien, which had been prescribed for insomnia. This recommendation was also not discussed with the provider, and there was no documentation to justify maintaining or reducing the dose. The failure to act on this recommendation had the potential to result in unnecessary medication use and side effects such as drowsiness, dizziness, and blurry vision, which could lead to falls. The Director of Nursing (DON) confirmed that the recommendations from the Consultant Pharmacist's Medication Regimen Review (CP-MRR) were not followed up on or documented. The facility's policies and procedures for Medication Regimen Review and the use of high-risk medications like anticoagulants and psychotropic drugs were not adhered to, leading to these deficiencies.

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 a resident's behaviors for all nursing shifts, who was prescribed an antipsychotic medication, Zyprexa, for schizophrenia. The resident, admitted with diagnoses including schizophrenia, was severely impaired in cognition and dependent on assistance for daily activities. Despite the care plan indicating the need for behavior monitoring for the use of Zyprexa, the facility did not consistently monitor the resident's behaviors across all shifts from November 2023 to April 2024. Specifically, there was no behavior monitoring for the 11 p.m. to 7 a.m. shift and inconsistent monitoring for other shifts during this period. During interviews, both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed the lack of behavior monitoring for the resident's use of Zyprexa. The LVN acknowledged the importance of monitoring behaviors to assess the medication's effectiveness and to determine if a gradual dose reduction could be conducted. The DON also verified the absence of behavior monitoring for all shifts and emphasized the need for accurate records to ensure appropriate medication dosage. The facility's policies and procedures indicated that psychotropic medications should only be given when necessary and that residents' responses to these medications should be monitored and documented. However, the facility did not adhere to these policies, resulting in a failure to monitor the resident's behaviors consistently. This deficiency had the potential to result in adverse reactions or impairments in the resident's mental or physical condition due to the lack of proper monitoring and assessment of the antipsychotic medication's effectiveness.

Penalty

No penalty information released

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

Summary

The facility failed to ensure safe and sanitary food storage and preparation practices. Three packs of frozen sliced ham and four packs of frozen ribs in the facility freezer were not labeled with a received date, which is necessary for tracking expiration. The Dietary Aid and Dietary Supervisor confirmed that these items should have been labeled to prevent the use of expired food. The facility's policy requires all stored food to be dated when placed in storage, but this was not followed in this instance. Additionally, newly delivered food was observed being stored directly on the floor outside the dry storage room. The food items included rolled dough, bread, milk, and a box of gelatin. Both the Dietary Aid and Dietary Supervisor acknowledged that food should not be placed directly on the floor as it can lead to contamination. The facility's policy mandates that all food and food containers be stored off the floor on clean surfaces, but this was not adhered to during the food delivery. Lastly, a resident was found with two plastic containers of leftover food that were not labeled or stored properly. The resident did not know when or who brought the food. The Registered Nurse Supervisor confirmed that leftover food should be labeled with the date it was brought in and stored in the refrigerator, with any uneaten food discarded within 24 hours. The facility's policy supports this practice to ensure the safety of the residents, but it was not followed in this case, potentially exposing the resident to foodborne illness.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's personal belongings upon discharge to a General Acute Care Hospital (GACH). Resident 70, who had intact cognition and required significant assistance for daily activities, was admitted with several personal items, including clothing, an electric blanket, a cell phone, and a charger. Upon discharge, an inventory was taken, but upon the resident's return, several items were missing, including a gray sweater, some socks, and the electric blanket. The resident reported the missing items to the facility staff, but only the electric blanket was replaced, and the other items remained unaccounted for two months later. During interviews, the Social Services Director (SSD) confirmed that the facility documents all items brought in by residents and inventories them upon discharge. However, the SSD was unsure where Resident 70's belongings were stored during the hospital stay. The facility's policy states that missing items should be searched for immediately and replaced or reimbursed if not found, but this procedure was not fully followed in this case. The failure to protect and account for Resident 70's belongings resulted in a deficiency in the resident's right to a dignified existence and self-determination.

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 Resident 71 and their responsible party were fully informed of the risks and benefits of the psychoactive medication Depakote. The medication order was documented incorrectly on the informed consent forms, which did not match the physician's order. This discrepancy meant that the responsible party was not fully informed of the actual medication regimen being administered to the resident. Resident 71 had diagnoses including metabolic encephalopathy, dementia, and psychosis, and was determined to have severely impaired cognition, making it crucial for the responsible party to be accurately informed about the resident's treatment. During an interview and record review, the Director of Nursing confirmed that the Depakote orders on the informed consent forms were incorrect. The facility's policy on informed consent requires that residents and their responsible parties be fully informed before any medical intervention or treatment is initiated. Additionally, the facility's documentation policy mandates that all records be accurate, relevant, and complete. The failure to provide accurate information on the informed consent forms violated Resident 71's right to make an informed decision regarding their care and treatment.

Penalty

No penalty information released

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

Summary

The facility failed to develop a baseline care plan within 48 hours of admission for Resident 82, who was admitted with diagnoses including dementia, gastro-esophageal reflux disease, and chronic obstructive pulmonary disease. The resident's physician's orders included an anticoagulant medication, apixaban, for atrial fibrillation. Despite the requirement to initiate a baseline care plan within 48 hours, the care plan for anticoagulant therapy was not developed until 4/1/2024, well beyond the 48-hour window following the resident's readmission on 3/18/2024. During an interview and record review, the Registered Nurse Supervisor confirmed that the baseline care plan should have been initiated within 48 hours of admission. The absence of a timely baseline care plan meant that there were no interventions in place to prevent potential bleeding, which could lead to life-threatening hemorrhage. The facility's policies on high-risk medications and baseline care plans both emphasize the importance of timely and effective care planning to ensure resident safety and quality 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 develop and implement a comprehensive person-centered care plan for Resident 46, who was diagnosed with diabetes mellitus (DM). Despite the resident's admission record and physician's orders indicating the need for insulin administration, there was no specific care plan addressing the resident's DM. The care plan only included limited mobility, with no specific interventions for managing DM. This oversight was confirmed during interviews and record reviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the absence of a DM-specific care plan. The deficiency was identified during a review of Resident 46's records from admission to the time of the survey. The DON stated that licensed nurses are responsible for initiating and updating care plans within 48 hours of admission and as changes occur. However, the review revealed that the care plan for Resident 46 did not include necessary interventions for DM management, such as diet and medication monitoring. This failure to develop a comprehensive care plan was contrary to the facility's policy, which mandates the creation of a care plan within seven days after completing the comprehensive Minimum Data Set (MDS) assessment.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that Medical Doctor 1 (MD 1) signed the physician orders for Resident 71 during MD 1's visit to the facility. Resident 71, who was readmitted to the facility with diagnoses including metabolic encephalopathy, dementia, and psychosis, had a physician order dated 2/2/2024 for transfer to the General Acute Care Hospital (GACH) due to continued poor oral intake. This order was not signed and dated by MD 1, leading to potential confusion and poor continuity of care for the resident. During an interview, Licensed Vocational Nurse 4 (LVN 4) confirmed that MD 1 last visited the facility on 3/22/2024. The Director of Nursing (DON) also acknowledged that the physician order for Resident 71's transfer was unsigned and stated that physicians are inconsistent with signing their orders during visits. The facility's policy on documentation requires timely signing of all entries, but this 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 ensure the control solution for the glucometer was labeled with an open date in one of three medication carts (Station 1 Medication Cart). During an observation and record review with a Licensed Vocational Nurse (LVN), it was noted that the control solution did not have an open date documented. The LVN confirmed this observation. This practice is crucial to ensure the control solution is not used beyond its effective period, which is 90 days after opening, as per the manufacturer's guidelines. In a subsequent interview and record review with the Director of Nursing (DON), it was reiterated that the control solution should be labeled with an open date to ensure it is disposed of after 90 days. The DON emphasized the importance of this practice to maintain the accuracy of glucometer readings, which are essential for assessing residents' blood sugar levels. The facility's document titled 'Assure Dose Control Solution' also supports this guideline, indicating the necessity of writing the open date on the control solution bottle label.

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 accurate and complete clinical records for two residents, specifically regarding the Physician Documentation of Informed Consents (PDIC) for psychotropic medications. For Resident 48, the PDIC for Wellbutrin 100 mg was neither signed nor dated by the physician who obtained the informed consent. This was confirmed during a review and interview with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the missing signature and date on the informed consent form. Resident 48 had been readmitted with diagnoses including metabolic encephalopathy, dementia, and depression, and had severely impaired cognition as per the Minimum Data Set (MDS) dated 3/8/2024. The resident was started on Wellbutrin in December 2023, but the informed consent remained incomplete by April 2024. The facility's policy required informed consents for psychotropic drugs to be signed and dated by the physician, which was not adhered to in this case. This failure had the potential to result in confusion in the care and services for Resident 48 and placed the resident at risk of receiving unwanted treatment or not receiving appropriate care based on their wishes due to incomplete medical care information. Similarly, for Resident 71, the PDIC for Depakote 125 mg was also undated and unsigned by the physician who obtained the informed consent. This was confirmed during a review and interview with the same LVN and DON. Resident 71 had been readmitted with diagnoses including metabolic encephalopathy, dementia, and psychosis, and had severely impaired cognition as per the MDS. The resident was prescribed Depakote for mood disorder and Risperdal for psychosis, but the informed consents for both medications were incomplete, lacking the physician's signature and date. The facility's policy required informed consents for psychotropic drugs to be signed and dated by the physician, which was not followed in this case either. This failure had the potential to result in confusion in the care and services for Resident 71 and placed the resident at risk of receiving unwanted treatment or not receiving appropriate care based on their wishes due to incomplete medical care information. The facility's policy and procedure titled 'Documentation in Medical Record' dated 12/19/2022, indicated that documentation should be complete, timely, signed with the name and credentials of the person making the entry, and dated. The failure to adhere to this policy for both Resident 48 and Resident 71's PDICs for psychotropic medications was identified during the survey, highlighting a significant deficiency in maintaining accurate and complete clinical records in accordance with accepted professional standards and practices.

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 infection control practices for two residents using nasal cannulas for oxygen therapy. For Resident 82, the nasal cannula tubing was observed touching the floor, which the Infection Preventionist acknowledged could lead to contamination and potential infection. Resident 82 had diagnoses including dementia, gastro-esophageal reflux disease, and chronic obstructive pulmonary disease, and required oxygen therapy as per physician's orders. The tubing was replaced after the observation, but the initial failure to maintain cleanliness was noted as a deficiency. For Resident 138, the nasal cannula was not labeled or dated, which is a critical step to ensure timely replacement and prevent infection. Resident 138 had severe cognitive impairment and was dependent on staff for daily activities. The Licensed Vocational Nurse confirmed the oversight and acknowledged the importance of labeling for infection control. The Director of Nursing also stated that nasal cannulas should be changed weekly and labeled accordingly, as per the facility's policy. The failure to follow these procedures was identified as a deficiency in infection control practices.

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 fix a non-functioning call light for a resident, identified as Resident 28, despite being informed by the resident about the issue. Resident 28, who was admitted with diabetes mellitus and had intact cognition, reported the malfunctioning call light to the staff, including certified nursing assistants (CNAs). The resident noticed that every time he pressed the call light, it took a very long time for the staff to respond, and he would sometimes fall asleep waiting. The CNAs informed the resident that they would monitor the nurse's station for his room number to light up since the light bulb outside his door was broken. However, the issue persisted for about a week without being addressed properly by the facility staff. During an observation and interview, it was confirmed that the call light in Resident 28's room was not functioning correctly, and the room number did light up at the nurse's station when activated. The Registered Nurse Supervisor (RNS) acknowledged the issue and stated that she would notify maintenance. The maintenance personnel later fixed the broken light bulb outside the resident's room. The facility's policy indicated that staff should report problems with the call light system immediately to prevent any adverse outcomes for residents. However, this protocol was not followed, leading to a delay in addressing Resident 28's needs.

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 space requirements of 80 square feet per resident were met in multiple resident bedrooms. Specifically, 36 out of 39 rooms did not meet the required space, with rooms having as little as 70.4 square feet per resident. This deficiency was identified through observation, interview, and record review, revealing that the rooms had the potential to result in inadequate space for safe nursing care and privacy. The facility had submitted a room waiver request for these rooms, indicating that despite the smaller size, the rooms provided enough space for care, dignity, and privacy, and did not interfere with the free movement of wheelchairs or sitting devices. During the survey conducted from April 1 to April 4, 2024, it was observed that the rooms were not occupied by more than three residents and provided ample space for residents to move freely. No concerns related to space or the safe provision of care were observed. The facility's letter dated April 4, 2024, requested a waiver, stating that the rooms met the special needs of the residents and would not adversely affect their health and safety or impede their ability to attain their highest practicable well-being.