Providence St Elizabeth Care Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow its own discharge planning and Medicare Notice of Non-Coverage (NOMNC) policies for a resident discharged home. The resident was originally admitted with diagnoses including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A history and physical indicated the resident had capacity to understand and make decisions, while an MDS assessment documented moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order directed discharge home with home health services, and a NOMNC dated two days before the last covered day stated that Medicare coverage for the SNF stay would end and provided instructions and a phone number for filing an appeal. The NOMNC form itself showed that the resident did not sign because she was documented as “Temporarily incapacitated,” and there was no signature from a representative. Admissions staff progress notes stated that a responsible party was informed by phone of the last covered day, the planned discharge date, options including discharge home and caregiver resources, and the right to appeal, and that the responsible party said she would appeal. The same note stated that a copy of the NOMNC and the appeal number was left at the resident’s bedside. However, the responsible party later reported that no information on how to appeal was received, and the Admissions Director and ADON acknowledged that there was no signed documentation from the resident or responsible party to demonstrate receipt of the NOMNC. The ADON stated that, because the family never received the NOMNC letter, they could not dispute the termination decision or attempt to extend the resident’s stay and coverage. The facility also failed to provide and document adequate discharge instructions and individualized care planning. The responsible party reported that no discharge instructions were given to anyone and described the discharge as unorganized and unsafe. The ADON’s review of the record found that discharge documentation focused only on Foley catheter teaching on the day of discharge, with no documentation of IV-related teaching, no evidence that the resident or family understood any teaching, and no documentation that caregiver capacity and availability were assessed as required by the discharge planning policy. The resident’s care plan for Foley catheter use included monitoring for UTI signs and symptoms but did not address catheter care or family teaching, and the discharge care plan noting the resident’s wish to return home did not include education or involvement of the family to prepare them for discharge. In addition, the facility discharged the resident home with an IV still in place. An LVN who performed the discharge recalled sending the resident home with an IV and acknowledged that an IV access site could lead to infection or bleeding requiring emergency care. The discharge order summary did not include that the resident was being discharged with an IV or with a Foley catheter, and the transfer/discharge report lacked information about the Foley catheter and IV. The ADON stated there was no documentation to show that the discharge planning process considered caregiver/support person capacity, or that return demonstration and understanding of required care were obtained, despite policy requirements. The facility’s Resident Rights policy also required appropriate advance written notice, usually 30 days, for any involuntary transfer or discharge, and the Admissions Director stated unfamiliarity with the 30-day notice requirement. Overall, the survey findings show that the facility did not implement its NOMNC, comprehensive care plan, resident rights, and discharge planning policies for this resident’s discharge. The facility’s own policies required that the NOMNC be delivered in a way that ensures the beneficiary or representative signs and dates the notice to demonstrate receipt and understanding that the termination decision can be disputed. The ADON and Admissions Director both confirmed that this did not occur for the resident, and that the lack of a signed NOMNC meant the resident and family effectively could not file an appeal. The discharge planning policy required sufficient preparation and orientation in a form and manner the resident can understand, identification and timely development of a discharge plan, regular reevaluation and updating of the plan, consideration of caregiver capacity, involvement of the resident and representative, and documentation that the resident was asked about interest in returning to the community. The ADON stated there was no documentation to prove caregiver capacity assessment, return demonstration, or understanding, and that the resident and family were not provided enough instructions to prepare them for discharge. These documented inactions and omissions formed the basis of the cited deficiency.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered discharge care plan for a resident, including measurable objectives and timeframes, and to involve the resident’s responsible party. The resident was originally admitted with multiple diagnoses, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. The resident’s MDS showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order indicated the resident was to be discharged home with home health services, but the discharge care plan did not specify goals, interventions, or family involvement needed to prepare the resident and responsible party for discharge. The facility did not provide an individualized discharge care plan that addressed the resident’s specific needs, including management of a Foley catheter and IV access, nor did it document that the resident or responsible party received or understood discharge teaching. The ADON acknowledged that the discharge care plan only reflected a wish to return home and did not discuss education or involvement of the family to prepare them for discharge. The care plan for the Foley catheter included monitoring for signs and symptoms of UTI but did not address catheter care or teaching for the resident or family. The facility’s own policies required that the IDT develop a comprehensive person-centered care plan with measurable objectives and timeframes, and that the discharge planning process involve the resident and representative, consider caregiver capacity, and provide sufficient preparation and orientation for a safe and orderly discharge, but these elements were not documented or implemented for this resident. The resident was discharged home with an IV still intact, and there was no documentation in the discharge order or transfer/discharge report that the resident was being discharged with an IV or Foley catheter, nor any related instructions. An LVN who discharged the resident recalled that the resident left with an IV in place and recognized that an IV access site could lead to infection or bleeding. The resident’s responsible party reported repeatedly stating that the resident was not ready for discharge and described the discharge as unorganized and unsafe, noting that the resident went home with an IV port and that no discharge instructions were given to anyone. The DON and ADON both confirmed that the facility failed to conduct a comprehensive, person-centered discharge care plan specific to the resident’s needs and did not show family involvement or the types of education needed for discharge, and that there was no documentation of caregiver capacity, return demonstration, or understanding as required by facility policy.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure nursing staff had and applied appropriate competencies in discharge planning and resident/family communication for one resident. The resident was admitted with multiple medical conditions, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical documented that the resident had the capacity to understand and make decisions, while an MDS assessment showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and dressing below the waist. A physician’s order directed that the resident be discharged home with home health services. The facility did not develop an individualized, person-centered care plan addressing the resident’s discharge needs, including the involvement of the responsible party. The Assistant Director of Nursing (ADON) acknowledged that the discharge care plan only reflected the resident’s wish to return home and did not discuss education or involvement of the family to prepare them for discharge. The ADON also noted that the care plan for the resident’s Foley catheter, which had been reinserted during the stay, included monitoring for signs and symptoms of UTI but did not address catheter care or resident/family teaching on interventions. There was no documentation that the discharge planning process considered caregiver/support person availability or capacity to perform required care, nor documentation of return demonstration or understanding by the resident or family. At the time of discharge, the facility failed to provide discharge instructions and teaching to the resident or responsible party. The responsible party reported repeatedly telling staff that the resident was not ready for discharge and described the discharge as unorganized and unsafe, stating that no discharge instructions were given and that no information was provided on how to appeal the discharge. The resident was discharged home with an IV access still intact, which was later confirmed by an LVN who recalled discharging the resident with an IV and recognized that an IV access site could lead to infection or bleeding requiring emergency care. The ADON and DON both acknowledged that the discharge order and transfer/discharge report did not include information about the IV or Foley catheter, and that the facility failed in communication and education of the resident and family regarding the resident’s needs, demonstrating a lack of nursing staff competency in person-centered care and communication as required by facility policy. The facility’s written policies required development of a comprehensive, person-centered care plan by the interdisciplinary team, with measurable objectives and timeframes to meet medical, nursing, mental, and psychosocial needs, and required advance notice and involvement of the resident and representative in care planning conferences. The discharge planning policy required identification of discharge needs on admission, timely development and implementation of a discharge plan, regular reevaluation and updating of the plan, consideration of caregiver availability and capability, involvement of the resident and representative in the discharge plan, and documentation of preparation and orientation to ensure a safe and orderly transfer or discharge. The nursing staff competency policy required sufficient nursing staff with appropriate competencies, including resident rights, person-centered care, and communication. The events surrounding this resident’s discharge, including the lack of individualized discharge care planning, lack of documented teaching and understanding, and discharge with an IV still in place, demonstrate that these policies were not implemented for this resident.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident and/or the resident’s responsible party, as required by facility policy and federal guidance. The resident was originally admitted with multiple diagnoses including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical documented that the resident had capacity to understand and make decisions, and a Minimum Data Set showed moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order documented a planned discharge home with home health services. The facility received a NOMNC dated 12/22/2025 stating that Medicare coverage for the resident’s skilled nursing stay would end on 12/24/2025, with discharge scheduled for 12/25/2025. The NOMNC included instructions and a contact number for requesting an immediate appeal, and required that the beneficiary or representative sign and date the form to demonstrate receipt and understanding of appeal rights. However, the NOMNC form for this resident was marked “Temporarily incapacitated” in the signature section, and there was no signature from the resident or responsible party. The resident’s responsible party later reported not receiving any information on how to appeal and described the discharge as unorganized and unsafe, stating that the resident was discharged home with an IV port and that no discharge instructions were given to anyone. An administrative progress note by the Admissions Coordinator documented a phone conversation with the responsible party explaining that insurance had issued a last covered day and a discharge date, outlining options such as discharge home, caregiver resources, and the right to appeal if the resident was felt not ready for a lower level of care. The note stated that the responsible party said she would appeal and that a copy of the NOMNC and the appeal number were left at the resident’s bedside. In a subsequent interview, the Admissions Coordinator acknowledged that the facility failed to obtain a signature from the resident or responsible party confirming receipt of the NOMNC. The Admissions Director confirmed that residents or responsible parties are required to sign the NOMNC to acknowledge receipt and that the notice contains the information and phone number needed to file an appeal, and also stated unfamiliarity with the policy requirement for 30 days’ written notice for involuntary transfer or discharge, despite the facility’s Resident Rights policy referencing such notice.

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 properly complete and maintain an accurate inventory of personal effects for one resident, resulting in a deficient practice related to residents' rights to retain and use personal possessions. The resident was originally admitted with diagnoses including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. The resident’s History and Physical indicated capacity to understand and make decisions, and the MDS documented moderate cognitive impairment and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. The facility’s policy required that, on admission, a staff member complete an Inventory of Personal Effects form, record all personal items brought in, and obtain signatures from the resident or responsible party and a staff member, with the original kept in the health record and a copy provided to the resident or representative. During an interview and concurrent record review, the DON acknowledged that the resident’s Inventory of Personal Effects form was not complete. On admission, the form was not signed by a facility representative as required by policy. On discharge, the form was again not properly completed, as it lacked the resident or responsible party’s signature to certify that the personal effects were received, and the facility representative’s signature was dated after the resident’s discharge date. The DON stated that, on discharge, residents or responsible parties are supposed to receive a copy of the discharge summary, medication list, follow-up orders, and the inventory, and that the inventory is important to show if any items are missing and to ensure important items go home with the resident and family. Despite this, the required signatures and completion of the inventory form were not obtained at admission or discharge for this resident, contrary to the facility’s written policy and procedure on personal effects.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow its own policies and procedures for timely and accurate documentation in a resident’s medical record. The resident was admitted with multiple diagnoses, including a periprosthetic fracture around an internal prosthetic left knee joint, type 2 diabetes mellitus, history of falling, difficulty in walking, and urinary retention. A History and Physical indicated the resident had capacity to understand and make decisions, while an MDS assessment documented moderately impaired cognition and a need for substantial/maximal assistance with toileting, bathing, and lower-body dressing. A physician’s order directed discharge home with home health services. Following the resident’s discharge home, the State Survey Agency identified documentation that had been newly added to the resident’s record on the same date the surveyors were onsite. A social worker acknowledged entering a progress note on that date with an “effective date” several weeks earlier, describing a family discussion about concerns regarding the resident’s readiness for discharge and the family’s decision to proceed with home discharge after declining alternative placement options. The social worker stated this was not the facility’s standard practice, admitted failing to document the interaction when it occurred, and expressed concern that the timing of the note’s creation coincided with the start of the State’s investigation. The note was not identified as a late entry as required by facility policy. The Assistant DON and DON both confirmed that staff did not document key discharge-related communications with the resident and family in a timely or policy-compliant manner. The Assistant DON stated that, per policy, late entries must be clearly identified as such, use the current date and time, and not give the appearance of having been written earlier, but acknowledged documenting a home visit and provision of discharge paperwork many days later without labeling it as a late entry. The DON stated that staff failed to timely document communication to the resident and family. The facility’s written policy on corrections, errors, omissions, and late entries requires that missed or delayed documentation be clearly identified as late entries or addenda, with current date and time and reference to the original incident, which was not followed in this case, resulting in an inaccurate account of the resident’s record.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that one of its resident rooms, Room A, met the required minimum size of 80 square feet per resident in a multiple occupancy room or to obtain an approved waiver for the deficiency. Room A, previously used as a physical therapy room, was converted to accommodate four residents, but measured only approximately 284.75 square feet, which is less than the required 320 square feet for four residents. The facility's documentation and interviews confirmed that Room A was not included in the list of rooms with approved size waivers, and no waiver request had been submitted for this room in the current year. The facility's policy also requires that resident rooms meet the minimum square footage per resident. During interviews and observations, it was noted that the limited space in Room A contributed to challenges in resident mobility and safety. One resident described an incident where she tripped over a rolling tray table while navigating the cramped space between beds and the bathroom, resulting in a fall. Staff interviews further confirmed that the room's size was insufficient for its current use, and the Director of Nursing acknowledged the importance of adequate space for residents to perform activities of daily living safely and comfortably.

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 properly manage controlled substances by not removing discontinued medications from the medication cart and by not maintaining accurate Controlled Drug Administration Records. Specifically, after physician orders for morphine sulfate and oxycodone/APAP were discontinued for two residents, the medications remained in the medication cart instead of being removed and surrendered to the Director of Nursing for secure storage. This was confirmed during observations and interviews with nursing staff, who acknowledged that discontinued controlled medications should be immediately removed to prevent confusion and potential medication errors. Additionally, the facility did not create a Controlled Drug Administration Record for one of two supplies of oxycodone prescribed to another resident. The pharmacy provided two supplies of oxycodone with different administration instructions—one scheduled and one PRN (as needed)—but only created records for the PRN supply, resulting in the scheduled supply not being accurately tracked. Facility staff failed to identify this discrepancy upon receipt of the medications, leading to incorrect documentation of medication administration. The residents involved had significant medical histories, including prostate cancer with collapsed vertebrae, heart failure with pulmonary edema, and hemiplegia following a stroke. The deficiencies were identified through observation, record review, and staff interviews, which confirmed that the facility's practices did not align with its own policies for the immediate removal of discontinued medications and the preparation of controlled medication accountability records.

Penalty

Fine: $35,670

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 reorder medications five days in advance as per their policy, resulting in two residents not receiving their prescribed medications on time. Resident 5 did not receive doses of metoprolol and bumetanide, which are critical for managing hypertension and edema, respectively. The medications were not available in the medication carts or emergency kits, and the licensed nurses did not follow up on the reordering process, leading to missed doses. Resident 31 also experienced medication omissions, including Eliquis, brimonidine, finasteride, folic acid, and tamsulosin. These medications are essential for preventing conditions such as blood clots, glaucoma, and benign prostatic hyperplasia. The medications were not available in the facility, and the staff failed to reorder them in a timely manner, resulting in missed doses. Additionally, Resident 31 received Eliquis from another resident's supply, which is against facility policy. The Director of Nursing acknowledged the lack of a consistent system for timely reordering and follow-up of medications, which contributed to the unavailability of medications for both residents. The facility's policies were not adhered to, leading to medication errors and the use of another resident's medication supply. These deficiencies highlight a systemic breakdown in the facility's medication management processes.

Removal Plan

• Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered.
• Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1).
• LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1).
• P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31.
• Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT) and MD 1 of the medication omissions, lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions.
• The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31.
• The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 to reconcile medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand.
• MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31. No untoward findings or side effects related to medication omission have been noted for either Resident 5 or 31.
• The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications.
• The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered.
• A Root Cause Analysis (RCA) was initiated by the ADMIN and the DON to determine causative factors for the systemic breakdown.
• The DON conducted in-service for the licensed nursing staff regarding the following: Daily review of resident medication supply for availability, ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, ensuring all licensed nurses are following facility policy and procedures on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, following through daily with the dispensing pharmacy for timely delivery of all ordered medications, how to utilize the Medication Refill Audit Tool.
• The DON or designee will track the following during the Daily Nursing Huddles: Timely (5 days) Ordering of Medications, Timely Delivery of Medication, Timely Administration of Medication.
• The DON or designee will present findings at the Daily Stand-Up Meeting for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved.
• The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved.
• The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at Quality Assurance Performance Improvement (QAPI) meetings with modifications to the process as warranted.

Penalty

Fine: $35,670

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, resulting in a 26.92% error rate during a survey. This deficiency affected two residents, who did not receive their prescribed medications as ordered by their physicians. Resident 5 missed doses of metoprolol and bumetanide, while Resident 31 missed doses of Eliquis, brimonidine, finasteride, folic acid, and tamsulosin. These omissions were observed during a medication administration task. The errors were attributed to the unavailability of medications in the facility's medication carts and emergency kits. Licensed nurses, including LVN 1, failed to reorder medications from the pharmacy within the required three to five-day timeframe before the last available dose. This led to the medications not being available for administration at the scheduled times, as confirmed by interviews with the DON and LVN 1. The facility's policies and procedures for medication administration and reordering were not consistently followed. The DON acknowledged the lack of a consistent system for timely reordering and follow-up of medications, which contributed to the medication errors. The failure to administer critical medications as prescribed posed a risk to the residents' health and safety.

Removal Plan

• Under the direction and leadership of the DON, all necessary medications for Residents 5 and 31 were reordered.
• Licensed Vocational Nurse 1 (LVN 1) completed Situation, Background, Assessment, Recommendation (SBAR) for Resident 5 for the potential change of condition related to the unavailability of medications and notified Physician 1 (P 1).
• LVN 1 completed SBAR tool for Resident 31 for the potential change of condition related to the unavailability of medications and notified Medical Director 1 (MD 1).
• P 1 ordered laboratory (lab) tests for Resident 5 and MD 1 ordered stat (emergent) lab tests for Resident 31.
• Resident 5 and Family Representative 1 (FR 1) were made aware by The Interdisciplinary Team (IDT) and MD 1 of the medication omissions, lab tests ordered by P 1, and updated plan of care related to the medication omissions. Resident 31 was made aware by the IDT and MD 1 of the medication omissions, lab tests ordered by MD 1, and updated plan of care related to the medication omissions.
• The IDT conducted a meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered lab tests, and updated plan of care related to the medication omissions for Resident 5. The IDT conducted meeting to review SBAR tool for the potential change of condition related to the unavailability of medications, ordered stat lab tests, and updated plan of care related to the medication omissions for Resident 31.
• The Consulting Pharmacist (CP) and Consulting Pharmacy Registered Nurse 1 (CPRN 1) conducted an audit of Medication Cart 1 to reconcile medications on hand against the physician orders for Residents 5 and 31, and all medications were on hand.
• MD 1 conducted physical assessments and provided progress notes for Residents 5 and 31. No untoward findings or side effects related to medication omission have been noted for either Resident 5 or 31.
• The DON, the Director of Staff Development (DSD), and LVN 2 conducted an audit of Medication Carts 1 and 2 to reconcile medications on hand and medication administration record against the physician orders and identified 12 residents with total of 17 medications with less than 5 days' supply on hand and re-ordered the medications.
• The CP and CPRN 1 conducted audits of Medication Carts 1 and 2 to reconcile medications on hand against the physician orders for all residents and identified nine remaining residents each with one medication with less than five-day supply on hand that was already re-ordered.
• A Root Cause Analysis (RCA) was initiated by the ADMIN and the DON to determine causative factors for the systemic breakdown.
• The DON conducted in-service for the licensed nursing staff regarding the following: Daily review of resident medication supply for availability, ensuring residents receive mediations as prescribed by the physician and administered at the scheduled times, ensuring all licensed nurses are following facility policy and procedures on Ordering and Receiving medications from the Dispensing Pharmacy, indicating that medications are re-ordered five days in advance, following through daily with the dispensing pharmacy for timely delivery of all ordered medications, how to utilize the Medication Refill Audit Tool.
• The DON or designee will track the following during the Daily Nursing Huddles: Timely (5 days) Ordering of Medications, Timely Delivery of Medication, Timely Administration of Medication.
• The DON or designee will present findings at the Daily Stand-Up Meeting for immediate intervention as warranted by the ADMIN and/or IDT. Trends will be discussed with MD 1, the IDT, and any relevant parties such as vendor pharmacy to support process improvement until 100% compliance is achieved.
• The CP and CPRN 1 will conduct critical medication pass audits with randomly selected licensed nurse monthly. The DON or designee will conduct medication pass audits with selected licensed nurse weekly. Trends will be discussed with MD 1, the IDT, and/or any relevant parties such as vendor pharmacy weekly or as often as necessary to support process improvement until 100% compliance is achieved.
• The ADMIN will monitor the outcomes of the systemic change. Any trends noted shall be discussed at Quality Assurance Performance Improvement (QAPI) meetings with modifications to the process as warranted.

Penalty

Fine: $35,670

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 inform and provide written information to residents regarding their rights to accept or refuse medical or surgical treatment and to formulate an advance directive (AD). This deficiency was identified for three residents, who were not provided with the necessary information or assistance to create an AD. The facility's policy requires that residents be informed of their rights and offered assistance in creating an AD upon admission, but this was not consistently followed. Resident 3 was readmitted to the facility with significant medical conditions and lacked the capacity to make decisions. The Social Services Director (SSD) confirmed that neither the resident nor their responsible party signed the consent to treatment form, which should have included information about ADs. This oversight meant that Resident 3's wishes regarding end-of-life care might not be respected. Similarly, Resident 11's responsible person did not sign the consent to treatment form, and the SSD failed to follow up after sending an email with the form attached. Resident 1's AD was not maintained in the resident's chart, and there was no documented evidence that the AD was discussed during admission. The facility's failure to maintain and provide access to ADs could result in the residents' medical wishes not being followed.

Penalty

Fine: $35,670

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 respiratory care consistent with professional standards for a resident who required supplemental oxygen. The resident, who was admitted with diagnoses including heart failure, emphysema, and anxiety disorder, had a physician's order for as-needed oxygen therapy to be administered when oxygen saturation levels fell below 92%. However, there was no documentation in the Medication Administration Record (MAR) indicating that oxygen was administered, despite observations of the resident using oxygen at various times. Observations and interviews revealed that the resident was frequently on oxygen via nasal cannula, yet this was not consistently documented in the MAR. Certified Nursing Assistant 3 and the Minimum Data Set Nurse both observed the resident using oxygen, but the MAR lacked entries for these instances. The Director of Staff Development admitted to not documenting the oxygen administration, mistakenly believing the resident was on continuous oxygen rather than as-needed. The Director of Nursing confirmed that oxygen use should be documented and monitored according to the physician's orders. The facility's policies on oxygen therapy and chart documentation emphasized the importance of recording oxygen therapy and maintaining accurate medical records. The lack of documentation could lead to a delay in care, as it prevents proper communication and planning for the resident's care needs.

Penalty

Fine: $35,670

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 residents were free from significant medication errors, as evidenced by multiple instances of missed or improperly administered medications. Resident 5 did not receive two doses of metoprolol, a medication for hypertension, due to the medication not being available in the facility. The Licensed Vocational Nurse (LVN) responsible for administering the medication confirmed that it was not available in the medication carts or the facility, and the Director of Nursing (DON) acknowledged that there was no consistent system in place to ensure timely reordering and follow-up of medications. Resident 19 received 24 doses of expired insulin, administered by several LVNs and the DON, over a period of time. The insulin was stored at room temperature beyond the manufacturer's recommended period, and the Director of Staff Development (DSD) confirmed that the expired insulin should have been removed and replaced with a new pen from the pharmacy. The DON admitted that the expired insulin was not removed from the medication cart, leading to its administration to Resident 19. Resident 31 did not receive scheduled doses of Eliquis and brimonidine due to the medications not being available. LVN 1 and the DON both confirmed that these medications were not available in the medication carts or emergency kits, and the DON admitted to failing to follow up on the status of the re-ordered medications. The facility's policies and procedures were not followed, resulting in significant medication errors and a lack of continuity in medication therapy for the residents involved.

Penalty

Fine: $35,670

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 properly manage medications, leading to the use of expired drugs. Specifically, an expired insulin Lispro Kwikpen was found in Medication Cart 2, which was used for Resident 19. The insulin was opened and stored at room temperature beyond the manufacturer's recommended 28-day period. Despite the expiration, several doses were administered to Resident 19, who has type 2 diabetes mellitus, potentially compromising the effectiveness of the medication in managing blood sugar levels. Additionally, an open Aplisol vial, used for tuberculosis testing, was found in the medication room refrigerator without a label indicating when it was opened. This lack of labeling made it impossible to determine the expiration date, as the manufacturer's guidelines require the vial to be used or discarded within 30 days of opening. The absence of proper labeling and storage practices increased the risk of using expired medication, which could lead to inaccurate tuberculosis test results. Interviews with the Director of Staff Development and the Director of Nursing confirmed these deficiencies. They acknowledged that the expired insulin should have been removed and replaced, and that the Aplisol vial should have been labeled with the date of opening. The facility's policies and procedures were not followed, as they require medications to be stored and labeled according to the manufacturer's recommendations, and expired medications to be promptly removed and disposed of.

Penalty

Fine: $35,670

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 established menu designed to meet the nutritional needs of its residents. On October 1, 2024, during lunch, the facility did not serve cornbread and substituted green beans for seasoned peas, affecting 42 out of 45 residents, including a specific resident who was part of the sample review. This deviation from the menu was observed during a kitchen tray line preparation, where it was noted that green beans were prepared for all diet types, and cornbread was neither prepared nor served. Resident 10, who was affected by this menu change, has a medical history that includes sepsis, metabolic encephalopathy, dysphagia, anxiety disorder, and unspecified dementia. The resident was admitted to the facility on May 24, 2022, and readmitted on June 16, 2022. The resident's Minimum Data Set (MDS) indicated that he required assistance with daily activities and had experienced significant weight loss in the past three months, putting him at risk for malnutrition. During an interview, Resident 10 expressed dissatisfaction with the facility's failure to follow the menu, stating that it was a common occurrence. The Dietary Supervisor confirmed that the menu was not followed and acknowledged that the cornbread was omitted due to an oversight. The Registered Dietician explained that the menus are planned to meet nutritional guidelines and that cornbread, as a grain, provides essential calories. The facility's policy requires that any menu changes be documented and communicated to residents, which did not occur in this instance. The Director of Nursing emphasized the importance of following the menu to meet residents' nutritional expectations.

Penalty

Fine: $35,670

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, affecting 42 of 45 residents. During a kitchen observation, it was noted that numerous food items in the kitchen refrigerator were not labeled according to facility policy. These included various prepared food items such as whipped cream, chocolate pudding, apple sauce, salads, watermelon, egg salad, cut fruits, tofu, margarine cubes, and several opened containers of condiments and bases. Additionally, an open carton of almond milk was found without a cap, and a zucchini with a mold-like substance was discovered in an outside fridge. In the dry storage area, several food items were found without open dates, and two large food storage bins were not properly secured, leaving their contents exposed. The report also highlighted the presence of a staff member's personal cup in the kitchen preparation area, which is against the facility's policy to prevent cross-contamination. The Dietary Supervisor acknowledged these issues and stated that all improperly labeled and stored food items would need to be discarded to prevent potential illness in residents. The facility's policies on food storage, labeling, and handling were not adhered to, as confirmed by the Dietary Supervisor, Director of Nursing, and Registered Dietician during interviews. Furthermore, the resident refrigerator in the employee lounge contained several food items that were not labeled per facility policy. These included water bottles, cultured milk, carrot juice, yogurt, soda bottles, take-out meals, and various containers of food, all lacking proper resident identifiers and dates. The Infection Preventionist and Director of Nursing confirmed that nursing staff were responsible for monitoring this refrigerator and ensuring proper labeling. The failure to label and date these items posed a risk of serving expired or contaminated food to residents.

Penalty

Fine: $35,670

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 Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube (GT), which is considered an indwelling device. During an observation, a Licensed Vocational Nurse (LVN) did not wear a gown while providing GT care, despite the resident having an indwelling device that increases the risk of infection. The Infection Preventionist (IP) acknowledged that the facility's policy was not aligned with the Centers for Disease Control and Prevention (CDC) guidelines, which recommend EBP for residents with indwelling devices. The facility's policy had not been updated to reflect current standards, and the IP was unaware of the CDC guidance, leading to an increased risk of infection for the resident. The facility also failed to ensure that nasal cannulas and humidifier bottles were changed weekly and labeled with the date last changed for a resident receiving oxygen therapy. During an observation, the nasal cannula and humidifier bottle were not labeled, and the Certified Nursing Assistant (CNA) stated that hospice staff were responsible for labeling them, but they had not done so. The Infection Preventionist and Director of Nursing (DON) confirmed that facility nurses were responsible for ensuring the equipment was labeled and changed weekly to prevent bacterial growth and potential respiratory infections. Additionally, the facility did not prevent a urinary catheter bag from touching the floor for a resident with a urinary catheter. During an observation, the catheter bag was seen touching the floor, which was confirmed by the resident and the Director of Staff Development (DSD). The facility's policy stated that catheter bags should not touch the floor to reduce the risk of contamination and subsequent catheter-associated urinary tract infections (CAUTI). The Administrator acknowledged that allowing the catheter bag to touch the floor could lead to infection due to germ transmission.

Penalty

Fine: $35,670

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

Summary

The facility failed to uphold resident rights by not ensuring that residents were aware of where to find the most recent survey results. During an interview, three residents attending a resident council group stated they did not know where to locate the state inspection results. This indicates a lack of communication and accessibility regarding the survey results, which are meant to be available for residents, family members, and legal representatives to review. Additionally, an observation revealed that the survey binder was posted on a wall-mounted holder by the information board, but it did not contain the most recent survey results from 2023. The Minimum Data Nurse confirmed that the survey results were not updated and acknowledged that the information should be publicly accessible to inform the public about the facility's operations and any complaints related to resident care. The facility's policy on Resident Rights, last approved in July 2024, states that residents have the right to examine facility survey results, which was not being fulfilled.

Penalty

Fine: $35,670

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 homelike environment for a resident by not properly securing the ceiling light's screen and not ensuring a chain or cord was attached to the wall light. The ceiling light screen was observed to be not fully clipped in place, which concerned the resident as it might fall. Additionally, the resident was unable to turn the wall light on and off due to the absence of a chain or cord, which limited their ability to control the lighting in their living space. The resident, who was admitted with conditions including osteomyelitis and cellulitis, was noted to have intact cognition and required supervision or assistance with walking. During observations, the Maintenance Supervisor confirmed the ceiling light screen was unsecured and the chain or cord for the wall light was missing. The Director of Nursing acknowledged the importance of allowing residents to control their lighting for safety and dignity. The facility's policy emphasized providing adequate lighting to promote a safe and comfortable environment, which was not adhered to in this instance.

Penalty

Fine: $35,670

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 notification of discharge to the ombudsman for a resident who was reviewed under closed record review. The resident was admitted with diagnoses including orthopedic aftercare and generalized weakness and was discharged to a hospital for further evaluation due to altered mental status. The resident was capable of understanding and making decisions, as indicated in the Minimum Data Set and Internal Medicine Initial Evaluation. However, the Notice of Transfer/Discharge did not indicate that a copy was sent to the state long-term care ombudsman office. During an interview, the Social Services Director confirmed that the checkbox for notifying the ombudsman was left unchecked, and no fax transmittal was attached to the notice. The responsibility for sending the notification on weekends fell to the licensed vocational nurses or registered nurses, but the process was not completed. The facility's policy indicated that ombudsman notification should occur during unplanned hospitalizations and be sent when practical, but not less than monthly. The failure to notify the ombudsman was acknowledged by both the Social Services Director and the Administrator, who emphasized the importance of protecting the resident's rights regarding a safe discharge.

Penalty

Fine: $35,670

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 residents were informed of the bed-hold policy upon transfer to a general acute care hospital (GACH), as evidenced by the case of a resident who was not provided with a seven-day bed hold agreement. The resident, who was admitted with diagnoses including orthopedic aftercare and generalized weakness, was transferred to the hospital for further evaluation due to altered mental status. Despite the resident's ability to understand and make decisions, as indicated in their medical records, the facility did not complete or provide the necessary bed hold agreement upon the resident's transfer. Interviews with the Medical Record Director and the Social Services Director confirmed the absence of the bed hold agreement in the resident's medical record. The Social Services Director acknowledged that the facility's process involves informing residents and their representatives about the bed hold policy upon admission and again when a transfer occurs. The Administrator also confirmed that the facility discusses the bed hold policy with residents upon admission and when they are transferred, emphasizing the importance of safeguarding residents' rights to their home. However, in this case, the facility did not adhere to its policy, resulting in the resident and their representative not being informed about the bed hold option.

Penalty

Fine: $35,670

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 two residents, leading to deficiencies in their care. For Resident 3, the facility did not create a care plan for the use of Eliquis, an anticoagulant medication prescribed to prevent blood clots. Despite the resident's lack of capacity to understand and make decisions, as indicated in the Minimum Data Set and History and Physical, the care plan was not developed. This omission was confirmed by the MDS Nurse, who acknowledged that the absence of a care plan meant staff lacked guidance on interventions and monitoring for adverse side effects. For Resident 148, the facility failed to implement the existing care plan related to the resident's urinary catheter. The care plan included interventions to prevent infection or injury from catheter use, yet during an observation, the resident's urinary catheter bag was found touching the floor, which poses an infection control risk. This was confirmed by the Director of Staff Development, who stated that the catheter bag should not be in contact with the floor. The resident's care plan was not effectively followed, compromising the standard of care outlined in the facility's policy. The deficiencies in care planning and implementation for both residents were identified through observation, interview, and record review. The facility's policy emphasizes the importance of care plans as communication tools to ensure consistent and appropriate nursing care based on resident needs. However, the failure to develop and implement these plans for Residents 3 and 148 indicates a lapse in adhering to these standards, potentially delaying necessary care.

Penalty

Fine: $35,670

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

Summary

The facility failed to update the care plan for Resident 34, who was at risk for further weight loss. The resident was admitted with diagnoses including unilateral primary osteoarthritis and gastro-esophageal reflux disease. The Minimum Data Set indicated the resident was independent with eating but had experienced a 5% weight loss without being on a physician-prescribed weight-loss program. Despite the resident's capacity to understand and make decisions, the care plan was not revised to include current nutritional interventions recommended by the registered dietitian. Observations revealed that Resident 34 frequently left meals untouched or partially eaten, expressing dissatisfaction with the food provided. The resident's care plan, dated prior to the registered dietitian's recommendations, did not reflect the updated interventions such as providing soup with meals, updating snack options, and including prune juice with breakfast. Interviews with staff confirmed that the care plan was not revised to incorporate these recommendations, placing the resident at risk for further weight loss. The Director of Nursing acknowledged that the care plan should have been updated to reflect the registered dietitian's recommendations. The facility's policy on weight change protocol and care plan review emphasized the need for revising care plans as goals and interventions change. However, the failure to update the care plan in a timely manner resulted in a significant weight loss for the resident, which was not addressed adequately by the interdisciplinary team.

Penalty

Fine: $35,670

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 an environment free from accidents and hazards for a resident, identified as Resident 10, by allowing medications to be accessible for self-administration without staff supervision. Resident 10, who had a history of sepsis, metabolic encephalopathy, dysphagia, anxiety disorder, and unspecified dementia, was observed with a bottle of Refresh eyedrops and a bottle of clindamycin phosphate topical solution on a table in the activities room. The resident was assessed as not capable of self-administering medications, yet these medications were left unattended and accessible to other residents. During observations, it was noted that the medications remained on the table in front of Resident 10, despite the resident's care plan indicating periods of confusion and disorientation. The Minimum Data Set Nurse (MDSN) acknowledged the presence of the medications and attempted to remove them, but the resident refused to relinquish them. The MDSN informed the Director of Nursing (DON) about the situation but did not follow up, leaving the medications accessible. The facility's policy on self-administration of medications requires an assessment by the interdisciplinary team to ensure safety for the resident and others. However, this policy was not adhered to, as the medications were not authorized for self-administration by Resident 10. The DON confirmed that medications should not be left unattended with residents, as it poses a risk of improper handling and potential ingestion by other residents, which could lead to adverse reactions.

Penalty

Fine: $35,670

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 nutritional care and services for a resident, leading to significant weight loss. The resident, who was admitted with diagnoses including osteoarthritis and GERD, had severe impaired cognition but was able to make herself understood and was independent with eating. Despite physician orders for weekly weight documentation and a care plan goal of gaining one to two pounds per month, the facility did not consistently record the resident's weight, missing a crucial week when the resident experienced a significant weight loss. The resident's care plan was not revised to address the weight loss, and the facility failed to complete an SBAR form for the weight loss incidents. Observations revealed that the resident often left meals untouched, indicating a lack of adherence to food preferences. The resident expressed dissatisfaction with the meals provided, and despite attempts by staff to offer alternatives, the resident's intake remained low. The facility's dietary supervisor and MDS nurse did not consider the weight loss significant due to the resident being within her ideal body weight, and thus did not adjust the care plan or notify the resident's physician and RD. Interviews with facility staff, including the DON, revealed that the facility's weight protocol was not followed, and the IDT care plan meeting was not conducted to address the resident's weight loss. The facility's policies required significant weight changes to be addressed with revised care plans and communication with the resident's physician and family, which did not occur. The failure to adhere to these protocols and communicate effectively placed the resident at risk for further weight loss.

Penalty

Fine: $35,670

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

Summary

The facility failed to ensure a resident's drug regimen was free from unnecessary drugs, specifically for a resident who was prescribed Eliquis, an anticoagulant medication. The deficiency was identified during a review of the resident's physician orders, which indicated that Eliquis was prescribed without specifying the indication or diagnosis for its use. This omission was confirmed during an interview with the MDS Nurse, who acknowledged that the lack of indication in the physician order could lead to staff not knowing the purpose of the medication, potentially causing a delay in care. The resident in question was originally admitted to the facility in 2015 and readmitted in 2024 with diagnoses including acute respiratory failure with hypoxia and generalized muscle weakness. The resident's Minimum Data Set (MDS) assessment indicated that the resident lacked the capacity to understand and make decisions and required maximal assistance with activities of daily living. The facility's policy and procedure for medication orders, last approved in 2024, required that medication orders specify the diagnosis or indication for use, which was not adhered to in this case.

Penalty

Fine: $35,670

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 inform a resident or their representative about potential non-coverage and the option to continue services with financial liability. This deficiency was identified during a review of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) for a resident who was readmitted with acute respiratory failure and generalized muscle weakness. The resident's Minimum Data Set (MDS) and History and Physical (H&P) indicated that the resident lacked the capacity to understand and make decisions, requiring maximal assistance with activities of daily living. The SNFABN, dated 7/19/2024, did not indicate which option the resident chose, nor did it have a signature from the resident or an authorized representative. The Social Services Director confirmed that the form was not signed and that the resident's family was only notified over the phone. The facility's policy requires verbal and written notice to residents or their legal representatives when services are non-covered, but this was not adhered to, leading to a lack of awareness about financial responsibility and options for the resident and their family.

Penalty

Fine: $35,670

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

Summary

The facility failed to ensure an accurate assessment for a resident, identified as Resident 46, during a closed record review. The Minimum Data Set (MDS) for Resident 46 inaccurately indicated that the resident was discharged to home or the community, whereas the resident was actually discharged to a hospital. This discrepancy was identified during a review of the resident's records, which showed that the resident was admitted with diagnoses related to orthopedic aftercare and generalized weakness and was discharged to the hospital due to altered mental status. The MDS Nurse confirmed the error in the MDS, acknowledging that it should have reflected the discharge to the hospital. The inaccurate MDS entry resulted in a communication error between the facility and the Centers for Medicare and Medicaid Services (CMS), as highlighted by the facility's Administrator. The Administrator emphasized the importance of accurate MDS entries for proper tracking and communication with CMS, noting the significant difference between discharge settings such as home/community and acute care. The facility's policy on MDS accuracy, revised in October 2024, underscores the need for assessments to accurately reflect the resident's status at the time of assessment.

Penalty

Fine: $35,670

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

Summary

The facility failed to post the total number and actual hours worked by licensed nurses, including registered nurses and licensed vocational nurses, as well as Certified Nursing Assistants (CNAs) directly responsible for resident care per shift on October 1, 2024, and October 2, 2024. This information was supposed to be displayed at the nursing station, but the posted document titled 'Census and Direct Care Service Hours Per Patient Day' did not include the required details about the hours worked by the staff. The omission was observed during a survey on October 1, 2024, at 8:05 a.m., where the document only indicated a census of 45 without specifying the hours worked by the nursing staff. Interviews conducted with the Director of Staff Development (DSD) and the Administrator (ADM) confirmed the deficiency. The DSD acknowledged that the nurse staffing information posted on the specified dates did not include the total number and actual hours worked by the licensed nurses and CNAs per shift. The ADM emphasized the importance of posting this information to maintain safe staffing levels and to inform residents, families, and the public about the facility's staffing. The facility's policy and procedure, last approved in September 2022, also required this information to be posted daily in a location easily accessible to residents and the public.

Penalty

Fine: $35,670

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 16 out of 25 resident rooms met the federal square footage requirement of 80 square feet per resident in multiple resident rooms. The rooms in question included Rooms 1, 2, 3, 4, 5, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, and 28. The room sizes were observed to potentially provide inadequate space for resident care and mobility. Despite this, during a Resident Council Meeting, residents did not express concerns about the space in their rooms. Observations conducted from October 1 to October 4, 2024, indicated that residents had enough space to move freely, and the room variance did not affect the care and services provided by the nursing staff. The facility had submitted an application for a Room Variance Waiver for the 16 rooms that did not meet the square footage requirement. The waiver letter indicated that the rooms had enough space to provide for each resident's care, dignity, and privacy, and would not adversely affect the residents' health and safety or impede their ability to attain their highest practicable well-being. The facility's policy and procedure titled "Accommodations Assessment" required a distance of at least three feet between all beds to ensure adequate space for residents to get in and out of bed, use wheelchairs, or ambulate between the bed and bathroom, and to provide adequate space for nursing 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 maintain a safe, comfortable, and homelike environment for two residents by not ensuring their room temperature remained below 81 degrees Fahrenheit. Resident 1, who was admitted with diagnoses including aftercare following joint replacement and lack of coordination, preferred to keep the window open for fresh air, which led to the room temperature rising above the acceptable range. Resident 2, who was readmitted with conditions such as metabolic encephalopathy and cerebral infarction, was observed sweating and feeling hot due to the elevated room temperature. Despite the presence of a fan, the open window allowed hot air to enter, exacerbating the situation. The Maintenance Supervisor noted the room temperature at 82 degrees Fahrenheit and observed Resident 2 sweating, prompting a call to the nurse. The Restorative Nursing Assistant (RNA) attempted to address the issue by providing ice water to Resident 2 and explaining the need to close the window to Resident 1, who resisted. The Director of Nursing acknowledged the importance of maintaining room temperatures within the specified range to prevent dehydration and increased body temperatures. The facility's policy emphasized providing a safe and comfortable environment, yet the actions taken were insufficient to prevent the room from becoming excessively hot.

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 written grievance documentation and address the grievances of a resident who was admitted with diagnoses including aftercare following joint replacement and lack of coordination. The resident, who had intact cognitive status and required partial/moderate assistance with certain activities, expressed grievances about the room being excessively hot and increased noise levels at night. Despite the resident's capacity to understand and make decisions, the grievances were not documented or resolved, as evidenced by the absence of records in the facility's grievance log for the relevant period. Interviews with staff revealed that the resident had complained about the room temperature and noise from a roommate, but these concerns were not properly addressed or documented. The Maintenance Supervisor noted the room temperature was high due to an open window, and the Licensed Vocational Nurse mentioned the resident's complaint about noise at night. However, the Director of Nursing was unaware of the noise complaint, and the Social Services Designee did not maintain the grievance log. The facility's grievance policy requires prompt resolution and documentation of grievances, but these procedures were 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 obtain a physician order for oxygen therapy for a resident who was receiving oxygen at 5 liters per minute via nasal cannula. The resident, admitted with diagnoses including aftercare following joint replacement and lack of coordination, had intact cognitive status and required partial/moderate assistance with certain activities. During an observation, the resident mentioned feeling out of breath and using oxygen for relief, but there was no physician's order documented for this therapy. Licensed Vocational Nurse 1 confirmed that the resident had been on oxygen therapy since admission without a physician's order. The Director of Nursing stated that a physician's order and care plan should be in place before administering oxygen therapy to prevent adverse effects. The facility's policy requires that care and services administered by licensed nurses conform to physician orders, ensuring accuracy and timely documentation, 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 update and revise the care plan for a resident after a fall, which included not incorporating physician-ordered interventions. The resident, who was admitted with diagnoses including stroke with hemiplegia, aphagia, and muscle weakness, had no prior history of falls according to the Minimum Data Set (MDS). However, after a fall on 9/07/23, the care plan was not updated to include new physician orders such as applying floor mats and initiating a bed alarm sensor. This oversight was confirmed during a review of the resident's records and interviews with the Director of Nursing (DON) and a Registered Nurse (RN), who acknowledged that the care plan should have been updated to reflect these new interventions to prevent further falls. The resident's care plan, created on 8/18/23 and revised on 9/07/23, included various interventions for fall risk but did not incorporate the new physician orders following the fall. The resident was found lying on the floor with a hematoma on the occipital region of the head and was transferred to a Generalized Acute Care Hospital (GACH) for evaluation. Upon return, the resident's condition was monitored, but the care plan still lacked the necessary updates. The facility's policies on care planning and fall prevention were not adhered to, leading to potential inconsistencies in care delivery.