Santa Fe Post-acute

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide adequate monitoring and supervision to prevent elopement for a resident identified as high risk. The resident was admitted to the secured unit with major depressive disorder, bipolar disorder, opioid dependence, and alcohol dependence, and had an elopement risk score of 14 on admission and 16 on a later assessment, both above the facility’s threshold of 10 for elopement risk. The resident’s BIMS score of 15 indicated full cognitive function. An initial wandering/elopement care plan was created due to attempts to exit the unit unattended, alcohol abuse, and mental health illness, with interventions including resident education about supervision when going outside the unit, maintaining a safe and hazard-free environment, and providing structured activities. After a first elopement through the room window, an actual elopement care plan was developed that included a 1:1 sitter until psychiatric evaluation, every 30-minute monitoring, moving the resident to another room, and social services involvement. Despite these identified risks and prior elopement, the resident eloped a second time through the room window without being detected by staff. On the night of the second elopement, staff observed the resident in his room around 11:00 p.m., and a CNA saw him walking in the hallway near his room between approximately 11:00 and 11:20 p.m. The resident later reported that he waited until after staff made their rounds and then left through the window around 11:00 p.m. At approximately 11:30 p.m. to midnight, nursing staff discovered the resident was not in his room and found the window open with the screen removed. Law enforcement was contacted, and the resident was located at a nearby convenience store and returned to the facility around midnight to 1:00 a.m. Interviews with the DON and Behavioral Health Director confirmed the resident was alert and oriented, and the DON stated that every 30-minute monitoring had been discontinued after the team developed a plan. The facility’s written policy on wandering and elopement stated that the facility would identify residents at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision and monitoring for a resident who was a known high risk for elopement, resulting in the resident leaving the facility unnoticed and remaining away for seven days. The resident had schizoaffective disorder, bipolar type, and epilepsy, and was fully ambulatory with an expressed desire to leave the facility. An admission elopement assessment categorized the resident as high risk, with a score of 18, and an updated elopement risk assessment completed on 12/28/25 remained at 18, which met the facility’s threshold for elopement risk. Despite this, the resident was not listed as a high elopement risk in the facility’s elopement binder at the nurses’ station and front desk. On the day of the elopement, a licensed nurse was unable to locate the resident in his room and searched the dining area and common spaces without success, then notified the assigned CNA. The CNA reported that the resident frequently ambulated independently throughout the facility and typically returned on his own. The CNA, who was assigned to the resident from 6:30 A.M. to 2:30 P.M., last saw the resident around 7 A.M. while taking vital signs and, after being informed later that the resident could not be located, only checked the dining room/activity area before returning to complete scheduled room-sweep tasks. The CNA stated he did not look further and later noted that the resident was still not in his room during rounds, and also stated he was unaware that the resident was an elopement risk. Other staff interviews and observations showed that the resident was known to wander around the building, staying in the dining area and outside patio, and that from the patio a resident could access the street through a service/delivery gate that was open during the day. Another CNA confirmed the gate was open during the day and reported not being aware that the resident was an elopement risk. The DON acknowledged that the resident had been assessed as high risk for elopement on initial admission and that residents at high risk should have their pictures and information in the elopement binder, but this resident was not listed. The DON also stated that staff should have visually monitored residents at least every hour. The administrator confirmed that the service/delivery gate observed open during the survey was kept open during the day for deliveries.

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 residents on the behavioral health unit (BHU) from physical abuse and did not provide adequate supervision or timely interventions for a resident with escalating aggressive behaviors. After a resident with schizoaffective disorder and bipolar type stopped consistently taking her prescribed antipsychotic medication, Zyprexa, there was no written plan of care developed to monitor or prevent potential inappropriate and aggressive behaviors resulting from the medication refusal. Despite a documented increase in behavioral manifestations such as screaming, yelling, anger outbursts, and refusal of care, the facility did not initiate individualized interventions or update the care plan to address these changes. The resident subsequently engaged in multiple incidents of physical aggression, including slapping another resident in the face, making threatening gestures, and throwing a lunch tray at her roommate. These incidents were witnessed by staff and reported by the affected residents, who expressed fear and a lack of safety. Staff interviews confirmed that the resident's behavior had become unpredictable and aggressive, and that other residents were afraid. Despite these events, the facility did not promptly implement increased supervision, such as 1:1 monitoring, or revise the care plan to address the ongoing risk to other residents. Facility policies required immediate safety measures, individualized care planning, and prompt reporting and intervention in cases of resident-to-resident altercations or behavioral escalations. However, the interdisciplinary team did not convene to address the resident's change in condition, and the care plan remained generic and insufficiently tailored to the resident's needs. The lack of timely and appropriate interventions resulted in continued aggressive incidents, leaving other residents exposed to harm and feeling unsafe.

Removal Plan

• Resident 1 was placed on 1:1 supervision and moved to an individual room.
• Resident 1's care plan was revised to address her aggressive behavior and her needs of supervision.
• Director of Staff Development (DSD) started all staff in-services on abuse prevention, mandatory reporting, and immediate interventions during altercations.
• DON/designee started rounds and interviews in BHU to ensure no other residents were at immediate risk.
• Resident 1's care plan was revised and included 1:1 supervision, alerted triggers, and de-escalation protocol.
• Resident 1's 1:1 supervision and utilization of the individual room will continue until IDT, attending physician, and/or psychiatrist determined Resident 1 was stabilized.
• IDT reviewed risks including room safety and potential for further resident - resident abuse.
• Root cause analysis conducted to determine why supervision and interventions were delayed.
• Implementation of weekly behavioral risk rounds.
• Implementation of de-escalation protocol included: CNAs to immediately inform LN when a change of condition occurs related to mood, behavior, aggression or psychiatric decompensation including medication refusal, the LN escalates the report to the on-duty Supervisor, and the Supervisor communicates to Manager, Social Services, DON, and ADM.
• To ensure timely implementation of interventions, the attending physician and/or psychiatrist will be notified simultaneously.
• Interventions to prevent further harm to others were implemented to prioritize resident safety.
• Care plans were reviewed and revised to address Resident 1's current conditions, behavioral triggers, and new interventions.
• The IDT to ensure care plans were individualized to each resident's needs.
• To prevent the recurrence of abuse, immediate safety action and long-term care plan modifications are expected after all incidents.
• Collaborating with the DON, the Mental Health Case Manager/Provider and Social Services will oversee the BHU.

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 complete and accurate clinical records for two residents with significant psychiatric diagnoses, including schizoaffective disorder and bipolar disorder. For one resident, provider progress reports and nursing notes related to changes in medical condition were not available in the clinical record in a timely manner. There was no documentation of the rationale or provider responsible for discontinuing a key medication, and psychiatric documentation was delayed by up to three weeks before being uploaded to the resident's record. Additionally, there was no evidence that the resident was seen by a psychiatric provider within 24 hours of a change in condition, as required. Medication Administration Records (MARs) for both residents contained numerous blank entries over several months, with one resident having over 100 blank entries and the other over 20. Staff interviews confirmed that MARs should not have blank entries, as this prevents determination of what care and treatment was provided. Furthermore, one resident's MAR incorrectly indicated hospitalization on a specific date, despite no supporting documentation in the clinical record. A psychiatric assessment progress report for one resident was found to be inaccurate, with documentation referencing an incident before it occurred and appearing to be copied from another date. Both the Mental Health Case Manager and the Director of Nursing acknowledged that provider progress notes were not uploaded in a timely manner and that documentation in the clinical records was incomplete and inaccurate. Facility policy requires that documentation in the medical record be complete and accurate, which was not met in these instances.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that antipsychotic medications were used appropriately and that behavior monitoring was resident-specific for two residents with diagnoses including schizoaffective disorder and paranoid schizophrenia. Physician orders for these residents required monitoring of 'refusal of care every shift' as an indicator for antipsychotic medication effectiveness. Interviews with nursing and mental health staff revealed that refusal of care is a resident right and should not be used as a behavioral indicator for antipsychotic medication monitoring. The Director of Nursing acknowledged that the behavior monitoring was too broad and not resident-specific, and that refusal of care should not be the sole behavior monitored. Additionally, the facility did not administer PRN intramuscular (IM) Zyprexa as ordered for one resident. The medication administration records showed that IM Zyprexa was given at times that did not correspond with the scheduled oral doses, and sometimes outside the prescribed administration window. Both the licensed nurse and mental health case manager confirmed that the IM Zyprexa was to be administered only when the oral dose was refused and within a specific time frame, which was not consistently followed. The physician's orders for IM Zyprexa were described as confusing, and there was no documentation to support late administration or deviations from the prescribed schedule. Facility policies required medications to be administered according to prescriber orders and within one hour of the scheduled time. However, the review of records and staff interviews confirmed that these policies were not followed for the administration of antipsychotic medications. The lack of clear, resident-specific behavior monitoring and failure to adhere to medication administration protocols resulted in residents being at risk for receiving unnecessary antipsychotic medications and not having their right to refuse care respected.

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 timely care plans for two residents following an incident of physical abuse, where one resident slapped another. Both residents had significant mental health diagnoses, including schizoaffective disorder, bipolar disorder, and paranoid schizophrenia. After the incident, the care plan categories for alleged abuse were initiated on the day of the event, but the specific goals and interventions were not created until five days later. For one resident, the interventions section remained blank. Multiple staff interviews confirmed that the care plan interventions should have been developed and implemented on the day of the incident to address the immediate needs and protection of the residents involved. Record reviews and staff statements indicated that the delay in developing and implementing the care plan interventions was not due to any reported electronic medical record (EMR) glitches, as the Medical Record Director was unaware of any such issues. The facility's policy requires that care plans be person-centered, targeted, and updated promptly when there is a significant change in a resident's condition. Despite this, the Interdisciplinary Team did not review or update the care plans in a timely manner after the incident, resulting in a deficiency related to delayed treatment and care planning for the affected residents.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizoaffective disorder, bipolar type, when the resident began refusing her prescribed antipsychotic medication, Zyprexa. The resident had a history of stable behavior while compliant with her medication regimen, but after refusing Zyprexa starting on 8/25/25, she exhibited a marked increase in aggressive and inappropriate behaviors, including yelling, anger outbursts, refusing care, and physical aggression toward staff and other residents. Despite these changes, the facility did not develop or implement a written, individualized plan of care to monitor or address the resident's behavioral health needs resulting from her medication refusal. The clinical record and interviews revealed that the resident's behavioral episodes escalated significantly after she stopped taking Zyprexa, with multiple incidents of screaming, anger outbursts, and physical aggression documented over several days. Staff interviews confirmed that the resident's baseline behavior was calm and non-aggressive prior to the medication refusal, and that the escalation in behavior was directly associated with the lack of antipsychotic medication. The facility's care plan for medication non-compliance was generic and did not address the specific risks or interventions needed for the resident's decompensation, nor did it include strategies for monitoring or preventing further behavioral escalation. Additionally, the facility did not convene an Interdisciplinary Team (IDT) meeting or revise the care plan in response to the resident's change in condition, despite multiple incidents of aggression and staff awareness of the situation. The facility's own policies required immediate safety strategies, individualized interventions, and timely care plan updates in response to significant changes in a resident's condition, but these actions were not taken. As a result, the resident was not adequately monitored or supervised, and interventions to prevent harm to herself and others were not implemented.

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 Invega Sustenna, a long-acting antipsychotic medication, to a resident diagnosed with schizoaffective disorder, bipolar type, for three consecutive months. The resident was admitted with significant mental health diagnoses and had a physician's order for monthly administration of Invega Sustenna. Review of the Medication Administration Record (MAR) showed that the medication was not administered in May, June, or July, with documentation indicating the medication was either on hold, not available, or not delivered. Progress notes and MAR entries confirmed the medication was not given, and there was a lack of documentation that the provider was notified or that further instructions were obtained after the medication was found to be unavailable. Interviews with the Mental Health Case Manager and the Director of Nursing revealed that nursing staff did not follow up with the provider for further direction or document any such communication when the medication was unavailable. The facility's policy on administering medications required medications to be given according to prescriber orders but did not provide guidance for situations when ordered medications were unavailable. The Director of Nursing stated that nurses were expected to notify her if a medication was not available and to obtain further instructions from the provider, which did not occur in this case.

Penalty

Fine: $98,87515 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 accurately assess and code the Minimum Data Set (MDS) for a resident regarding the presence and staging of a pressure ulcer. Upon admission, the initial skin assessment conducted by a registered nurse indicated no pressure ulcers and documented only a rash on the sacrum. However, subsequent documentation by another licensed nurse the following day identified a new wound on the sacrum, but it was not staged at that time. The wound nurse stated that staging was typically done in conjunction with the wound nurse practitioner, who did not assess the wound until several weeks later. During this period, the wound was variously documented as a rash, a stage II pressure ulcer, and later as an unstageable ulcer, with changes in the care plan and physician orders reflecting these evolving assessments. The MDS nurse coded the resident's MDS as having a stage II pressure ulcer on admission, relying on later nurse practitioner notes rather than the initial admission assessment. The MDS nurse acknowledged not reviewing the initial assessment and recognized that the MDS should have been modified to accurately reflect the resident's status at admission. Interviews with nursing staff revealed inconsistencies in the assessment and documentation of the wound, with differing opinions on whether the wound was present and its stage at the time of admission. The Director of Nursing confirmed that initial admission skin assessments are expected to be completed accurately by an RN and that MDS coding should follow the Resident Assessment Instrument (RAI) Manual guidelines. The deficiency resulted from a lack of accurate and timely assessment, staging, and documentation of the resident's pressure ulcer status upon admission, leading to the submission of inaccurate information to the federal database. The facility's failure to ensure that the MDS accurately reflected the resident's condition at admission was confirmed through record review, staff interviews, and observation, as required by federal regulations.

Penalty

Fine: $98,87515 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 properly assess, stage, and provide timely wound care interventions for pressure ulcers in two residents. For one resident, the initial admission assessment documented a rash on the sacrum, but this was later staged as a Stage II pressure ulcer nearly two months after admission. The initial assessment did not include measurements, and the wound was not staged until much later by a nurse and nurse practitioner. The resident's care plan and treatment orders were not updated promptly, and there were missed treatments according to the treatment administration record. Interviews with nursing staff revealed confusion and delays in wound assessment and staging, with reliance on the wound nurse practitioner for staging and evaluation, which did not occur in a timely manner. Another resident was admitted with a history of diabetes mellitus and an existing wound on the right hip. The initial admission assessment did not properly identify or stage the wound, which was later determined to be a Stage III pressure ulcer by the wound nurse practitioner over two weeks after admission. The initial assessment described the wound but did not confirm its stage, and the resident did not have appropriate pressure-relieving devices in place. The resident reported not being turned while in bed, and the wound nurse practitioner did not assess the wound until well after admission, resulting in delayed interventions. Record reviews and staff interviews indicated that registered nurses responsible for admission assessments either did not stage wounds or deferred staging to the wound nurse practitioner, leading to delays in care. The facility's policy required examination of newly admitted residents for pressure ulcers, but this was not consistently followed. The minimum data set (MDS) assessments were also inaccurately coded due to reliance on delayed or incomplete documentation, further contributing to the delay in appropriate wound care and interventions.

Penalty

Fine: $98,87515 days payment denial

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

Summary

The facility failed to provide adequate supervision and ensure timely reporting of an elopement for a resident with severe cognitive deficits. The resident, who had a history of non-traumatic intracerebral hemorrhage and a BIMS score indicating severe cognitive impairment, was able to leave the facility unsupervised. The resident reported walking up and down the street to go to a store, and was eventually returned to the facility by a staff member who happened to see him outside. Interviews with staff confirmed that the resident was not being supervised at the time of the incident, and that no staff were following him when he left the premises. Further review revealed that the incident was not reported to law enforcement, the ombudsman, or the California Department of Public Health (CDPH) as required by facility policy and state regulations. The Social Service Assistant stated that the incident was not reported because the resident did not disappear, while the Director of Nursing acknowledged that the resident did not have an out-of-facility pass and was vulnerable to injury during the episode. The facility's policy requires reporting of unusual occurrences affecting resident safety within 24 hours, 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 honor a resident's preference for care to be provided only by female CNAs, despite this preference being documented in the resident's care plan and discussed in care conferences. The resident, who had diagnoses including rheumatoid arthritis, hemiplegia, and hemiparesis, and was cognitively intact, expressed discomfort and distress when a male CNA assisted with her care. On at least two occasions, a male CNA was involved in providing personal care, even though the resident and her family had repeatedly communicated her preference for female caregivers to facility staff. Interviews with staff confirmed that the resident's preference was known, but staff proceeded with care involving a male CNA due to perceived staffing limitations or urgency, despite several female CNAs being scheduled during the relevant shifts. The facility's own policies and the resident's care plan emphasized the importance of respecting resident preferences and rights, but these were not followed in practice, resulting in the resident experiencing psychological discomfort.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary services to maintain personal hygiene for three residents who were dependent on staff for activities of daily living (ADLs). For one resident with Parkinson's disease, hemiplegia, and diabetes, observations revealed long, uneven fingernails with a brown substance underneath. The resident reported that staff would not clip their nails due to their diabetic status, despite care plan interventions directing staff to check, trim, and clean nails as needed. Staff interviews confirmed that nail care for diabetic residents was deferred to nursing staff, but the resident's nails remained untrimmed and uncleaned. Another resident with severe cognitive impairment, diabetes, and monoplegia was observed to have obvious facial hair on the upper lip and chin during multiple observations. The care plan required daily grooming and hygiene, but a CNA stated that shaving was not completed due to time constraints. Facility leadership confirmed that staff were expected to provide grooming and hygiene as needed and to request assistance if unable to complete tasks. A third resident, also with severe cognitive impairment and hemiplegia, was observed over several days to have long, thick, yellow, and jagged fingernails with debris underneath. The care plan directed staff to check, trim, and clean nails on bath days and as necessary. A CNA reported difficulty trimming the resident's thick nails and did not complete the task, while the assigned nurse was not informed of the issue. Facility leadership stated that concerns with nail care should be reported to nursing staff for follow-up, but this was not done, resulting in the resident's nails remaining in poor condition.

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 residents had access to their personal funds after hours and on weekends, as required by regulation. Observations revealed that the business office, which managed resident trust accounts, was only open Monday through Friday from 11:00 AM to 2:00 PM, and was closed on weekends and holidays. A posted sign outside the business office confirmed these limited hours. Interviews with three residents indicated that they were unable to access their funds during non-banking hours or on weekends, and some were not aware of any process to request funds outside of posted hours. The facility managed 53 resident trust accounts at the time of the survey. Staff interviews confirmed that only business office staff had access to residents' personal funds, and there was no system in place for residents to obtain funds during weekends or after hours. The Business Office Manager stated that residents or their families would need to make advance requests to access funds on weekends, but residents were not informed of this option. Other staff, including a receptionist and an LVN, reported that they would instruct residents to wait until the business office reopened if funds were requested outside of posted hours. The Executive Director acknowledged that no system existed for weekend access to personal funds, and the Director of Nursing expected staff to follow federal guidelines regarding resident access to funds.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for one resident who was admitted with a history of schizophrenia, depression, anxiety disorder, and persistent mood affective disorder. The resident's admission and annual MDS assessments both indicated that the resident was not considered by the state Level II PASRR process to have a serious mental illness or intellectual disability, despite documentation from the State of California showing that a Level II evaluation had been conducted and confirmed the presence of a serious mental illness requiring nursing facility services. The facility's policy required that all portions of the MDS be completed and certified for accuracy by the responsible staff, and that the information reflect the resident's status during the observation period. Interviews with facility staff, including the MDS Director and the Director of Nursing, confirmed that the MDS assessments for this resident were inaccurate regarding the resident's PASRR status. The care plan for the resident also noted impaired cognitive status and thought processes related to the resident's mental health diagnoses, which was inconsistent with the MDS documentation. The Executive Director acknowledged the expectation for MDS assessments to be accurate, but the deficiency was identified due to the failure to correctly document the resident's PASRR status on the MDS.

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 person-centered care plan to address exit-seeking behavior for a resident with severe cognitive impairment and a history of hepatic encephalopathy, schizophrenia, and bipolar disorder. Despite multiple documented episodes of the resident attempting to leave the secured, locked unit, including instances where the resident was able to exit the unit and required staff intervention to return, there was no care plan in place to address these behaviors. Facility policy required that residents at risk for wandering or elopement have care plans with strategies and interventions to maintain safety, but this was not followed for this resident. Staff interviews confirmed that the resident's exit-seeking behavior was frequent, often occurring daily and intensifying in the afternoons. Staff reported using redirection, which was often ineffective, and acknowledged that the resident was able to move quickly and reach exit doors multiple times a day. Nursing and social services staff, as well as facility leadership, confirmed that the resident's care plan did not address these behaviors, despite awareness of the ongoing risk and facility expectations for care planning in such cases.

Penalty

No penalty information released

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

Summary

The facility failed to clarify a physician's order regarding a resident's fluid restriction and did not ensure that staff adhered to the prescribed fluid limits for a resident requiring dialysis. The resident, who had end stage renal disease, was dependent on renal dialysis, and had additional diagnoses including hypertensive heart and chronic kidney disease and dysphagia, was admitted with a physician order for a daily fluid restriction of 1,000 mL. The care plan and dietary instructions reflected this restriction, with specific breakdowns for fluid amounts to be provided by nursing and dietary staff. Despite these orders, documentation in the medication administration record (MAR) and electronic medical record showed that the resident repeatedly received fluids in excess of the prescribed 1,000 mL per day on multiple occasions. Nursing staff and CNAs recorded fluid intakes that exceeded the ordered amount, with some days totaling up to 1,440 mL. There was no documentation of communication with the physician or dialysis physician regarding these overages, nor any indication that the resident or family was noncompliant with the restriction. Interviews with nursing staff, the registered dietician, and the physician confirmed that the fluid restriction was not consistently followed and that the order itself contained unclear or incorrect breakdowns for fluid distribution. Staff acknowledged the discrepancies and the lack of notification to the physician when the resident received excess fluids. The DON and executive director both stated that staff were expected to follow the fluid restriction orders and notify appropriate parties if the orders could not be followed.

Penalty

No penalty information released

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

Summary

Facility staff failed to ensure that medications and medication carts were properly secured in accordance with facility policy and accepted professional standards. During an observation, a medication cart was found unattended and unlocked, with a glucometer and lancets left in an open tray on top of the cart. A certified nursing assistant had to locate the nurse responsible for the cart, who confirmed that the cart should always be locked when not in the nurse's sight. Additionally, a nurse was observed leaving medications on top of the unlocked cart while entering a resident's room to administer medication, during which time the cart was not visible to the nurse. The nurse acknowledged that medications should not be left unattended and that the cart should be locked. Further interviews with staff, including the DON and Executive Director, confirmed that facility policy requires medication carts to be locked when out of sight and that medications should not be left unattended. Despite this, the nurse left a resident's refused medication in a plastic bag on top of the unlocked cart and left the area, stating she needed to use the bathroom. These actions were inconsistent with facility policy and resulted in medications and the medication cart being left unsecured and unattended.

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 enhanced barrier precautions (EBPs) for a resident with a stage 4 pressure ulcer and an indwelling urinary catheter. According to facility policy, EBPs require staff to use gowns and gloves during high-contact care activities for residents with certain conditions, including wounds and catheters. Observations revealed that a certified nursing assistant (CNA) emptied the resident's urinary catheter bag while wearing gloves but did not don a gown, contrary to policy requirements. The CNA stated she was not required to wear a gown for catheter care. Additionally, a licensed vocational nurse (LVN) provided wound care to the same resident without wearing a gown and acknowledged this omission during an interview. Interviews with the infection preventionist, director of nursing, and executive director confirmed that EBPs, including the use of gowns and gloves, were expected for residents with catheters, wounds, or gastrostomy tubes. The resident involved had a medical history of type 2 diabetes, a stage 4 pressure ulcer, and obstructive and reflux uropathy, and was dependent on staff for all activities of daily living. Despite clear facility policy and leadership expectations, staff did not consistently follow EBP protocols during high-contact care activities for this resident.

Penalty

No penalty information released

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

Summary

The facility failed to conduct a comprehensive skin assessment on a resident upon their return from an Emergency Department (ED) visit after a change in condition. The resident, who had diagnoses including neurocognitive disorder and dysphagia, was sent to the ED and returned the same day. However, no skin assessment was documented upon their return, and the next assessment occurred six days later. During this time, ECG stickers from the prior ED visit remained undetected on the resident's skin. Interviews with facility staff revealed that a Certified Nursing Assistant (CNA) noticed one ECG sticker during a bed bath but did not report it, assuming the nurses were already aware. Registered Nurses (RNs) stated that full body checks are typically done upon admission, on shower days, or if a resident has been out for more than 24 hours, which is considered a readmission. The Director of Nursing (DON) emphasized the importance of conducting a head-to-toe assessment upon a resident's return from the hospital, even if it is less than 24 hours, as per best nursing practices. The facility's policy requires a comprehensive skin assessment upon admission and daily skin inspections during personal care.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident had a written care plan for falls that was individualized with resident-specific interventions. The resident, who had a history of dementia, hallucinations, restlessness, agitation, muscle weakness, and falls, was admitted to the facility and experienced multiple falls. Despite these incidents, the care plan did not address the resident's behavior of rolling or crawling out of bed, which was a significant factor in the falls. The care plan included general interventions such as keeping the call light within reach and promoting exercise, but these were not tailored to the resident's specific needs and abilities. Observations and interviews revealed that staff members were not aware of the resident's fall incidents or the specific interventions needed to prevent further falls. For instance, a mental health worker and two CNAs were unfamiliar with the use of landing mats and the resident's fall history. Additionally, the CNAs did not receive adequate information during shift reports about the resident's fall risk or behavior. Licensed nurses acknowledged that the resident's care plan was not individualized and did not address the resident's specific behavior of rolling or crawling out of bed. The Director of Nursing (DON) and the administrator confirmed that the resident's care plan should have been individualized and that all staff should have been knowledgeable about the resident's fall risk and specific interventions. The DON acknowledged that the care plan had been revised but should have included individualized interventions earlier to prevent further falls. The facility's policy on comprehensive, person-centered care plans was not followed, leading to a deficiency in the resident's care plan for falls.