The Gardens Of El Monte

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 written notice to two residents prior to changing their rooms, as required by policy and resident rights regulations. One resident, who had diagnoses including depression, anxiety disorder, abnormalities of gait and mobility, and schizophrenia, was assessed as mildly impaired in cognitive skills and required varying levels of assistance with daily activities. This resident reported not receiving any written notice before being moved to a different room and expressed not wanting the room change. Similarly, another resident with diagnoses of gait and mobility abnormalities, depression, anxiety disorder, hypertension, and schizophrenia, and who was also mildly cognitively impaired, stated that no written notice was given prior to their room change and did not consent to the move. Interviews with facility staff, including the Assistant Director of Nursing and the Social Service Director, confirmed that written Notices of Room Change (NORC) were not provided to the residents before the room changes occurred, nor were signatures obtained to verify receipt or consent. The facility's policy requires that residents receive written notice, including the reason for the change, before any room or roommate change is made. The lack of written notice and consent was acknowledged by both the nursing and social services staff during the investigation.

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 a safe and orderly transfer or discharge for three residents by not following required procedures and documentation. For one resident with depression, anxiety disorder, and schizophrenia, the facility discharged the individual to another skilled nursing facility without a physician's order specifying the discharge location, without indicating the appropriate reason for discharge, and without providing or obtaining a signed Notice of Transfer/Discharge (NTD) from the resident. Interviews with staff confirmed that the NTD was not provided or signed prior to discharge, and the resident's discharge goal was to move to a lower-level care facility, not another skilled nursing facility. Another resident with chronic obstructive pulmonary disease, diabetes mellitus, and schizophrenia was discharged to a different skilled nursing facility without a documented reason for discharge and without a signed NTD. Staff interviews and record reviews confirmed that the required notice and consent were not obtained prior to the discharge, and the discharge reason was not clarified or documented on the NTD form. A third resident, who had hypertension, chronic kidney disease, dementia, and schizophrenia, and was severely impaired in cognitive skills, was discharged to an independent living home with home health services, despite requiring assistance with activities of daily living such as dressing and personal hygiene. Staff acknowledged that the discharge location was inappropriate given the resident's needs, and documentation confirmed the resident was not independent in ADLs at the time of discharge. Facility policies required notification, documentation, and preparation for discharge, but these were not followed in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to properly document and communicate required information on the Notice of Transfer/Discharge (NTD) forms for three residents. For one resident with depression, anxiety disorder, gait abnormalities, and schizophrenia, the NTD form incorrectly stated the reason for transfer as health improvement, despite the resident being transferred to another skilled nursing facility (SNF) of the same care level, contrary to the resident's discharge goal of moving to a lower-level care facility. The responsible staff did not provide the NTD form to the resident prior to discharge, and interviews confirmed that the discharge plan was not accurately reflected in the documentation. Another resident, diagnosed with COPD, diabetes mellitus, and schizophrenia, was transferred to a different SNF without any reason documented on the NTD form. The resident was cognitively intact and self-responsible, but both the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged that the required reason for transfer was missing from the documentation. This omission was confirmed during interviews and record reviews. A third resident, with hypertension, chronic kidney disease, dementia, and schizophrenia, was transferred to an Independent Living Home (ILH), but the NTD form did not specify the location of the ILH. This resident was severely cognitively impaired and required significant assistance with daily activities. Facility policy requires that the reason for transfer/discharge and the location be clearly documented and communicated to the resident and/or their representative, but this was not done in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a person-centered care plan to monitor a resident's psychosocial well-being and satisfaction following a room change. The resident, who had diagnoses including depression, anxiety disorder, and schizophrenia, was admitted with mild cognitive impairment and required varying levels of assistance with daily activities. After the resident was moved to a new room, there was no care plan created to address the resident's adjustment or to monitor their psychosocial condition, as confirmed by review of the resident's records and interviews with nursing staff and facility leadership. Interviews with the LVN, ADON, and DON all confirmed that no care plan was developed after the room change, despite facility policy requiring comprehensive, resident-centered care plans that include measurable objectives and timeframes to meet each resident's needs. The absence of a care plan was also evident in the resident's current care plan documentation, which did not address the room change or the need to monitor the resident's psychosocial status following the move.

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 medically-related social services to assist a resident in obtaining a legal personal identification (ID) card. The resident, who was admitted with diagnoses including depression, anxiety disorder, abnormalities of gait and mobility, and schizophrenia, was able to make needs known but could not make medical decisions. Assessment records indicated the resident was mildly impaired in cognitive skills and required varying levels of assistance with daily activities. Despite the resident's repeated requests for help in applying for a state ID card from the Department of Motor Vehicles (DMV) since admission, the facility did not provide the necessary assistance. Interviews with facility staff confirmed that the resident had asked for help obtaining an ID card, but no staff member was assigned to assist with the process. The Social Service Director acknowledged the request and the facility's responsibility to provide such assistance, while the Director of Staff Development confirmed that no arrangements were made for staff to accompany the resident to the DMV. Review of the facility's policy indicated that social services should include assistance with obtaining personal identification and other personal items, but this was not carried out for the resident in question.

Penalty

No penalty information released

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

Summary

A facility failed to ensure that a resident was treated with respect and dignity by not allowing the resident to get up from a reclining wheelchair, despite the resident's attempts to do so. The resident, who had a history of impaired mobility, unsteady gait, and severely impaired cognition, was observed multiple times throughout the day in a large reclining wheelchair with the chair tilted back and feet elevated. Staff interviews confirmed that the resident was kept in the chair for most of the day, with the chair often tilted back to prevent the resident from attempting to get up, as the resident was considered a fall risk. On one occasion, an Activities Assistant physically prevented the resident from getting up by placing hands on the resident's shoulder and instructing the resident to remain seated. The Activities Assistant stated that the chair was used to keep the resident from getting up due to fall risk and staff convenience, and that the chair was sometimes tilted back to make the resident more comfortable and discourage attempts to stand. A Certified Nurse Assistant confirmed that the resident required substantial assistance but was not completely dependent, and stated that if a resident wanted to get out of a reclining wheelchair, staff were supposed to assist them, as it was the resident's right. Further interviews with therapy staff indicated that using the wheelchair in this manner constituted a restraint, as it restricted the resident's freedom of movement and hindered quality of life. The facility's own policies defined restraints as any device that a resident cannot easily remove and that restricts movement, and stated that restraints should not be used for staff convenience. The Director of Nursing acknowledged that restricting residents from getting up when they wanted was a violation of resident rights, although there was confusion among staff regarding the definition and use of restraints.

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 was free from unnecessary restraint. One resident, who had diagnoses including metabolic encephalopathy, gait and mobility abnormalities, and anxiety disorder, and who was assessed as having severely impaired cognition and requiring assistance with daily activities, was reportedly tied to a wheelchair with a white sheet. Interviews with staff and another resident confirmed that residents, including this individual, were observed tied to wheelchairs or Geri chairs, often covered with blankets, and unable to move freely. Staff acknowledged that using a sheet to tie a resident to a wheelchair constitutes a restraint if the resident cannot untie themselves and exit the chair independently. There were no physician orders for restraints in the resident's medical record, and the facility's policy explicitly states that residents have the right to be free from physical restraints used for discipline or staff convenience. Despite this policy, multiple interviews indicated that the use of sheets to restrain residents occurred, particularly in the early morning hours. The Director of Nursing stated that the facility does not use restraints, but this was contradicted by staff and resident interviews.

Penalty

No penalty information released

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

Summary

The facility failed to provide a care plan addressing mental health services and increased socialization for a resident diagnosed with anxiety disorder and exhibiting symptoms of depression and withdrawal. The resident, who had severely impaired cognition and lacked capacity to make medical decisions, was under psychiatric care and had documented needs for emotional support and increased socialization to prevent isolation. Despite these identified needs, there was no care plan in the medical record to address the resident's mental health services, withdrawn behavior, or need for increased socialization. Observations revealed the resident was often alone, not interacting with others, and expressed feelings of sadness, boredom, and isolation. The resident reported having no friends or visitors at the facility. Staff were observed monitoring residents but not engaging with this resident. The facility's policy emphasized residents' rights to dignity, respect, and participation in social activities, but these were not reflected in the care provided to 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 implement and revise a care plan for a resident assessed at high risk for falls, as required by its own policy and procedures. The resident, who had a history of falls prior to admission and multiple medical diagnoses including metabolic encephalopathy, abnormal gait, and severe cognitive impairment, was admitted with existing skin injuries and was identified as high risk for falls upon admission. The initial care plan included interventions such as visual checks every two hours, maintaining a well-lit room, keeping the bed in the lowest position, and ensuring brakes were applied during transfers. However, the care plan was not updated or revised after the resident experienced subsequent falls. On one occasion, the resident fell in the hallway while ambulating with a front-wheeled walker and sustained bruises, swelling, and an open wound on the forehead. Documentation did not indicate that staff supervised or assisted the resident during ambulation, despite the care plan's requirements. Following this fall, there was no evidence in the medical record that the care plan was updated to reflect new interventions or to address the increased fall risk, even though the resident's fall risk score increased and the physical therapist recommended supervision at all times. The resident experienced another fall in their room, resulting in additional injuries, including abrasions and bruising to the head and face. Despite these incidents and recommendations from the rehabilitation department for increased supervision, the care plan remained unchanged from its original version. Interviews with nursing staff and the Director of Nursing confirmed that the care plan was not updated after the falls, contrary to facility policy, which requires care plan updates within 72 hours of a fall to develop or revise interventions.

Penalty

No penalty information released

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

Summary

The facility failed to follow its own Fire Policy during an incident in which the main electrical panel room's switchboard caught fire. When smoke was discovered, staff members responded by calling 911 and notifying other staff, but did not activate the manual fire alarm system. The fire alarm did not trigger automatically, and no one pulled the nearest manual fire alarm, which was located near the exit doors by Resident Room 17 and the Director of Staff Development's office. This omission was confirmed through interviews with the Director of Staff Development and the Maintenance Supervisor, as well as direct observation of the location of the manual pull station. A review of the facility's Fire Policy indicated that staff are required to alert others over the intercom and pull the nearest fire alarm in the event of a fire. Despite this clear directive, staff did not follow the procedure, resulting in a failure to alert all individuals in the facility during the fire event. The deficiency was identified through interviews, record review, and observation, and it affected the safety of all 49 residents, staff, and visitors present at the time.

Plan Of Correction

K 0711 Corrective action for residents found to have been affected by this deficiency: On 07/28/2025, the Administrator provided a 1:1 in-service to the Director of Staff Development (DSD) and to Housekeeping 1 (HSK 1) on the Facility's Fire Policy and Procedure; and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Corrective action for residents that may be affected by this deficiency: On 07/27/2025, 07/28/2025, and 08/03/2025, the DSD provided an in-service to department heads, nurses, dietary, activity, housekeeping/laundry, maintenance, and other staff on the Facility's Fire Policy and Procedure and course of action for all personnel to follow in the event of a fire, including pulling the nearest fire alarm. Measures that will be put into place to ensure that this deficiency does not recur: During daily rounds, the DSD will randomly ask staff members on all shifts what to do in case of fire to ensure pulling the fire alarm is identified. Discussion on activating the fire alarm will be part of the monthly fire drills performed by the facility's Fire Life Safety & Security vendor. During the initial orientation, the DSD will ensure new hires will be familiar with the facility's Fire Policy and Procedure, including pulling the fire alarm. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use the indicator, "Fire Drill Program," monthly, to ensure staff

Penalty

No penalty information released

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

Summary

The facility failed to provide documentation that its emergency generator underwent a required four-hour continuous load test within the past 36 months, as mandated by NFPA 110 standards. During the survey, the Administrator and DON were unable to produce written documentation of the most recent four-hour generator load test when requested. The Administrator indicated that the Maintenance Supervisor (MS) might have the documentation, but he was unavailable at the time due to being on vacation. Upon the MS's return, a generator service report dated 9/21/2021 was provided, which indicated that the emergency generator was tested for only 3 hours and 15 minutes, falling short of the required four-hour duration. No other documentation was available to demonstrate compliance with the four-hour continuous load test requirement within the last 36 months. The MS acknowledged the absence of a four-hour load test during an interview with the surveyor. The deficiency was identified through observation, interviews, and record review, and it affected all three smoke compartments of the facility. The lack of proper documentation and completion of the four-hour generator load test was confirmed by both administrative and maintenance staff during the survey process.

Plan Of Correction

has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be put into place to ensure that this deficiency does not recur: has accessibility to Fire Policy & Procedure and to ensure alarm is initiated from the "fire area". The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. Corrective action for residents found to have been affected by this deficiency: On 08/03/2025, the Maintenance Supervisor witnessed a four-hour load test of the facility's emergency generator by Alliance Generators. Corrective action for residents that maybe affected by this deficiency: On 07/28/2025, the Maintenance Supervisor observed all other emergency generators. No other areas were affected by this deficient practice. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025. On 07/28/2025, the Administrator provided a 1:1 in-service to the Maintenance Supervisor to ensure a continuous four-hour emergency generator load test is conducted every 36 months. The Maintenance Supervisor will conduct an annual maintenance record review to ensure a continuous four-hour emergency generator load test is conducted within 36 months. Measures that will be implemented to monitor the continued effectiveness of the corrective action taken to ensure that this deficiency has been corrected and will not recur: The QAPI Risk Management Practices Subcommittee will use indicator, "Physical Plant Maintenance", monthly, to ensure the generator is maintained and testing is done according to procedures outlined NFPA. The results will be submitted to the Administrator for review. The DSD will report the findings to the monthly QAPI committee for further review and recommendations. The plan of correction will be completed on or before August 15, 2025.

Penalty

No penalty information released

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

Summary

The facility failed to implement its Policy and Procedure on Advance Directives for two residents, leading to potential treatment against their wishes. For Resident 49, the facility did not complete the Advance Directive Acknowledgement Form upon admission, despite the resident having intact cognition and requiring assistance with daily activities. The Social Services Director confirmed that the form was not completed, which should have been done to inform the resident of their rights to refuse or accept treatment and to formulate an advance directive. For Resident 42, who had severely impaired cognition and was dependent on staff for daily activities, the Advance Directive Acknowledgement Form was not filled out completely. The Social Worker acknowledged the incomplete form and emphasized the importance of accurately documenting the resident's medical preferences. The Director of Nursing reiterated that the form should be discussed and completed upon admission to ensure the resident's medical wishes are respected in emergencies. The facility's policy, revised in 2017, mandates providing residents with information about their rights to accept or refuse treatment and to prepare an advance directive upon admission.

Penalty

No penalty information released

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

Summary

The facility's licensed staff failed to perform a thorough assessment and notify the physician of a resident's sudden change of condition. Resident 53, who had been readmitted to the facility with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus, experienced heavy breathing and a change in face color to purple. Despite these symptoms, the Registered Nurse Supervisor did not check the resident's vital signs or notify the physician immediately, which are critical steps in managing a sudden change of condition. The Director of Nursing confirmed that the nurse should have assessed the resident's vital signs and reported the change of condition to the physician to facilitate timely treatment. The facility's policy on Change of Condition requires thorough assessment and physician notification for early clinical management, which was not adhered to in this case. This oversight had the potential to delay necessary treatments and services, contributing to the resident's health decline.

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 care and services for residents on oxygen therapy, as observed in four cases. Resident 17, who had a physician's order for continuous oxygen therapy, was found without the nasal cannula in use, and the tubing was left hanging on the oxygen concentrator. There was no care plan developed for Resident 17's use of oxygen therapy, which was confirmed by both a CNA and an LVN. The Director of Nursing (DON) acknowledged that residents with continuous oxygen orders should always be on oxygen to prevent shortness of breath and desaturation. Resident 30's oxygen tubing was not labeled with the date it was last changed, which is a requirement for infection control. The resident had an order for continuous oxygen therapy, and the facility's policy indicated that cannulas should be replaced weekly. The DON confirmed that all oxygen tubing should be labeled with the resident's name and date to ensure proper infection control practices. Resident 42 was observed with oxygen tubing touching the floor and nasal cannula prongs not properly placed inside the nostrils, which could lead to inadequate oxygen therapy. The DON stated that the nasal cannula should not touch the floor to prevent cross-contamination and should be properly placed to ensure the resident receives the prescribed oxygen. Additionally, Resident 24 was receiving oxygen therapy without a physician's order, which is against the facility's policy. The DON confirmed that a physician's order is necessary to ensure the appropriateness of oxygen therapy for 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 implement a physician's order for fluid restriction for a resident requiring dialysis care from March 1, 2025, to March 15, 2025. The resident, who was admitted with diagnoses including diabetes mellitus, hypertension, and end-stage renal disease, had a physician's order for a fluid restriction of 1000 ml every 24 hours. However, a review of the Medication Administration Record (MAR) for March 2025 revealed that there was no monitoring of the fluid restriction during this period. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the resident's fluid restriction was not monitored, which could potentially lead to fluid imbalance. The facility's policy and procedure for dialysis care indicated that the dialysis unit physician should be notified of any noncompliance with diet or fluid restrictions, but this was not adhered to. The lack of monitoring was acknowledged by the DSD and DON, who recognized the potential for fluid overload and other complications due to this oversight.

Penalty

No penalty information released

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

Summary

The facility failed to administer medications according to its policy and procedure, specifically in the case of a resident who was prescribed Losartan for hypertension. During a medication pass observation, a registered nurse administered Losartan to the resident without checking the resident's blood pressure beforehand, as required by the physician's order. The resident's blood pressure was recorded at 105/67 mmHg the previous evening, which was below the threshold of 110 mmHg specified for withholding the medication. The nurse acknowledged the oversight, and the Director of Nursing confirmed that medications should be administered as prescribed for resident safety. Additionally, the facility did not adhere to its policy for medication destruction, which requires the presence of two licensed nurses. Records showed that 72 medications were destroyed with only one nurse signing off on the destruction forms. The Director of Staff Development and the Director of Nursing both stated that medication destruction should be witnessed by two licensed nurses to ensure safety and prevent misappropriation. The facility's policy mandates that medication destruction be documented with the signatures of two witnesses.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its policy and procedure on food preparation and serving standards, specifically regarding the use of hairnets by kitchen staff. During an initial tour of the kitchen, Kitchen Aide 1 (KA 1) was observed not wearing a hairnet while pushing a food cart with meal trays in the food preparation area. KA 1 acknowledged forgetting to wear a hairnet and recognized its importance in preventing hair from contaminating food. The Dietary Supervisor confirmed that hairnets are required for staff in the kitchen to prevent hair from falling into food or onto kitchen utensils, which could lead to contamination. The facility's undated Dietary Policy and Procedure Manual mandates that all dietary employees follow good personal hygiene practices, including wearing head coverings such as hairnets or caps while on duty. This oversight in following the established policy had the potential to cause foodborne illnesses among residents receiving food from the facility's kitchen.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the call light was within reach for a resident, identified as Resident 4, which was contrary to the facility's policy and procedure titled Call Lights. Resident 4 was admitted with diagnoses including paraplegia and dysphagia, and was assessed as having severely impaired cognition, making them dependent on staff for various activities of daily living. The resident was also assessed as high risk for falls due to disorientation and incontinence. Despite these conditions, during an observation, the call light was found hanging on the top of the head of the bed, out of the resident's reach, which was confirmed by both the resident and a Licensed Vocational Nurse (LVN 2). The Director of Nursing (DON) acknowledged that the call light should be within reach at all times to ensure resident safety and prevent falls. The facility's policy, dated January 2017, clearly stated that staff should ensure the call light is within easy reach when a resident is in bed or seated. This oversight had the potential to delay care or assistance for Resident 4, which could lead to falls or injuries, as the resident was unable to independently access the call light to request help.

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 accurate coding of a resident's Minimum Data Sheet (MDS), which is a critical resident assessment tool. This inaccuracy was identified for a resident who was discharged from the facility. The resident, who had been admitted with conditions including cellulitis, seizures, and anemia, was discharged with an order for home health care services. However, the MDS inaccurately indicated that the resident was discharged to a short-term general hospital instead of home. Interviews with the MDS Coordinator and the Director of Nursing confirmed the discrepancy, with both acknowledging the importance of accurate MDS coding for continuity of care and accurate reporting to the Centers for Medicare & Medicaid Services (CMS). The facility's policy on the Resident Assessment Instrument (RAI) process emphasizes the need for accurate assessments of residents' functional capacity and health status, 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 ensure that medications were administered before being documented as given in the Electronic Medication Administration Record (EMAR) for a resident. During a medication pass observation, a registered nurse supervisor was unable to unclog the resident's gastrostomy tube and could not administer the scheduled 9:00 am medications. Despite this, the nurse marked ten medications as given in the EMAR before they were actually administered. The resident involved had a history of severe cognitive impairment and was dependent on staff for personal care. The facility's policy and procedure on medication administration clearly stated that medications should be documented in the EMAR only after they have been administered. Both the registered nurse and the Director of Nursing acknowledged that documenting medications before administration could lead to missed doses and medication errors, which was inconsistent with the facility's 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 facility failed to ensure that a resident with a gastrostomy tube (GT) received necessary treatment and services as per the facility's policy and procedure on enteral feedings. The resident, who was admitted with diagnoses including paraplegia and dysphagia, had severely impaired cognition and was dependent on staff for various daily activities. The resident's order summary indicated that Glucerna 1.2 formula was to be administered via an enteral pump machine at a specific rate and duration. However, during an observation, it was found that the GT feeding bottle was unlabeled, and the enteral pump machine was turned off, contrary to the prescribed continuous administration. Licensed Vocational Nurse 2 admitted to hanging the feeding but not turning on the machine until later, which was necessary to prevent dehydration and electrolyte imbalance. The Director of Nursing confirmed that the GT bottle formula should have been labeled with the resident's name, date, time, and the nurse's signature to ensure the correct feeding was administered. The facility's policy on enteral feedings required documentation on the formula label to prevent errors, 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 document the administration of Hydralazine and blood glucose monitoring for two residents, leading to potential medication errors. For Resident 37, the Medication Administration Record (MAR) did not show that Hydralazine was given at 6 am or that blood glucose monitoring was performed at 6:30 am on 3/13/2025. The resident was admitted with diagnoses of diabetes mellitus and hypertension and was independent in personal hygiene and transfers. The Director of Staff Development and the Director of Nursing both emphasized the importance of signing the MAR immediately after medication administration and monitoring to prevent missed doses or overdoses. For Resident 42, the MAR did not indicate that blood glucose monitoring was performed on 3/13/2025 as ordered. The resident, who was admitted with pneumonia and type 2 diabetes mellitus, had severely impaired cognition and was dependent on staff for daily activities. During an interview, a registered nurse acknowledged that the MAR was not signed and could not explain why the monitoring was not documented. The facility's policy requires that medication administration and monitoring be recorded immediately to ensure resident safety.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that six of 23 resident rooms met the square footage requirement of 80 square feet per resident in multiple resident rooms. Specifically, Rooms 2, 8, 10, 11, 15, and 16 did not meet the minimum square footage requirement. Room 2, which housed four residents, measured 286.92 square feet, falling short of the 320 square feet required for a four-bed room. Rooms 8, 10, 11, 15, and 16, each housing two residents, measured between 147.50 and 152.24 square feet, below the 160 square feet required for two-bed rooms. During observations, it was noted that residents in these rooms were able to ambulate freely and nursing staff had sufficient space to provide care with dignity and privacy. Interviews with the residents did not reveal any concerns regarding the size of their rooms. The facility had submitted a room waiver request, indicating that there was enough space for nursing care and that the health and safety of the residents were not in jeopardy. The waiver also stated that the room sizes were in accordance with the needs of the residents and would not adversely affect their health and safety or impede their ability to attain their highest practicable well-being.

Penalty

No penalty information released

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

Summary

The facility failed to notify the responsible party of a resident's fall, which occurred while the resident was under the facility's care. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, urinary tract infection, and dementia, was found on the floor next to her bed early in the morning. Despite the fall being documented in the resident's Situation-Background-Appearance-Review and Notify Communication Form (SBAR), the responsible party, who is the resident's daughter, was not informed of the incident. The Licensed Vocational Nurse (LVN) involved confirmed that although a call was made, no detailed voicemail was left, and the responsible party was not directly informed about the fall. The Director of Nursing (DON) acknowledged that charge nurses are required to notify family members or responsible parties when a resident experiences a fall. However, it was revealed that the facility lacked a policy and procedure regarding the notification of responsible parties about residents' falls or changes in condition. This oversight in communication and procedural guidelines led to the responsible party being unaware of the resident's fall, despite the facility's obligation to keep them informed of any changes in the resident's health status.

Penalty

No penalty information released

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

Summary

The facility failed to provide a daily skin assessment for a resident who was at risk of developing skin breakdown and pressure injuries. The resident, who had been admitted and readmitted to the facility, had diagnoses including type 2 diabetes mellitus, metabolic encephalopathy, and dysphagia. The Minimum Data Set (MDS) indicated the resident was severely impaired in cognitive skills and required assistance for daily activities. Despite being at risk for pressure injuries, the resident's daily skin assessments were not conducted as required, and existing skin conditions were not documented accurately. During observations and interviews, it was noted that the resident had a healing laceration on the nose and discoloration under the eyes, which were not documented in the admission assessment or daily skilled nurse's notes. The Assistant Director of Nursing and a Registered Nurse confirmed that the daily notes were completed without a physical assessment, relying instead on outdated information from the admission assessment. The Director of Nursing stated that daily notes should include a physical assessment to ensure accurate documentation and treatment of skin issues. The facility's policy required a baseline care plan to address health care information, goals, and objectives, 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 maintain a complete and accurate medical record for a resident, identified as Resident 8, by not accurately documenting skin assessments. Resident 8 was admitted with diagnoses including type 2 diabetes mellitus, metabolic encephalopathy, and dysphagia. The Minimum Data Set (MDS) indicated that Resident 8 was at risk of developing pressure injuries and had open lesions other than ulcers, rashes, or cuts. However, during a review of Resident 8's Comprehensive Resident Assessment (AA), it was found that the assessment did not document a laceration on Resident 8's nose and discoloration around the eyes, which were present upon readmission. The Assistant Director of Nursing (ADON) and Treatment Nurse (TN) 1 acknowledged the omission of these injuries in the documentation. Additionally, Registered Nurse (RN) 1 admitted to copying the skin assessment information from the AA without conducting a physical assessment, leading to further inaccuracies in the Daily Skilled Nurse's Notes. The Director of Nursing (DON) confirmed that nurses are required to physically assess residents to ensure accurate documentation of skin issues. The facility's policy on documentation principles emphasizes the need for accurate, timely, and descriptive entries, 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 adhere to its policy and procedure titled 'Documentation Principles' by not maintaining complete documentation for a resident who underwent a diagnostic service. The resident, admitted with conditions including parkinsonism, pneumonia, and dysphagia following a stroke, had a scheduled video swallow study to evaluate swallowing difficulties. Although the resident attended the appointment, there was no documented follow-up in the resident's chart regarding the results of the video swallow test, which was crucial for ensuring appropriate care and treatment. The Director of Nursing acknowledged the importance of documenting follow-up actions to prevent complications, especially for residents with aspiration precautions. Despite the Assistant Director of Nursing contacting the hospital's radiology department to inquire about the test results, this follow-up was not recorded in the resident's chart. The facility's policy required that if diagnostic service reports were not received within 48 hours, the service should be contacted immediately, and a copy of the report requested. The lack of documentation in this case represents a failure to comply with the facility's established procedures for maintaining current and detailed clinical records.

Penalty

1 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 hydration for a resident, leading to severe health complications. The resident, who had a history of dysphagia, chronic kidney disease, and impaired cognition, was assessed to require 1950 mL to 2040 mL of fluids per day. However, from the period of May 16, 2024, to June 1, 2024, the resident consistently received less than the required amount of fluids, with daily intake ranging from 120 mL to 930 mL. This inadequate fluid intake was not properly monitored or addressed by the facility staff, despite the resident's care plan indicating a risk for dehydration and the need for monitoring fluid intake and output. The facility's staff, including CNAs and LVNs, failed to ensure the resident received the necessary fluids and did not adequately monitor or report the resident's fluid intake. The CNAs did not report any issues with the resident's fluid intake to the LVNs, and the LVNs were unaware of the resident's fluid requirements and did not notify the resident's physician or dietician about the inadequate fluid intake. The resident's altered level of consciousness and other symptoms on June 1, 2024, led to an emergency transfer to a hospital, where the resident was diagnosed with hypernatremia, dehydration, uremia, and acute kidney injury. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's fluid needs and intake. The Director of Nursing acknowledged that the staff should have been aware of the resident's fluid requirements and should have reported any changes in the resident's condition to the appropriate medical personnel. The facility's policies on hydration management and intake and output monitoring were not effectively implemented, contributing to the resident's severe dehydration and subsequent hospitalization.

Penalty

1 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 notify the physician of a change in condition for a resident, as required by their policy and procedure on significant change in condition. The resident, who had a history of dysphagia, chronic kidney disease, and impaired cognition, was noted to struggle with fluid intake and required encouragement to drink. Despite these observations, the licensed vocational nurses (LVNs) did not promptly notify the resident's primary physician or obtain a physician's order to monitor the resident's intake and output, which was necessary to address the resident's potential for fluid-electrolyte imbalance related to hypernatremia. The resident's laboratory results showed elevated serum sodium levels, indicating hypernatremia, which could suggest dehydration. The resident's fluid intake was consistently below the estimated daily requirement, as documented in the facility's records. However, the registered dietician (RD) was not informed of the resident's inadequate fluid intake, and the LVNs did not communicate this critical information to the physician. The lack of communication and failure to act on the resident's fluid intake needs resulted in the resident being transferred to a general acute care hospital with diagnoses of hypernatremia, dehydration, uremia, and acute kidney injury. Interviews with facility staff, including the director of nursing (DON), LVNs, and certified nursing assistants (CNAs), revealed a lack of awareness and communication regarding the resident's fluid needs and the significance of the resident's condition. The facility's policy required immediate reporting of changes in resident status to licensed personnel and the nursing supervisor, but this protocol was not followed. The failure to notify the physician and obtain necessary orders led to a delay in providing appropriate care and treatment for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe discharge for a resident who was discharged 497 miles away from the facility with nowhere to stay. The resident had diagnoses including abnormalities of gait and mobility, unspecified psychosis, and Type 2 diabetes mellitus. Despite having intact cognition, the resident required assistance for various activities of daily living. The discharge care plan indicated a potential discharge to home with assistance, but the family member explicitly stated that the resident could not come to their home and that they were not obligated to take care of the resident. Despite this, the facility proceeded with the discharge, believing the resident had arranged everything. Upon discharge, the resident was left at the Social Services department with belongings but no place to stay. The family member reiterated their inability to care for the resident, and the resident ended up in the welfare department and later in a motel with no further accommodation arranged. The facility's policy on discharge planning required re-evaluation and updates to the discharge plan, considering caregiver availability and capability, which was not adequately followed in this case. The Social Services Director and Director of Nursing were informed of the resident's situation but believed the discharge was safe based on the resident's statements, which proved to be inaccurate.

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 an effective pest control program, resulting in the presence of fruit flies in both a resident's room and the conference room. During an observation, a fruit fly was seen flying in front of a resident's face, causing the resident to move away from it. Another observation noted a fruit fly in the conference room. Interviews with the Maintenance Supervisor and the Director of Nursing revealed that the facility's doors needed to be kept closed to prevent pests and that the pest control company should be called when fruit flies are present. The facility's policy indicated that pests should be managed using a pest management company, with routine and additional services as needed.

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 reasonable accommodation for two residents. For Resident 1, who was admitted with diagnoses including unspecified dementia and required assistance with personal care, the call light was not within reach. Observations revealed that the call light was under the bed of Resident 1's roommate, making it inaccessible. Both the Infection Preventionist Nurse and the Director of Nursing confirmed that the call light should have been within reach to ensure timely assistance and maintain Resident 1's safety. The facility's policy also indicated that call lights should be within easy reach of residents when they are in bed or in a wheelchair or chair in the room. For Resident 38, who had intact cognition and no impairments in upper or lower extremities, the facility failed to adjust the clock in the resident's room after Daylight Saving Time. Despite Resident 38's requests to staff to change the time, the clock continued to display an hour earlier than the actual time, causing confusion for the resident. The Licensed Vocational Nurse acknowledged that the clock was not adjusted and stated that it should reflect the actual time to avoid confusion for residents. The facility's policy emphasized providing a safe, clean, and comfortable environment for 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 follow its policy and procedure titled, Advance Directive, for two of three sample residents. For Resident 38, the facility did not provide information regarding Advance Directives (AD) upon readmission, despite the resident having intact cognition and the capacity to understand and make decisions. The Social Service Director (SSD) confirmed that there was no documentation indicating that AD information was offered to Resident 38, which is crucial for ensuring that the resident's treatment preferences are known and respected by the staff. For Resident 18, the facility failed to ensure that the AD copy was readily retrievable in the resident's medical records. Resident 18 had severely impaired cognition and required total dependence on staff for daily activities. Despite having an AD upon admission, the SSD was unable to locate the AD in the medical record, and the resident and their responsible party were unaware of its existence. The Director of Nursing (DON) also confirmed that the AD should be easily accessible in the medical record for immediate access in case of an emergency.

Penalty

No penalty information released

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

Summary

The facility failed to provide safety and protection for a resident who had injuries from an unknown source. The staff did not immediately report the resident's injuries to the Department of Public Health (DPH), Ombudsman, and local law enforcement within the required two-hour timeframe. Additionally, the staff did not investigate the injuries in accordance with the facility's policy and procedures for resident abuse prevention, nor did they notify the resident's physician and responsible party about the injuries. These deficiencies compromised the resident's safety and protection from potential abuse in the facility. The resident, who was admitted with diagnoses including dementia and chronic kidney disease, was observed with dark red-purple skin discoloration and a bump on the forehead, as well as dark purple skin discoloration below both eyes. The resident was non-communicative, and the injuries were first noticed by family members during a visit. Despite the family members' inquiries, the staff did not provide specific information about the cause of the injuries, and there was no documented evidence of an incident or fall in the resident's medical record. Interviews with staff revealed that they were aware of the resident's injuries but did not know how they occurred. The injuries were not reported or investigated as required by the facility's policy. The Director of Nursing (DON) and the Administrator were also unaware of the injuries until the survey. The facility's policy on abuse reporting and prevention mandates that injuries of unknown sources be reported within two hours to ensure resident rights are protected, but this protocol was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents receiving oxygen therapy were provided with respiratory care in accordance with the facility's policy and procedure. Specifically, Resident 25's nasal cannula tubing was observed touching the floor, and there was no cautionary sign posted on the door indicating oxygen was in use. Resident 25 had severe impaired cognition and was totally dependent on staff for daily activities. The Licensed Vocational Nurse (LVN) confirmed that the nasal cannula tubing should not touch the floor to prevent cross-contamination and that a smoking sign should be posted to avoid fire hazards. The Director of Nursing (DON) reiterated these points during an interview, emphasizing the importance of preventing infections and ensuring safety by posting appropriate signage. The facility's policy on oxygen administration and storage of oxygen cylinders also required such precautions, which were not followed in this case. Similarly, Resident 45's nasal cannula tubing was not labeled, and it was also observed touching the floor. Additionally, there was no precautionary signage posted on Resident 45's door indicating oxygen was in use or that smoking was prohibited. Resident 45 had severe cognitive impairment and was totally dependent on staff for daily activities. The LVN confirmed the absence of the required signage, and the DON stated that such signs should be posted to inform visitors and residents about the oxygen therapy and to prevent fire hazards. The facility's policies on oxygen administration and storage of oxygen cylinders were not adhered to, leading to this deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week from March 1, 2024, through March 15, 2024, for 12 of 15 days. During an interview and record review on March 15, 2024, with the Director of Staff Development (DSD), it was revealed that the nurse staffing sign-in sheet for the month of March 2024 indicated no RN was on duty for twelve days. The DSD confirmed that the facility had no full-time RN working eight hours per day, seven days a week since February 2024. The facility's policy and procedures (P&P) titled 'Staffing' dated March 2020 indicated that RN staff should be available to provide and monitor the delivery of resident care services. The DSD emphasized the importance of having a full-time RN to oversee residents' assessment and care in the facility every day.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the sanitizing solution used for cleaning the food preparation area had the correct concentration to meet industrial standards. During a tour of the facility's kitchen, it was observed that one of the three red buckets containing sanitizing solution had a concentration of 100 parts per million (ppm) instead of the recommended 200 ppm. The Dietary Assistant (DA) confirmed that the solution should reach 200 ppm to effectively kill bacteria and viruses. The DA acknowledged that a concentration below 200 ppm would not fully sanitize the countertops, potentially leading to contamination and foodborne illness among residents. In an interview, the Dietary Supervisor (DS) stated that the facility used Multi-Quat Sanitizer from Ecolab and that the solution in the red buckets should be changed every two hours or as needed. The DS reiterated that the solution should reach 200 ppm to prevent contamination and foodborne illness. A review of the facility's undated Policy and Procedure Manual confirmed that manual sanitizing should be accomplished with a solution of 200 ppm quaternary ammonium for one minute.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the call light was within reach for Resident 204, who had severe cognitive impairment and required total assistance for daily activities. Resident 204 was readmitted to the facility with diagnoses including abnormalities of gait and mobility, muscle wasting, and a contracture of the left hand. The resident's care plan specifically indicated that the call light should be within reach to mitigate fall risk and ensure timely assistance from staff. However, during an observation, the call light was found clipped to the pillow and not within the resident's reach. Certified Nursing Attendant 1 confirmed that the call light should have been within reach. The Director of Nursing also acknowledged that the call light needed to be within reach to maintain the resident's safety and ensure timely response to the resident's needs. The facility's policy and procedure on call lights, revised in January 2017, also stipulated that the call light should be within easy reach of the resident when in bed. This deficiency was identified through a combination of observation, interviews, and record reviews, highlighting a failure to adhere to established protocols designed to ensure resident safety and timely 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 obtain an informed decision from Resident 17's representative regarding payment for non-covered services after the resident was discharged from Medicare Part A. Resident 17, who was admitted with diagnoses including dementia and hypertensive heart disease, continued to reside in the facility after the last covered day of Medicare Part A services. The Business Office Manager (BOM) issued the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) but did not follow up to ensure the resident's representative was informed about financial responsibilities. The BOM mistakenly checked an incorrect option on the form and did not make a follow-up call to obtain an informed decision from the representative.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that its alternating pressure pad (APP) mattress was in good working condition for Resident 38. During an observation and interview, it was noted that the dial knob for weight adjustment on the APP mattress controller was missing. The Treatment Nurse (TX) confirmed that the dial knob should be set to the resident's weight to provide a comfortable and therapeutic bed surface for pressure ulcer (PU) management. Resident 38, who had a resolved PU, was at risk due to this missing component. The TX acknowledged responsibility for checking the APP and reporting any issues to the maintenance staff, but this was not done in this instance. Resident 38 was readmitted with diagnoses including dysphagia and ascites and had intact cognition and no impairments in upper or lower extremities. The facility's policy on general maintenance, revised in 2017, mandates daily maintenance and housekeeping services to ensure all functional equipment is in good condition. However, the missing dial knob on the APP mattress controller was not reported or repaired, potentially compromising the resident's skin management and PU prevention.

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 assess and monitor for the presence of sediments in the urine of a resident with an indwelling catheter, as required by the facility's policy and the resident's care plan. The resident, who was admitted with neuromuscular dysfunction of the bladder and had severe impaired cognition, had a care plan that included monitoring for signs and symptoms of UTIs every shift. However, during an observation, white sediments were found in the resident's urinary catheter tubing, and it was noted that the licensed nurses had not been monitoring the catheter every eight hours as required. During interviews, both the LVN and the DON confirmed that the presence of sediments indicated a potential UTI and that the catheter should be monitored every shift. The facility's policy on indwelling catheter use also required ongoing monitoring for changes related to potential catheter-associated urinary tract infections. The failure to monitor the catheter as per the care plan and facility policy had the potential to result in delayed care and treatment for a UTI for the resident.

Penalty

No penalty information released

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

Summary

The facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff. On the day of the recertification survey, the staffing information was posted inside nurse's station 1, which was not easily accessible for viewing by residents and visitors. The posted information inaccurately indicated that one RN worked eight hours during the morning shift, while in reality, the Director of Nursing (DON) only provided direct resident care for a limited time by administering antibiotics to two residents. The staffing information was also not posted in nurse's station 2. During an interview and record review, the Director of Staff Development (DSD) confirmed that the posted staffing information reflected projected hours rather than actual worked hours. The DSD acknowledged that the DON did not provide direct resident care for the full eight hours and that the staffing information should have been posted in a more accessible location. The facility's policy and procedures indicated that staffing information should include actual worked hours and be posted in a prominent place accessible to residents and visitors.

Penalty

No penalty information released

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

Summary

The facility failed to act upon the pharmacist's recommendations for medication regimen review (MRR) for one of five sampled residents. Resident 6, who was admitted with diagnoses including bacteremia and hypertension, was prescribed Miralax for constipation. The Consultant Pharmacist's Medication Regimen Review (CPMRR) indicated that Miralax should be administered two hours before or after other medications and with 8 ounces of water to avoid decreased absorption of other medications. However, the facility did not respond to the pharmacist's MRR within the required 72-hour timeframe, as confirmed by the Director of Nursing (DON) during an interview. The DON acknowledged that the MRR dated 3/8/2024 should have been acted upon by 3/11/2024 and reflected as a physician's order. The failure to follow up on the MRR in a timely manner was attributed to the facility's staff, which could potentially result in medication interactions and reduced effectiveness of the resident's medication. The facility's policy and procedure for Drug Regimen Review, revised in 10/2017, mandates that the DON must fax the pharmacist's recommendations to the attending physician, who must respond within 72 hours, or the licensed nurse must call the physician. This protocol was not followed in the case of Resident 6, leading to the identified deficiency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident on a psychotropic drug was free from unnecessary medication. Specifically, Resident 24, who was non-communicative and diagnosed with dementia and chronic kidney disease, was prescribed Lorazepam 0.5 mg twice daily for anxiety. The target behavior symptom for the anti-anxiety medication was verbalization of feeling anxious. However, Resident 24 was unable to express feelings of anxiety through verbalization or writing, making the indication and monitoring of the medication inadequate. During an observation, it was noted that Resident 24 was non-communicative and sitting in a wheelchair. The Licensed Vocational Nurse (LVN) stated that any sound made by Resident 24 was counted as verbalization of feeling anxious, despite the resident's inability to communicate effectively. The LVN acknowledged that the target symptom was inadequately indicated and monitored, and emphasized the importance of accurate monitoring to evaluate the medication's effectiveness and the potential for a gradual dose reduction. The facility's policy on psychotropic drug treatment indicated that unnecessary drugs are those used without adequate indications, which was the case for Resident 24.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the intravenous catheter (IV) site for Resident 254 was labeled with the date and time of insertion. Resident 254, who was admitted with diagnoses including metabolic encephalopathy, cellulitis, and a urinary tract infection, was observed with an IV in the left antecubital area that was dry and intact but lacked a label indicating the date and time of insertion. The resident mentioned that the IV was placed at the facility four days ago but could not recall the name of the nurse who inserted it. During an interview, the Director of Nursing (DON) confirmed that the IV site should have been labeled with the date, time, and initials of the nurse who inserted it. The facility's policy and procedures for Peripheral Venous Catheter Insertion, dated June 2018, also indicated that all dressings should be labeled with this information and documented in the medical record. The failure to label the IV site had the potential to result in an infection for Resident 254, which could worsen the resident's health 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 provide a minimum of 80 square feet per resident area for six of twenty-three resident rooms (Rooms 2, 8, 10, 11, 15, and 16). This deficiency was identified through observation, interview, and record review. The rooms in question did not meet the required space standards, with Room 2 having 286.92 square feet for 4 beds, and the other rooms having approximately 150 square feet for 2 beds each. Despite this, the facility requested a room waiver, stating that there was ample room to accommodate wheelchairs, medical equipment, and space for mobility and movement of ambulatory residents. The waiver request letter indicated that the rooms were adequate for nursing care and did not jeopardize the residents' health and safety or impede their ability to attain their highest practicable well-being. During observations and interviews, it was noted that the rooms had adequate space for nursing care, comfort, and privacy. Residents were observed to have enough space to move freely inside the rooms, and each resident had beds and bedside tables with drawers. Certified Nurse Assistant 1 and Licensed Vocational Nurse 2 both confirmed that there was enough space in the rooms to provide care and move wheelchairs and walkers without issues. Additionally, a resident interviewed stated that the room space was great and suitable for their needs.