Juniper Village - The Spearly Center

Penalty

No penalty information released

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

Summary

A deficiency occurred when staff failed to provide a safe environment free from accident hazards for a resident with severe cognitive impairment and a history of choking. The resident, who was prescribed a mechanically altered diet and required staff assistance and supervision during meals, was observed eating independently without supervision on multiple occasions. During these times, the resident was able to take large bites, eat inappropriate foods, and take food from other residents' plates, all without staff intervention. The resident's care plan specifically directed staff to assist with controlling the rate of eating, monitor bite sizes, and prevent the resident from stuffing food into his mouth. Despite these interventions being documented, staff did not consistently implement them. Observations showed that the resident was served food items not consistent with the prescribed diet and was not monitored to prevent access to other residents' food. Staff were also observed delivering food and then leaving the resident unsupervised, failing to ensure safe eating practices. Interviews with staff confirmed that the resident had a known tendency to grab food from others and put inappropriate items in his mouth, and that supervision was required during meals. However, staff were not always aware of previous choking incidents, and meal observations confirmed that the required supervision and care-planned interventions were not provided. This lack of supervision and failure to follow the care plan placed the resident at continued risk for further choking incidents.

Removal Plan

• Serve R77 food per the physician's ordered diet of a mechanical soft diet.
• The Certified Nurse Aide (CNA) and/or nurse will provide R77 with supervision during intake to ensure he is eating safely.
• Place R77 on safety checks due to his behavior of taking other residents' food that is not within his prescribed diet texture.
• Address any additional safety concerns or behaviors, document in the behavior log, and update the care plan with appropriate interventions.
• Review and update the care plan and interventions with every change of 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 implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to accident hazards and resident safety. Despite holding monthly QAPI meetings and daily interdisciplinary team discussions to review resident risks, the facility did not prevent repeat deficiencies or initiate adequate corrective actions for issues cited under F689 (Accident Hazards) and F867 (Quality Assurance Program) across multiple surveys. These deficiencies were cited at high levels of scope and severity, including immediate jeopardy to resident health or safety. A specific incident involved a resident with a known history of choking who was not provided with the required supervision and assistance during meal times, as outlined in their care plan. This failure to follow care planned interventions resulted in a situation where a serious adverse outcome was likely, rising to the level of immediate jeopardy. The facility's QAPI committee did not identify or address this lapse in supervision, contributing to the ongoing 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 menus were followed to meet residents' nutritional needs, specifically by not providing the correct portion sizes as outlined in the menu extensions. During a lunch meal observation, the dietary aide used a #12 scoop (1/3 cup) instead of the required #8 scoop (1/2 cup) for serving seasoned couscous and pureed seasoned couscous to residents on regular, mechanical soft, therapeutic, and pureed diets. Additionally, the aide used a partially filled #12 scoop for the vegetable blend, resulting in some residents receiving less than the prescribed 1/2 cup serving. At one point, only about 1/8 cup of vegetables was served due to running out of the vegetable blend, and couscous was omitted from a mechanically soft plate when it was unavailable. The dietary manager confirmed that the dietary aide should have used a full 1/2 cup scoop for vegetables and that the use of the #12 scoop was incorrect. The aide's actions were influenced by concerns about running out of food, leading to inconsistent and inadequate portion sizes. These deviations from the prescribed menu and portion sizes resulted in residents not receiving the nutrition as planned and required by their dietary orders.

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 food was prepared, distributed, and served under sanitary conditions in both the main kitchen and a nourishment refrigerator. Surveyors observed multiple food items in the main walk-in refrigerator and nourishment room refrigerators that were either unlabeled, undated, or stored past their safe use dates. Items such as half and half, pitchers of lemonade, hotdogs, hamburger patties, and various nutritional supplements were found without proper labeling or dating. Additionally, opened jars of jelly were left unrefrigerated despite manufacturer instructions to refrigerate after opening. During meal service, a certified nurse aide was observed preparing a sandwich in the nourishment room using bare hands to handle ready-to-eat foods, including bread, jelly, and peanut butter, without using gloves or utensils as required by food safety regulations. The dietary manager confirmed that this was not in accordance with facility policy or professional standards for food handling. The physical environment of the kitchen and nourishment rooms was also found to be unsanitary and conducive to pest harborage. Observations included open windows without screens, standing water on the dishwashing area floor, cracked or missing floor tiles, gaps between floors and walls, holes in walls, accumulated dirt, and the presence of dead cockroaches and ants. Glue traps containing numerous dead cockroaches were found, and ants were observed emerging from gaps in the baseboards. Maintenance and pest control records were requested but not provided.

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 an effective infection prevention and control program, as evidenced by multiple lapses in following Enhanced Barrier Precautions (EBP) and proper hand hygiene during resident care. During wound care for two residents with significant wounds, staff members, including a CNA, RN, Nurse Manager, ADON, and LPN, did not don gowns as required for high-contact care activities. In one instance, a Nurse Manager performed wound care on a resident's stage 3 pressure ulcer without wearing a gown, although she did perform hand hygiene and changed gloves between steps. In another case, both the ADON and LPN failed to wear gowns during wound care for a resident and did not change gloves after removing soiled packing from the wound, contrary to CDC guidelines. Staff interviews revealed a lack of awareness and training regarding EBP requirements, with some staff believing gowns were only necessary for wounds with resistant organisms or visible drainage. Housekeeping staff also failed to adhere to infection control protocols. During cleaning of a triple occupancy resident room, a housekeeper did not change gloves after cleaning the bathroom (a dirty area) before moving to clean areas within the same room. Additionally, high-touch surfaces such as door knobs, light switches, and call lights were not cleaned or sanitized during the observed cleaning process. The Maintenance Director confirmed that housekeeping staff were expected to change gloves between rooms and clean high-touch surfaces at least twice per week, but was unaware that gloves should be changed during the cleaning of a single room. These deficiencies were identified through direct observation, staff interviews, and record review. The lapses in following EBP, hand hygiene, and environmental cleaning protocols were not limited to isolated incidents but reflected a broader lack of consistent training and adherence to infection control standards among both nursing and housekeeping 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 ensure that residents and their representatives were given the opportunity to participate in the development and implementation of person-centered care plans. Specifically, for two residents with severe cognitive impairment, the facility did not invite their representatives to attend care conferences, nor was there documentation that such invitations were made. The facility's policy requires resident and, if agreed, family participation in care planning, with attendance to be documented in the medical record. For one resident with Alzheimer's disease, bipolar disorder, and other significant health issues, the representative reported not being contacted or invited to care conferences, and the medical record lacked evidence of any such communication or attendance. Similarly, for another resident with anoxic brain damage and dementia, the representative stated she had not been invited to care conferences for over a year, despite previously participating by phone. Record reviews for both residents showed that the sections for documenting representative attendance at care conferences were left blank, and there was no evidence in the electronic medical records that representatives were contacted for multiple care conferences. Interviews with facility staff indicated that while care conference schedules were communicated internally and residents were informed, there was no consistent process or documentation to show that representatives were notified or invited. Staff acknowledged that representatives could participate by various means, but could not provide documentation that this occurred for the residents in question. The lack of documentation and communication with representatives led to the deficiency in involving them in the care planning process.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely written notification and obtain proper consent for room changes for one resident, as required by both facility policy and federal regulations. The policy states that residents or their representatives must be given written notice and the opportunity to consent or appeal before a room change occurs, except in cases of safety. However, documentation showed that the required written notifications were either missing or incomplete for two separate room changes involving the same resident. The resident in question, an 81-year-old with diagnoses including bipolar-type schizoaffective disorder, borderline personality disorder, and muscle weakness, was cognitively intact at the time of the incidents. On one occasion, the resident was moved following a physical altercation with a roommate, with the move documented as being for safety reasons. However, the room change notification form did not indicate that the resident was provided written notification, nor did it include the resident's signature. On another occasion, the resident was moved again, with the form stating the move was at the resident's request, but there was no documentation of consent or the resident's signature, and no supporting notes in the electronic medical record. Interviews with facility staff confirmed that the process for room changes should include obtaining the resident's or representative's signature on a notification form prior to the move, and that this was not done in these cases. Staff also acknowledged that the facility had recently changed its documentation process and was attempting to catch up on missing forms, but the required notifications and consents were not properly documented at the time of the room changes.

Penalty

No penalty information released

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

Summary

The facility failed to develop a comprehensive care plan addressing the functional abilities and activities of daily living (ADL) for a resident with quadriplegia, legal blindness, encephalopathy, and chronic pain. The resident was under 65 years old, severely cognitively impaired, and fully dependent on staff for all ADLs, including toileting and hygiene. Despite being always incontinent of bowel and bladder, the care plan revised in March 2025 did not include a focus or interventions for the resident's quadriplegia or ADL needs. The Kardex lacked specific information about the resident's strengths and did not document ADL, toileting, or transfer needs. Interviews with staff, including CNAs, LPNs, and the DON, revealed that the resident was known to be totally dependent on staff for ADLs and required frequent repositioning and incontinence care. However, staff were unable to locate an ADL focus in the resident's care plan, and the DON confirmed that an ADL care plan was not present in the electronic medical record. The resident's representative reported that family members often provided hygiene care, indicating a gap in staff-provided care planning and execution.

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 treatment and care in accordance with physician orders and professional standards for two residents. One resident with a history of alcohol-induced persisting dementia, dermatitis, and psoriasis experienced ongoing issues with thick, scaly, and cracked skin on his hands. Despite multiple physician orders and dermatologist recommendations to switch topical medications, the facility did not timely discontinue the previous medication or initiate the newly prescribed treatment. Documentation showed that the resident continued to receive the discontinued medication, and the new order was not entered or administered as directed. Additionally, the resident's care plan did not address his skin conditions, and required consent forms for dermatology visits and procedures were missing from his record. Another resident, diagnosed with schizoaffective and depressive disorders, developed a generalized skin rash affecting multiple areas of her body. The rash was initially documented by staff, but there was a delay of several days before the physician was notified. The initial treatment order only addressed a limited area, despite the rash spreading to other regions. The referral to dermatology was not obtained until weeks after the rash was first noted and had extended to additional body areas. Interviews with staff revealed inconsistent awareness of the extent of the rash and incomplete communication regarding the resident's condition. In both cases, the facility did not ensure that physician orders were followed promptly or that care was provided in accordance with professional standards. There were lapses in communication, documentation, and timely implementation of prescribed treatments, resulting in residents not receiving appropriate care for their skin conditions as ordered.

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 treatment and services to prevent and treat pressure injuries for one resident, resulting in the development and progression of pressure ulcers. The resident, who had a history of major depressive disorder, dementia, hemiplegia, hemiparesis, and was dependent on staff for all activities of daily living, was identified as being at risk for pressure ulcers. Despite this, timely assessment and intervention were not provided after new wounds were discovered. Specifically, there was a delay in updating the care plan and implementing interventions such as an air mattress, Broda chair, and pain management, which were only added after the wounds had already developed and worsened. The facility did not provide timely wound care orders or notify key individuals, including the wound care provider and hospice, when new wounds were identified. For example, a deep tissue injury (DTI) to the resident's left heel was documented by the wound care provider, but no wound care orders were in place until several weeks later, after the issue was brought to the facility's attention during the survey. Similarly, a stage 2 pressure ulcer on the coccyx progressed to a stage 3 ulcer before the wound care provider was notified and appropriate interventions were implemented. Documentation also revealed inconsistencies in repositioning records, with the resident being left on his back for several hours on multiple days, despite being at high risk for pressure injuries and requiring frequent repositioning. Staff interviews confirmed that the resident was dependent on staff for repositioning and did not refuse care, contradicting claims that refusals contributed to the development of wounds. There was also a lack of thorough and accurate wound care documentation, and delays in notifying the physician and obtaining wound care orders. The facility's failure to follow its own policies and procedures for skin integrity assessment, timely intervention, and communication with the care team contributed to the resident's pressure injuries worsening.

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 hospice services provided to a resident met professional standards and principles, specifically regarding the accessibility and documentation of hospice care notes. According to facility policy and the hospice agreement, both the facility and hospice agency were required to maintain complete, accurate, and readily accessible clinical records for each resident receiving hospice services. However, for one resident receiving hospice care, the hospice communication binder and electronic medical record lacked documentation of hospice Certified Nurse Aide (CNA) visits and activities of daily living (ADL) care, as well as hospice nursing assessments. Only a single CNA note from a joint visit was present, and there was no verification of ongoing hospice CNA visits as outlined in the plan of care. The resident involved was over 65 years old, with multiple diagnoses including high blood pressure, psoriatic arthritis, depression, anxiety, dementia, a history of fractures, a stage 3 pressure ulcer, and cognitive impairment. The resident was dependent on staff for hygiene, bathing, transfers, and repositioning, and was receiving hospice services as documented in the minimum data set assessment. The hospice plan of care specified that a hospice CNA was to provide showers and other personal care twice a week, but the required documentation of these visits and care activities was missing from the records reviewed during the survey. Interviews with facility staff, including LPNs, CNAs, the Social Services Director, and the Assistant Director of Nursing, confirmed that hospice staff were expected to provide showers and ADL support to the resident. Staff reported that hospice CNAs checked in with facility nurses upon arrival, but also acknowledged that hospice CNA notes were not present in the facility's records and were being sought during the survey. The lack of accessible and complete documentation of hospice services constituted a failure to meet the standards required by facility policy and the hospice agreement.

Penalty

Fine: $175,555

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, who was severely cognitively impaired and impulsive with poor safety awareness, remained as free from accidents as possible. Initially assessed as not at risk for elopement, the resident exhibited escalating behaviors, including wandering and attempts to leave the facility, which were not adequately documented or addressed in the care plan. On the day of the incident, the resident eloped from the facility by following a staff member through an emergency exit door that was not properly secured, leading to the resident being found deceased two days later. Staff interviews revealed a lack of consistent documentation and understanding of the resident's supervision needs. Despite the resident's known behaviors, there was conflicting information among staff regarding the level of supervision required, and no interventions were documented to minimize the resident's safety risk beyond administering psychotropic medication. The facility's elopement assessment process was not effectively implemented, as the resident's wandering behaviors and attempts to leave were not documented or addressed in a timely manner. Additionally, the facility failed to take adequate steps to prevent further elopements after the incident. During a survey, it was observed that a door to the boiler room, which led to an outside exit, was left unlocked and unsecured, providing potential access for residents to elope. This oversight, along with the initial failure to secure the emergency exit door, contributed to a situation of immediate jeopardy for the residents' safety.

Removal Plan

• The boiler door was locked by the NHA.
• No other doors in the community were found to lead to an exit. The boiler room was verified to be secured by the NHA.
• The maintenance director or a designated team member will conduct daily verification of the boiler door lock each morning. All checks will be documented in TELS.
• Staff were educated that locked doors need to be locked at all times sent via SmartLinx messages. The NHA reviewed the SmartLinx report to verify that all staff received the education.
• Signs were placed on the boiler room door stating this door to be always locked.
• Education was provided to staff about the elopement procedure and wandering interventions. The staffing coordinator and director of nursing provided the education. The education is recorded on a training sign in sheet.
• The social services director reviewed the most recent elopement assessments for all residents to ensure those residents identified as at risk for elopement have interventions in place to prevent elopement.

Penalty

Fine: $175,555

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 Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to accidents and resident safety. This deficiency was highlighted by the failure to prevent an elopement incident involving a resident who left the facility by following a staff member through an emergency exit door. The staff member did not adhere to the 15-second rule, which requires waiting for the door to lock after exiting, and failed to check if anyone was following. This oversight led to the resident being found in critical condition two days later, approximately ten miles away from the facility, and subsequently passing away in the hospital. The facility's regulatory record showed repeat deficiencies in the area of accidents and hazards, with previous citations for similar issues. Observations during the survey revealed that the boiler room door and an additional door leading outside were unlocked, further compromising resident safety. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) indicated that while some assessments and discussions were conducted, there were significant gaps in documentation, monitoring, and communication regarding residents at risk for elopement. These deficiencies contributed to the immediate jeopardy situation, with widespread potential for serious harm to residents.

Removal Plan

• Staff member and all other staff in the building were educated and reminded to wait 15-seconds after exiting through the emergency exit doors.
• Signs were placed on all doors throughout the building as a reminder to staff.
• Education for all staff to ensure they were aware of residents at risk for elopement on all units.
• Binders were created with pictures and care plans of residents who were identified as at risk for elopement, located at the nurses station.
• All staff were educated on specific interventions that were in place and the location of the binders.
• Corrective action in response to Resident #1's elopement.
• Education to all staff on ensuring exit alarms reengaged before walking away doors.
• Protocol was initiated to share information between units on residents unable to leave units.

Penalty

Fine: $21,615

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

Summary

The facility failed to ensure that a resident's lower extremities were handled appropriately during a Hoyer lift transfer, resulting in bilateral distal femoral fractures. The resident, who was non-weight bearing and had a history of osteoporosis, was being transferred from her bed to a wheelchair using a split leg sling. This type of sling required the straps to be placed under and crossed around the thighs, which caused pressure and external rotation on the resident's thighs during the transfer. This improper handling was consistent with the location of the fractures sustained by the resident. The incident occurred when the resident was being lowered into her wheelchair, and a popping noise was heard, followed by the resident's complaints of pain in her lower extremities. Despite being evaluated by nursing staff and given pain relief, the resident continued to experience pain, leading to a physician's notification and an x-ray that confirmed a fracture in the right femur. The resident was subsequently transported to the hospital, where it was discovered that she had fractures in both femurs, necessitating surgical intervention. Interviews with staff involved in the transfer revealed that the resident typically complained of pain during transfers, but the severity and persistence of the pain on the day of the incident were unusual. The facility's investigation identified that the placement of the sling straps during the transfer was a contributing factor to the fractures. The resident's care plan did not initially include the use of a full body sling, which was later identified as a necessary intervention to prevent similar incidents in the future.

Removal Plan

• Conduct an investigation of Resident #2's accident.
• Interview all staff on duty involved in care for the resident on the day of the accident.
• Implement the use of a full body sling for Resident #2 during Hoyer transfers to prevent pressure on the lower extremities.
• Report the resident's transfer injury to the sling manufacturer.
• Complete an audit to identify other residents at risk due to using the Hoyer lift for transfers and assess them for appropriate Hoyer lift slings.
• Re-educate nursing staff on Hoyer lift safety and the use of full body slings.
• Ensure the IDT, DON, and ADON are responsible for identifying and ensuring all residents requiring Hoyer lifts have the appropriate sling.
• Provide education and reeducation to all nursing staff on the correct use of Hoyer lifts and full body slings.
• Order additional full body slings to maintain a sufficient par level.

Penalty

Fine: $66,255

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 evacuation plan for residents in case of an emergency, affecting the safety of all 130 residents. Observations and interviews revealed that emergency exits led to outdoor courtyards with gates secured by padlocks and a C clamp, which staff were unable to unlock or remove. Staff were unaware of the evacuation process and lacked access to necessary keys or tools, creating a hazardous environment with potential for serious harm. Additionally, the facility failed to prevent a fall with injury for a resident with known cognitive and functional limitations. The resident, who was severely cognitively impaired, fell from her wheelchair and sustained injuries. The facility did not conduct a comprehensive investigation or implement effective fall interventions, deeming the incident a behavior rather than a fall. Interviews with staff confirmed a lack of training and understanding of evacuation procedures and fall prevention measures. The facility's policies and procedures were not effectively communicated or implemented, contributing to the deficiencies observed.

Removal Plan

• All padlocks have been removed. C clamp was removed. The consultants provided interdisciplinary team (IDT) members training and education on never placing padlocks on emergency egress gates.
• The ESD and consultants completed a walkthrough of the community. Verified all locks were removed. Recommendations were made to change the layout of primary exit doors. The ESD updated the emergency exit floor plan to reflect the necessary changes to the emergency exits. Additionally, the ESD updated the emergency exit signage and removed emergency exit signs that will no longer be emergency exits. All staff were re-educated on looking for emergency exit signs and new emergency exits.
• The community is purchasing a new emergency preparedness (EP) manual. The consultants will provide education and training with the NHA/ESD on the content of the EP manual.
• All community staff (IDT members, licensed nursing, nursing assistants, dietary, housekeeping/maintenance) have been educated on the procedure to evacuate a resident in case of an emergency. Specifically, staff received additional training and education on the following: Evacuation Procedure - 1. Staff members have been trained to pull fire alarm in the event of an emergency that would require potential evacuation / call 911. 2. Designate staff member to complete and maintain resident tracking 3. Evacuation exit doors /community evacuation floor plan 4. Phases of evacuation including Phase 1 ambulatory Phase 2 wheelchair dependent Phase 3 bed bound.
• The community ordered five evacuation sleds for emergency exits with stairs. The emergency sled will be stored in the stairwell. When the sleds arrive the ESD will provide education and training with staff on how to use the emergency sleds. In the meantime, the ESD trained community staff on the use of a mattress to transport wheelchair or bed bound residents.
• All community staff (IDT members, licensed nursing, nursing assistants, dietary, housekeeping/maintenance) have been educated on the location of the disaster preparedness binders and where to find them. All departments have been provided the education with signatures.
• When the new emergency manual arrives the community will remove old manuals.
• The ESD /NHA confirms no other doors or exits have physical barriers. All secured /locked evacuation routes can be quickly opened to safely evacuate residents.
• Emergency doors will be checked daily by the ESD or designee for functioning and accessibility. The ESD or designee will check the emergency door weekly for a month and report to the QAPI committee for review and recommendations. Recommendations made by the QAPI committee will be executed by the ESD or designee.
• Facility staff will continue to be trained on evacuation routes and procedures monthly during scheduled drills.
• The IDT team will complete visual door checks on emergency exits to ensure there are no barriers present daily. The checks will be documented on an audit sheet. These visual checks will be conducted daily for 30 days. Findings of the audits will be reported to the QAPI committee for review and recommendations. The Administrator will be responsible to execute findings of the QAPI committee related to ongoing audits and frequency of the audits.
• Emergency Preparedness will be reviewed monthly in QAPI and Safety Committee monthly for three months and quarterly thereafter.

Penalty

Fine: $66,255

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

Summary

The facility failed to provide an environment that supported and enhanced the dignity, self-worth, sense of satisfaction, and control over the lives of residents residing on the second and third floors. Observations and interviews with residents and staff revealed practices that disregarded residents' quality of life and were inconsistent with the facility's Resident Rights policy. Residents reported restrictions on their day-to-day lives, such as limitations on meeting without staff at Resident Council, accessing personal funds, moving freely within the facility, choosing dining options, having visitors, participating in social activities, and communicating privately by phone and mail. Observations confirmed these restrictions, showing that staff were not responsive to call lights, contributing to residents feeling neglected. Residents lacked access to information on outside assistance and survey results. Specific incidents included residents being limited to one soda per day, having to use plastic cutlery, and being restricted to certain floors. Residents expressed feelings of being jailed, trapped, and angry due to these limitations. Interviews with residents further highlighted their concerns, such as the inability to make private phone calls, restricted visitation hours, and limited access to personal funds. Some residents reported feeling trapped and unable to leave their floors without an escort. The facility's practices created an immediate jeopardy situation with the likelihood of serious harm if not immediately corrected.

Removal Plan

• Residents will be asked before each Resident Council whether they would like staff to attend the meeting or not. Residents are able to meet without staff present.
• A new Resident Council Form was implemented to include the question about staff attendance and the resident's response. The resident's response will be documented in the minutes of each Resident Council Meeting.
• Resident Council Meeting Minutes will be reviewed during QAPI to ensure compliance.
• Postings were updated with the correct contact information and are located in each neighborhood at wheelchair level.
• Postings will be monitored by the Leadership Team to ensure they are in place and at the proper level.
• Survey Results Binder is located in the Front Lobby on the first floor, containing surveys. Residents have access to the Survey Results independently.
• NHA or designee will update the binder with all annual and complaint surveys moving forward and ensure that the binder is in place.
• Resident #8's care plan was updated to include guardian input and court-ordered placement stipulations regarding movement throughout the community.
• A Resident Preferences Interview was conducted with Resident #8, and her care plan was updated to reflect her preferences.
• Resident #8's preferences will be updated as needed, and the community will maintain contact with resident's guardians for further care plan revisions and as needed.
• All residents are encouraged to eat in the dining areas. If a resident chooses to eat in their rooms, a room tray will be provided.
• The kitchen is open. If a resident misses a meal, they can request food or a tray during these times.
• Snacks are available in the neighborhoods.
• Dining Services will be reviewed with the Food Committee.
• Residents can purchase and/or request soda any time they wish. Residents on the second floor will have soda served to them in a disposable cup for safety.
• The use of disposable cups for soda will be discussed during the second floor Resident Council meetings.
• There is a cordless phone at the Nurses' Station in each neighborhood, available to all residents for private conversations.
• There are also stationary resident phones located throughout the community, and a private phone in the Town Hall Room on the first floor.
• The use of cordless phones will be discussed during the Resident Council Meetings for each neighborhood.
• Residents on the second floor will utilize plastic cutlery for safety. This information is located in the Resident Handbook for all admissions to the second floor.
• The use of plastic cutlery will be discussed during the Resident Council Meetings for the second floor.
• Visiting hours are twenty-four hours per day. Visitors may be asked to leave items in a locker if there are concerns about contraband.
• All responsible parties were notified of the visiting hours policy.
• Elevator operates and residents have access to it at all times.
• Elevator availability will be discussed during the Resident Council Meetings in each neighborhood.
• The facility will continue to follow the CDPHE directed plan regarding safe smoking.
• Resident smoking abilities are assessed, and care plans are updated accordingly.
• Mail is delivered if/when received from the USPS, and will be delivered by the Leader on Duty.
• The community follows regulations regarding resident's personal needs accounts, ensuring access to $100.00 ($50.00 for Medicaid residents) in cash within a reasonable period.
• Assessments and behavior care plans are developed and created on a resident-specific and individualized basis.
• A Resident Preferences Questionnaire has been completed, and residents have been interviewed regarding all of the above topics.
• All above items will be reviewed in QAPI and Safety Committee.

Penalty

Fine: $66,255

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 meals served to residents were consistent with the posted daily menu, which did not meet the residents' nutritional needs. During a resident group interview, several residents expressed that the meals served rarely matched the posted menu, noting a lack of variety and specific items like mashed potatoes and gravy. Observations over three consecutive days revealed discrepancies between the posted menus and the meals served. For instance, on one day, the menu listed barbeque beef brisket and hot German potato salad, but residents received mashed potatoes instead, and soup was not served. Similarly, on another day, the menu indicated grilled chicken with onions and cheesy potato casserole, but the chicken was baked without onions or gravy, and mashed potatoes were served instead. The dining services manager (DSM) explained that the facility's corporate office created the menus, and any changes were authorized by her. The DSM stated that the menus were reviewed by a registered dietitian and that changes were only made if a product was unavailable from a vendor. Despite this, the DSM claimed not to have received any resident complaints about menu changes without prior notice. The facility's failure to adhere to the posted menus and provide the expected meals led to dissatisfaction among residents and a failure to meet their nutritional needs.

Penalty

Fine: $66,255

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 sanitary conditions in the kitchen, as evidenced by several observations and staff interviews. Food temperatures were not consistently monitored or maintained at safe levels. During meal service, dietary staff did not take food temperatures before serving, and several food items were found to be below the required hot holding temperature of 135 degrees Fahrenheit. Despite knowing the correct temperature standards, staff served food that was not reheated to the appropriate temperature, posing a risk to resident safety. The physical condition of the kitchen was also found to be unsatisfactory. Observations revealed missing and broken tiles in the kitchen and dry storage areas, which were visibly dirty and coated with a dark substance. The floor of the walk-in refrigerator was particularly deteriorated and uncleanable, indicating a failure to maintain a clean and sanitary environment as required by professional standards. Additionally, the facility did not ensure proper handling of kitchen equipment and utensils. A can opener was found with dried food residue, and staff were observed handling cups and silverware inappropriately, touching surfaces that come into contact with residents' mouths. These practices were contrary to established guidelines for preventing contamination and ensuring food safety, as confirmed by staff interviews.

Penalty

Fine: $66,255

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 Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, which resulted in deficiencies related to the quality of life and accident/hazards. The QAPI committee did not identify or address issues concerning the environment that should support and enhance each resident's quality of life. This oversight led to a situation of immediate jeopardy, where a serious adverse outcome was likely due to the cumulative effect of noncompliance. Additionally, the facility did not have a system in place to ensure staff followed the emergency evacuation procedures, which included physical barriers such as locks that prevented staff and residents from evacuating the premises. This failure also rose to the level of immediate jeopardy, creating a situation where a serious adverse outcome was likely. The facility's policy required a data-driven QAPI program focused on care outcomes and quality of life, but the committee did not previously identify these concerns. Interviews with the medical director and nursing home administrator revealed that while the QAPI committee met monthly and reviewed various reports and data, they had not previously identified concerns related to quality of life or accidents/hazards. The medical director, who attended QAPI meetings and provided oversight, was informed of the immediate jeopardy situations and suggested steps to address them. However, the QAPI committee had not included these issues in their reviews, indicating a gap in the facility's quality assurance processes.

Penalty

Fine: $66,255

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 four residents were kept free from abuse, specifically failing to implement person-centered interventions to prevent resident-to-resident altercations. Resident #118 entered Resident #32's room and laid in her bed, leading to a physical altercation when Resident #32 asked him to leave. Both residents were placed on 15-minute checks, but their care plans were not updated with person-centered interventions to prevent future incidents. Additionally, Resident #118 had a history of behaviors directed towards staff and residents, which was not adequately addressed in his care plan following the incident. Another incident involved Resident #49 and Resident #90, where Resident #49 gestured offensively to Resident #90, who responded by slapping Resident #49. Both residents were assessed for injuries and placed on 15-minute checks, but their care plans were not updated with interventions to prevent future altercations. Resident #49 had a history of behaviors that provoked peers, and despite recommendations, he was not referred to a community mental health provider. Staff interviews revealed that resident-to-resident altercations were discussed in daily meetings, but interventions were not consistently documented in care plans. The Director of Nursing (DON) and other staff members indicated that behaviors and interventions were often communicated verbally rather than being formally documented. This lack of documentation and follow-through on recommended interventions contributed to the facility's failure to protect residents from abuse.

Penalty

Fine: $66,255

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 residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility did not have the required documentation to justify the placement of these residents in a secure locked unit. The residents involved had varying degrees of cognitive impairment and other medical conditions, but the facility did not perform the necessary pre-admission evaluations, obtain physician's orders, or create care plans for secure unit placement. Additionally, ongoing evaluations for the necessity of secure unit placement were not documented in the residents' electronic medical records (EMRs). Resident #118, who had severe cognitive impairment and multiple diagnoses including PTSD and Alzheimer's disease, did not have any documented evidence of wandering behavior or a physician's order for secure unit placement. Similarly, Resident #126, with moderate cognitive impairment and multiple mental health diagnoses, did not have a completed elopement risk evaluation or a care plan focus related to secure unit placement. Resident #121, who had mild cognitive impairment and no mental health or dementia diagnoses, was also placed in the secure unit without proper documentation or justification. Other residents, such as Resident #115, who was cognitively intact but had a high risk of wandering, and Resident #72, who had severe cognitive impairment, were also placed in the secure unit without the necessary assessments and documentation. Staff interviews revealed inconsistencies in the facility's procedures for secure unit placement, with some staff members unable to locate justification for the placements in the residents' EMRs. The facility's social services director, assistant director of nursing, director of nursing, nursing home administrator, and medical director all provided varying explanations for the secure unit placements, but none could provide the required documentation to justify the restrictions placed on these residents.

Penalty

Fine: $66,255

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

Summary

The facility failed to ensure proper disposal of garbage and refuse, as observed in the dumpster area located in the west-facing alley accessible from the main kitchen. On multiple occasions, the dumpster lids were found open, and trash bags were left on the ground beside the dumpster. These observations were made over several days, indicating a consistent issue with maintaining the cleanliness and security of the waste disposal area. The open lids and scattered trash could potentially attract pests and insects, as the facility's pest control invoices documented ongoing issues with cockroach and rodent activity. Interviews with staff revealed a lack of clarity regarding responsibility for maintaining the dumpster area. The dining services manager indicated that various departments used the dumpsters, but there was no clear assignment of responsibility for ensuring the lids were closed and the area was kept clean. The manager was unaware that it was the kitchen staff's responsibility to maintain the area, and there was uncertainty about when staff were last trained on these procedures. This lack of clear responsibility and training contributed to the deficiency in waste management practices.

Penalty

Fine: $66,255

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 satisfactory resolution to a resident's grievance regarding missing blue prescription glasses. The resident, who had multiple diagnoses including dementia and Parkinson's disease, was admitted with glasses as documented on the admissions inventory list. Despite multiple communications from the resident's representative, the facility did not address the missing glasses adequately. The resident's representative filed a written grievance, but the facility's response did not resolve the issue of the missing blue prescription glasses, and the grievance form was incomplete. The resident's representative reported that the facility mailed plastic reader glasses that did not belong to the resident and failed to replace or reimburse the missing blue prescription glasses. The facility's grievance policy required a status report within two business days and a resolution within seven working days, but these timelines were not met. The facility's records and communications showed attempts to address other missing items but did not provide evidence of resolving the issue of the blue prescription glasses. Interviews with the NHA and SSD revealed that the facility did not follow its grievance policy and failed to provide a satisfactory resolution. The NHA acknowledged that the facility mailed a second box to the resident but did not provide evidence of its contents. The SSD confirmed that items listed on the inventory list that were not returned should be reimbursed, but this was not done for the blue prescription glasses. The facility's failure to address the grievance promptly and adequately led to the deficiency.

Penalty

Fine: $66,255

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 thoroughly investigate an allegation of neglect involving a resident who sustained second-degree burns on her thighs. The resident, who was cognitively intact and dependent on staff for personal care, was readmitted to the facility and given a shower the following morning. Later that night, staff discovered blisters on her thighs, and the resident called 911 to be taken to the hospital, where she was diagnosed with partial thickness burns and transferred to a burn center for treatment. The facility's investigation was inadequate. The Director of Nursing (DON) conducted what he referred to as a 'soft investigation,' which lacked thoroughness and did not follow the facility's policy for investigating allegations of neglect. The investigation failed to interview the CNA who performed the shower, did not monitor water temperatures regularly, and did not interview other residents and staff regarding the water temperatures and the burns. The DON assumed that Adult Protective Services (APS) would handle the investigation and did not continue further. Interviews with staff revealed gaps in the facility's procedures. The CNA who showered the resident did not use a thermometer to check the water temperature, relying instead on her hand. The Environmental Service Director (ESD) stated that water temperatures were checked weekly but was unaware of any specific actions taken following the incident. The facility did not have a formal investigation form, and the DON did not pursue a thorough investigation, leading to a failure to determine the cause of the resident's burns.

Penalty

Fine: $66,255

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 residents on one of its units had the right to a dignified existence by not answering call lights in a timely manner. The facility's policy requires prompt response to call lights, but observations and interviews revealed significant delays. During a resident group interview, several residents reported waiting over an hour for assistance, with one resident waiting an hour and 45 minutes. Another resident expressed concerns about her call light not working, although it was observed to be functional during the survey. Observations showed that call lights were left unanswered for extended periods, with staff members either unaware or unresponsive to the alerts. On multiple occasions, call lights were activated without any staff response, despite staff presence nearby. Interviews with staff indicated that the audible alert system was not functioning effectively, as the sound was too low to be heard. The nursing home administrator was unaware of this issue and stated that staff were expected to respond to call lights within seven minutes.

Penalty

Fine: $66,255

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 trauma-informed and culturally competent care for two residents, both diagnosed with PTSD, among other conditions. Resident #118, a 73-year-old with severe cognitive impairment, was admitted with diagnoses including PTSD, Alzheimer's disease, and bipolar disorder. Despite having an active diagnosis of PTSD, the facility did not conduct a trauma assessment or develop a care plan addressing his PTSD, triggers, or personalized interventions. The resident exhibited behaviors such as refusing meals, expressing suicidal ideations, and becoming agitated and aggressive, which were not adequately addressed due to the lack of a trauma-informed care plan. Resident #126, over the age of 65, was admitted with diagnoses including bipolar disorder, dementia, PTSD, and anxiety disorder. The facility also failed to conduct a trauma assessment or develop a care plan for this resident's PTSD. The resident required supervision and assistance with ADLs and had a moderate cognitive impairment. Despite a referral from the VA indicating a PTSD diagnosis, there was no care plan focus on PTSD, and no trauma screen was found in the resident's electronic medical record. Interviews with facility staff, including the DON and an LPN, revealed that the facility was not conducting PTSD assessments or initiating care plans for residents with known PTSD diagnoses. The DON acknowledged the importance of such assessments and care plans in providing person-centered care and reducing the risk of retraumatization. The lack of trauma-informed care plans for these residents indicates a deficiency in the facility's approach to managing residents with PTSD.

Penalty

Fine: $66,255

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 drugs and biologicals were stored in accordance with professional principles, specifically by not keeping medication carts locked when unattended. During an observation, a medication cart on the east side of the second floor was found unlocked and positioned in the dining room next to the nurse's desk. The LPN seated at the nurse's desk was facing away from the cart, and several residents were walking around the area. The LPN acknowledged that the facility policy required the cart to be locked at all times to prevent unauthorized access, but admitted that when focused on the computer screen, the cart was not fully within their line of sight. Further observations revealed that the same medication cart was left unlocked and unattended while several residents were present in the dining room. An unidentified CNA was nearby, distracted by a cell phone. The LPN admitted to leaving the cart unlocked while assisting a resident in the shower room, acknowledging the high-risk nature of the resident population. The DON confirmed that the facility required medication carts to be locked when not attended by a licensed nurse, especially given the behavioral health concerns of some residents on the second floor.

Penalty

Fine: $66,255

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 staffing information was posted in a prominent place and updated daily, as required. Observations on multiple occasions revealed that the staffing information was either outdated or did not reflect the current census. For instance, on 5/14/24, the posted staffing information was dated 4/21/24, and on 5/19/24, it was dated for the previous day. Additionally, the posted census numbers were incorrect, showing 122 instead of the actual 130 residents. Interviews with staff revealed confusion and miscommunication regarding the responsibility for posting staffing information. The Social Services Director indicated that the postings were placed too high for residents in wheelchairs to read. The Nursing Home Administrator explained that the staffing coordinator, who was new to the position, was responsible for the postings, but prior to their start, another staff member handled this task. On weekends, the concierge was tasked with posting the information. The administrator acknowledged that the information should be updated daily, sourced from the daily staffing report produced by the scheduling department.