Mountain Vista Health Center

Penalty

No penalty information released

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

Summary

The facility failed to ensure that medications and biologicals were stored and labeled according to accepted professional principles in three medication carts and two medication storage rooms. Surveyors found discontinued medications left in resident-specific drawers on medication carts, including mirtazapine and levothyroxine for one resident, Xarelto for another resident, and benzonatate for a third resident. An ondansetron tablet was also found in a medication cart after its expiration date, and one inhalation solution in a cart did not have an expiration date visible. Surveyors also found multiple expired medications and supplies in medication storage areas. In the secured unit medication storage room, there were pre-filled normal saline flush syringes that had expired years earlier, ceftriaxone vials that had expired, and an emergency medication supply box that had expired in March 2026 and contained insulin products and other emergency medications. In the 200 unit medication storage room, the refrigerator contained Basaglar KwikPens that had expired in September and October 2025, and Lumigan eye drops that had expired in November 2025. In addition, a 16-ounce bottle of Drug Buster, an activated charcoal-based disposal system for unwanted medications, was stored in the same drawer as liquid medications on a rehabilitation unit medication cart. Staff interviews showed nurses stated they were responsible for checking expiration dates and removing expired medications, while the DON stated medications should be discarded immediately if discontinued and that night supervisors should check medication storage rooms weekly. The DON also stated the night supervisors did not understand her instructions and that education and training would be initiated.

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 16 residents on mechanical soft diets received food and fluids prepared in a form consistent with their diet orders, speech therapy recommendations, and care plans. During dinner meal service, residents whose meal tickets documented mechanical soft diets were served a whole grilled tuna melt sandwich cut in half rather than the documented ground grilled tuna melt sandwich, and sweet potato rounds were served fried or otherwise not prepared as listed on the mechanical soft menu extensions. The facility’s mechanical soft diet description and recipe guidance did not clearly define the required consistency, and the tuna melt recipe did not specify what the desired consistency should be. During direct observation, cooks assembled multiple meal trays for residents on mechanical soft diets that included whole grilled tuna melt sandwiches cut in half and sweet potato rounds. Staff stated the sweet potatoes in hot holding were frozen rounds and were fried, and later said the facility ran out of sweet potato rounds and substituted canned sweet potato for a mechanical soft diet backup. A test tray for a mechanical soft diet was also evaluated and contained a whole grilled tuna melt sandwich cut in half and canned sweet potato; surveyors noted the edges of the tuna melt sandwich were hard and crumbly. Record review showed the facility’s menu extensions called for a ground grilled tuna melt sandwich, four-ounce sweet potato rounds, soft fruit, and banana pudding, but the recipe binder did not contain the tuna salad recipe for the meal served. Staff interviews indicated cooks relied on training and experience to modify textures, and the dietary manager said the facility did not use IDDSI diets and instead treated an IDDSI EC7 paper as the mechanical soft diet. The dietary manager also stated that for alternate menus there was no reference in the menu program, so texture modifications were created based on his experience.

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 prompt efforts were made to resolve grievances related to call light response times for two residents. The grievance policy stated that the Administrator and staff would make prompt efforts to resolve grievances to the satisfaction of the resident or representative, and the call light policy required staff to answer call lights as soon as possible and document issues affecting use of the system. Interviews and record review showed that both residents had submitted written grievances about prolonged delays in receiving assistance after activating call lights or other alert devices. Resident #71, who was cognitively intact and had diagnoses including type 2 diabetes mellitus, necrotizing fasciitis, and depression, reported that call lights had gone unanswered for long periods over several weeks. In the grievance form, the resident described going out of his room to seek help from CNAs who were on their phones, being passed from one CNA to another, and not being offered assistance. The grievance follow-up documented that staff were instructed to answer all call lights timely and that the iPads were checked and found to be working properly. However, the resident stated that long call light wait times continued after the grievance was filed. Call light logs for the resident showed repeated delays, including multiple activations not answered for 20 to 39 minutes, 40 minutes to one hour, one hour and one minute to one hour and 30 minutes, and over one hour and 30 minutes. Resident #86, who was cognitively intact and had diagnoses including hypertensive heart disease, peripheral vascular disease, polyneuropathy, personality disorder, and bipolar disorder, filed a grievance about waiting for help to get to the bathroom and being left in a soiled brief for an extended period. The resident wrote that she pressed the call button and pulled the bedside string without response, waited through dinner and into the evening, and remained in her brief while staff were busy with other tasks. She also described repeated failures of staff to respond to her bell and stated that some staff would not assist her because she was not on their list. Although the grievance form was later marked as satisfied, the call light log still showed numerous unanswered activations after that point, including delays of 20 to 39 minutes, 40 minutes to one hour, one hour and one minute to one hour and 30 minutes, and over one hour and 30 minutes.

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 infection control program for residents on enhanced barrier precautions, housekeeping disinfection procedures, and transmission-based precautions. For one resident on enhanced barrier precautions because of a catheter, two CNAs entered the room and provided catheter care, cleaned the resident’s face, and placed belongings within reach without putting on gowns before providing care. The room had PPE supplies and signage for enhanced barrier precautions, and the infection preventionist stated staff should have donned proper PPE before direct care activities. Housekeeping staff also failed to follow the facility’s cleaning and disinfection procedures for resident rooms and high-touch surfaces. In one double-occupancy room, a housekeeper sprayed disinfectant onto green rags and wiped door knobs, light switches, and bedside tables, but the surfaces were not visibly wet for the required dwell time. Call bells in the room were not cleaned during the observed cleaning. In another observation of the same type of room, a housekeeper did not clean the call bells. Staff interviews showed that housekeepers used different techniques, including spraying cloths instead of surfaces, and that call lights were sometimes only cleaned during deep cleans. The facility also failed to ensure PPE was worn for a resident on transmission-based precautions for contact and droplet precautions due to rhinovirus. Signs outside the resident’s door indicated that staff and providers must clean their hands and wear gloves, gowns, and face protection before entering. A CNA entered the room twice to deliver meals without performing hand hygiene or wearing a gown, gloves, or face protection. The resident stated staff told her she had tested positive for rhinovirus and that sometimes staff did not put PPE on. Multiple staff members and the IP confirmed that gown, gloves, and a face mask were required before entering the room.

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 certified nurse aides received the required 12 hours of annual in-service training for continued competence. Based on record review, CNA #2, hired on 3/13/24, had completed only 3 hours of the required 12 hours of continuing education units, and CNA #3, hired on 5/16/24, had completed only 7 hours of the required 12 hours on the facility’s education platform. The facility also provided other in-service documentation, but the contact hours for those sessions could not be determined because the documentation did not include contact time. The facility’s policy stated that it would provide at least 12 hours of in-service training annually based on employment date and that documentation would be maintained in the employee file. During interview, the staff development coordinator said CNAs were required to complete a minimum of 12 hours of CEU per year and that the facility used both an education platform and in-service training during staff meetings, but she was unable to locate or provide contact hours for the in-services given at those meetings. The DON stated that completing the 12 hours of CEUs was important for job safety and 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 conduct a thorough investigation and provide complete documentation regarding an incident of physical abuse involving two residents. According to the facility's own Abuse, Neglect and Exploitation policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying and interviewing all involved persons and witnesses, and documenting the findings. However, after an altercation in the dining room where two residents kicked each other, the facility's investigation did not identify or interview all staff and resident witnesses, nor did it document their statements. The investigation noted that both residents involved had a history of aggressive behaviors, and that staff and another resident witnessed the incident. Despite this, there was no documentation of interviews with the residents involved or with the witnesses. One resident witness, who was alert and oriented, reported that she was present during the altercation and that a dietary staff member intervened, but stated that no one from the facility interviewed her about the incident, even after the police had spoken with her. Staff interviews confirmed that key witnesses, including the dietary aide who separated the residents and the resident witness, were not interviewed as part of the facility's investigation. The social service assistant acknowledged not interviewing all involved parties, and the current nursing home administrator stated that all witnesses should have been interviewed but were not. The facility's documentation and investigative process did not meet the requirements outlined in its own policy, resulting in an incomplete investigation of the abuse incident.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper sanitation and food safety practices in the main kitchen, as evidenced by multiple observations during a kitchen tour. Surveyors found that the kitchen was not clean or sanitary, with greasy and dusty vents, a yellow puddle of unidentified liquid under a shelf, and used aprons stored next to clean dishes. Additional issues included shelves covered in dust and sticky residue, an uncovered trashcan with food splatters, greasy and dirty equipment, a leaking sink, and various appliances with caked-on food and grime. The ice machine, coffee machine, and juice machine were also found to be dirty, and there was a buildup of dark substances on baseboards and drains throughout the kitchen. Further deficiencies were noted in the storage and handling of food items. Surveyors observed two dented cans of tuna and one dented can of mushrooms stored on a shelf in the dry storage area, rather than being removed and segregated as required by food safety regulations. Staff interviews confirmed that these cans should have been removed from storage and either discarded or returned to the vendor, but this procedure was not followed. Additionally, the facility failed to ensure that food items were properly labeled and dated. Several opened or repackaged food items, including a container of dark brown food, a jar of jalapenos, a bag of pancake mix, a plate of carrots, a container of taco shells, a package of pepperoni, and a tray of lettuce, were found without labels or dates in the dry storage and refrigerators. Staff acknowledged that all food should be labeled with the name and date, and that unlabeled items should be discarded, but this was not consistently done.

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 its resources effectively and efficiently, leading to several deficiencies in resident care and safety. There was a lack of sufficient leadership to address and prevent multiple concerns, including the failure to prevent, report, and investigate allegations of abuse in a timely manner. An incident of sexual abuse was not immediately reported to facility leadership, delaying the implementation of interventions to prevent further abuse. Additionally, the facility did not report the incident to the proper authorities promptly, resulting in a delay in the arrest of the resident responsible for the abuse. The facility also failed to report an injury of unknown origin in a timely manner, which hindered the establishment of an accurate timeline and effective treatment of the injury. A resident's injury, which included swelling, bruising, and broken fingers, was not reported to facility leadership until it worsened, and there was no record of proper monitoring for healing. The Director of Nursing (DON), who was acting as the abuse incident coordinator in the absence of a licensed Nursing Home Administrator (NHA), admitted to not being well-versed in regulatory requirements for reporting and investigating abuse, leading to further delays and mismanagement of incidents.

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 promote dignity and respect for a resident by not providing meal assistance in a dignified manner. The resident, who was over 65 years old and diagnosed with dementia with behavioral disturbance, protein-calorie malnutrition, and bilateral cataracts, required assistance with meals. Observations revealed that a CNA approached the resident without communication and began to spoon-feed her in a rushed manner while standing, which was not in line with the facility's policy of maintaining eye contact and engaging the resident in conversation during meals. This behavior was repeated on consecutive days, indicating a pattern of inadequate care. The resident's care plan indicated the need for cueing and supervision during meals, with interventions such as maintaining eye contact and offering meal alternatives. However, the staff did not adhere to these guidelines, as evidenced by the observations and staff interviews. Interviews with the CNA and LPN confirmed that the staff should sit with the resident and encourage her to eat independently, but this was not consistently practiced. The DON also stated that staff should communicate with residents while assisting them with meals, highlighting a discrepancy between the facility's policies and the actual care 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 report alleged violations of potential abuse, neglect, exploitation, or mistreatment and injuries of unknown origin to the state oversight agency in accordance with state laws. Specifically, the facility did not timely report an allegation of sexual abuse by a resident towards four other residents. The incidents involved a resident exposing his genitals to other residents on multiple occasions, with video footage confirming the indecent exposure. The facility delayed reporting the incident to the State Agency, exceeding the 24-hour reporting requirement. Additionally, the facility did not report an injury of unknown origin involving another resident. The resident's representative noticed swelling in the resident's hand, which was later confirmed to be a fracture. The facility's investigation suggested the injury might have occurred due to the resident's impulsive movements, but there was no documentation that the incident was reported to the State Agency. The Director of Nursing was unaware of the injury until later and acknowledged that the injury of unknown source protocol was not followed. Interviews with staff revealed a lack of adherence to reporting protocols. The Director of Nursing and other staff members indicated that incidents involving abuse or injuries of unknown origin should be reported immediately to the appropriate authorities. However, in these cases, the required notifications and investigations were not conducted in a timely manner, leading to deficiencies in the facility's compliance with state reporting requirements.

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 received appropriate treatment and care for optimal skin condition, specifically for moisture-associated skin damage (MASD) and a pressure wound. The resident, who was admitted with MASD to the coccyx, did not have a care plan developed to address the MASD or the potential for pressure injury. Despite the resident's cognitive intactness and dependency on staff for mobility, the facility did not reassess alternative methods for pressure-relieving interventions when the resident refused repositioning. The resident's condition worsened as the MASD developed into a skin tear, and the facility did not reassess treatment methods or implement alternative interventions promptly. The resident's electronic medical record documented MASD upon admission, but the comprehensive care plan failed to address this. The resident's representative expressed concerns about the worsening condition and suspected infection, leading to the resident's removal from the facility for hospital treatment. Interviews with staff revealed that the resident was resistant to repositioning, which was crucial for pressure relief and healing. Despite recommendations for an alternating pressure mattress, it took the facility approximately 14 days to implement this intervention. The facility's delay in providing appropriate pressure-relieving equipment and failure to develop a comprehensive care plan contributed to the deterioration of the resident's skin 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 appropriate treatment and services to residents diagnosed with dementia, specifically in managing wandering behaviors. Two residents, identified as Resident #7 and Resident #14, were observed wandering into other residents' rooms without effective interventions being implemented. The facility's policy required an interdisciplinary team approach to develop person-centered care plans, but this was not effectively executed for these residents. Resident #7, an 85-year-old with Alzheimer's disease and dementia with agitation, was observed wandering into other residents' rooms and displaying signs of distress and anxiety. Despite having a care plan that included interventions such as offering activities, closing doors, and providing one-on-one attention, these measures were inconsistently applied. Observations showed that staff did not engage Resident #7 in activities or consistently document the effectiveness of interventions, leading to repeated wandering incidents. Similarly, Resident #14, who also had Alzheimer's disease and dementia with agitation, was observed wandering and attempting to exit the unit. The care plan for Resident #14 included family input and redirection strategies, but staff failed to consistently redirect him or document the interventions used. The lack of consistent documentation and implementation of interventions contributed to the residents' continued wandering and intrusion into other residents' spaces.

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 investigate an allegation of physical abuse involving two residents, both diagnosed with Alzheimer's disease and dementia with behavioral disturbances. The incident occurred when one resident grabbed the other's arm or hand over a pack of wet wipes, causing no physical harm but resulting in a resident-to-resident altercation. The facility's documentation and investigation into the incident were inconsistent, with conflicting reports about whether the resident's hand or arm was grabbed. The facility's investigation was inadequate, as it did not include interviews with other potential witnesses and relied on limited staff accounts. The Director of Nursing, temporarily acting as the Nursing Home Administrator, acknowledged that the investigation was brief due to the residents' friendship and lack of injury. However, the investigation failed to thoroughly document the incident, as required by the facility's policy on abuse, neglect, and exploitation. Staff interviews revealed discrepancies in the accounts of the incident, with different staff members reporting varying details about the altercation. The facility's failure to conduct a comprehensive investigation and provide consistent documentation of the incident led to the deficiency. The lack of thoroughness in addressing the alleged abuse between the residents highlights a significant oversight in the facility's adherence to its own policies and procedures.

Penalty

Inspection fine: $7,718

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 neglect, resulting in an injury of unknown origin. The resident, who had a history of bladder cancer and Alzheimer's disease, suffered a hematoma on the left forehead after a shower provided by a hospice CNA. Despite the visible injury, the staff did not conduct a full skin assessment to check for other potential injuries. This oversight led to a delay in identifying a clavicle fracture, which was only discovered after an x-ray was performed several days later. The resident experienced a fall three days after the initial injury, but again, no full skin assessment was conducted to determine if additional injuries were present. Subsequent assessments revealed multiple bruises on the resident's body, including the left shoulder, hip, and eye, but the origin of these injuries was not documented. The lack of timely and thorough assessments contributed to a delay in care and increased pain for the resident. Interviews with facility staff indicated that there was confusion and a lack of communication with the hospice company, which hindered the investigation into the resident's injuries. The facility's procedures for post-fall assessments were not adequately followed, and the resident's refusals of care were not properly documented. These factors combined to create a situation where the resident's injuries were not promptly identified or treated, resulting in a deficiency in the care provided.

Removal Plan

• The facility notified the hospice company that the hospice CNA and the hospice social worker were suspended from entering the facility pending the investigation.
• The facility terminated their contract with the hospice company due to their lack of communication with the facility and lack of cooperation with the investigation.
• Education was provided to staff members on procedures after a resident fall, including calling the physician and power of attorney, completing neurological checks, fall assessment, post-fall evaluation, skin evaluation, and risk management form, and obtaining witness statements if applicable.
• The remaining care staff obtained fall prevention education at the skills fair.
• Fall binders were created and placed at every nurses station as a reference for the staff and discussed by the unit manager.
• The facility began an investigation of Resident #1's injuries and interviewed all staff on duty who were involved in care for the resident on the day of the fall and a few days prior.
• The facility made an update to their post-fall management procedures, which included documentation in a root cause analysis form to help identify causes and potential preventive measures for future falls.
• All risk management (incident reports) were reviewed in the interdisciplinary team meetings.
• Completion of all required assessments after a fall were part of the review process.
• The incident was brought to the facility quality assurance and process improvement meeting for discussion of the investigation, findings, and actions taken.
• Falls were reviewed at QAPI and ongoing review of all risk management/incident reports was conducted.

Penalty

Inspection fine: $23,319

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 care and services to meet the nutritional needs of two residents, identified as Resident #87 and Resident #92. Resident #87, admitted with various health conditions including prediabetes and dementia, experienced a significant weight loss of 10% over six months due to poor meal intake and lack of preventative measures to address her eating patterns. Despite recommendations for weekly weights and nutritional interventions, the facility did not consistently monitor her weight or implement necessary measures to prevent weight loss. Similarly, Resident #92, admitted with dementia and anxiety disorders, suffered a severe weight loss of 17.36% over six months, with a significant 15.1-pound weight loss in just one month. The facility failed to add nutritional interventions promptly after the weight loss was documented, indicating a lack of proactive care and monitoring. The deficiencies in care for Resident #87 and Resident #92 were further highlighted by inadequate documentation and communication among staff members. The facility's failure to consistently obtain and record weights as ordered by physicians and dietitians, as well as the delayed implementation of nutritional interventions, contributed to the residents' severe weight loss. Despite clear policies outlining the importance of nutritional assessments, care plans, and weight monitoring, the facility did not adhere to these guidelines effectively. Staff interviews revealed discrepancies in understanding and execution of weight monitoring protocols, with some staff members unaware of the significance of regular weight assessments and the implications of weight loss on residents' health.

Penalty

Inspection fine: $23,319

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 establish an infection control program for antibiotic stewardship, specifically lacking a process to track antibiotic usage. The facility's policies, revised in December 2016, required antibiotics to be prescribed and administered under the guidance of an antibiotic stewardship program, with data collected and documented using a facility-approved antibiotic surveillance tracking form. However, the infection preventionist (IP) and corporate nurse consultants (CNCs) were unsure of the criteria used for antibiotic stewardship and could not identify which residents were on antibiotics or if they met McGreer's criteria. The IP also admitted to being unfamiliar with the antibiotic tracking system embedded in the electronic medical record. During interviews, it was revealed that a resident frequently called her physician outside the facility to request antibiotics, and the physician could order medications without oversight. The medical director was unaware of this practice and stated he would review the resident's chart. The IP found a map used to track infections for February 2024 but had not created similar maps for January and March 2024. This lack of a systematic approach to tracking and reviewing antibiotic use led to the deficiency in the facility's antibiotic stewardship program.

Penalty

Inspection fine: $23,319

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 policies and procedures related to pneumococcal immunizations for five residents. Specifically, the facility did not administer the pneumococcal vaccination to four residents after consent was provided and failed to document risk versus benefit education for one resident. This deficiency was identified through record reviews and staff interviews, revealing that the facility did not follow its own vaccination policy, which mandates offering vaccines to all residents unless medically contraindicated or previously vaccinated, and documenting education provided to residents or their representatives regarding the benefits and potential side effects of the vaccinations. Resident #17, over the age of 65 with diagnoses including dementia, heart failure, and chronic kidney disease, did not receive the pneumococcal vaccination despite consent being provided on 10/24/23. Similarly, Resident #31, age 66 with diagnoses including a fracture of the left tibia and respiratory failure, did not receive the vaccination after consenting on 10/24/23. Resident #7, over the age of 65 with diagnoses including anxiety and dementia, also did not receive the vaccination after consenting on 10/24/23. Resident #11, over the age of 65 with diagnoses including Alzheimer's disease, morbid obesity, and GERD, did not receive the vaccination after consent was provided on 10/12/23. Resident #36, age 81 with diagnoses including COPD, heart failure, chronic kidney disease, type two diabetes mellitus, and GERD, refused the pneumococcal vaccination on 10/24/23, stating she had already received it and been tested for pneumonia. However, there was no documentation of education provided to the resident regarding the importance of receiving an updated pneumococcal vaccination. The infection preventionist confirmed these findings and acknowledged the need to review CDC guidance on offering pneumococcal vaccinations.

Penalty

Inspection fine: $23,319

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 certified nurse aides (CNAs) received at least 12 hours of annual in-service training, including mandatory dementia management and resident abuse prevention training. Specifically, four out of five CNAs reviewed did not meet the annual training requirements. CNA #4 participated in only four hours of training and did not complete dementia management training. CNA #5 had no record of completing dementia management training. CNA #6 participated in nine and a half hours of training but did not meet the 12-hour requirement. CNA #7 did not participate in any of the required annual training topics, including dementia management and resident abuse prevention training. Interviews with the staff development coordinator (SDC), director of nursing (DON), and nursing home administrator (NHA) revealed that the facility staff were assigned training topics and were expected to complete them. However, the NHA was unable to locate additional training records to show proof that the CNAs had completed the required training modules. The NHA stated that moving forward, employees would be required to complete all required training modules or be taken off the schedule until they completed their assigned training.

Penalty

Inspection fine: $23,319

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 consent was obtained for the use of psychotropic medications for two residents. Resident #31, who was cognitively intact with a BIMS score of 15 out of 15, was prescribed Trazodone for insomnia and Vortioxetine for major depressive disorder. However, the medical record did not contain informed consent for either medication. The Director of Nursing (DON) and the Social Services Director (SSD) were unaware that consents had not been obtained, despite the facility's policy requiring licensed nurses to obtain informed consent for psychotropic medications. The SSD also conducted monthly audits but did not identify the missing consents for Resident #31's medications. Similarly, Resident #47, who had moderate cognitive impairments with a BIMS score of 12 out of 15, was prescribed Zoloft, Lorazepam, and Seroquel for depression, anxiety, and depression with psychosis, respectively. The medical record for Resident #47 also lacked informed consent for these medications. Interviews with the SSD, an LPN, and the DON revealed that the responsibility for obtaining consents was understood to lie with the nursing staff, but the consents were not obtained. The DON acknowledged the oversight and confirmed that consents were not in place for Resident #47's psychotropic medications.

Penalty

Inspection fine: $23,319

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 two residents, who resided in the secured unit, had the required assessment to justify such restrictions. Resident #17, who had severe cognitive impairment and multiple health issues, was moved to the secured unit without a proper assessment. The resident's care plan was not revised when he moved to the secured unit, and there were no documented elopement attempts between June 2023 and February 2024. Despite two minor elopement incidents in February 2024, the facility did not identify predisposing factors or notify the resident's power of attorney. The decision to move the resident to the secured unit was made without a comprehensive evaluation or family involvement, and the resident did not exhibit exit-seeking behaviors after the move. Resident #72, who also had severe cognitive impairment and multiple health issues, was placed in the secured unit without a proper assessment. The resident's care plan did not identify specific times or patterns for wandering and elopement attempts. Despite a history of elopement behaviors, the facility did not document current behaviors or suggested interventions. The resident was moved to the secured unit after two minor elopement incidents in May 2023, but the power of attorney was not part of the evaluation team, and the resident did not exhibit exit-seeking behaviors after the move. Interviews with staff revealed that the facility did not have a clear policy for secured unit placement and that assessments were not consistently completed prior to moving residents to the secured unit. The director of nursing and social services director acknowledged the importance of proper assessments and family involvement but admitted that these steps were not always followed. The facility also lacked a wander management system, relying instead on door alarms and staff monitoring.

Penalty

Inspection fine: $23,319

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

Summary

The facility failed to ensure that Resident #72, who had a left hand contracture, received appropriate treatment and services to prevent the contracture from worsening. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was observed multiple times without a brace, splint, or other assistive device on his hand. The resident's care plan indicated the need for a splint to be worn during the day and night, but there was no documentation explaining why the splint was not on the resident's hand or if the resident refused to wear it. The facility's policy required restorative nursing care to help promote optimal safety and independence, including the use of splints for contracture management. However, the March 2024 treatment administration record (TAR) showed several instances where the splint was documented as off, and there was no follow-up documentation or notification to the restorative nurse. Interviews with the director of nursing (DON), licensed practical nurse (LPN), and restorative nurse revealed a lack of awareness and inconsistent implementation of the contracture management program for Resident #72. The facility's follow-up documentation indicated that the hand splint was removed and that the certified nurse aides (CNAs) were responsible for assisting with the splint program. However, there was no documentation of the resident's refusal to wear the splint or reasons for its removal. The lack of consistent application and documentation of the splint use contributed to the deficiency in providing appropriate care for Resident #72's hand contracture.

Penalty

Inspection fine: $23,319

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 manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two residents. Specifically, the facility did not offer non-pharmacological pain interventions and did not determine an acceptable pain level for the residents. Resident #25, who had a skin cancer lesion causing significant pain, did not receive non-pharmacological pain interventions and had inconsistent administration of pain medications. The resident's pain assessment and care plan did not document an acceptable pain level or person-centered non-pharmacological pain interventions. Additionally, the resident was administered pain medication even when reporting a pain level of 0, and there was no clear guidance on when to administer different pain medications. The resident's pain was not adequately managed before wound treatments, leading to unnecessary discomfort. The facility's documentation and pain management practices were inconsistent and did not align with the resident's needs and preferences. Resident #7, who had chronic pain due to osteoarthritis and other conditions, also did not receive non-pharmacological pain interventions and had an unclear acceptable pain level. The resident reported frequent pain that affected daily activities and sleep, but the facility did not consistently offer or document non-pharmacological pain interventions. The resident's pain assessment and care plan lacked documentation of an acceptable pain level and person-centered non-pharmacological pain interventions. The facility's pain management practices for this resident were inconsistent, with unclear guidance on when to administer different pain medications. The resident's pain was not adequately assessed or managed, leading to ongoing discomfort and a lack of person-centered care. Interviews with staff revealed a lack of clarity and consistency in pain management practices. LPN #4 admitted to using personal judgment to decide which pain medication to administer, despite the need for physician guidance. The DON acknowledged the need for clear parameters in physician orders and the importance of documenting an acceptable pain level and non-pharmacological pain interventions. The facility's failure to adhere to its pain management policy and provide consistent, person-centered care resulted in inadequate pain management for both residents, highlighting significant deficiencies in the facility's pain management program.

Penalty

Inspection fine: $23,319

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 emergency response carts in safe operating condition, specifically for one out of three emergency carts. The crash cart in the special care unit was found to be covered with debris, including food crumbs, dust, and hair. Additionally, the cart contained several miscellaneous items and medical supplies that were not listed on the crash cart inventory list. The daily checks for the crash cart had not been completed for several days in March, and the check/signature sheet was improperly stored in the medication cart three-ring binder. LPN #1 confirmed that it was the responsibility of the night shift nurses to check the crash cart nightly, but this had not been done consistently. The Director of Nursing (DON) was interviewed and expressed uncertainty about the frequency with which the crash cart should be checked. The DON initially stated that crash carts should be checked monthly but then mentioned that the emergency oxygen supply should be checked weekly or after use, with checks completed by the pharmacy contractor. The DON also indicated that after the crash cart's emergency kits were opened or used, the medications were exchanged with the pharmacy. This inconsistency in policy understanding and execution contributed to the deficiency in maintaining the emergency response cart in a ready and clean state.