Skylake Post Acute

Penalty

No penalty information released

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

Summary

The facility failed to ensure appropriate treatment and monitoring after a resident with dementia, pancytopenia, and protein-calorie malnutrition experienced a change in condition and multiple unwitnessed falls. The resident had decreased oral and fluid intake beginning the day before the first fall, then was found on the floor next to his bed with part of his mattress off the bed frame. Although staff documented the fall and started neurological checks, the record showed missed or incomplete monitoring, including refusals of neurological checks and no documented vital signs after the first fall until later in the day. Staff also documented that the resident refused breakfast, slept most of the morning, and later showed a drop in blood pressure, increased pulse, decreased appetite and fluid intake, generalized weakness, pallor, and increased need for assistance with ADLs. Despite these changes, the record did not show that the physician was notified when the resident’s intake declined or when his condition worsened later that day. The resident continued to decline, was unsteady when trying to stand, and remained confused and weak. He then sustained a second unwitnessed fall from bed, was found with external rotation of the right leg and pain, and was transferred to the hospital. Hospital records documented a right intertrochanteric hip fracture, multiple subdural hematomas, severe anemia, and hemorrhagic shock. The resident later returned to the facility on hospice care and died shortly thereafter. The facility also failed to appropriately assess and monitor another resident after an unwitnessed fall. During observation, the resident was found sitting on the floor with a bleeding forehead wound, and staff performed neurological assessments using a cellphone flashlight because a pen light was unavailable. Later, an LPN documented pupil findings on the neurological assessment sheet even though she did not have a flashlight or pen light available during that assessment period. The DON stated that pupil reactivity should be assessed using a flashlight or pen light, and that the LPN should have used a light source.

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 keep multiple residents free from abuse when it did not prevent resident-to-resident physical altercations involving a resident with dementia, agitation, verbal aggression, and episodes of physical aggression. The report states that four residents were affected in three separate incidents: an altercation between two residents in the hallway, an incident in which one resident entered another resident’s room and pushed her, and an incident in which the same resident struck another resident in the face while she was seated in the hallway. In the first incident, one resident was sitting in a wheelchair in the hallway yelling about having her bed made when another resident walked by. The resident in the hallway screamed at him to hit her, then swung her arm at his stomach. He grabbed her by the neck/shoulder area to stop her from hitting him. Staff separated the residents and documented that both were de-escalated and placed on 15-minute checks. The investigation also noted that the resident who grabbed the other resident had a history of verbal aggression, sundowning, and becoming irritated with loud noises, while the other resident had a history of anger, foul language, and hearing impairment that caused her to speak loudly. In the second incident, staff heard yelling and found the same resident standing in the doorway of another resident’s room. The resident in the room reported that he had entered her room and pushed her, and she pushed him back. Staff described her as frightened and frantic, while he was unable to recall the incident. The resident who entered the room had a history of verbal outbursts, anxiety related to delusions, and behaviors that included wandering into other residents’ rooms. The resident whose room was entered had poor impulse control, was territorial of her room and possessions, and could become verbally aggressive when others entered her room. In the third incident, the same resident walked behind another resident seated in a wheelchair near the nurses’ station and struck the left side of her face with a closed fist. The resident who was struck was tearful and non-redirectable for about 15 minutes afterward and said someone hit her in the head while she was just sitting there. Staff interviews confirmed that the resident in the wheelchair was hit while praying, and the resident who struck her claimed she had hit him first. The resident who struck her had a documented history of verbal aggression, delusions, anxiety, and physical aggression toward others, while the resident who was struck had dementia, cognitive impairment, and disruptive noises at times.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding bathing, specifically by not ensuring showers were provided consistent with the resident’s preferences. The resident, an older adult with diagnoses including severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact with a BIMS score of 15 and required assistance with several activities of daily living. The MDS documented bathing as not applicable for assistance, while the ADL care plan initiated shortly after admission indicated the resident needed partial to substantial assistance for bathing or showering but did not include the resident’s bathing preferences or specific shower days. The resident’s representative reported that the resident stated staff were busy and not providing showers, and that the resident requested a shower during the week after admission but did not receive one. The representative observed the resident wearing the same clothing on multiple occasions and noted a personal female odor, and the resident expressed a desire to be clean. When the representative requested documentation of completed showers from the DON, the facility was unable to provide it. Review of the CNA bathing task documentation from admission through discharge showed no documented showers during the resident’s stay, and the electronic medical record revealed that the shower preference assessment was not completed upon admission. Staff interviews indicated that residents were scheduled for showers multiple times per week and could choose morning or evening showers, with refusals to be documented and communicated between shifts. A CNA stated that this resident was scheduled for showers three times weekly and sometimes refused due to fatigue after therapy, with refusals to be documented and missed showers potentially made up on subsequent days. An LPN described a process of repeated offers, documentation of refusals, and family notification if a resident refused showers. The DON stated residents were to be offered showers at least twice weekly, that a preference evaluation was part of the admission packet, and that new admissions were to be offered a shower the day after admission, but acknowledged staff reported they forgot to document offers or refusals and that she was unaware of any bathing concerns until after the resident had discharged. These findings collectively show that the facility did not ensure the resident’s shower preferences were assessed, care planned, and carried out in practice, nor consistently documented.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure safe assistance and adequate supervision during incontinence care, resulting in a fall with minor injuries. The facility’s Falls – Clinical Protocol policy required identification of residents at risk for falls and assessment and documentation of falls and related factors. Resident #1, an older adult with severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact and required substantial to maximal assistance with toileting and other ADLs. A fall risk assessment identified her as a high fall risk, and her fall care plan cited risk factors including respiratory failure, COPD, and chronic pain. The resident’s ADL care plan noted a self-care performance deficit and need for staff assistance, but the bed mobility intervention did not specify the level of assistance or number of staff required. The fall care plan, however, included an intervention that two staff members were to provide incontinence care. On the date of the incident, a CNA was providing incontinence care when the resident rolled out of bed, landing on her lower extremities. The resident reported right shoulder pain, and the nurse observed multiple skin tears on the toes and a right knee abrasion. An IDT note later described that the resident lifted her right leg, her weight shifted, and she rolled left and slid out of bed onto her knees during incontinence care. The resident’s representative reported that the resident stated an unknown CNA kept pushing her to roll over during incontinence care, leading to her falling off the bed, and that a nurse entered and saw the CNA pulling the resident up from the floor by her right arm despite the resident’s complaints of pain. The representative also reported abrasions or bruising on every toe of the resident’s right foot, with bandages applied, and that the facility notified her later that the resident had a fall and was fine, without informing her of injuries. Staff interviews showed inconsistency between the care plan requirement for two-person assistance during incontinence care and staff understanding of the needed level of assistance, with the DON stating the resident required one-person assistance for turning in bed prior to the fall. Review of the electronic medical record revealed no nursing progress notes documenting the fall event on the date it occurred.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure that food served accommodated a resident’s documented allergy, resulting in the resident being served and ingesting pineapple despite a known pineapple allergy. Facility policy on Food Allergies and Intolerances, revised August 2017, states that residents with food allergies are to be identified upon admission, have allergies documented in the care plan, and be offered appropriate substitutions, with steps taken to prevent exposure to allergens. For the resident involved, the comprehensive care plan initiated in mid-January identified allergies to pineapple and wool, and the care plan report listed pineapple as an allergy and included an intervention for staff to honor food preferences, although it did not document specific food likes and dislikes. The resident, an older adult with diagnoses including severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact with a BIMS score of 15 and required set-up or clean-up assistance with eating. On an evening in January, nursing documentation shows that pineapple was present on the resident’s dinner tray even though the resident had a documented pineapple allergy. The progress note states the resident ate two pieces of pineapple before the error was recognized and the pineapple was removed. The resident’s representative reported that the allergy was documented in the medical record and on the meal ticket, yet pineapple was still served, and that the resident became upset and did not understand how this occurred. According to the facility’s own root cause analysis, the dietary aide responsible for serving food did not correctly review the resident’s meal card and failed to note the highlighted pineapple allergy, placing pineapple on the tray as dessert. The CNA delivering the tray identified the pineapple only after the resident had already eaten two pieces. Interviews with the dietary manager, dietary aide, cook, RD, CNA, RN, and DON consistently described a system in which resident allergies are entered into an electronic system, printed on meal tickets, and highlighted so that kitchen and nursing staff can verify trays before service. However, in this incident, staff did not adequately review or follow the meal ticket information, and subsequent resident council notes documented ongoing resident concerns that CNAs were not following meal tickets correctly and were not consistently asking residents for their meal choices. Resident council meeting notes from late January and late February further describe meal service concerns, including reports that CNAs blamed the kitchen for meal mistakes and did not correct issues when errors occurred, and that meal tickets were not being followed correctly by CNAs on a specific unit. These resident reports indicate that, beyond the single documented pineapple incident, residents perceived ongoing problems with adherence to meal tickets and proper verification of meals against documented diets and allergies. The deficiency is thus centered on the facility’s failure, in at least one case, to prevent exposure to a known food allergen despite clear documentation and an established process intended to identify and avoid such allergens.

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 store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen. During observations, an unidentified male dietary aide with facial hair was seen multiple times in the kitchen without a beard net, including while standing by the three-compartment sink, while washing dishes, and while helping with food preparation after washing his hands. The dietary supervisor stated that beard nets should have been worn. The facility also failed to perform hand hygiene appropriately during meal service and dishwashing. During a continuous observation of lunch service, a dietary aide removed gloves and put on new gloves several times without washing her hands, a cook scratched her head and continued serving without hand hygiene, and another dietary aide handled dirty containers and then clean dishes at the three-compartment sink without changing gloves, removing gloves, or performing hand hygiene. A cook also touched the backside of her pants and then resumed serving meals without hand hygiene. The dietary supervisor stated that hand hygiene should be performed after taking off gloves and when hands were soiled. The facility further failed to ensure food was labeled and dated in the walk-in freezer, walk-in refrigerator, and reach-in refrigerators. Surveyors found multiple unlabeled and undated items, including meats, breakfast sausages, mixed foods in a black bin, opened liquid eggs, diced potatoes in water, tuna salad, marinara sauce, and soup. During meal service, tuna salad and marinara sauce containers used for sandwiches and reheated spaghetti were also not labeled or dated. The dietary supervisor stated that everything should be labeled and dated.

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 designed to provide a safe, sanitary, and comfortable environment to prevent the development and transmission of disease and infection. Survey findings showed the facility did not ensure monitoring measures were maintained for all control measures identified that may contribute to the spread of legionella bacteria, did not ensure the water management plan was reviewed annually, and did not ensure the plan was personalized and specific to the facility. The Legionella Water Management Program policy and procedure, revised June 2021, stated that specific measures used to control the introduction and/or spread of legionella include a system to monitor control limits and effectiveness of control measures, and that the water management program is reviewed at least once a year. The Water Management Plan, dated 12/20/23, listed control measures such as daily cleaning of ice coolers, twice-yearly HVAC filter service, daily soaking and weekly cleaning of the juice machine, quarterly draining and cleaning of hot tubs, and monthly plumbing cleaning, as well as decorative fountains run daily. When surveyors requested audit logs for these measures, the documents were not provided during the survey. The maintenance director said the facility followed the audit and cleaning schedule and discussed the program monthly in QA, while the regional clinical resource stated the program should be reviewed and updated annually and noted the plan was outdated and not specific to the facility because it included decorative fountains that were not present.

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 resident dignity and privacy when Resident #155, who had diagnoses including traumatic subarachnoid hemorrhage without loss of consciousness, dementia with agitation, thyroid cancer, and rheumatoid arthritis, was using the restroom. On 9/23/25 at 9:14 a.m., CNA #3 knocked on the resident’s door and immediately walked into the room. Resident #155 was heard yelling that he was on the toilet. CNA #3 then asked to grab the resident’s tray and later told a CNA trainee that he was a very private person. The facility also failed to ensure staff announced themselves before entering resident rooms. After entering Resident #155’s room, CNA #3 went from room to room on the 800 hall, knocking and immediately entering rooms to gather trays without announcing herself. On 9/24/25 at approximately 2:22 p.m., an unidentified male CNA was observed going room to room on the 700 hall taking dinner orders, knocking and immediately entering without waiting for residents to respond. During a group interview, alert and oriented residents stated staff knocked but did not wait for a response, describing the practice as "knock then walk." The DON stated staff should knock and ask if they could enter, and should wait up to fifteen seconds for a response unless there was an emergency.

Penalty

No penalty information released

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

Summary

The facility failed to ensure medications and biologicals were stored and labeled according to accepted professional principles in multiple medication rooms, one medication cart, and the vaccine refrigerator. Surveyors found expired vaccines in the Garden unit vaccine refrigerator, including COVID-19 vaccine and influenza vaccine that had passed their expiration dates, along with two vials of Tubersol that had been opened but were not dated. The infection preventionist stated that Tubersol is only good for 30 days once opened and that expired vaccines should be removed from the refrigerator. In the Evergreen medication refrigerator, surveyors observed an open vial of Tubersol with no open date and three vials of gentamicin sulfate, two expired in July 2025 and one expired in May 2025. In the Garden medication refrigerator, surveyors found an expired bottle of magnesium citrate and an open Lantus insulin pen with no open date. Staff stated that open dates were important because medications may not be effective if used past the recommended date, and one nurse said the expired gentamicin should have been removed the month it expired. In the Aspen medication room, surveyors found two open vials of Tubersol without open dates and a dormitory-style refrigerator used for vaccine storage, with ice buildup in the freezer compartment. The room also contained a cabinet of over-the-counter medications, all of which were expired, including vitamins, laxatives, aspirin, and stool softener products. The Garden medication room also contained a large box on the floor and a cabinet full of discontinued medications belonging to residents who no longer resided in the facility. Staff and the DON stated that discontinued medications were to be returned to the pharmacy or destroyed, but the medications remained stored in the room and box at the time of observation.

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

Money from personal funds accounts was not managed accurately for two residents who were Medicaid funded. Resident #175 had an account balance of $1,915.07, and there was no documentation that the facility notified the resident or her legal representative when the account reached $200 less than the eligibility resource limit. Resident #45 had an account balance of $1,892.06, and there was no documentation that the facility notified the resident or her legal representative when the account reached $200 less than the eligibility resource limit. During interview, the NHA stated there was confusion about the allotted limit for Medicaid funded residents and said the facility was going to reach out to the residents' representatives to spend down the funds.

Penalty

No penalty information released

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

Summary

The facility failed to provide supervision, assistance, services, and effective person-centered interventions to prevent falls with injuries for one resident with dementia, diabetes, osteoporosis, and a history of falls and fractures. The resident had significant cognitive impairment with a BIMS score of 1 out of 15, required extensive assistance with showers and transfers, and used a wheelchair for mobility. The fall care plan identified multiple interventions, including keeping the call light within reach, ensuring appropriate footwear, leaving the room door open while the resident was in the room, assisting with transfers after meals to lie down, and keeping the resident in high visibility areas during waking hours as tolerated. After an unwitnessed fall on 6/29/25, the resident was found on the floor between her wheelchair and bed with a puncture wound to the right elbow, bruising to the right knee, and bruising with a raised area to the back of her head. The fall interdisciplinary team identified risk factors such as difficulty locking wheelchair brakes when self-transferring, impulsivity, poor safety awareness, and walking without assistance. The team added interventions including brake extenders and keeping the room door open, but observations later showed the resident’s door was not open while she was in her room. The resident also had an unwitnessed fall on 8/4/25 after trying to move a tray from the side table to the vanity; she was found on the floor in her room with a reddened area and scratch to the left cheek. Another unwitnessed fall occurred on 8/18/25 when she was found on the bathroom floor, and on 8/21/25 she was found sitting on the floor by her bed after being heard screaming in her room. The record also showed that fall interventions were not consistently available to or understood by staff. The CNA abbreviated care plan did not reveal resident-specific fall interventions, and staff interviews showed LPNs and CNAs relied on general fall precautions or could not locate the resident’s specific interventions in the EMR. One LPN said she could not locate specific fall interventions, a CNA said she was not aware of where to find them, and an RN said he checked tasks because he did not have access to the care plan. The DON stated that after falls, the IDT reviewed the events and staff were verbally informed of new interventions, but staff were unclear on where to find the resident’s fall interventions in the record.

Penalty

No penalty information released

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

Summary

The facility failed to ensure culturally competent, trauma-informed care was provided for a resident with a history of trauma and PTSD. The resident’s diagnoses included cerebral infarction, PTSD, psychotic disorder not due to a substance or known psychological condition, and anxiety. Her MDS showed she was cognitively intact with a BIMS score of 15 and no documented behaviors. The facility policy required individualized care plans that address past trauma, identify triggers, and decrease exposure to triggers that may re-traumatize the resident. The resident told the surveyor she was scared of the NHA because he entered her room, made himself look taller, and raised his voice at her. She also said she had filed grievances and the NHA responded by telling her she should find a new place to live since she was not happy and had filed so many grievances. During an observation, the NHA offered to assist the resident to an activity, but the regional clinic resource intervened and said she would assist the resident because the resident had an issue with men. The resident did not want to move facilities. Record review showed the psychosocial care plan addressed a history of sexual assault by a male physician and included interventions such as allowing extra time to respond, normalizing feelings, and safeguarding the resident from the alleged or suspected abuse perpetrator. The trauma-informed care plan listed multiple past traumatic events and interventions such as allowing choices, approaching calmly, encouraging family interaction, and monitoring psychosocial well-being, but it did not include interventions to address the resident’s fear of the NHA. Staff interviews showed inconsistent awareness of the resident’s triggers: one RN said she was unaware of triggers involving men, a CNA said the resident preferred females but she was unsure why, and the DON stated the resident’s triggers were hard to identify but felt male figures were a trigger and that the resident feared the NHA would pack up her room and kick her out. The DON also stated more education would be provided so staff knew where to find pertinent information like trauma and triggers.

Penalty

No penalty information released

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

Summary

The facility failed to provide necessary behavioral health care and services for one resident with dementia and behavioral disturbances. The resident was admitted with diagnoses including cognitive communication deficit and dementia with behavioral disturbances and agitation, and the MDS showed severe cognitive impairment with a BIMS score of 7 out of 15. Although care plans identified anxiety, delusions, yelling out, physical aggression, and adjustment issues, the record did not show resident-specific, person-centered interventions tied to the resident’s target behaviors before PRN lorazepam was used. The anti-anxiety and psychosocial care plans documented general interventions such as giving medication as ordered, monitoring for side effects, anticipating needs, encouraging expression of feelings, and maintaining a calm approach. However, the record review did not reveal documented person-centered approaches to trial before PRN lorazepam administration. The EMR also did not show non-pharmacological interventions that were to be attempted before giving the PRN medication. Progress notes documented multiple administrations of PRN Ativan for agitation, anxiety, yelling, and other behaviors, but the notes did not document non-pharmacological interventions before the medication was given. Staff interviews confirmed that non-pharmacological interventions should be attempted and documented prior to PRN psychotropic administration, and the DON and regional clinical resource were unable to find resident-specific non-pharmacological interventions before PRN Ativan was administered.

Penalty

No penalty information released

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

Summary

The facility failed to implement its policy regarding foods brought to residents by family and visitors to ensure safe and sanitary storage, handling, and consumption of food items in residents’ personal refrigerators. The policy stated that staff would assist with safe food handling practices, including safe reheating, hot/cold holding, handling of leftovers, and contamination avoidance, and that potentially hazardous foods left out longer than two hours without heat or refrigeration would be discarded. In one resident’s personal refrigerator, surveyors observed a clear four-ounce container of cottage cheese dated 9/12/25 and a four-ounce container of yogurt with a use-by date of 9/18/25. When the refrigerator was rechecked two days later, those outdated food items had not been removed. The resident stated that only two staff members checked his refrigerator and that one night shift nurse consistently checked it. In another resident’s personal refrigerator, surveyors observed three thawed Uncrustables that were not dated, and there was no thermometer in the refrigerator or freezer. Record review showed the Garden unit’s personal refrigerator logs for September 2025 had approximately 12 to 14 missing temperature entries on each log. Resident #14’s log also documented that her refrigerator was new and did not have a thermometer for multiple days, with later entries again noting the thermometer was missing. Staff interviews indicated that overnight staff, including nurses or delegated CNAs, were responsible for checking refrigerator temperatures and that logs were kept in different places, including a binder at the nurse’s station.

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 establish and document a communication process with hospice providers for residents receiving hospice services. The hospice agreement and facility policy stated that the facility and hospice were to maintain complete clinical records and document communications, care, and services provided. However, the record showed that for two residents reviewed for hospice care, the facility did not maintain the hospice documentation in a way that reflected the care provided and the communication required by the agreement. For one resident with diagnoses including acute respiratory failure, acute kidney failure, heart disease with heart failure, and depression, the MDS showed moderate cognitive impairment and that hospice care was being received. The resident’s care plan documented hospice involvement and skin impairment treatment needs, but it did not document what care was to be completed by hospice or when. The hospice binder contained weekly visit verification forms, but the hospice notes in the EMR were incomplete: one routine visit note did not identify the staff member who completed the visit, and several other notes were signed by an RN without documenting any care or assessments provided. Additional hospice notes later uploaded during the survey showed multiple hospice visits by CNA, LPN, social worker, and RN staff, including personal care, wound care, and assessments, but these notes had not been present in the EMR at the time of review. For another resident with diagnoses including subacute osteomyelitis, quadriplegia, type 2 diabetes, and pressure-induced deep tissue damage, the hospice care plan documented hospice services and interventions related to comfort, ADLs, and pleasure foods. However, hospice notes from March 2025 through mid-July 2025 and the hospice care plan from the hospice provider were missing from the EMR. Staff interviews showed that hospice communication was often verbal, that hospice binders were used mainly by hospice staff, and that facility staff did not routinely review the uploaded hospice notes. The DON stated that hospice notes should have been uploaded into the EMR and that she had received the resident’s notes from the hospice provider.

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 staff not adhering to established protocols for personal protective equipment (PPE) and wound care. Specifically, staff did not wear gowns when providing direct care to a resident on enhanced barrier precautions (EBP), despite facility policy requiring both gloves and gowns for high-contact care activities involving residents at risk for or colonized with multi-drug resistant organisms (MDROs). Observations showed that a certified nurse aide and two LPNs provided care to a resident on EBP while only wearing gloves, omitting the required gown. Additionally, infection control measures were not followed during wound care procedures. One LPN used scissors from her pocket to cut wound dressing without sanitizing them before use, and another LPN used a retractable tape measure to measure an open wound, then retracted and stored it without sanitization. Wound care supplies were also placed directly on a resident's nightstand among personal items, rather than on a clean surface. Staff interviews confirmed that these actions were inconsistent with facility policy and best practices for infection control.

Penalty

Inspection fine: $25,5722 days payment denial

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

Summary

The facility failed to protect residents from abuse and neglect, specifically in the memory care-secured unit, where two residents were involved in incidents of resident-to-resident abuse. Resident #6, who had a known history of aggressive behavior, was admitted without a comprehensive assessment or a behavioral management care plan. The facility did not inform staff about Resident #6's history of aggression, which led to an incident where Resident #6 physically assaulted Resident #2, causing severe injuries. The staff did not closely monitor Resident #6's activities, despite observing changes in his behavior, which resulted in the assault on Resident #2. Resident #2, an 89-year-old with severe cognitive impairment and dementia, was unable to protect herself from the assault. She suffered significant injuries, including facial trauma and fractures, requiring hospitalization. The facility's failure to assess and manage Resident #6's behavior and to communicate his history to staff contributed to the incident. Additionally, the facility did not implement effective interventions to prevent resident-to-resident abuse, as evidenced by another incident where Resident #5 physically abused Resident #11. The facility's screening and admission process was inadequate, as it did not ensure the safety and appropriateness of admissions for residents with behavioral needs. The facility did not obtain or communicate sufficient information about Resident #6's history, which could have prevented the incident. The lack of a behavior-focused care plan and interventions for Resident #6, along with the failure to reassess his care needs, created a situation of immediate jeopardy for other residents in the memory care-secured unit.

Removal Plan

• Resident was discharged from the facility.
• Resident was placed on one-to-one monitoring and will continue one-to-one support with a review by the interdisciplinary team.
• The facility will hold admissions until it can review the pre-admission screening tool for residents with known behaviors.
• An ad hoc quality assurance performance improvement (QAPI) meeting will be held after the review of the pre-admission screening tool.
• The abuse policy was reviewed.
• The nurse practice educator/designee educated all staff on the facility abuse policy.
• Facility management staff reviewed the facility assessment on staffing and skills to care for residents with behaviors.
• The facility revised its pre-admission screening intake form to include a history of behaviors and supervision needs by the admissions director.
• The director of nursing educated the admissions team on the pre-admission screening tool and process.
• Residents in the memory support unit will be reviewed by social services and/or nursing/designee for behaviors, wandering, current interventions, and their care plan related to behaviors.
• Staff assigned to the memory support unit will be trained in specific resident care needs upon completion of the review, with training completed prior to their next assigned shift.
• Any admission to the memory support unit will be reviewed by social services and nursing to enter behavior tracking and a baseline care plan to meet the resident's needs.
• The facility assessment was reviewed and revised to include staffing levels for all departments in the memory support unit.
• New hires will receive education on abuse prevention and de-escalating behaviors during onboarding by the nurse practice educator.
• The nursing home administrator will implement a review with the quality assurance performance improvement (QAPI) committee to review and interpret all abuse findings, with all audit findings reviewed at the monthly meeting for at least three months or until the compliance pattern is maintained.

Penalty

Inspection fine: $25,5722 days payment denial

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

Summary

The facility failed to maintain a written transfer agreement with at least one local hospital certified by Medicare or Medicaid. This deficiency was identified during a record review and staff interviews. On a specific date, a request was made to the Director of Nursing (DON) and a corporate nurse consultant for the facility's hospital transfer agreement, but they were unable to provide such a document for the area hospital. During an interview, the interim nursing home administrator (INHA) and two corporate nurse consultants confirmed that the facility did not have a hospital transfer agreement. The INHA explained that local hospitals accepted residents based on their availability, and therefore, a formal transfer agreement was deemed unnecessary by the facility.

Penalty

Inspection fine: $25,5722 days payment denial

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

Summary

The facility failed to ensure that a resident's legal representative was informed and involved in the care planning process. The resident, who had severe cognitive impairment and was unable to participate in care planning, had a legal representative appointed to make decisions on their behalf. However, the facility did not notify the representative in advance of care plan meetings, nor did they inform her of the resident's podiatry and dental appointments or changes in the resident's condition, such as falls. The legal representative reported that she was not informed of a care conference meeting held on a different date than initially scheduled. She only learned about the resident's frequent falls and medical appointments through a voicemail left by the facility after the meeting. Despite being present at the facility daily, the representative was not kept informed of the resident's care and treatment changes, which hindered her ability to participate actively in the resident's care. Interviews with facility staff revealed inconsistencies in the notification process for care conferences and medical appointments. The social services assistant admitted to not notifying representatives of routine medical appointments and only contacting them by phone when there was insufficient time to send a letter. The director of nursing acknowledged issues with scheduling care conferences and emphasized the need for notifying representatives of all scheduled visits and changes in the resident's condition.

Penalty

Inspection fine: $25,5722 days payment denial

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

Summary

The facility failed to report an allegation of an injury of unknown origin, specifically a bite wound, to the State oversight agency within the required 24-hour timeframe. The incident involved a resident who was discovered to have a bite wound on the top of his left hand, which was suspected to have been caused by someone other than the resident himself. The facility's policy mandates that such incidents be reported immediately, defined as within two hours for serious bodily injury or within 24 hours for other allegations. However, the facility did not adhere to this policy, as the incident was not reported to the appropriate authorities. Interviews and record reviews revealed that the resident's representative and hospice nurse were the first to notice and report the bite wound. The hospice nurse informed the resident's representative and attempted to contact the facility, leaving a voicemail when unable to reach the memory care unit manager. Despite these efforts, the facility staff, including the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #3, were either unaware of the bite wound or did not take appropriate action to investigate or report the incident. The DON acknowledged hearing about the allegation but did not ensure an investigation was conducted or that the incident was reported. The lack of documentation and follow-up by the facility staff further compounded the issue. The DON could not provide evidence of an investigation or assessment of the resident's injury, and there was no documentation of any nurse's assessment of the bite wound. This failure to investigate and report the injury of unknown origin represents a significant deficiency in the facility's adherence to its policies and regulatory requirements.

Penalty

Inspection fine: $25,5722 days payment denial

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

Summary

The facility failed to thoroughly investigate an allegation of physical abuse involving a resident who was found with a bite wound of unknown origin. The resident, who had severe cognitive impairments and was known to wander, was discovered with a bite mark on the top of his wrist. Despite the resident's representative and hospice nurse raising concerns about the injury, the facility staff did not document or investigate the incident as required by their policies. Interviews with staff revealed inconsistencies and a lack of awareness regarding the resident's injury. The resident's representative reported the bite mark to the facility staff, but no one could provide an explanation for how the injury occurred. The hospice nurse also noted the injury and attempted to communicate with the facility, but the staff did not follow up with an investigation or report the incident to the appropriate authorities. The facility's Director of Nursing (DON) acknowledged that no investigation was conducted and that the incident was not reported as an injury of unknown origin. The DON admitted to hearing about the allegation but did not personally assess the resident or ensure that the staff documented the incident. This lack of action and documentation led to a failure in addressing the potential abuse and ensuring the resident's safety.