Westwood Post Acute

Penalty

Inspection fine: $23,95912 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 with a known history of dysphagia, intellectual disability, and behavioral issues received adequate supervision and implementation of care-planned interventions to prevent choking incidents. The resident had previously experienced a choking episode after grabbing and consuming a large amount of food before staff could intervene, requiring the Heimlich maneuver and suctioning. Physician orders and speech therapy assessments specified that the resident required one-on-one supervision during meals, cueing for small bites and sips, a slow eating rate, redirection to prevent wandering, and upright positioning during all oral intake. During survey observations, staff assigned to provide one-on-one supervision did not consistently offer the required cueing for small bites, slow eating, or ensure the resident maintained an upright position while eating. The staff member also left the resident unattended during meals, contrary to the care plan and physician orders. The resident was observed eating with her hands, taking large amounts of food at once, and falling asleep while chewing, all without adequate staff intervention or prompting. These actions were not in line with the interventions identified to address the resident's choking risk. Interviews with staff revealed a lack of understanding regarding the reasons for the resident's one-on-one supervision and the specific interventions required during meals. Some staff were unaware of the need for cueing and supervision to prevent choking, and the speech therapist and DON were not aware that the care plan was not being followed. Documentation and care plans indicated the necessity for these interventions, but they were not consistently implemented, resulting in a continued risk of choking for the resident.

Removal Plan

• Resident #45 was placed on one-on-one supervision to ensure continuous monitoring during mealtimes and to reduce the risk of choking. The resident will be reviewed by the interdisciplinary team (IDT) to determine appropriateness of remaining on one-on-one supervision.
• An audit of all nursing staff cardiopulmonary resuscitation (CPR) certifications, specifically including verification of Heimlich maneuver training, will be completed.
• The facility will have a minimum of one person who is CPR certified and Heimlich maneuver trained in the facility and observing meals at all times.
• All residents were screened utilizing the swallowing disorder section from their most recent minimum data set (MDS) assessment.
• For any residents identified as having swallowing difficulties, the IDT ensured care plans were reviewed and appropriate interventions were implemented. Communication will occur with staff by updating care plans and by updating Kardex (staff directive tool). The director of nursing (DON) or designee will perform education to all nursing staff.
• The DON or designee conducted in-service training on the Foreign Body Airway Obstruction policy for all currently scheduled facility and agency staff. Staff not present will receive education.
• The speech language therapist (SLP) or a designee who has been trained by the SLP, provided training to all nursing and agency staff regarding expectations when assigned as a one-on-one during meals, including not leaving the resident unattended, intervening if the resident begins to fall asleep, and implementing appropriate interventions if the resident exhibits unsafe eating behaviors. Staff not trained will be educated.
• The DON or designee educated nursing and agency staff on all relevant physician's orders related to Resident #45. Staff not in attendance will receive training.
• The DON or designee reviewed the care plan interventions for Resident #45 with all available nursing and agency staff. Staff not trained will be educated.

Penalty

Inspection fine: $23,95912 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 its binding arbitration agreement included all required components as outlined in its own policy and federal regulations. Specifically, the agreement did not provide for the selection of a neutral arbitrator agreed upon by both parties, nor did it include language allowing for the selection of a venue that was convenient to both parties. The facility's policy stated that residents or their representatives should have the opportunity to suggest an arbitrator and venue, and that both should be agreed upon by both parties, with documentation provided if there was disagreement. However, the actual arbitration agreement only allowed for the selection of an arbitrator from a list provided by a contracted provider and mandated that the hearing be held in the county where the facility is located, without input from the resident or their representative. During staff interviews, the social services assistant confirmed that the arbitration agreement did not contain information about the selection of a neutral arbitrator or a mutually convenient venue. The assistant also noted that information about residents' rights to speak with surveyors or ombudsmen was included in a separate admission agreement, not in the arbitration agreement itself. The assistant had been trained on the arbitration agreement but acknowledged these omissions, and reported that no residents had refused to sign the agreement.

Penalty

Inspection fine: $23,95912 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 implement an effective Quality Assurance and Performance Improvement (QAPI) program as required by its own policy and federal regulations. The QAPI committee did not identify or address a wide range of compliance concerns, including issues related to personal funds, survey results, bedholds, re-admissions, PASRR recommendations, quality of care, activities of daily living, activities, ancillary services, accidents/hazards, respiratory care, dialysis, mental/psychosocial concerns, drug regimen, dental care, hydration, snacks, arbitration agreements, immunizations, and maintaining a safe and comfortable environment. These deficiencies were identified through record review and interviews, which revealed that the QAPI committee's oversight was insufficient in monitoring and correcting these areas. Cross-referenced citations further detailed specific failures, such as not updating resident accounts with the current facility name, not making state inspection results readily available, not providing bed hold information at transfer, failing to re-admit residents after hospital transfers, not following PASRR recommendations, and not ensuring qualified staff provided necessary care (e.g., nail care for diabetic residents). Additional deficiencies included lack of personalized activity programs, untimely ancillary and dental services, inadequate supervision for residents at risk of choking, improper cleaning of CPAP machines, missing physician orders for dialysis, failure to identify trauma triggers, incomplete monthly medication reviews, insufficient hydration and snacks, improper arbitration agreement language, lack of immunization notifications, and unsanitary communal showers. Interviews with the Nursing Home Administrator (NHA) confirmed that the QAPI committee met monthly and reviewed certain areas, but failed to identify or address several of the cited concerns. The NHA was unaware of issues such as improper CPAP cleaning, insufficient snacks, and missed pharmacy medication reviews until they were brought up during the survey. The QAPI committee's process for identifying and following up on deficiencies was not effective in capturing or resolving these significant areas of noncompliance.

Penalty

Inspection fine: $23,95912 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 personal funds accounts were managed in accordance with policy for four residents when the facility underwent a name change. Specifically, the facility did not have these residents sign a new Resident Fund Management Service (RFMS) authorization and agreement form reflecting the updated facility name, as required by the facility's policy. Documentation reviewed showed that the forms on file for these residents still listed the old facility name, and there was no evidence that updated forms had been signed or uploaded into the RFMS system. Interviews with the business office manager (BOM) and the nursing home administrator (NHA) revealed that both were hired after the facility's name change and were not present during the transition. The BOM was unable to locate any updated RFMS forms for the affected residents and was unsure why the forms had not been updated at the time of the name change. The NHA confirmed that residents had been informed of the name change and had signed new admission agreements, but could not confirm whether new RFMS forms had been completed. Attempts to contact the previous BOM for clarification were unsuccessful.

Penalty

Inspection fine: $23,95912 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 licensed pharmacist performed a monthly drug regimen review (MMR), including a review of the medical chart, for four out of five residents reviewed for unnecessary medications. Specifically, the facility did not have documentation of completed MMRs for certain months, lacked pharmacist signatures on the reviews, and did not have physician signatures indicating that recommendations had been addressed. The facility's policy required monthly reviews by a consultant pharmacist, with written reports provided to the attending physician and documentation of physician responses, but these steps were not consistently followed. For the residents involved, medical records showed complex conditions such as obstructive sleep apnea, major depressive disorder, dementia, Parkinson's disease, diabetes, hypertension, bipolar disorder, schizophrenia, COPD, and catatonic schizophrenia. These residents were prescribed multiple medications, including antidepressants, antipsychotics, anticonvulsants, hypoglycemics, antiplatelets, diuretics, opioids, antianxiety agents, anticoagulants, and antibiotics. The Minimum Data Set (MDS) assessments for these residents did not indicate that a drug regimen review had been completed, and in several cases, the documentation provided by the facility was either missing, incomplete, or contained inconsistencies in dates and signatures. Interviews with facility staff revealed that the facility had recently changed pharmacy providers and was still adjusting to new processes. The DON and pharmacy staff confirmed that MMRs were sometimes conducted remotely, and the forms sent to the facility did not always include the required pharmacist signature. Additionally, the DON's signature was sometimes dated prior to the actual review date, and recommendations from the pharmacist were not always signed off by the physician, as required by facility policy.

Penalty

Inspection fine: $23,95912 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 six residents consistently had access to water and other beverages in accordance with their needs and preferences, resulting in insufficient hydration. During a group interview, all six residents reported not receiving fresh ice water daily and noted that water was no longer routinely passed to their rooms, despite their desire for daily ice water. Observations confirmed that at least one resident did not have a water pitcher or bottle in her room on multiple occasions, and she was only provided limited beverages with meals. Staff interviews revealed that CNAs were responsible for passing water each shift, but this was not consistently done. The registered dietitian and director of nursing both acknowledged the importance of regular hydration and the expectation that water should be provided every shift, but were unaware that residents were not receiving it as required. One resident, who had diagnoses including severe protein malnutrition, multiple sclerosis, dysphagia, and dementia, required assistance with all activities of daily living and was unable to obtain water independently due to dexterity and mobility limitations. Her records indicated a history of low fluid intake, and her care plan noted the need for assistance with meals and a recommendation for nectar thick liquids, though she had signed a waiver for thin liquids. Despite these needs, there was no documented assessment of her fluid requirements, and observations showed she was not provided with adequate fluids beyond limited beverages at meals.

Penalty

Inspection fine: $23,95912 days payment denial

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

Summary

The facility failed to provide snacks in accordance with residents' needs, preferences, and requests, as required by facility policy. Observations revealed that the nourishment refrigerator on the Santa Fe unit was repeatedly empty or contained only a minimal amount of snacks, insufficient for the number of residents. During a group interview, several alert and oriented residents expressed concerns about not receiving bedtime snacks and stated that snacks were not routinely offered; they had to request them if they wanted any during the day. Staff interviews confirmed that snacks were stored in a locked breakroom refrigerator, limiting access for residents who could not ambulate independently or communicate their needs effectively. The dietary manager acknowledged that the amount of snacks provided was not sufficient for all residents to have more than one snack if desired. Facility policies indicated that nourishing snacks should be available to residents 24 hours a day and that intake should be documented in the medical record. However, the practice of locking snacks in a breakroom and not maintaining adequate stock in the nourishment room resulted in limited access, particularly for residents unable to request snacks or access the kitchen independently. The registered dietitian confirmed that snacks should be available at all times, and the dietary manager admitted to the shortfall in snack availability relative to the resident population.

Penalty

Inspection fine: $23,95912 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 incorporate and arrange for the recommended neurocognitive evaluation for a resident with serious mental illness, as outlined in the resident's PASRR Level II Notice of Determination (NOD) from the State Mental Health Agency. The resident, a 71-year-old individual with diagnoses including dementia with mood disturbances, major depressive disorder, traumatic brain injury, and schizophrenia, was identified as requiring a neurocognitive evaluation due to a qualifying diagnosis of major depressive disorder. Despite this recommendation, the resident's care plan and physician orders did not include any reference to a neurocognitive evaluation, and there was no documentation of such an evaluation being scheduled or completed since admission. Record review further revealed that progress notes and social services documentation from the relevant period did not address the PASRR recommendations or any communication with the State Mental Health Agency regarding the delay or inability to follow through with the recommended evaluation. During interviews, the social services director confirmed awareness of the PASRR requirements and the process for arranging neurocognitive evaluations but could not provide a reason for the omission in this case.

Penalty

Inspection fine: $23,95912 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

A deficiency occurred when a staff member who was not qualified to perform nail care for diabetic residents cut the fingernails of a resident with diabetes. The resident, under the age of 65, had multiple diagnoses including dementia, diabetes, quadriplegia, contractures of both hands, and an anoxic brain injury. The resident was severely cognitively impaired and used a wheelchair. During an observation, an activities assistant removed a splint from the resident's contracted hand and proceeded to cut the fingernails on both hands, then applied lotion and replaced the splint. Interviews with facility staff revealed that activities staff are not permitted to trim or cut the fingernails of diabetic residents, as this task is reserved for the podiatrist or, in some cases, nurses due to the increased risk of wounds and infections in diabetic individuals. The activities director was unaware that the activities assistant had performed this task, and the DON confirmed that only the podiatrist or nurses should cut the nails of diabetic residents, not CNAs or activities staff. The incident demonstrated a failure to ensure that care was provided by individuals with the appropriate skills and training as outlined in the resident's plan of care.

Penalty

Inspection fine: $23,95912 days payment denial

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

Summary

The facility failed to provide necessary care and assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. One resident with severe cognitive impairment, quadriplegia, and incontinence was observed for multiple periods exceeding three hours without being offered repositioning or toileting assistance, despite care plans and staff interviews confirming the need for two-hour checks to prevent skin breakdown. Staff were unaware that the resident had not been changed for extended periods, and documentation of care provided was lacking. Two other residents, both with cognitive impairment and requiring assistance or encouragement with eating, did not receive timely meal assistance. One resident, who required her meat to be cut and needed verbal cueing, was served meals without appropriate preparation and did not receive encouragement or alternatives when she consumed less than 25% of her meal. Staff also failed to document meal intake accurately, and no alternative meals were offered as required by her care plan and physician's orders. The third resident, who had severe cognitive impairment and was missing dentures, required set-up assistance and encouragement during meals. Observations showed that she was not encouraged to eat the main portion of her meals, was not offered alternatives when she did not eat, and was routinely given dessert or ice cream instead of a nutritional alternative. Staff interviews confirmed that encouragement and alternative options were not consistently provided, and the resident's representative noted a lack of staff engagement during meals.

Penalty

Inspection fine: $23,95912 days payment denial

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

Summary

The facility failed to provide a personalized and ongoing activity program for one resident with severe cognitive impairment, as required. The resident, an 86-year-old with dementia, anxiety, mood disturbance, and heart failure, was assessed as having a strong interest in religious activities and animal visits. Despite these documented preferences, the care plan and activity participation records did not include or reflect these interests. Observations over several days showed the resident sitting alone in her wheelchair, not engaged in meaningful activities, and not invited to participate in group activities occurring nearby. Staff interviews confirmed that the resident required reminders and assistance to attend activities, but there was no evidence that her specific interests in religious services or animal visits were addressed or offered. The activity care plan only listed general group activities such as Bingo and music, and interventions were limited to providing a calendar and reminders. The resident's representative also confirmed the importance of religious activities and animal visits to the resident's well-being. Participation records for the previous month showed no evidence that the resident was offered or participated in religious or animal-related activities. Staff acknowledged the need for encouragement and individualized approaches but did not implement these for the resident's stated preferences, resulting in a failure to meet her psychosocial and activity needs.

Penalty

Inspection fine: $23,95912 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 proper follow-up and coordination of vision services for a resident with severe cognitive impairment and multiple medical diagnoses, including dementia and heart failure. The resident was evaluated by an optometrist, who recommended a referral for cataract surgery due to blurry vision in both eyes. Despite this recommendation, there was no documentation in the electronic medical record indicating that a referral to an ophthalmologist was made or that further tests for cataract surgery were scheduled. Interviews with facility staff revealed that the social service director received the referral in February and passed it to the transportation staff member but did not follow up on the process. The transportation coordinator reported not receiving the referral and acknowledged that the scheduling was missed. The facility's policy required social services to coordinate and assist with vision services, but this process was not completed, resulting in the resident not receiving the recommended follow-up care.

Penalty

Inspection fine: $23,95912 days payment denial

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

Summary

The facility failed to provide respiratory care consistent with professional standards of practice for one resident who required the use of a continuous positive airway pressure (CPAP) machine. The facility's policy required daily cleaning of the CPAP mask, nasal pillow, and tubing with mild soap and water, as well as proper storage in a bag to prevent contamination. However, observations revealed that the resident's CPAP mask, tubing, and headgear were repeatedly stored loosely in a nightstand drawer alongside personal items and visible debris, rather than in a clean bag as required. The care plan and electronic medical record did not specify instructions for cleaning or storing the CPAP equipment. Interviews with staff indicated inconsistent knowledge and practices regarding the cleaning and storage of the CPAP equipment. A CNA was observed cleaning the CPAP components with Super Sani-wipes, which is not in accordance with the manufacturer's recommendations or the physician's order, and then placing the items in a trash bag. Staff interviews revealed conflicting information about the appropriate cleaning agents and storage methods, with some staff incorrectly stating that Super Sani-wipes could be used on the CPAP mask and tubing, while others correctly identified that only mild soap and water should be used. The resident involved had multiple medical conditions, including obstructive sleep apnea, dementia, Parkinson's disease, and hemiplegia, and was dependent on staff for most activities of daily living. The resident reported that staff cleaned the CPAP mask and machine with a white wipe but was unsure of the frequency, and had never seen the equipment stored in a bag. The lack of adherence to cleaning and storage protocols, as well as the absence of clear documentation and staff training, led to the deficiency in providing safe and appropriate respiratory care.

Penalty

Inspection fine: $23,95912 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 requiring dialysis care received services consistent with professional standards of practice, specifically regarding the assessment of the resident's arteriovenous fistula (AVF) shunt. The facility's policy required daily assessment of the AVF, including checking for color, temperature, radial pulse, and patency by palpating for a thrill or auscultating for a bruit, with documentation every shift. However, review of the resident's electronic medical record, medication administration record, and treatment administration record revealed no documentation that the AVF was assessed for patency, thrill, or bruit from the time of readmission. There was also no physician's order in place to monitor the shunt for patency, and the care plan intervention to check the shunt twice daily was not consistently followed. The resident in question had a history of chronic obstructive pulmonary disease and renal failure, requiring hemodialysis three times a week. Staff interviews confirmed that the AVF was not assessed as required, and the necessary physician's order was missing following the resident's readmission. The minimum data set (MDS) assessment also failed to indicate that the resident was receiving hemodialysis, despite this being the case. Documentation showed that the AVF was only checked on a few isolated dates, rather than consistently twice daily as required by the care plan and facility policy.

Penalty

Inspection fine: $23,95912 days payment denial

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

Summary

The facility failed to provide trauma-informed and culturally competent care to two residents with significant histories of trauma, as required by its own policies and professional standards. For one resident with diagnoses including dementia, major depressive disorder, traumatic brain injury, and schizophrenia, the care plan documented a history of sexual assault, traumatic brain injury, incarceration, and suicidal ideations. However, the care plan did not include the resident's history of homicidal ideations, nor did it provide behavior monitoring for suicidal or homicidal ideations. Staff interviews revealed that direct care staff were unaware of the resident's history of suicidal or homicidal ideations, despite this information being documented in the PASRR Level II evaluation and psychiatric notes. The facility also failed to assess and identify potential triggers that could cause re-traumatization or behaviors towards others for this resident. For the second resident, who had diagnoses including PTSD, schizoaffective disorder, and bipolar disorder, the care plan noted a history of sexual assault and PTSD but did not include individualized, person-centered, non-pharmacological approaches to address the resident's needs. The social history assessment lacked documentation of the specific support needed for the resident's PTSD, and there was no evidence that the facility completed an assessment to identify or mitigate triggers that could cause re-traumatization. The resident reported that the facility had not asked about her past traumatic event, and staff interviews confirmed a lack of awareness and assessment regarding trauma triggers. Overall, the facility did not perform universal screening or in-depth assessment to identify trauma triggers for these residents, nor did it develop or implement individualized care plans and interventions to address their trauma histories. Staff were not adequately informed of the residents' trauma-related risks, and the care plans did not reflect the necessary information to guide trauma-informed care, resulting in a failure to meet the residents' psychosocial and emotional needs as outlined in facility policy.

Penalty

Inspection fine: $23,95912 days payment denial

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

Summary

The facility failed to provide timely dental services to a resident with severe cognitive impairment, dementia, dysphagia, and adult failure to thrive. The resident, who was edentulous, had all teeth extracted and received new dentures, but experienced ongoing issues with the fit and comfort of the dentures. Documentation indicated that the resident's gums had healed, and she was having difficulty chewing food with the dentures, which were reported as loose and causing discomfort. Although the registered nurse was to notify the social worker to add the resident to the dental list for evaluation, there was no documentation in the electronic medical record that the resident was seen by the dentist after these issues were reported. Observations over several days showed the resident not wearing her dentures during meals and while in her room. Interviews with staff revealed that the resident did not wear her dentures consistently, with some staff believing the dentures caused pain and others attributing non-use to the resident not being accustomed to them. The social services director stated that the dentist visited weekly but confirmed the resident was not seen during the relevant period and was not notified about the denture issues. The resident's representative was aware the resident was not wearing dentures but was not informed about the need for adjustment.

Penalty

Inspection fine: $23,95912 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 implement its policies and procedures regarding pneumococcal immunizations for one resident. An 86-year-old resident with severe cognitive impairment, as indicated by a BIMS score of three out of 15 and diagnoses including dementia, anxiety, mood disturbance, and hypertensive heart disease with heart failure, received the Prevnar 20 pneumococcal vaccine. The resident required partial to moderate assistance with activities of daily living and was not up to date on the pneumococcal vaccine, as the vaccine had previously been offered and declined. The deficiency occurred when the infection preventionist (IP) signed the vaccination consent form on behalf of the resident, rather than obtaining consent from the resident's representative. The resident's representative was not notified or asked for consent prior to the administration of the vaccine and only learned of the vaccination after the resident complained of arm pain. Review of the electronic medical record confirmed the absence of documentation showing that the representative was notified or gave consent for the vaccination.

Penalty

Inspection fine: $23,95912 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 the residents' shower room in a safe and sanitary condition. During an observation, black residue was noted on the grout lines around the perimeter of the inside of the shower. A resident's representative reported that the shower room was not clean and had needed a thorough cleaning for some time. The maintenance director and the nursing home administrator were unable to identify the black residue during their inspection, and the maintenance director stated that while the shower was cleaned daily and deep cleaned weekly, he could not determine the nature of the residue. Further interviews revealed that the maintenance director could sanitize the shower but was not equipped to test for mold. The facility subsequently arranged for environmental testing, which later reported potential water damage, possible visual growth, and excessive humidity and moisture in the shower area. Laboratory results indicated the presence of common allergens but did not confirm fungal growth.

Penalty

Inspection fine: $23,95912 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 residents, family members, and legal representatives had full access to review the results of the facility's most recent survey findings, including survey results, certifications, complaint investigations, and plans of correction for the preceding three years. During a group interview, several alert and oriented residents reported that they did not know where the binder containing the survey results was located. Observations revealed that the survey result binder was kept behind the receptionist's desk in the front lobby, making it inaccessible without requesting it from the receptionist. The binder was only available when the receptionist was present and was stored in a cabinet when the receptionist was not at the desk, further limiting access. Additionally, the binder did not contain all required surveys from the past three years, as several survey reports were missing. Staff interviews confirmed that the binder was not easily accessible to residents and family members, and the social service director acknowledged that the receptionist was not on site all day, restricting around-the-clock access. The nursing home administrator, who had been in the role for four months, stated that it was his responsibility to keep the binder up to date but had not identified this as an issue.

Penalty

Inspection fine: $29,17725 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 Resident #6 was free from significant medication errors related to anticoagulants and insulin management. Resident #6 had multiple significant health conditions requiring close monitoring and medication administration, including warfarin for blood clot prevention and insulin for diabetes management. The facility's nursing staff did not consistently administer the prescribed medications to Resident #6, leading to missed doses and errors in dosage administration. This failure put Resident #6 at increased risk of serious health problems such as strokes, heart attacks, and deep vein thrombosis. The facility's deficiencies included not ensuring all medications were ordered and administered according to physician orders, resulting in Resident #6 missing several prescribed medications over a period of weeks. The nursing staff failed to document reasons for medication unavailability, did not promptly reorder medications, and did not communicate effectively with the resident's physician or pharmacy to address medication shortages. Errors in medication administration, such as giving incorrect doses and failing to discontinue or adjust medication orders as per physician instructions, were also noted. Staff interviews revealed issues with poor documentation, failure to administer medications as prescribed, lack of communication with the physician for new prescriptions, and inadequate training on emergency medication access for agency nursing staff. The facility's leadership, including the Director of Nursing and Assistant Director of Nursing, were unaware of the extent of the medication errors and did not have proper procedures in place to address medication availability issues promptly. These deficiencies led to Resident #6 being at risk of harm due to significant medication errors and inadequate medication management practices within the facility.

Penalty

Inspection fine: $29,17725 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 Resident #15, who was unable to carry out activities of daily living (ADL), received the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Resident #15, admitted for long-term care with diagnoses including depression, quadriplegia, neurogenic bowel, neuromuscular dysfunction of bladder, and colostomy status, was dependent on staff for all ADLs. Despite being cognitively intact, Resident #15 expressed concerns about not receiving assistance with bathing, oral hygiene, and meals regularly. The resident reported staying in the same clothes for days, experiencing discomfort, itching, and burning skin due to lack of hygiene care, and feeling frustrated to the point of not wanting to live anymore. Observations and interviews revealed that Resident #15 had body odor, food on clothes, yellow teeth, bad breath, dry and flaky skin, and long toenails. The resident reported not being assisted with showering, teeth brushing, or changing clothes regularly. Additionally, Resident #15 mentioned issues with his catheter care, leading to a urinary tract infection and sepsis. Despite documented care plans for ADL assistance, including shower preferences, the resident's bathing schedule was not consistently followed, with missed opportunities for bathing noted in the records. Staff interviews indicated that Resident #15's care preferences were not always communicated or followed, leading to deficiencies in providing essential care and hygiene services. The facility's failure to provide adequate ADL assistance to Resident #15 resulted in emotional distress, physical discomfort, and a decline in the resident's state of mind. Despite documented care plans and interventions for ADL support, including shower preferences and two-staff assistance requirements, the resident reported significant gaps in receiving necessary care. Staff members acknowledged deficiencies in shower documentation, missed care opportunities, and the need for improved communication and understanding of resident preferences. The lack of consistent and appropriate assistance with ADLs, hygiene, and nutrition for Resident #15 highlights critical deficiencies in the facility's provision of care for residents unable to carry out daily living activities independently.

Penalty

Inspection fine: $29,17725 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 consistently provide catheter care, treatment, and services to minimize the risk of urinary tract infections for two residents (#15 and #11) out of three residents reviewed for catheter care. Resident #15, admitted for long-term care with a complex medical history including quadriplegia, neurogenic bowel, and neuromuscular dysfunction of the bladder, experienced severe sepsis related to a catheter-associated urinary tract infection (CAUTI). The resident was found soaked in urine upon arrival at the hospital, with significant skin breakdown and cellulitis likely due to poor hygiene and catheter care. Despite having a catheter care plan in place, the resident reported instances of prolonged catheter bag emptying intervals, lack of leg anchors causing discomfort, and inadequate hygiene practices leading to adverse outcomes. Similarly, Resident #11, also admitted for long-term care with quadriplegia and neurogenic bladder dysfunction, experienced issues with catheter care. The resident reported staff not regularly checking and emptying the catheter drainage bag, leading to discomfort and potential complications. Despite physician orders for catheter irrigation and monitoring, records revealed instances where these procedures were not completed as prescribed, indicating a lack of adherence to care protocols. The resident's catheter care was further compromised by delayed or missed interventions, such as monitoring for catheter placement and patency, potentially contributing to the deficiency in care observed by surveyors. Staff interviews highlighted gaps in practice, with observations of inadequate catheter care procedures and lack of attention to resident needs. Registered nurses and consultants acknowledged deficiencies in catheter care practices, emphasizing the importance of proper technique, hygiene, and monitoring in preventing catheter-related complications. The facility's failure to consistently provide appropriate catheter care, treatment, and services for residents with complex medical needs resulted in adverse outcomes and raised concerns about the overall quality of care provided to residents requiring catheter management.

Penalty

Inspection fine: $29,17725 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 two out of two residents sampled received the necessary care and services to meet their nutrition needs. Resident #11, admitted for long-term care with multiple diagnoses including quadriplegia, diabetes, and neurogenic bowel, experienced significant weight loss of 14.2% (25.8 lbs) over six months. Despite interventions like Glucerna supplementation and liquid protein, the resident's weight loss continued. The facility did not consistently monitor the resident's weight, failed to provide vegetarian meal options as per his preferences, and did not offer adequate diabetic education. During observations and interviews, it was noted that Resident #11, a vegetarian, often received meals inconsistent with his dietary preferences, leading to decreased oral intake. The resident expressed dissatisfaction with the food options provided, resulting in him purchasing his own meals. Despite the RD's efforts to address the resident's preferences and weight loss, the interventions were not effectively monitored for their impact. Additionally, the facility did not adhere to its policy of weighing residents regularly to track changes in weight and nutritional status.

Penalty

Inspection fine: $29,17725 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 develop and implement appropriate quality assurance and performance improvement (QAPI) plans to correct identified quality deficiencies, specifically related to medication errors. The QAPI committee did not identify and address concerns related to medication errors, which were cited during the recertification survey. The facility's policy outlined the objectives and processes for the QAPI program, including tracking performance, establishing goals, and developing corrective actions. However, the committee did not effectively follow these processes, leading to repeated deficiencies in medication management. During the survey, it was found that the facility had significant medication errors, including the unavailability of medications from the pharmacy and failure to administer medications according to physician's orders. Interviews with the nursing home administrator (NHA) and interim director of nursing (IDON) revealed that the QAPI committee met monthly but did not have records of previous meetings or discussions about the medication errors cited in the previous survey. The IDON was unaware of the repeated citation, indicating a lack of communication and follow-up within the committee.

Penalty

Inspection fine: $29,17725 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 timely response to resident call lights, which compromised the residents' dignity and self-determination. Observations revealed significant delays in answering call lights, with some residents waiting over an hour for assistance. For instance, a call light activated at 9:10 a.m. was not answered until 10:41 a.m., and another at 2:20 p.m. was not answered until 3:20 p.m. These delays were consistent across multiple observations and involved several CNAs who either did not respond promptly or failed to provide immediate assistance upon entering the room. Resident interviews corroborated these findings, with multiple residents reporting long wait times for assistance. One resident mentioned waiting two to four hours for help in December 2023, while another described a 30-minute wait to address a wet bed. Another resident reported waiting four to six hours for help during the night shift. These delays were attributed to miscommunication among staff, inadequate staffing during certain shifts, and staff being preoccupied with other tasks or on their phones. Staff interviews indicated that call light response times were often delayed due to CNAs being occupied with other residents or tasks. One CNA mentioned that call lights should be answered within five to ten minutes but acknowledged that delays occurred during meal times or when assisting other residents. Another CNA highlighted poor communication and lack of teamwork as contributing factors. The corporate nurse consultant acknowledged the issue and indicated that the facility would look into the call light delays.

Penalty

Inspection fine: $29,17725 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 prompt action was taken upon the filing of a grievance of a group. Specifically, the facility did not follow up with residents' concerns regarding meals, staff cell phone usage, batteries not being charged, and trash not being taken out. The facility's policy stated that all grievances should be responded to in writing, including a rationale for the response, but this was not adhered to in practice. Residents reported that their concerns were repeatedly brought up in resident council meetings without resolution, leading to frustration and a sense of futility among the residents. One resident even expressed fear of punishment for voicing concerns. Interviews with staff revealed a lack of clarity and responsibility regarding who should document and address grievances raised in resident council meetings. The social services director and assistant were unsure who was responsible for filling out grievance forms for concerns brought up in these meetings. The activities director, who was new to the role, also confirmed that the same concerns had been raised in several meetings without resolution and that the activities department did not fill out grievances for these concerns. Record reviews of resident council meeting minutes from October 2023 to January 2024 showed that issues such as staff cell phone usage, uncharged batteries, unemptied trash bins, and cold meals were repeatedly reported but remained unresolved. The facility's failure to address these concerns in a timely and effective manner indicates a significant lapse in following their grievance policy and ensuring resident satisfaction and well-being.

Penalty

Inspection fine: $29,17725 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 adequate supervision and a safe environment for five residents, leading to multiple deficiencies. Resident #1, who had severe cognitive impairment and a history of substance use disorder, was not properly assessed for elopement risk or community safety. Despite multiple documented instances of the resident expressing a desire to leave the facility, no comprehensive care plan was developed to address these risks. The resident eventually eloped and was missing for four days, during which time he was found intoxicated and in unsafe conditions. The facility also failed to notify the resident's responsible party about his elopement and did not conduct a thorough investigation or reassessment upon his return to the facility. Resident #23, who had multiple sclerosis and dementia, was found smoking in her room while wearing oxygen, posing a significant safety risk to herself and others. The facility did not conduct regular quarterly smoking assessments to ensure the resident's compliance with smoking safety protocols. Despite being care-planned to require supervision while smoking, the resident managed to obtain cigarettes and a lighter, leading to an incident where her roommate, who had respiratory issues, was exposed to smoke and felt unsafe. The facility did not investigate how the resident obtained the smoking materials or why staff did not intervene sooner. Additionally, the facility failed to develop and implement person-centered care plans for Residents #13 and #9 to address their fall risks and did not complete registered nurse assessments or neurological checks following their falls. Resident #4's substance abuse disorder was also not addressed in a care plan. The facility's policies on safety and supervision, as well as wandering and elopement, were not effectively implemented, and staff were not adequately trained on how to respond to residents at risk for elopement or unsafe behaviors. The facility's elopement binder was outdated, and non-nursing staff were not informed about residents at risk for elopement, leading to inadequate supervision and response to these risks.

Penalty

Inspection fine: $29,17725 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 certified nurse aides (CNAs), licensed practical nurses (LPNs), and registered nurses (RNs) demonstrated the necessary competency skills and techniques to care for residents' needs. This deficiency was identified through staff interviews and record reviews, which revealed that the facility did not conduct staff competency evaluations for any of its nursing staff. The lack of competency evaluations placed all residents at risk of receiving inadequate care. The facility's policy, revised in August 2002, mandates that nursing staff must meet specific competency requirements and demonstrate skills in various areas, including resident rights, behavioral health, dementia care, medication management, and infection control. However, the facility was unable to provide documentation of competency or training for its nursing staff in these critical areas. During interviews, the corporate nurse consultant (CNC) and the newly hired nursing home administrator (NHA) confirmed that no staff competency evaluations had been completed. The CNC mentioned that several key members of the facility leadership team were no longer working at the facility, and they were in the process of hiring a new leadership group to manage nursing services. Additionally, the facility had several agency nursing staff on contract to fill open shifts, and the leadership was assessing their competency to determine their suitability for additional shifts until permanent staff could be hired. The failure to conduct competency evaluations was cross-referenced with multiple deficiencies, including inadequate assistance for activities of daily living, failure to provide diabetic care, and failure to follow appropriate infection control practices.

Penalty

Inspection fine: $29,17725 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 consistently serve food that was palatable and attractive at the appropriate temperatures. Observations revealed that a test tray for a regular diet included a sloppy joe sandwich, a bag of potato chips, and coleslaw. The coleslaw was found to be bland, soggy, and at an inappropriate temperature of 48.4 degrees Fahrenheit. The sloppy joe sandwich was greasy, and the potato chip bag was placed directly on top of the sandwich, making the meal unappetizing. Record reviews from food committee notes indicated ongoing resident dissatisfaction with food quality, including requests for specific food items and complaints about food orders not being taken, food being served cold, and a lack of variety in menu options. Resident interviews corroborated these findings, with multiple residents expressing that the food was often served cold, tasteless, and not cooked correctly. Some residents even resorted to ordering their own food due to the poor quality of meals provided by the facility. Staff interviews further confirmed the issues, with the Nutrition Services Director (NSD) acknowledging that the coleslaw served was bland and not kept at the correct temperature. The NSD also mentioned that a new cook would receive additional education. The Corporate Nurse Consultant (CNC) agreed that the presentation of the meal was unappetizing and that the food should be served at the correct temperature, be tasty, and look good. Despite monthly food committee meetings, residents felt their concerns were not being addressed, leading to a general sense of dissatisfaction with the food services provided by the facility.

Penalty

Inspection fine: $29,17725 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 a clean, safe, and homelike environment for two residents. Resident #19, who has a gastric tube for nutrition and an esophageal ostomy bag, was observed with a large bucket at his bedside filled with discarded food and liquid waste. The bucket was not regularly emptied or cleaned, resulting in a foul odor and unsanitary conditions. Additionally, the room shared by Resident #19 and Resident #11 was cluttered and dirty, with soiled privacy curtains, a dirty floor, and dead flies on the windowsill. The sink was covered with personal care items and the trash can was visibly dirty. Resident #19's care plan did not include specific interventions to manage the discarded food and liquid waste in a sanitary manner. The resident's condition requires him to dispose of food waste in a bucket, but staff did not consistently empty or clean the bucket. Resident #19 expressed reluctance to complain about the conditions due to fear of being labeled a troublemaker. The observations revealed that the room environment was not maintained in a clean and orderly manner, contributing to the unsanitary conditions. Resident #11, who is dependent on staff for most activities of daily living, also reported that the room was not cleaned regularly. The nursing home administrator acknowledged the issues and mentioned plans to implement a rounding program to address housekeeping concerns. However, at the time of the survey, the facility had not ensured a clean and safe environment for the residents, as evidenced by the observations and resident interviews.

Penalty

Inspection fine: $29,17725 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 grievance regarding missing cigarettes and money was promptly addressed and resolved. The resident, who was cognitively intact and had multiple medical conditions including depression, diabetes, and schizophrenia, reported that his cigarettes and money were missing after returning from the hospital. Despite informing several staff members, including the previous nursing home administrator, no investigation or resolution was provided. The facility's grievance policy, which mandates prompt efforts to resolve grievances, was not followed in this case. Interviews with the social services director, social services assistant, and corporate nurse consultant revealed that the grievance process was not properly executed. The social services department did not have any documentation of the resident's grievance, and the corporate nurse consultant confirmed that the grievance forms lacked appropriate resolutions. The facility had attempted to implement a process improvement plan, but it was deemed ineffective. The corporate nurse consultant eventually replaced the resident's missing items, but this action was not part of the initial grievance resolution process.

Penalty

Inspection fine: $29,17725 days payment denial

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

Summary

The facility failed to provide regular and consistent supervised guidance to assist Resident #4 in making educated decisions on determining an appropriate sliding scale insulin dose based on blood glucose assessment and carbohydrate intake. The facility's policy required the physician and staff to summarize factors contributing to the resident's diabetes and assess the impact on the individual's function and quality of life. However, the nursing staff did not document the insulin dosage administered or the rationale for the dose administered if it was not in line with the physician's order. Additionally, there was no documentation of the supervision and guidance efforts of the nurses administering the resident's sliding scale insulin dose or how the dosing was determined based on the assessment of the resident's blood glucose level and carbohydrate intake. Resident #4, who was under the age of 65 and had multiple diagnoses including type one diabetes mellitus, visual loss, and schizophrenia, reported difficulties in managing his diabetes due to inconsistent meal times and portion sizes. He mentioned that his insulin was often administered late, causing his blood sugar to drop significantly, leading to hospitalizations. The resident's medical records revealed that he had been to the hospital multiple times due to hypoglycemia, with blood glucose levels dropping as low as 20. Despite the resident's ability to titrate his insulin dosing, there was no clear documentation of the nursing staff's involvement in guiding and supervising this process. Interviews with the facility staff, including the corporate nurse consultant and the nursing home administrator, indicated that diabetic education should have been offered to Resident #4 and documented in his medical record if he refused it. The staff acknowledged that diabetic education was part of diabetic management, but there was no information on why Resident #4 was allowed to titrate his insulin, which was not within normal standards of practice. The resident's comorbidities, including blindness and substance use, further complicated his ability to correctly dose his insulin, leading to multiple emergency room visits related to low blood sugar.

Penalty

Inspection fine: $29,17725 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 residents requiring colostomy care received services consistent with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not maintain the colostomy bags of two residents, Resident #15 and Resident #11, per physician's guidance and professional standards. Both residents reported issues with their colostomy bags being full of gas and not being properly managed by the staff, leading to concerns about the bags potentially exploding and leaking feces on their persons. Resident #15, who was cognitively intact and dependent on staff for all ADLs, reported that his colostomy bag was often full of gas and would explode. Observations confirmed that his colostomy bag was fully inflated with gas on multiple occasions. The care plan for Resident #15 included specific interventions for colostomy care, but there were no orders for routine maintenance, including replacing the colostomy bag per standards of practice. Staff interviews revealed that colostomy care was not being provided adequately, and the resident's concerns were validated by the corporate nurse consultant (CNC). Resident #11, also cognitively intact and dependent on staff for most ADLs, reported similar issues with his colostomy bag being full of gas and not being checked by staff as required. Observations confirmed that his colostomy bag was extremely extended with gas. The care plan for Resident #11 failed to document a care focus for the maintenance of his newly placed colostomy. Staff interviews indicated that colostomy care was not being provided as needed, and the resident's concerns about the bag leaking were documented in progress notes. The CNC acknowledged that the facility had not provided staff with education on colostomy care, contributing to the deficiencies observed.

Penalty

Inspection fine: $29,17725 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 menus were followed to meet the residents' nutritional needs. Specifically, the facility did not adhere to correct portion sizes and recipe modifications for texture-modified diets. During a lunch meal observation, it was noted that the cook used incorrect scoop sizes for cole slaw and pasta salad, providing 1.33 oz less than the specified 4 oz. Additionally, residents on a regular diet received only one cookie instead of the two specified on the menu extension sheet. The cook also did not use a measuring device to ensure correct portion sizes for pureed diets and failed to puree the bread for the pureed sandwich sloppy joe, instead adding water to the meat, which decreased its nutritional value. Furthermore, residents on a pureed diet did not receive all components of their meal, including the bun, pasta salad, cookie, or milk, as specified in the menu extension sheets. The cook also served regular textured meat to residents on a mechanically altered diet, contrary to the specified pureed texture, putting them at risk for choking. Interviews with the Nutrition Services Director (NSD) and the Registered Dietitian (RD) confirmed these deficiencies, with both acknowledging that the correct portion sizes, textures, and all meal components were not provided, thereby failing to meet the residents' nutritional needs.

Penalty

Inspection fine: $29,17725 days payment denial

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

Summary

The facility failed to provide Resident #11 with a nourishing, well-balanced diet that met his daily nutritional and special dietary needs, specifically his preference for a vegetarian diet. Despite the facility's policy requiring the identification and accommodation of individual food preferences upon admission, Resident #11 reported that he had to purchase most of his own food because the facility did not accommodate his vegetarian preference. During an observation of the lunch service, it was noted that Resident #11 received only a cookie and a bag of chips, as the main menu item was a sloppy joe, which he could not eat due to his dietary preference. The resident expressed dissatisfaction with the limited vegetarian options available, such as grilled cheese, cheese quesadilla, and bean burrito, and reported weight loss since his admission to the facility. The nutrition care plan for Resident #11, which was revised during the survey, indicated potential for alteration in body composition integrity and unintended weight changes due to his medical conditions, including type one diabetes mellitus, quadriplegia, and a history of pressure ulcers. The care plan included interventions such as monitoring for signs of malnutrition, providing supplements, and offering vegetarian items per resident preferences. However, these interventions were not effectively implemented, as evidenced by the resident's complaints and the observed meal service. Interviews with other residents revealed similar issues with meal orders not being taken or followed correctly. The nutrition services director (NSD) and the registered dietitian (RD) acknowledged that Resident #11's preferences should be included in the care plan and that his lunch of chips and cookies was not nutritionally adequate. The NSD stated that the certified nurse aides (CNA) were responsible for taking meal orders, but there was a lack of communication and follow-through in updating care plans and ensuring residents' dietary needs and preferences were met.

Penalty

Inspection fine: $29,17725 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 an infection control program designed to provide a safe, sanitary, and comfortable environment, leading to potential development and transmission of infectious diseases. Specifically, the facility did not follow aseptic techniques during the replacement of a suprapubic catheter for Resident #15 and during wound care for Resident #18. These deficiencies were observed during a survey conducted by the regulatory body. In the case of Resident #15, the registered nurse (RN) did not perform hand hygiene or set up a clean or sterile field before starting the suprapubic catheter change. The RN used the same gloves throughout the procedure, touched various surfaces, and adjusted his mask without changing gloves or performing hand hygiene. The RN also failed to clean and lubricate the suprapubic stoma site before inserting the new catheter. These actions were contrary to the facility's policies and professional standards for aseptic technique. For Resident #18, the wound care nurse (WCN) did not wash her hands before entering the resident's room and setting up the wound care supplies. The WCN set up the supplies on a cluttered nightstand without cleaning the surface and did not perform hand hygiene between glove changes. The WCN handled clean wound dressing supplies with the same gloves used to remove the soiled dressing and did not use a secondary clean field barrier. These actions were inconsistent with the facility's wound care policy and compromised the aseptic technique required for wound care procedures.