Winding Trails 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 protect multiple residents from physical and verbal abuse by other residents, as evidenced by several documented incidents. One resident with schizophrenia and a history of behavioral symptoms, including delusions, hallucinations, and aggression primarily directed toward male residents, physically assaulted another resident by hitting him on the cheek and pulling his beard. This incident was witnessed by staff, and the victim, who had a history of being the target of altercations, reported feeling unsafe and described multiple threats and prior incidents involving the same aggressor. The aggressor had previously refused psychiatric services and medication, and her care plan included interventions such as redirection and frequent checks, but these measures did not prevent the abuse. Another resident reported being physically abused by the same aggressor, who threw water on his head. This resident, who was moderately cognitively impaired and had a history of behavioral issues, stated that staff were notified but did not take action. Additionally, a third resident received a threatening note from the aggressor, indicating intent to cause harm. This resident, who was cognitively intact but experienced anxiety and impaired coping, also reported the incident to staff but felt that no effective response was provided. The aggressor was known to leave threatening notes and enter male residents' rooms, causing fear among other residents. The report also documents a verbal altercation between two other residents, involving racial and discriminatory insults, which was witnessed by staff, residents, and surveyors. Staff interviews revealed that while some interventions such as redirection and frequent checks were attempted, staff did not consistently investigate or address all incidents of abuse, particularly those involving threatening notes. The DON acknowledged awareness of the threatening behavior but stated that not all incidents were investigated, as the notes were considered part of the aggressor's behavior and not deemed dangerous.

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 wound care treatment in accordance with physician orders and the resident's care plan for one resident. The resident, under 65 years old, had multiple diagnoses including vascular dementia, type 2 diabetes, diabetic neuropathy, atrial fibrillation, and hemiplegia following a stroke. The resident was cognitively intact and required substantial assistance with daily activities. According to the physician's order, the resident's venous wound on the left shin was to be cleaned and dressed daily during the day shift. However, during an interview and observation, it was found that the wound dressing had not been changed for three days, as evidenced by the date on the dressing and confirmed by staff during the dressing change. Staff interviews confirmed that the wound care order required daily dressing changes, and the wound care physician expected nursing staff to perform this task if the wound care nurse or physician was not present. The DON was unable to provide an explanation for why the dressing was not changed as scheduled. The failure to follow the physician's order for daily wound care resulted in the resident's dressing remaining unchanged for three days, contrary to professional standards of practice and the resident's comprehensive care plan.

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 protect multiple residents from abuse, including physical and verbal abuse, primarily involving one resident with known behavioral issues. Facility policy defined abuse broadly, including resident-to-resident altercations, and required written procedures to prohibit and prevent abuse, neglect, and exploitation, as well as investigation and staff training. Despite this, the facility did not consistently act on known patterns of threatening and aggressive behavior by one resident toward male residents, nor did it investigate all threatening notes or verbal threats as potential abuse incidents. One incident involved a cognitively intact male resident with schizoaffective disorder, diabetes, major depressive disorder, PTSD, and a history of being the victim in altercations. He reported that another resident with schizophrenia, cognitive impairment, delusions, hallucinations, and a history of odd and sexually threatening statements had threatened him multiple times, including threats to kill him and cut him into small pieces in his bathroom. He stated that this resident had physically hit him by striking his cheek and pulling his beard when they returned from the smoking patio, and that he had reported these incidents to staff. He also reported that this same resident had hit another male resident. The behavior care plan for the aggressor resident documented delusions, hallucinations, refusal of care, sexual and odd statements, yelling at other residents, and behaviors mostly directed toward males, yet the facility did not prevent the subsequent physical contact and threats that occurred. Another male resident with dementia, psychotic and mood disturbances, depression, anxiety, and moderate cognitive impairment reported that the same aggressor resident had thrown water on his head months earlier and that he notified staff but "they did nothing." He also reported that she sometimes spoke to him in an aggressive way. A third cognitively intact male resident with cerebral atherosclerosis, sequelae of cerebral infarction, generalized anxiety disorder, anxiety, ineffective coping, and verbal aggression reported that the same aggressor resident entered his room and left a note stating she would come to his bedroom and cut his penis while he slept. He stated he should not be threatened in that way, reported it to staff, and believed nothing would be done, adding that she had threatened others verbally or with notes and went into men’s bedrooms, causing him fear. The DON, acting as abuse coordinator, acknowledged awareness that this resident passed threatening notes to residents and staff, characterized the notes as part of her behavior, stated she was not dangerous, and reported that the facility did not investigate every note she wrote. The deficiency also includes an observed incident of verbal abuse between two cognitively intact male residents. One resident with PTSD, severe major depressive disorder, COPD, diabetes, and a cognitive communication deficit, who had a care plan noting a loud voice often perceived as yelling and risk for verbal altercations, was speaking loudly near the nurse’s station. Another resident with anxiety, ineffective coping, and verbal aggression came out of his room and yelled racial and discriminatory insults and profanity at him, and the first resident yelled back using similar language. This altercation, involving racial and discriminatory insults, was witnessed by staff, other residents, and surveyors. Staff interviews confirmed that the loud resident often spoke in a way that disturbed others and that the verbally aggressive resident had prior arguments with him, usually initiated by the verbally aggressive resident, but the facility had not effectively prevented such abusive exchanges.

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 wound care treatment in accordance with physician orders and the resident’s person-centered care plan by not changing a venous leg ulcer dressing daily as prescribed. The resident, under 65 years old, had multiple diagnoses including vascular dementia, type 2 diabetes, diabetic neuropathy, atrial fibrillation, and hemiplegia following a stroke, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with toileting hygiene, dressing, transfers, and showering. A physician’s order dated 9/18/25 directed that the venous wound on the left shin be cleansed with wound cleanser, patted dry, treated with calcium alginate and an ABD pad, and wrapped with kerlix gauze every day shift. On interview, the resident reported that nursing staff were not changing the wound dressing and pointed to the dressing on the left calf. Observation on 10/1/25 showed the left calf wrapped in kerlix gauze with tape dated 9/28/25 and marked with a smiley face, indicating the dressing had not been changed for three days. During a wound care observation later that day, the ADON and an LPN removed the old dressing, revealing a calf wound with a generally red appearance, some beefy red open areas approximately quarter-sized with well-defined borders, and several quarter-sized scabbed areas. The LPN stated the wound was overall healing and then performed wound care per the existing order. The wound care physician confirmed the order for daily dressing changes and stated she expected nursing staff to change the dressing daily when she or the wound care nurse were not present. The DON stated she did not know why the dressing had not been changed as scheduled and acknowledged that nursing staff should follow the physician’s wound care orders.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the security of all personal funds of residents deposited with the facility by not maintaining a surety bond that covered the entire balance of the residents' personal needs account. The facility's policy required them to act as a fiduciary for the residents' funds, safeguarding and managing these funds according to established financial management policies. However, the surety bond in place was for $14,000, which was insufficient to cover the account balance that exceeded this amount on multiple occasions from May 2024 to October 2024. During interviews, the business office manager (BOM) acknowledged that the surety bond coverage was increased to $50,000 during the survey, with the bonding company making this increase retroactive to October 1, 2024. The BOM admitted that the need for increased coverage was recognized during the survey, as the balance totals had been greater than $14,000 at times over the past several months. The nursing home administrator (NHA) also confirmed that the facility should have maintained a surety bond covering the total balance in resident personal funds at all 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 facility failed to provide a response, action, and rationale to residents involved in group grievances, specifically regarding food concerns raised during resident council meetings. The facility's policy requires that all grievances, complaints, or recommendations from resident or family groups concerning issues of resident care be considered and responded to in writing, including a rationale for the response. However, during a group interview with five alert and oriented residents, it was revealed that their concerns about the snacks provided by the facility were not addressed. The residents expressed dissatisfaction with the snacks, preferring different options or bringing their own, and felt that the facility did not provide prompt resolutions to their concerns. The resident council notes from June, July, October, and November 2024 were reviewed, showing that residents had repeatedly raised concerns about the quality and variety of food, including requests for infused water, fresh snacks, more protein at breakfast, and larger portion sizes. Despite these ongoing concerns, there was no documentation indicating that the facility had reviewed or approved the residents' concerns or provided any response or rationale. Interviews with the Nursing Home Administrator (NHA) revealed that the Activities Director (AD) was responsible for coordinating the resident council meetings and communicating concerns to the relevant departments. However, the NHA was unaware that the AD did not follow up with the residents to ensure their concerns were addressed, and there was no documentation of staff responses to the residents' concerns from the June or October meetings.

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 consistently serve food that was palatable and attractive, as evidenced by multiple resident interviews and surveyor observations. Residents reported that the food was often served cold, with complaints about the taste and texture. One resident mentioned that the eggs were served cold and were terrible, while another stated that the food was not nutritious and did not meet their preferences. Additional complaints included food being undercooked or overcooked, difficulty in cutting and chewing the food, and the food not being fresh. The June and October 2024 resident council meeting notes also highlighted issues with the food being too spicy and the presence of too many processed foods, with no documentation of actions taken to resolve these grievances. Surveyors observed a test tray evaluation, which revealed that the cheese pizza was dry, crunchy, and bland, and the salad lacked variety. Interviews with the dietary manager and corporate dietary director confirmed issues with the pizza's texture and the salad's lack of garnish. The pork chop was reportedly stored in hot water to prevent drying, but residents found it hard to slice. The nursing home administrator was unaware of the residents' dissatisfaction with the food and noted that a performance improvement project was in place, but it did not address the palatability of the food. A food satisfaction survey was conducted, but it did not include questions about the taste, texture, and consistency of the meals served.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the self-administration of medications was clinically appropriate for two residents. Resident #4, who was cognitively intact with a BIMS score of 14 out of 15, was found with tubes of lidocaine on the bedside table and nearby rack, despite no physician's orders or assessments indicating the resident was able to self-administer medications. The care plan did not reveal any desire from the resident to self-administer medications. Similarly, Resident #60, also cognitively intact with a BIMS score of 14 out of 15, had several medications left on the bedside table during a medication pass, without any physician's orders or assessments for self-administration. The care plan for this resident also did not indicate a desire to self-administer medications. Interviews with the DON and RN #1 revealed that the facility did not assess or allow any residents to self-administer medications. The DON emphasized the importance of nursing staff observing residents as they took their medications to ensure proper administration. RN #1 reiterated that medications should not be left at the bedside, as they could be misused, discarded, or taken by other residents. The facility's policy on medication storage also required drugs to be stored in locked compartments, accessible only to authorized personnel.

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 incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination into the care planning and transition of care for a resident. The resident, who was over 65 years old and had diagnoses including renal insufficiency, dementia, anxiety disorder, depression, and bipolar disorder, was admitted with a PASRR Level II evaluation that recommended services such as individual therapy by a qualified community mental health professional. However, the facility did not include these recommendations in the resident's care plan, nor did they document any efforts to request or establish the recommended services. The facility's comprehensive care plan and electronic medical records did not reflect the PASRR Level II recommendations, and there was no physician's order for psychotherapy, despite the resident being prescribed medications for depression, anxiety, and psychosis. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the facility had not conducted a thorough audit to identify residents with PASRR Level II recommendations, and the SSD acknowledged gaps in the program. The SSD, who had been in the position for only a month, was in the process of auditing all residents' PASRRs to ensure compliance with recommendations.

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 individualized activities for a resident at the end of life, who was identified as having severe cognitive impairments and was dependent on staff for activities of daily living. The resident's preferences, which included listening to music, being around animals, and keeping up with the news, were not incorporated into her care plan. Observations revealed that the resident's room lacked personalization and comforting activities, with no music or personal belongings present, except for a small stuffed animal. Staff interviews indicated a lack of awareness and implementation of the resident's preferences, with the CNA and LPN unaware of the resident's activity preferences and the AD lacking supplies to play music. The resident's representative confirmed that the resident was receiving hospice care and required comfort measures. Despite the facility's policy to provide a homelike environment and activities based on resident preferences, the care plan did not reflect the resident's identified preferences. The DON acknowledged the room's lack of personalization, and the RCR emphasized the expectation for staff to initiate care based on resident preferences. The AD admitted to not having training on the needs of hospice residents and only implemented a more homelike atmosphere during the survey, after reading about hospice care needs.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate treatment and services to a resident with limited mobility to maintain or improve their range of motion (ROM). Specifically, the facility did not establish a consistent restorative nursing program, which resulted in the resident not receiving the prescribed ROM therapy. The resident, who was cognitively intact and had diagnoses including heart disease, chronic respiratory failure, and muscle weakness, reported not receiving the daily ROM therapy as ordered, leading to feelings of weakness and loss of strength. The facility's lack of a restorative nursing program was confirmed through staff interviews. The physical therapist noted that the program had not been in place since October 2024, and efforts to train staff were only recently initiated. The nursing home administrator claimed a program existed, but the therapy consultant and other staff indicated otherwise, with training for restorative services only beginning shortly before the survey. The resident's records showed they received restorative services on only six days out of the past 30, highlighting the inconsistency in care delivery.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the binding arbitration agreement was thoroughly and accurately explained to two residents before they signed the agreement. The facility's policy requires that the terms and conditions of the agreement be explained in a manner that ensures understanding, taking into account the resident's language, literacy, and cognitive ability. However, the marketing coordinator, who was responsible for explaining the agreement, did not have a clinical background and assumed residents understood the legal terminology if they did not ask questions. There was no formal process to document the explanation or the residents' understanding. Resident #60, who was admitted with chronic respiratory failure, diabetes, and altered mental status, was found to be cognitively intact with a BIMS score of 13 out of 15. Despite this, the resident did not recall signing the arbitration agreement and later stated that the signature on the document was not his. The resident was under the influence of medications at the time of admission, which could have affected his cognitive capacity to understand the legal document. Resident #63, diagnosed with frontotemporal neurocognitive disorder, bipolar disorder, major depressive disorder, and anxiety disorder, had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. This resident also did not recall signing the arbitration agreement and did not understand what it entailed. The primary care provider noted that understanding legal terminology requires a different level of cognition than making daily decisions, and individuals with cognitive impairments may not fully grasp such agreements.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement an effective discharge plan for a resident, leading to a deficiency in the discharge process. The resident, who had severe cognitive impairment and was at risk of wandering, was transferred to another skilled nursing facility without proper notification or involvement of the family. The facility's policy required a discharge summary and post-discharge plan to be developed with the assistance of the resident and their family, but this was not followed in this case. The resident's family was first approached by a social worker about the possibility of transferring the resident to a facility with a secured unit due to concerns about wandering. The family expressed a desire to tour potential facilities before making a decision. However, just two days after this initial conversation, the family was informed that the resident had already been transferred to a new facility without their prior knowledge or consent. This abrupt transfer caused distress to the family, who were not given the opportunity to choose a suitable facility or prepare for the move. Interviews with facility staff revealed that there was a breakdown in communication and process regarding the resident's discharge. The Director of Nursing and corporate consultant acknowledged that the discharge was not handled correctly, and the family was not provided with options or informed about the transfer in advance. The social services assistant admitted to miscommunication and a lack of proper discharge planning, resulting in the resident being moved without a discharge care plan or summary being completed.

Penalty

Inspection fine: $90,65985 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 an environment free of accident hazards and did not ensure adequate supervision and assistance devices to prevent accidents for nine residents. Two residents with known exit-seeking behaviors eloped from the facility without the staff's knowledge. Both residents had physician orders for wander-prevention devices, but one was not wearing the device at the time of the elopement. The front door, equipped with a wander-prevention system, failed to lock or alarm, allowing the residents to leave the building. One resident fell and sustained a fractured hip, while the other was returned to the facility without injury. The facility did not have a plan to monitor the front door 24 hours a day, and the wander-prevention devices were not routinely checked for functionality. The facility's response to the elopement incident was inadequate. The receptionist was assigned to monitor the front door during the day, but there was no plan for monitoring the door after hours. Observations revealed that the front door did not alarm or lock when approached with a wander-prevention device, and the door took approximately two minutes to close once opened. Additionally, several residents with orders for wander-prevention devices did not have their devices checked for functionality each shift, and one resident assessed for a wander-prevention device did not have an order for its use. The facility's elopement policy did not include procedures to prevent elopement, and staff training on elopement prevention was insufficient. The facility's investigation into the elopement incident identified several contributing factors, including the absence of a receptionist at the front desk, residents leaving group activities without an escort, and the malfunctioning wander-prevention system. Despite these findings, the facility did not implement a comprehensive and effective plan to prevent future elopements. Interviews with staff revealed a lack of awareness of residents at risk for wandering and insufficient training on elopement prevention. The facility's failure to address these issues created a situation of immediate jeopardy for serious harm to the residents.

Removal Plan

• The Elopement and wandering policy was reviewed/revised by the director of nursing (DON) or Designee to ensure the facility is following policy.
• The DON or designee educated staff on the policy for Wandering, Elopement and Resident safety.
• The DON or designee educated staff on a new Elopement prevention policy.
• Staff not educated, including agency staff, will be educated by the NHA or designee before their next shift.
• Resident #2 was discharged from the facility and admitted to another facility.
• The NHA or Designee called the door company that services the wander guard system. They came out to adjust doors.
• A staff member has been stationed at the door until the door can be adjusted to function properly.
• The NHA will verify the door is working properly by checking the door with a wander-prevention device prior to discontinuing the front desk person monitoring the door.
• The elopement management binder, which includes pictures of residents with elopement risks, will be available at the front desk.
• All residents were reevaluated for elopement risk utilizing the elopement risk assessment form or evaluation in electronic record.
• Residents determined to require a wander guard have a consent, care plan, orders were updated to include placement of device monitoring every shift for function and placement.
• The DON or designee audited the elopement risk evaluations to match the care plans.
• The facility revised its pre-admission screening intake form to include a question about history and frequency of wandering and elopement.
• The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place by the next business day.
• The licensed nurses will be educated to implement elopement interventions if a resident was assessed at risk for elopement on admission.
• New hires will receive education on wandering and prevention, wander guards, elopement procedure, and resident safety on day one of employment.
• The facility revised the Elopement policy to include prevention of elopement.
• Facility staff were educated on the new policy.
• A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings.
• The QAPI committee reviewed the elopement, policies and procedures and reviewed interventions that can be used for residents attempting to elope.

Penalty

Inspection fine: $90,65985 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 four residents from physical abuse by two other residents with known aggressive behaviors. Resident #6, who had a history of aggression and multiple mental health diagnoses, was involved in several altercations with other residents, including an incident where Resident #3 sustained head trauma requiring twelve staples. Despite being aware of Resident #6's tendency to wander into other residents' rooms and take their belongings, the facility did not implement an effective plan to monitor and redirect her behavior, leading to repeated incidents of physical abuse. Additionally, the facility did not take adequate measures to prevent physical abuse by Resident #14, who also had a history of aggressive behavior. Resident #14 pushed and hit Resident #15 after an accidental collision, but the facility failed to update care plans or notify appropriate agencies about the incident. The lack of staff training in mental health and dementia care further exacerbated the situation, as staff were not adequately prepared to handle residents with aggressive behaviors. The facility's investigations into these incidents were incomplete and lacked thorough documentation. There were no comprehensive resident or staff interviews, and the facility failed to notify the police, ombudsman, or State Agency about the incidents. This lack of proper reporting and investigation highlights significant deficiencies in the facility's ability to protect residents from abuse and ensure their safety.

Penalty

Inspection fine: $90,65985 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 an effective pain management regimen for two residents with chronic pain, leading to increased pain levels and affecting their daily activities and sleep. Resident #17, who had a diagnosis of septic right knee, lumbar abscess, and chronic pain syndrome, reported not receiving her prescribed pain medication, Norco, consistently. Despite documentation indicating administration, the narcotic count sheet revealed missed doses, and the resident's pain levels were inaccurately recorded as zero. This inconsistency in medication administration and documentation resulted in the resident experiencing pain levels of 6 to 8 out of 10, affecting her sleep and mobility. Similarly, Resident #8, diagnosed with osteoarthritis and chronic pain, reported not receiving his prescribed pain medications, including Oxycodone and Neurontin, on several occasions. The resident's pain levels were frequently documented as zero, despite his report that his pain never went below a 4 out of 10. The facility's records showed multiple instances where the medications were not available and not administered, with no documented follow-up actions to obtain the medications or notify the physician for further orders. This led to the resident experiencing increased pain levels of 8 out of 10, affecting his sleep and mobility. The Director of Nursing (DON) acknowledged the discrepancies in medication administration and documentation for both residents. The DON confirmed that the pain medications were not consistently administered as ordered and that the facility had an emergency medication system that was not utilized. The DON also noted the lack of parameters for PRN pain medications and the need for comprehensive pain assessments. The facility's failure to ensure accurate pain assessments and consistent administration of pain medications resulted in both residents experiencing increased pain and a decline in their quality of life.

Penalty

Inspection fine: $90,65985 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 food items were stored and served under sanitary conditions in the main kitchen. Specifically, the staff did not correctly and accurately test for the correct parts per million (ppm) of the chemical sanitizer used to clean equipment and surfaces where food was prepared. During an observation, two red tubs of quat (benzalkonium chloride) solution were found in the main kitchen, and the dietary director (DD) indicated that the solution should register 200 ppm. However, when tested, the solution did not register on the strip and remained at 0 ppm. The DD attempted to retest the solution multiple times with new test strips, but the results continued to show 0 ppm. The DD then contacted the company that installed the machine dispensing the quat solution to inspect the machine. The DD later discovered that the facility had been using the wrong test strips to test the solution. The correct test strips were obtained, and the quat solution then tested at 200 ppm. The test logs for February 2024 documented that the quat solution tested at 200 ppm each shift, but the DD acknowledged that these logs could not be accurate given the facility had been using the wrong test strips. The DD stated that she would educate the dietary staff on how to test the quat solution. The duration for which the facility had been using the wrong test strips was unknown.

Penalty

Inspection fine: $90,65985 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 effectively administer its resources to ensure the highest practicable wellbeing for each resident. Specifically, the facility did not implement and maintain safety measures to prevent elopements, resulting in significant injury. Additionally, the facility failed to prevent, report, and investigate allegations of resident-to-resident abuse. There were multiple instances where residents were not protected from physical abuse, and allegations of abuse were not reported or investigated as required. For example, one resident was found with a blanket held around her head by another resident, and another resident was pushed down, resulting in head trauma and stitches. These incidents were not reported to the police, and staff were instructed to document the abuse as falls by the Director of Nursing (DON). The facility also failed to provide sufficient leadership to address and avoid multiple significant concerns, including the lack of follow-up on missed medications and abuse reports, and the intimidation of staff and residents who reported issues. The facility also failed to ensure residents were free from significant medication errors and did not implement an effective pain management program. Several residents reported missing multiple doses of their medications, including pain medications, and there was no follow-up from the administration. The facility admitted a large number of residents with mental health and substance abuse diagnoses but did not provide the necessary training for staff to handle these residents' behaviors. This lack of training and support led to inappropriate roommate pairings and increased incidents of abuse and neglect. Interviews with staff and residents revealed a culture of fear and intimidation, with staff being threatened with retaliation if they spoke to state surveyors. The Nursing Home Administrator (NHA) and DON were reported to dismiss concerns and not follow up on reported issues. The facility's quality assurance and performance improvement systems were ineffective, failing to conduct structured investigations and analyses of underlying causes of problems affecting quality of care, quality of life, and resident safety. The facility's administration did not adequately address the influx of residents with mental health issues, the need for smoking assessments and assistive devices, and the thorough investigation and reporting of abuse incidents.

Penalty

Inspection fine: $90,65985 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 conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, last reviewed on 3/1/24, was found to be incomplete and missing several critical components. Specifically, it did not include staff competencies, training programs for new and existing staff, or information on the facility's wander prevention system. Additionally, the assessment lacked a facility or community risk assessment using an all-hazards risk approach, a description of the infection prevention and control program, a list of contracts, recruitment and retention strategies for medical practitioners, technology resources, and considerations for ethnic, cultural, or religious needs of the residents. During an interview, the Nursing Home Administrator (NHA) acknowledged that the facility assessment had many missing components and had not been fully completed on the template used. The NHA admitted that the assessment did not cover necessary trainings or competencies for different staff members, details on the facility's wander prevention system, or a facility map for emergency preparedness. The NHA was unaware that all these items needed to be included in the facility assessment, indicating a significant oversight in the facility's preparedness and resource planning processes.

Penalty

Inspection fine: $90,65985 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 an effective quality assurance program to identify and address compliance concerns, impacting the quality of life, quality of care, and resident safety. The QAPI program committee did not adequately identify and address issues such as resident safety with accident hazards, timely smoking assessments, and the provision of smoking assistive devices. Additionally, the facility did not secure chemicals and used razors safely, leading to immediate jeopardy situations and actual harm to residents. The facility also failed to manage residents' pain effectively, prevent abuse, and report allegations of abuse to the appropriate authorities. Furthermore, the facility did not ensure thorough investigations of abuse allegations and failed to prevent significant medication errors. The administration did not provide adequate follow-up actions, and the facility assessment was incomplete, failing to determine necessary resources for resident care during day-to-day operations and emergencies. Staff training was also insufficient, particularly in dementia care, substance abuse, and mental health, and nurse aides did not receive the required 12 hours of annual education. The QAPI policy was requested but not provided by the end of the survey. The facility had repeat deficiencies in several areas, including accident hazards, pain management, facility assessment, administration, and QAPI. Interviews with the NHA, DON, and MD revealed that the QAPI committee did not discuss or address critical issues in enough detail to identify and correct them. The NHA was unaware of several deficiencies, including the lack of timely smoking assessments, missed medications, and unavailability of medications. The MD was not informed about the facility accepting residents who smoked, multiple abuse allegations, and issues with obtaining medications timely. The MD also noted that the facility had not conducted training on substance abuse or dementia care despite the increased admission of residents with those diagnoses.

Penalty

Inspection fine: $90,65985 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, implement, and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility did not ensure that all direct and non-direct care staff received training in dementia care, substance abuse, and behavior management. The facility's In-Service Training Policy, revised in August 2022, required training in behavioral health and dementia management, with additional training in substance abuse as necessary based on the facility assessment. However, the regional director of clinical services (RDCS) was unable to provide documentation indicating that such training had been provided to the staff. Interviews with a frequent visitor, the social services director (SSD), and a restorative nurse aide (RNA) revealed that there had been an increase in admissions of residents with mental health diagnoses, behaviors, and substance abuse issues. Despite this, no training on mental health care, behavior management, or substance abuse had been offered to the staff. The facility assessment, last reviewed during the survey, did not identify substance abuse as part of the resident population served, despite multiple residents with known current or history of substance abuse. This lack of training and inaccurate facility assessment contributed to the deficiency identified by the surveyors.

Penalty

Inspection fine: $90,65985 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 written policies and procedures that prohibit and prevent retaliation for abuse reporting. Specifically, the facility did not post a conspicuous notice of employee rights, including the right of staff to be free from retaliation for reporting abuse. Additionally, the facility's abuse policy did not include protection for employees against retaliation for reporting abuse or neglect. This deficiency was identified through observations, record reviews, and staff interviews conducted by surveyors. During the survey, it was observed that there was no signage in the facility regarding employees' right to non-retaliation. The facility's Abuse and Neglect policy, revised in March 2018, was reviewed and found to lack any mention of retaliation protection. Interviews with the Director of Nursing (DON) and a Certified Nurse Aide (CNA) revealed that they were unaware of any posted notice indicating the facility's stance against retaliation for reporting abuse. The DON acknowledged that such a notice should have been posted, and the CNA confirmed that she had never seen any signage notifying staff of their right to be free from retaliation for reporting abuse.

Penalty

Inspection fine: $90,65985 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 alleged violations of potential abuse to the proper authority in accordance with State law for eight residents. Specifically, the facility did not report an allegation of verbal abuse by one resident to another, nor did it report multiple allegations of physical abuse involving several residents. These incidents were not communicated to the nursing home administrator (NHA), director of nursing (DON), local police, or the State Agency as required by the facility's policy and state regulations. In one instance, a resident threatened another resident at the nurse's station, but the incident was not documented or reported. The NHA confirmed that the nurse involved did not report the threats as verbal abuse. In another case, a resident with a history of traumatic brain injury and other severe conditions physically assaulted another resident by holding a blanket around their face. This incident was also not reported to the appropriate authorities. Additional incidents included physical altercations between residents, such as one resident pushing another and causing a laceration, and another resident taking a cane and pulling hair. Despite these events being documented in nursing progress notes and facility investigations, there was no evidence that the State Agency or police were notified. The NHA and DON were unable to recall if these incidents were reported, and a review of the State Agency system confirmed no reports were submitted for these abuse incidents.

Penalty

Inspection fine: $90,65985 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 incidents of potential abuse were thoroughly investigated for three residents. Specifically, the facility did not thoroughly investigate a known physical abuse incident between two residents. Resident #6 repeatedly entered Resident #18's room, took his cane, and was subsequently involved in a physical altercation where Resident #18 pulled Resident #6's hair. The facility's investigation was incomplete, lacking sufficient resident and staff interviews, and did not adequately document non-verbal observations as claimed by the NHA. Additionally, the facility failed to investigate reports of physical abuse by Resident #6 towards Resident #7. Resident #6 was reported to have held a blanket around Resident #7's face, but there were no progress notes or an investigation file for this incident. The DON was not present during the incident and was unable to provide an investigation file, stating that the NHA, who was present, did not conduct an investigation or report the incident to the police and the State Agency. The facility's failure to conduct thorough investigations into these incidents of potential abuse highlights significant lapses in following their own Abuse and Neglect policy. The lack of proper documentation, resident and staff interviews, and timely reporting to appropriate authorities contributed to the deficiency in ensuring resident safety and compliance with regulatory standards.

Penalty

Inspection fine: $90,65985 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 were free from significant medication errors, specifically errors of omission, for five residents. These residents did not receive all their prescribed medications due to the medications being unavailable or on order from the pharmacy. The facility's policy required immediate action when medications were unavailable, including notifying the physician and obtaining alternative treatment orders, but this was not consistently followed. For example, Resident #8 frequently did not receive medications such as clonazepam and oxycodone, and there was no documentation that the provider was notified for further orders when medications were unavailable. Similar issues were observed for Residents #9, #3, #17, and #21, with multiple instances of medications not being administered due to unavailability and lack of provider notification for alternative orders. Resident #8, who was cognitively intact, reported not receiving medications like clonazepam and oxycodone, which were documented as not given on multiple occasions due to being on order. Resident #9, with mild cognitive impairment, also had multiple medications not administered, including potassium chloride and Lasix, due to unavailability. Resident #3, with severe cognitive impairment, missed doses of medications like Ingrezza and Atenolol for similar reasons. Resident #17, who was cognitively intact, reported not always receiving medications such as Norco, and the narcotic count sheet revealed discrepancies in administration records. Resident #21, with severe cognitive impairment, also had multiple medications not given due to being on order. Staff interviews revealed that there were ongoing issues with the pharmacy not providing timely refills and not notifying the facility when medications could not be refilled. Licensed Practical Nurses (LPNs) reported borrowing medications from other residents and expressed concerns to the pharmacy consultant without resolution. The Director of Nursing (DON) was unaware of the medication availability issues and stated that nurses should call her, the pharmacy, and the provider if medications were not available. The resident council minutes also documented concerns about missing medications, but there was no follow-up on these concerns.

Penalty

Inspection fine: $90,65985 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) received the required 12 hours of annual training based on their performance evaluations and facility assessment. Specifically, CNAs #2, #3, #4, #5, and #6 did not receive the mandated training. The facility's policy, revised in August 2022, mandates regular in-service education for all staff, covering topics such as effective communication, resident rights, abuse prevention, infection control, behavioral health, and compliance. However, the training documentation provided did not include the length of abuse training, and additional annual training records were not available for the CNAs mentioned. During interviews, the regional director of clinical services (RDCS #1) confirmed the lack of documentation for the required 12 hours of annual training for the five CNAs. She also mentioned that the facility had undergone new ownership, and annual evaluations had not been conducted for the CNAs. Furthermore, she was unable to obtain the necessary training records from the previous owner. The new company plans to start tracking the CNAs' education moving forward.

Penalty

Inspection fine: $90,65985 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 honor Resident #14's right to refuse treatment, specifically by administering medications without his knowledge and against his wishes. Resident #14, a 77-year-old with a history of aphasia, diabetes, pulmonary embolism, paranoid personality disorder, and dementia, was observed to have medications mixed into his food and beverages without his consent. Despite the resident's increased paranoia and aggression when given pills, the facility continued to disguise medications in his drinks, leading to his refusal to eat and drink once he became suspicious of the practice. The facility's policy on administering medications requires that any refusal or withholding of drugs be documented, but this was not adhered to in Resident #14's case. The resident's care plan included mixing medications into his food due to his paranoia and aggression, but this was done without his knowledge or consent. Multiple notes from physicians and nursing staff indicated that the resident was refusing medications and food once he realized they were being hidden in his drinks, leading to a significant decrease in his meal intake. Interviews with staff, including the LPN, DON, and the nursing home administrator, confirmed that they were aware of the practice of disguising medications and that it was done with the consent of the resident's guardian. However, the facility failed to inform the resident of his right to refuse treatment, and the guardian was not made aware of this right either. The practice continued despite the resident's clear refusal and the negative impact on his trust and willingness to eat and drink.