Beacon Brook Center For Health & Rehabilitation

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 maintain a complete and accurate medical record reflecting physical therapy directions for the use of a gait belt during transfers. Resident #1, who had diagnoses including falls and anemia, was cognitively intact with a BIMS score of 15, was dependent for toileting, and required maximal assistance with transfers per the admission MDS. The resident’s care plan identified deficits in functional mobility and potential for falls, with interventions specifying assistance of one staff for transfers. On the date of the fall, an APRN note documented that the resident sustained a fall resulting in a skin tear on the left knee and right forearm while transferring, but the record did not identify that a gait belt was used or required during the transfer. Interviews and record reviews with the Director of Rehabilitation and the primary Physical Therapist established that, prior to the fall and on the date of the incident, the resident required assistance of one staff and the use of a gait belt for transfers. However, the Physical Therapist had not documented in the therapy notes that a gait belt was required, believing it to be a facility policy, and the Director of Rehabilitation could not provide documentation or evidence of communication to nursing regarding this requirement. The DNS confirmed that at the time of the fall the resident required a one-person stand-pivot transfer, that the resident’s knees buckled leading to the fall, and that there was no physician order, care plan directive, facility policy, or therapy communication specifying the use of a gait belt. This was inconsistent with the facility’s Charting and Documentation Policy, which directed that records provide a complete account of the patient’s stay and information used in developing the plan of care.

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 follow physician orders and the care plan for skin protection and positioning for one resident, and failure to provide required supervision and feeding assistance during meals for another resident. Resident #14 had diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left side, dysphagia, diabetes, and was identified on the MDS as cognitively intact but dependent on staff for eating, showering, toileting, dressing, and transfers. The MDS and care plan documented that the resident was at risk for pressure ulcer development and required a pressure-reducing device for the bed and chair, a bed cradle at the bottom of the bed at all times, offloading boots to both feet at all times, and skin integrity checks every shift. Physician orders dated 12/2/25 mirrored these interventions, directing use of a bed cradle at all times and bilateral offloading boots with skin checks each shift. Surveyor observations on multiple occasions showed that these orders and care plan interventions were not consistently implemented for Resident #14. On 12/30/25 in the morning, the resident was observed in bed with only one heel protector on the left leg, no bed cradle in place, and the sheets resting on the resident’s toes while the lower extremities were elevated on a pillow. Later that afternoon, the resident again was observed in bed without a bed cradle, which was instead on the floor by the dresser, and still only one heel protector on the left leg with sheets contacting the toes. On 12/31/25, the resident was again observed in bed without the bed cradle in place, the cradle remaining on the floor, and the right heel protector not in place while the sheets hit the resident’s toes. A nurse aide reported believing the resident was to wear only one heel protector with the other foot elevated on a pillow and stated she did not know how to place the bed cradle on the bed and had never asked for instruction. She also reported never having seen a second heel protector in the room, despite the care card specifying bilateral offloading boots and a bed cradle at all times. Interviews with licensed nursing staff and leadership confirmed awareness of the physician orders and the responsibility for oversight, but also confirmed that the orders were not followed. An LPN acknowledged that the orders required a bed cradle at the bottom of the bed and offloading boots to both feet at all times and that she was responsible for following physician orders and providing oversight, but she could not identify why this was not done. She also stated that the resident had a past history of skin breakdown and that the bed cradle and offloading boots were ordered for protection and prevention of skin breakdown. The DNS confirmed that the resident had orders for bilateral offloading boots and a bed cradle at all times and that the nurse on the unit was responsible for oversight. The DNS also indicated that the facility did not have a policy for heel protectors or bed cradles when one was requested. The deficiency also includes the facility’s failure to ensure that meal supervision and feeding assistance were provided in accordance with physician orders and the care plan for Resident #125, resulting in a choking incident. Resident #125 had diagnoses including dementia, COPD, and seizure disorder, and the care plan identified a potential for aspiration and weight loss due to missing teeth and unintentional weight loss. Interventions included encouraging dining room meals, providing a full feed to promote intake, giving verbal encouragement and attention to the meal task, ensuring the resident ate while upright and remained upright after meals, and promoting slow eating with small bites and thorough chewing. The MDS showed mild cognitive impairment and a need for substantial assistance with eating. Physician orders included a consistent carbohydrate regular diet with regular texture and thin liquids, and an order dated 12/6/25 directed assistance with all meals and a speech therapy consult for difficulties swallowing related to weight loss. Speech therapy documentation indicated that Resident #125 had mildly extended mastication due to missing teeth but good oral clearance and no signs of aspiration, and required maximum verbal cues and supervision to improve oral intake due to frequent distraction. The SLP recommended supervision with meals to enhance intake and keep the resident on task and documented that staff had been educated on strategies to promote oral intake. The facility’s reportable event form and nursing notes described that on 12/6/25, staff observed the resident with sudden drooling of fluid and seizure-like activity while seated in a wheelchair in the room, with a piece of chicken falling from the resident’s mouth. Staff assessed the airway, noted the resident was breathing with some coughing, and initiated back blows and abdominal thrusts per facility policy. The resident remained breathing but unresponsive and was transferred to the hospital by EMS. Further interviews and documentation clarified that Resident #125 was supposed to have meals supervised or be a full feed, with a staff member staying with the resident to assist feeding and provide cues, consistent with the care plan and SLP recommendations. Due to a respiratory outbreak, communal dining was suspended, and a nurse aide brought the lunch tray to the resident’s room, placed it on the bedside table, cut up the chicken, replaced the lid, and left the room to feed another resident, leaving the tray accessible while the resident was alone. Another nurse aide later observed the resident in the wheelchair with jerking motions and found the tray on the bedside table with the plate cover removed and small cut-up pieces of chicken on the plate. LPNs responding to the call for help observed the resident slumped forward, drooling with apparent food particles in the mouth, unresponsive but attempting to cough or breathe, and they performed abdominal thrusts and finger sweeps without dislodging visible food. EMS and hospital records documented that the resident was believed to have choked, lost pulses en route, and was found to have a large food bolus within the glottic opening that was removed during laryngoscopy, with subsequent cardiac arrest and death on 12/8/25. The DNS and regional nurse confirmed that the resident required supervised or full feed meals and that the nurse aide who delivered the tray had not reviewed the care card before the shift and left the tray despite the resident’s need for supervision.

Penalty

No penalty information released

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

Summary

The facility failed to provide supervision in accordance with the care plan for a resident with severe cognitive impairment, resulting in two incidents involving another resident with similar cognitive deficits. Both residents had diagnoses including dementia, major depressive disorder, anxiety, and cognitive communication deficits, and were assessed as having severely impaired cognition based on their BIMS scores. The care plans for both residents specifically directed staff to supervise them when together, with interventions including every 15-minute checks and, at times, 1:1 observation. On one occasion, a staff member observed the two residents together in a room, left to provide care for another resident, and returned approximately 15-20 minutes later to find both residents in bed without clothing. Although the care plan required supervision when the residents were together, staff did not provide the required level of supervision, and the residents were left alone for an extended period. Assessments following the incident found no injuries, and both residents denied discomfort or harm. Staff interviews confirmed awareness of the supervision requirements but revealed a lack of adherence to the care plan directives. Documentation and interviews indicated that staff failed to implement the care plan interventions as written, specifically the need for constant or frequent supervision when the two residents were together. The facility's policy required all clinical department heads to ensure implementation of resident care plans, but the supervision outlined in the care plans was not provided, leading to the incident where the residents were found unsupervised and unclothed in a private room.

Penalty

No penalty information released

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

Summary

A resident with multiple complex medical conditions, including diabetes mellitus, dysphagia, anemia, heart failure, and chronic kidney disease, experienced a significant and rapid weight loss over a short period. The resident's care plan identified high nutritional risk factors, such as malnutrition, increased nutrient needs, and the presence of chronic wounds. Despite documented weight losses of 5% in one month, 7.6% in two weeks, and 13% in three weeks, there was a delay in obtaining a timely dietician evaluation to address these changes. The dietician last evaluated the resident on 5/6/2025 and did not reassess until 6/3/2025, despite the weight loss being evident in the facility's records and weight reports. Facility policy required that significant weight changes be verified, reported to the interdisciplinary team, and the care plan revised as appropriate. The dietician relied on weight reports and notifications from nursing staff to identify residents needing evaluation but did not recall noticing the resident's significant weight loss in the reports. The DON confirmed that a weight change of 5% or more should have triggered immediate notification and evaluation by the dietician, which did not occur. The facility did not have a specific policy addressing the timing of dietician evaluations for significant weight loss.

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 complete and document weekly skin risk assessments, specifically Braden scale evaluations, for two residents following re-admission, as required by both physician orders and facility policy. One resident, with diagnoses including dementia, peripheral vascular disease, and sepsis, was identified as being at risk for pressure injuries and required extensive assistance with activities of daily living. After returning from a hospital stay, this resident had a physician's order for weekly Braden scale assessments for four weeks, but the medical record did not show that these assessments were completed as ordered. Another resident, admitted with metabolic encephalopathy and heart failure, was also identified as a moderate risk for pressure injuries. Following a hospital stay and re-admission, there was no documentation of a Braden scale assessment upon re-admission or weekly thereafter for four weeks, as required. The facility's policy and the Clinical Director confirmed that these assessments should have been completed on admission/re-admission and weekly for four weeks, but this was not done for the residents reviewed.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with severe cognitive impairment, aphasia, hemiplegia, and total dependence for care did not receive timely incontinence care as required by their care plan. The resident was care planned to receive incontinence care every two to three hours and required two staff for bed mobility and transfers. On the day of the incident, the assigned nursing assistant (NA) provided care at 11 AM but did not provide further incontinence care for the next four hours, despite the resident being dependent for all activities of daily living and unable to communicate needs. The NA, who was new to the facility and to long-term care, attempted to reposition the resident but was unable to provide full care due to lack of assistance and did not notify the nurse or other staff about her inability to complete the assignment. The NA also placed two briefs on the resident and did not check for incontinence with each attempted repositioning. The charge nurse was not made aware of the missed care, and other available NAs were not approached for help. The nursing supervisor discovered the issue after a visitor raised concern, finding the resident with a soiled and drying brief, a stained drawsheet, and two briefs in place, indicating care had not been provided within the care-planned timeframe. Facility documentation and staff interviews confirmed that the resident did not receive incontinence care for a period exceeding the care plan's requirements, and the staff member responsible did not seek assistance or report the issue. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid physical harm or distress, and the incident was documented as an event of neglect. No negative effects on the resident's skin were observed at the time of discovery.

Penalty

No penalty information released

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

Summary

A resident with a history of stroke, severe cognitive impairment, aphasia, and high risk for pressure ulcers was dependent on staff for all activities of daily living (ADLs), including incontinence care, and required assistance from two staff members for bed mobility and transfers. Physician orders and the resident's care plan specified that incontinence care should be provided every two to three hours and that two staff members were required for all ADL care. On the day of the incident, the assigned nursing assistant (NA) provided care at 11 AM but was unable to find a second staff member to assist with subsequent care, resulting in the resident not receiving incontinence care for approximately five hours. The NA attempted to reposition the resident alone, which was not in accordance with the care plan, and did not check for incontinence each time. The NA did not notify the nurse or other staff that she was unable to provide care as required, despite being aware of the resident's needs and the facility's expectations. The NA was newly off orientation, unfamiliar with the residents on the unit, and reported struggling to complete her assignment. The charge nurse was not informed that the resident had not received timely care, and other available NAs were not approached for assistance. The deficiency was identified when a visitor alerted the nursing supervisor to the resident's condition, leading to the discovery of soiled and drying briefs, a stained drawsheet, and a delay in care. Facility policy required staff to provide ADL assistance per the care plan and to report when care could not be provided. However, the NA did not follow these protocols, resulting in a delay in incontinence care and failure to provide care according to physician orders and the resident's plan of care.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with multiple diagnoses, including diabetes, cardiac infarction, atrial fibrillation, and neuromuscular bladder dysfunction, was transferred to the Emergency Department due to hallucinations, pallor, hematuria, and low blood pressure. Upon return to the facility, the resident's medication orders were not fully resumed, resulting in the omission of several critical medications for eleven days. The hospital discharge summary indicated no changes to pre-hospital medications except for the addition of an antibiotic, and the discharge instructions listed all medications to be continued. The failure to resume all medications was due to a breakdown in the medication reconciliation process. Nursing staff did not recognize that the second page of the medication orders had not been activated, and some assumed the medications were held for a pending surgical procedure. Multiple nurses noticed the medications were still on hold but did not notify the Nursing Supervisor or the Advanced Practice Registered Nurse (APRN) to clarify or obtain new orders. The APRN and Assistant Director of Nursing (ADON) confirmed that the process for resuming medications after a short hospital stay was not followed, and the omission was not identified until eleven days later. Facility policy required that a licensed nurse complete medication reconciliation in the electronic health record and resolve orders with the attending healthcare provider upon admission or re-admission. However, this process was not properly executed, leading to the prolonged omission of essential medications for the resident. The deficiency was identified through clinical record review, facility documentation, and staff interviews.

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 supervision for a resident who was on one-to-one (1:1) supervision due to a history of aggressive and sexual behaviors. Despite a physician's order and care plan interventions requiring 1:1 supervision when the resident was out of bed, the resident was able to approach another resident in the reception area without effective staff intervention. The resident initiated inappropriate physical contact by touching another resident's private chest area over clothing, an act witnessed by staff and the facility's administrative assistant. The resident who committed the inappropriate contact had diagnoses including dementia with behavioral disturbances, frontotemporal neurocognitive disorder, and antisocial personality disorder, and was known to have poor decision-making and behavioral symptoms. The other resident involved also had dementia with behavioral disturbances and was independent in mobility. Both residents' care plans included interventions to address their behavioral and mood issues, but the supervision in place was not sufficient to prevent the incident. Staff present at the time, including a nurse aide and the administrative assistant, observed the event as it occurred. The nurse aide was walking behind the resident but did not prevent the inappropriate contact. The administrative assistant confirmed that the resident moved closer to the other resident and grabbed their chest area after repeated verbal interaction. The incident was later substantiated as abuse by the facility after investigation.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with multiple diagnoses, including diabetes, cardiac infarction, atrial fibrillation, and neuromuscular bladder dysfunction, was transferred to the hospital and subsequently returned to the facility. Upon return, the resident's medication regimen was not accurately reconciled, resulting in the omission of several prescribed medications for eleven days. The hospital discharge summary indicated that only one new medication, Keflex, was added, and all other pre-hospital medications were to be continued. However, only some of the medications were resumed upon the resident's return, as the nurse on duty failed to recognize that there were two pages of medication orders, leading to incomplete transcription and activation of the resident's full medication regimen. The omitted medications included Baclofen, Lactulose, Eliquis, Atorvastatin, Amiodarone, and Oxybutynin, all of which were part of the resident's ongoing treatment for their complex medical conditions. The error was not identified until eleven days later, when it was discovered that the second page of medication orders had not been resumed. During this period, the resident did not receive these essential medications as prescribed. Interviews with facility staff revealed that the process for resuming medications after a hospital transfer involved placing all medications on hold and then resuming them upon the resident's return, provided there were no changes. The nurse responsible for resuming the medications was unaware of the need to activate each page of orders individually, and other staff members who noticed the omission did not question or report it, contributing to the prolonged medication error.

Penalty

Fine: $16,801

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

Summary

The facility failed to provide adequate supervision and implement necessary interventions to prevent accident hazards related to smoking for Resident #101, who was moderately cognitively impaired and had a history of nicotine dependence. Despite an initial smoking evaluation indicating no desire to smoke, Resident #101 was repeatedly found smoking on facility grounds and in their room, which was shared with another resident dependent on supplemental oxygen. This posed a significant safety risk, especially given the presence of oxygen, which could lead to a fire hazard. The facility's documentation and staff interviews revealed multiple incidents where Resident #101 was found with smoking materials, including cigarettes and lighters, despite being educated on the facility's no-smoking policy. The facility failed to conduct a new smoking evaluation assessment after these incidents and did not implement effective interventions to prevent further non-compliance. The resident was offered nicotine patches and transfers to a smoking-permitted facility, but these were declined. The facility's care plan included every fifteen-minute checks, but there were gaps in documentation, and no additional interventions were put in place to monitor the resident's non-compliance. Interviews with the Director of Nursing Services (DNS) and the Administrator indicated a lack of documentation and effective strategies to address the resident's non-compliance with the smoking policy. The facility was concerned about balancing the resident's rights with safety but failed to provide evidence of any additional measures taken to ensure the safety of all residents. The repeated incidents of smoking in the presence of oxygen therapy led to a finding of Immediate Jeopardy, highlighting the facility's failure to supervise and implement necessary interventions.

Removal Plan

• Any resident has the potential to be affected by this alleged deficient practice.
• The facility policy titled Smoking Policy was reviewed and remains current.
• All licensed staff were provided education on the facility smoking policy, the use of oxygen present with a smoking resident, significant harm that could occur, at risk factors involved in active smoking resident in the facility, and supervision needed to be provided with cognitively impaired residents who wish to smoke.
• All residents will be educated on the facility smoking policy and that the facility is a non-smoking facility. Residents will be educated on risk factors involved with smoking materials and contraband usage in the facility. Current residents in the facility will be educated, and all new admissions will be educated upon admission.
• Smoking evaluations audits will be performed on all residents currently in the facility, and any resident who chooses to smoke in the facility will be offered a transfer to a smoking facility. The resident will be assessed to determine if a nicotine patch is appropriate. An audit will be conducted to ensure all assessments have been done for all residents, and concerns for any resident will be addressed immediately. The physician and family will be notified of any concerns.
• Random audits will be completed. The results of the audit will be presented at Quality Assurance and Improvement Program as required.
• The DNS or designee is responsible for the completion of this Plan of Correction.

Penalty

Fine: $16,801

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 pressure ulcer care for Resident #418, who was admitted with diagnoses including Alzheimer's disease, traumatic spinal cord dysfunction, and paraplegia. The care plan for this resident included interventions such as skin inspections, use of a low air loss mattress, and regular repositioning. Despite these measures, a new wound on the resident's left heel was identified as a Deep Tissue Injury (DTI) and later reclassified as a stage 2 pressure ulcer. The facility did not perform the prescribed daily dressing changes from 8/2/22 to 8/23/22, as documented in the nurse's notes and Treatment Administration Record (TAR). Interviews with nursing staff revealed a lack of awareness and documentation of the necessary wound care treatments. Resident #90, with diagnoses including type 2 diabetes mellitus and quadriplegia, was also affected by the facility's failure to conduct weekly skin audits as per the physician's order. The resident was identified as being at very high risk for pressure ulcers, with a Norton Plus skin assessment score of 8. Despite this, the facility did not perform weekly skin audits on 12 occasions, as required by the facility's policy. This oversight contributed to the development of a new stage 2 pressure injury to the coccyx and a suspected deep tissue injury to the ball of the left foot. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed the lack of adherence to the weekly skin audit policy. The facility's policy for the prevention and management of pressure injuries was not followed, leading to deficiencies in the care of both residents. The wound specialist and medical director highlighted the importance of following physician orders and facility policies to prevent further skin breakdown. The failure to perform prescribed treatments and audits resulted in the deterioration of existing pressure ulcers and the development of new ones, indicating a significant lapse in the facility's wound care management.

Penalty

Fine: $16,801

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 physician visits and the signing of physician orders for 11 out of 12 sampled residents. Residents with various medical conditions, including respiratory failure, diabetes, dementia, and heart failure, did not have their physician orders renewed and signed as required. For instance, Resident #20's physician orders were not renewed every 60 days, with the last signature dated 7/23/23. Similarly, Resident #21's orders were not signed every 60 days, and Resident #44's orders were not signed on admission and not renewed every 30 days for the first 90 days. The deficiency was further highlighted by the facility's failure to provide a policy on the timely signing of physician orders. The Director of Nursing Services (DNS) acknowledged the responsibility of the facility to track and ensure timely signing of orders, noting that the physician was aware of the requirement to sign orders on admission and subsequently every 30 and 60 days. Despite this, the physician had not been signing orders timely, and the facility had identified this issue in their Quality Assurance and Performance Improvement (QAPI) process.

Penalty

Fine: $16,801

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 physician visits and order renewals for 11 out of 12 sampled residents. Residents had various medical conditions, including respiratory failure, diabetes, dementia, and heart failure, and required extensive assistance with daily activities. The physician's orders for these residents were not renewed and signed every 60 days as required. Additionally, for some residents, the orders were not signed on admission and not renewed every 30 days for the first 90 days. The facility's Quality Improvement and Performance Improvement review identified an issue with the timely signing of physician's orders. The Director of Nursing Services acknowledged the facility's responsibility to track and ensure timely signing of orders, which should occur on admission, every 30 days for the first 60 days, and every 60 days thereafter. Despite this acknowledgment, the facility policy was not provided upon request.

Penalty

Fine: $16,801

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 labeling and storage of medications across four nursing units. During observations, a medication cart was found to contain a bottle of Humalog insulin and an auto-injector of epinephrine without prescription labels or identification of ownership. Additionally, a clear bag of unlabeled medications was discovered, and the LPN present was unaware of their ownership. Another medication cart contained Cyclosporin ophthalmic eye drops without a prescription label, which were believed to belong to a specific resident but were not stored correctly. The facility's policy requires medications to be labeled and stored according to professional standards, which was not adhered to in these instances. The facility also failed to consistently document refrigerator temperatures that store vaccines, as required by their policy. Temperature logs for multiple refrigerators were missing entries for several days, and vaccines such as Prevnar and flu/RSV were stored in these refrigerators. Furthermore, a resident with a diagnosis of cellulitis, falls, and seizure disorder was found to have medications such as antifungal powder and medicated chest rub in their bathroom without a physician's order, contrary to the facility's policy that requires medications to be stored in locked compartments accessible only to licensed personnel.

Penalty

Fine: $16,801

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 sanitary environment in the dietary department due to a staff member not wearing a beard guard while preparing food. During an observation of the tray line, a dietary staff member was seen stirring a tray of beef stew at a steam table without a beard guard, despite having a beard. The staff member acknowledged that he had been instructed to wear a beard guard in the past but had forgotten to do so on this occasion, as he usually does not have a long beard. The Director of Dietary confirmed that the staff member should have been wearing a beard guard, as per the facility's Uniform Policy, which requires chefs or cooks to wear a beard guard along with other specified attire.

Penalty

Fine: $16,801

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 notify the physician and responsible party of a change in condition for a resident diagnosed with cerebral infarction, aphasia, dysphagia, and atrial fibrillation. On a particular day, the resident reported feeling 'funny' and had difficulty with speech, but the nursing staff did not immediately recognize these as significant changes. Despite the resident's reluctance to go to the hospital, the symptoms progressed to a left-sided mouth droop and slurred speech, prompting a delayed transfer to the emergency room. The hospital later diagnosed the resident with a right frontal lobe acute lacunar infarct. In another case, the facility failed to provide timely wound care for a resident with Alzheimer's disease and paraplegia, who had stage 3 pressure ulcers. The resident's care plan included specific interventions, but the facility did not consistently perform dressing changes as ordered. A new wound on the resident's left heel was identified, but there was a significant delay in implementing the recommended treatment, leading to further deterioration of the wound. Interviews with staff revealed a lack of communication and documentation regarding the residents' conditions and treatments. The facility's policies required timely communication with physicians and families about changes in residents' conditions, but these were not followed, contributing to the deficiencies observed during the survey.

Penalty

Fine: $16,801

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 address a resident's grievance in a timely manner, specifically regarding the noise level during shift changes and the delayed response to call lights. The resident, who was cognitively intact and had diagnoses including neuromuscular dysfunction of the bladder and diabetes mellitus, reported these issues. The resident's care plan included interventions to keep the call bell and needed items within reach and to provide assistance to maximize their level of function. Despite these measures, the resident experienced issues with noise and delayed call light responses. The Director of Nursing Services (DNS) was informed of the grievances, and while the noise level issue was addressed, there was no evidence of follow-up regarding the timely response to call lights. The DNS acknowledged discussing the noise concern with the resident and planned staff in-service training. However, the DNS could not provide documentation of follow-up actions taken to address the call light issue, indicating a lapse in the facility's grievance resolution process.

Penalty

Fine: $16,801

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 had a PASRR II or Level of Care re-screen completed upon admission. The resident, who was admitted with diagnoses including cerebral infarction, dementia, anxiety disorder, and depressive disorder, was identified in a Notice of Care Determination as approved for long-term care. However, the Inter-Agency Patient Referral report noted additional mental health concerns such as delusional disorder and suicidal ideations, which were not addressed in the PASRR process. The admission Minimum Data Set indicated the resident had severely impaired cognition and active diagnoses of non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, and suicidal ideations, and was on psychotropic medications. The Director of Social Services (SW #1) was unaware of the resident's history of suicidal ideation or delusional disorder upon their transfer from another LTC facility. SW #1 indicated that a new level of care determination should have been submitted upon the resident's admission, given the mental and behavioral health diagnoses. The state PASRR and Level of Care Screening Procedures require that any changes affecting a resident's placement or service decisions be reported, which was not done in this case.

Penalty

Fine: $16,801

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 #74's care plan addressed the use of antipsychotic medications. Despite a physician's order for Zyprexa to be administered daily for nausea, the care plans from late February to the present did not include a plan for the antipsychotic medication. An interview with RN #3 confirmed the absence of a care plan reflecting the antipsychotic use, which was contrary to the facility's policy on Psychotropic Medication Management that requires care planning for psychoactive medications and regular reviews with the interdisciplinary team. Additionally, the facility did not develop a comprehensive care plan for Resident #92, who had a history of mental disorders, including suicidal ideation. The admission MDS identified several active diagnoses, but the care plan failed to address goals and interventions for suicidal ideation. The Director of Social Services was unaware of the resident's history due to a transition in staff and acknowledged the lack of a care plan for suicidal ideation. The Director of Nursing Services also noted the absence of a focus on suicidal ideation in the care plan, which was expected to be included. The Corporate RN identified that the comprehensive care plan should be developed through an interdisciplinary approach, with the MDS Coordinator responsible for ensuring all diagnoses are reviewed and included in the care plan.

Penalty

Fine: $16,801

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 review and revise the care plan for a resident who was non-compliant with the facility's no-smoking policy. The resident, who was moderately cognitively impaired and had a history of nicotine dependence, was observed smoking in a visitor's car on the facility's grounds. Despite being informed of the no-smoking policy, the resident continued to attempt to smoke on the premises and was found with smoking materials multiple times. The facility did not conduct a new Smoking Evaluation Assessment after the resident was found smoking, nor did it implement effective interventions to prevent further non-compliance. The resident's care plan was not updated to address the ongoing smoking behavior, and there was a lack of documentation supporting the facility's actions to manage the situation. The resident was repeatedly found with cigarettes and lighters, and on one occasion, was intoxicated with alcohol found in their room. Interviews with facility staff revealed that the resident's non-compliance with smoking was a known issue, yet there were no additional interventions or updates to the care plan to ensure the safety of the resident and others. The facility's Comprehensive Care Plan policy requires the care plan to be developed and reviewed by an interdisciplinary team, but this was not adequately done in this case, leading to the deficiency.

Penalty

Fine: $16,801

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 wound treatments for a resident with pressure ulcers were transcribed and performed according to the physician's orders. The resident, who had Alzheimer's disease, traumatic spinal cord dysfunction, and paraplegia, was admitted with two stage 3 pressure ulcers. A new wound on the left heel was identified as a Deep Tissue Injury (DTI) and later reclassified as a stage 2 pressure ulcer. Despite the wound specialist's recommendations for treatment, the facility did not document any dressing changes for the left heel pressure ulcer from the time it was discovered until 22 days later. Interviews and record reviews revealed that the wound nurse and other staff members failed to transcribe the physician's orders into the electronic medical records. The Director of Nursing Services and other nursing staff were unable to identify dressing change orders for the left heel pressure ulcer during the specified period. The wound specialist confirmed that the facility was responsible for accepting and transcribing the recommendations into the medical records. The facility's policy for the prevention and management of pressure injuries indicated that wound treatments should be performed per physician's orders. However, the lack of documentation and failure to perform the prescribed treatments for the resident's left heel pressure ulcer led to the deficiency. The wound was noted to have deteriorated, with increased drainage and maceration, indicating a lack of proper care and attention to the resident's condition.

Penalty

Fine: $16,801

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 assess a resident's ability for self-care of a colostomy, despite the resident's repeated refusals to allow staff to provide the care. The resident, who was moderately cognitively impaired and had a history of alcohol abuse and nicotine dependence, was admitted with diagnoses including cellulitis of the abdominal wall. The physician's orders required colostomy care every shift, but the resident independently provided ostomy care on multiple occasions, refusing staff assistance. The facility did not conduct an assessment of the resident's ability to manage their colostomy care or develop a care plan to support the resident's desire for self-care. The clinical record review showed that the resident refused staff assistance with colostomy care 22 times, opting to perform the care independently. Despite the resident's cognitive impairment and the presence of abdominal cellulitis, the facility did not provide an assessment or a care plan to address the resident's self-care preferences. Interviews with the Director of Nursing Services (DNS) confirmed the lack of assessment and care planning for the resident's colostomy care. Additionally, the facility was unable to provide a policy for self-care when requested.

Penalty

Fine: $16,801

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 chronic obstructive pulmonary disease (COPD) and heart failure received oxygen therapy as prescribed. The resident was supposed to be on 2 liters of oxygen per minute (L/min) via nasal cannula to maintain oxygen saturations greater than 92%. However, during an observation, the oxygen concentrator was set at 3 L/min, which was not in accordance with the physician's order at that time. The resident indicated that they did not adjust the oxygen flow themselves, and it was the facility staff who made the adjustments. A Licensed Practical Nurse (LPN) confirmed that the resident was on 2 L/min but was unaware of why the oxygen was set at 3 L/min, suggesting that the night shift might have increased it. The nursing supervisor later indicated that the resident was not meeting the oxygen saturation threshold on 2 L/min, which led to a change in the oxygen order. However, the Advanced Practice Registered Nurse (APRN) was not informed of any decreased oxygen saturations on the day of the observation and expected staff to notify her if there were no physician's orders for a specific situation. The facility's policy required oxygen to be delivered per the physician's order, and the oxygen liter flow should be set to the prescribed rate, which was not adhered to in this instance.

Penalty

Fine: $16,801

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 pharmacy recommendations were obtained and reviewed, and did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment in a timely manner for a resident who was started on an antipsychotic medication, Zyprexa. The resident, who was cognitively intact, had a diagnosis of a blood disorder not yet in remission and iron deficiency anemia. A physician's order was given to administer Zyprexa for secondary prophylaxis for nausea. However, the Director of Nursing Services (DNS) was unable to locate an AIMS assessment completed at the start of the medication, which was later completed 34 days after initiation, only after surveyor inquiry. Additionally, the consulting pharmacist indicated that recommendations for orthostatic blood pressure and an AIMS assessment were made, but the facility only received recommendations related to insulin. The DNS confirmed only receiving one page of recommendations and was unable to provide the second page that was reportedly faxed by the pharmacist. The facility's policy on psychotropic medication management requires a baseline AIMS assessment upon initiation of any antipsychotic medication, which was not adhered to in this case.

Penalty

Fine: $16,801

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

Summary

The facility failed to maintain a complete and accurate medical record for Resident #101, as required by accepted professional standards. Resident #101, who was admitted with diagnoses including cellulitis of the abdominal wall, alcohol abuse, and nicotine dependence, was identified as having a conservator of both estate and person. Despite this, the clinical record did not contain a copy of the conservatorship document. This omission was discovered during a survey when the Director of Nursing Services (DNS) confirmed the absence of the conservatorship document upon request. Additionally, the facility's social service notes documented an incident where Resident #101 was observed smoking in a visitor's car on the facility's grounds, despite the facility's no-smoking policy. The social worker informed both the resident and the visitor of the policy and later met with the resident's conservator, who was unaware of the resident's smoking activities. The facility was unable to provide a policy on clinical record maintenance or conservatorship when requested, further highlighting the deficiency in maintaining complete and accurate records.

Penalty

Fine: $16,801

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

Summary

The facility failed to maintain sanitary conditions for Resident #74, who had a diagnosis of neuromuscular dysfunction of the bladder and diabetes mellitus. The resident's care plan indicated the use of a Foley catheter due to neurogenic bladder, with specific interventions to prevent infection, including changing the catheter and bag per physician's order and providing catheter care every shift. However, an observation on April 11, 2024, noted that Resident #74's urinary drainage bag was lying on the floor, which was confirmed by charge nurse LPN #3 as inappropriate. The facility's policy required urinary drainage bags to be hung in a privacy bag, not placed on the floor. Additionally, the facility did not ensure sanitary storage of resident equipment for Resident #101, who had diagnoses including cellulitis of the abdominal wall, falls, and seizure disorder. Observations on April 11 and April 15, 2024, identified unlabeled basins and personal care items left on the floor in Resident #101's bathroom, as well as a bedpan on the bedside table. RN #1 confirmed that bedpans and basins should be bagged, labeled, and not placed on the floor, according to the facility's policy. These observations indicate a failure to adhere to infection prevention and control protocols, potentially increasing the risk of infection spread within the facility.