Chelsea Place Care Center Llc

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 allow Resident #2 to go on a leave of absence (LOA) with a family member and failed to trial unsupervised visitation. Resident #2 had diagnoses including cellulitis of the left lower extremity, psychoactive substance abuse, anxiety, and adjustment disorder. The care plan identified the resident as at risk for substance use due to a history of addiction and medication assisted treatment, and included interventions such as supervised visits if illegal drug use was suspected, weekly interdisciplinary review, urine toxicology screening if suspected of using illegal substances, and observation after LOA for evidence of substance use and withdrawal. On 12/1/25, a person delivered bags of Fentanyl to the facility for Resident #2, and the drugs were intercepted at the front desk. The resident reportedly jumped at the receptionist to recover the drugs, and told EMS personnel that Fentanyl had been used the day before. The resident was transferred to the ED and later returned to the facility with orders for no visitors, no parcels or deliveries, and 1:1 observation for 24 hours. The record then showed the resident remained on supervised visitation through discharge. The resident submitted two LOA requests, both of which were denied. The LOA approval forms documented the denials but did not include a reason, and only one IDT signature was present on each form. The EMR did not contain documentation regarding approval or denial of the LOAs. Facility leadership stated the resident had been on supervised visits since admission, that the LOA requests were denied after IDT review, and that no trial of unsupervised visits was attempted during the resident's stay. The facility policy stated that residents have the right to participate in activities inside and outside the facility and that LOA requests are to be reviewed based on the resident's individual care needs and safety 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 deficiency involves the facility’s failure to identify and control accident hazards and to provide adequate supervision and safety interventions for residents with known opioid use disorder, resulting in opioid overdoses for two residents. For one resident with psychoactive substance abuse and opioid dependence with withdrawal, the admission nursing assessment documented fentanyl use within the prior 30 days and intact cognition. The resident’s care plan noted risk for substance use related to a history of addiction and receipt of medication-assisted treatment (MAT), but did not include specific interventions for substance use risk or MAT management. Although physician orders included PRN Naloxone (Narcan) for suspected overdose and daily Methadone for opioid use disorder, the clinical record did not show that psychiatric/psychology services or contracted substance use disorder (SUD) program services were provided or refused. On one occasion, this resident became lethargic, drowsy, and difficult to arouse, with bilateral pinpoint pupils. A nurse administered two doses of Narcan one minute apart; the first was ineffective and the second produced a positive response, after which the resident admitted to using “illegal stuff.” Security and the APRN were involved, and the APRN documented that the resident admitted to using fentanyl brought into the facility at the time of admission. Security and social work staff conducted a room search and found five bags or dime bags with suspicious white residue tucked into the resident’s hat. Security staff reported that these bags were flushed down the toilet and that no further room searches had been conducted between admission and the overdose event, despite the known SUD history. The DNS acknowledged that the SUD/MAT care plan had been initiated but not completed, that there were no prior room searches, that the police were not notified because the bags were empty, and that the facility had no policy or procedure for suspected drug overdose. For a second resident with diagnoses including opioid dependence, cocaine dependence, and adjustment disorder, physician orders included PRN Narcan for suspected overdose, Gabapentin three times daily for pain, Sertraline daily for anxiety, and room searches every shift. The resident had intact cognition, was largely independent in mobility and toileting, and had a care plan identifying risk for substance use related to a history of addiction, with an intervention only to observe for signs and symptoms of withdrawal. A nursing note documented that the resident was observed in a wheelchair with slightly slurred speech and dilated pupils but remained alert, oriented, and able to follow commands; the resident refused to provide a toxicology sample and refused hospital transfer, and a room check revealed no contraband. The care plan was later updated to note the episode of dilated pupils and slumped posture, with interventions including 15-minute checks, monitoring labs, evaluating need for psychiatric services, and reinforcing the recovery plan, and documentation showed 15-minute checks were performed for 72 hours. Subsequently, the DNS documented responding to a STAT call and finding this resident on the bathroom floor with a formed bowel movement, unresponsive to verbal or tactile stimuli and without a pulse. CPR was initiated, 911 was called, and two doses of Narcan were administered without response before transfer to the emergency department, where the resident was pronounced deceased. The hospital record indicated the case was referred to the Medical Examiner due to suspected drug use and noted that facility staff reported the resident had a history of drug use and was observed associating with other residents known to use drugs. The DNS stated she questioned whether to report the unanticipated death to the State Agency and did not contact the Medical Examiner’s office for the cause of death. The Medical Examiner’s report later identified the cause of death as acute intoxication due to the combined effects of fentanyl, gabapentin, and sertraline. The DNS acknowledged that the resident’s care plan for risk of substance use contained only one initial intervention (observation for withdrawal), that additional monitoring beyond the 72-hour 15-minute checks was not implemented, that group therapy attendance was not tracked, and that the facility lacked a policy, procedure, or protocol for suspected drug overdose and Narcan administration. These failures, including incomplete risk-based care planning for residents with known SUD, lack of specific controls such as supervised visits, random room searches, visitor log management, random urine toxicology, and documented SUD support/refusal handling, absence of an overdose/Narcan protocol, failure to contact law enforcement when illegal drugs were suspected or observed, and failure to maintain chain of custody for contraband, led to one resident requiring two doses of Narcan for a suspected fentanyl overdose and another resident’s death from acute intoxication. Surveyors determined that these failures constituted noncompliance at the level of Immediate Jeopardy.

Removal Plan

• Ensure new admissions with a known recent history of substance use are evaluated for appropriate supervision based on a person-centered risk evaluation, with interventions initiated based on the level of risk.
• Educate nursing supervisors to ensure the Resident Care Plan (RCP) on admission for residents with substance use disorder (SUD) contains interventions to provide adequate support.
• Conduct audits of RCPs for new admissions with a history of SUD to ensure appropriate interventions and adequate 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 deficiency involves the facility’s failure to ensure that practitioners reviewed, signed, and dated physician orders at each required visit in accordance with Connecticut General Statute 19-13-D8t. For one resident with dementia and bipolar disorder who had severely impaired cognition and was receiving routine antipsychotic medication, the care plan identified risk for complications related to psychotropic drugs and included interventions such as gradual dose reduction and monitoring for side effects. However, review of provider orders showed that monthly orders were last signed by an APRN in mid-June, with no signed orders identified for July, August, November, or December. Another resident with dementia and hypertension, also with severely impaired cognition and receiving routine antipsychotics, had a care plan directing that medications be administered as ordered, but provider orders were only signed in mid-October, with no signed orders identified for November or December. A third resident with type II diabetes and schizophrenia, with moderately impaired cognition, was receiving routine antipsychotics and insulin injections, and had a care plan directing that medications be administered as ordered by the physician. For this resident, monthly orders were last signed in late September, with no signed orders identified for October, November, or December. A fourth resident with schizophrenia and hyperlipidemia, with moderately impaired cognition and receiving routine antipsychotics, had a care plan that included explaining the importance and risks of taking or not taking medications, but provider orders were only signed in late September, with no signed orders identified for October, November, or December. In an interview, the DNS stated that monthly orders are reviewed and signed in the medical records, that practitioners or the physician can sign off on resident orders, and that there was no facility policy for timeliness of signing orders, with the facility following a practice of signing orders every 60 days per the Connecticut Public Health Code.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to honor a resident’s right to be treated with dignity and to have preferences respected regarding medication administration. Resident #3, admitted with osteomyelitis of the vertebra, PTSD, and opioid dependence, had intact cognition (BIMS score of 15), ate independently, and had no issues with holding food in the mouth. Provider orders initially directed Hydromorphone tablets to be given whole by mouth as needed for pain. In early December, amid concerns about inappropriate use of controlled substances by other residents, the APRN issued a new order that all narcotic medications for this resident be crushed and administered in applesauce or pudding. This change was made without an individualized assessment of Resident #3’s swallowing ability or behavior and without honoring the resident’s stated preference to receive whole tablets. Resident #3 reported that controlled substances were being misused by other residents and that their Hydromorphone order was changed from whole to crushed tablets by the APRN to avoid misuse of the tablets. The APRN confirmed that any resident with an order for Hydromorphone and a diagnosis of opioid use disorder had their orders changed from whole tablets to crushed form to prevent pocketing or diversion. The DNS stated that some residents with a history of substance use disorder had controlled substances crushed and that mouth checks were regularly performed, but also acknowledged there was no facility policy for crushed medication practice. The DNS was aware that Resident #3 did not want their Hydromorphone crushed, yet the order remained in place based on the APRN’s discretion, and if the resident refused crushed medication it was documented as refused. This practice conflicted with the facility’s stated Resident Rights, which include the right to be treated with consideration, respect, and full recognition of dignity and individuality.

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 its change in condition and physician notification policy for a resident who experienced ongoing vomiting, abdominal pain, and non-verbal signs of distress. The resident had diagnoses including chronic respiratory failure, sepsis, and heart failure, and was admitted with bowel and bladder incontinence and an indwelling Foley catheter. Orders included PRN Milk of Magnesia (MOM) and Bisacodyl for constipation, and later Ondansetron for nausea and vomiting. After the resident vomited, Ondansetron was administered and an abdominal scan showed diffuse constipation without obstruction. The APRN ordered MOM in prune juice and a suppository. However, the MAR did not show administration of MOM as ordered earlier, and there was no documentation of the effectiveness of either MOM or Bisacodyl. During the evening and night shifts, multiple staff members were aware of the resident’s vomiting and abdominal pain, but the response and documentation were incomplete and not consistently escalated. A nursing assistant reported initial vomiting to an LPN, and the nursing supervisor obtained orders for diagnostic imaging and Ondansetron. Later, the resident vomited multiple times again, and the LPN believed the resident should be transferred to the hospital, administered MOM around midnight, but did not document this administration or its outcome. The nursing supervisor on the night shift reviewed the KUB results, obtained orders for MOM and a suppository, and reported that these were administered by the LPN. The supervisor also reported that the resident refused transfer to the hospital. Despite ongoing symptoms, including dry heaving, repeated vomiting, and later groaning and moaning with eyes closed, there was no timely notification to licensed nursing staff of these later changes, and no documented follow-up assessment of the effectiveness of the PRN interventions. The nursing assistant who observed dry heaving and non-verbal signs of pain at approximately 3:00 AM and 6:45 AM did not notify a nurse. The APRN stated that if PRN medications were ineffective or symptoms persisted, the physician or APRN should have been contacted for additional evaluation and orders, and that the resident had standing orders for Tylenol that could have been used for pain. The DNS indicated that new onset moaning/groaning could be a sign of pain requiring nurse notification and that follow-up after MOM administration should occur within a timeframe based on the resident. The facility’s policy required that significant changes in condition be assessed, documented, and reported to the physician, with new orders obtained and documented, which did not occur in this case.

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 develop and implement a complete, person-centered care plan with measurable interventions for a resident with a known history of psychoactive substance abuse and opioid dependence who was receiving Medication Assisted Treatment (MAT). On admission, assessments documented that the resident was alert and oriented, had used fentanyl within the prior 30 days, and had intact cognition with a BIMS score of 15. The Resident Care Plan identified that the resident was at risk for substance use related to a history of addiction and was receiving MAT, but it did not include specific interventions to address the identified risk for substance use disorder (SUD) or the management of MAT. Physician orders included methadone for opioid use disorder and PRN naloxone for suspected overdose, and the Medication Administration Record showed methadone was administered on multiple days. Despite the resident’s identified SUD and ongoing MAT, the clinical record did not show that psychiatric/psychology services or contracted SUD program services were offered, provided, or refused. The social worker later stated that the resident had been offered SUD support services through an outside vendor and refused, but there was no documentation of this refusal or of any alternative interventions offered after the refusal. The facility’s Care Plan Policy required that care plans contain identified problems, measurable realistic goals, and interventions to reach those goals, but the Director of Nursing Services acknowledged that the resident’s SUD/MAT plan of care was initiated but not completed and that specific interventions such as supervised visits, random room searches, random urine toxicology screens, and support services were not included. The DNS also reported that room searches were only conducted when there was suspicion or observed contraband, and that the facility had no policy or procedure for suspected drug overdose. An overdose event occurred when the resident became lethargic, drowsy, and difficult to arouse, with bilateral pinpoint pupils. Nursing staff administered a sternal rub and two doses of naloxone; the first dose was ineffective, and the second dose produced a positive response, after which the resident admitted to using “illegal stuff.” Security and the social worker conducted a room search and found five bags or dime bags with suspicious white residue tucked into the folded rim of the resident’s hat; security reported flushing five empty bags down the toilet. The resident reported bringing the bags into the facility at the time of admission. The resident was transferred to the emergency department for further evaluation, and a toxicology screen was positive for opiates and fentanyl. The DNS confirmed that the resident had no prior room searches before the overdose event, and the police were not notified because the bags were empty. The facility was unable to provide a visitor log for the day of the family visit, and there was no documentation in the clinical record of SUD service refusals or related interventions, contributing to the failure to implement a comprehensive, measurable care plan for the resident’s SUD and MAT.

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 complete and accurate medical records for PRN medications, including documentation of administration and resident response, as required by physician orders and facility policy. For one resident with a history of opioid and cocaine dependence and a care plan identifying risk for substance use, the physician had ordered intramuscular and intranasal Naloxone (Narcan) as needed for suspected overdose. On the day of the event, the DNS responded to a STAT page and found the resident unresponsive on the bathroom floor with no pulse. CPR was initiated, 911 was called, and Narcan was administered twice without effect before the resident was transferred to the ED, where death was reported. A Narcan Administration Report documented the times and lack of effectiveness of both doses, but the MAR for that date did not contain any documentation that Narcan had been administered or its effectiveness, despite the DNS stating that administered medications should be signed off in the MAR. For another resident with chronic respiratory failure, sepsis, heart failure, bowel and bladder incontinence, and a history of addiction, physician orders included PRN Milk of Magnesia (MOM) for constipation and PRN Bisacodyl suppository if MOM was ineffective. The resident was also ordered PRN Ondansetron for nausea and vomiting. The MAR showed that Ondansetron was administered for nausea and vomiting and that Bisacodyl was administered later that night. An abdominal scan identified diffuse constipation. However, the MAR did not show that MOM had been administered, and it did not document the effectiveness of either MOM or Bisacodyl. The nursing supervisor on the night shift reported that the APRN ordered MOM in prune juice and a suppository, and that these were administered by an LPN. The LPN caring for the second resident stated she administered Ondansetron earlier in the evening with noted improvement, and later, after multiple episodes of vomiting, she believed the resident should be transferred to the hospital. She reported administering MOM around midnight but acknowledged that she did not document its administration or outcome. The DNS stated that the timing of follow-up assessment after MOM administration depends on the resident and could range from one hour to a few hours. Facility policy on administration procedures for all medications directed that when administering PRN medications, staff must document the reason for giving the medication, observe for actions or reactions, and record on a PRN effectiveness sheet or similar form. These requirements were not met in the cited instances for both residents.

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 two cognitively intact residents from sexual abuse by a staff member, specifically a male housekeeper. One resident, with diagnoses including anxiety, depression, chronic substance abuse, and PTSD, reported that the housekeeper entered the room before breakfast, touched the resident inappropriately, made sexual advances, and engaged in further inappropriate physical contact. The incident was reported to a registered nurse, and the resident expressed feeling violated and scared, with a flat affect noted during the investigation. A second resident, also with a history of anxiety, bipolar disorder, chronic substance abuse, and PTSD, reported that the same housekeeper had kissed the resident on the cheek after making other inappropriate advances. This resident initially did not report the incident, believing it had been handled, but came forward after learning of the similar incident involving the first resident. Both residents were described by the social worker as cognitively intact, able to make their needs known, and not known for making false accusations. A third resident, the roommate of the second, did not witness the alleged incident but observed the housekeeper being overly affectionate and noted the resident appeared uncomfortable. The facility's Director of Nursing acknowledged that if the incidents occurred, the facility failed to keep the residents safe and did not follow its abuse policy. The facility ultimately terminated the housekeeper's employment during the probationary period, citing inability to substantiate the allegations due to lack of direct witnesses.

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 abuse by other residents, as evidenced by several documented incidents involving physical altercations. Residents with significant psychiatric and cognitive impairments, including schizophrenia, bipolar disorder, dementia, and anxiety, were involved in repeated episodes of aggression. In one instance, a resident with paranoid schizophrenia and mild cognitive impairment was struck in the face by another resident during a supervised smoking session. Witnesses confirmed the altercation, and the aggressor had a documented history of agitation and aggressive behavior. Further incidents involved the same resident with a history of aggression, who slapped a roommate in the face and later struck another resident on the head following a verbal and physical confrontation. Staff interviews revealed that the aggressor was known for unpredictable and aggressive responses, particularly when provoked, and had a pattern of such behavior. Despite care plans noting the risk for harm to self or others and interventions to monitor and redirect behavior, these measures did not prevent the repeated occurrences of resident-to-resident abuse. Another incident involved a resident with severe cognitive impairment who punched a peer in the face after a dispute over rummaging through garbage. The victim exhibited visible redness on the face following the altercation. The facility's abuse policy prohibits abuse, neglect, and mistreatment by anyone, including other residents, but the documented events show that residents were not adequately protected from abuse by their peers. The report details that interventions were added to care plans after each incident, but does not describe any actions taken prior to the events that could have prevented the abuse.

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 documented food allergies to mayonnaise and eggs was repeatedly served meals containing these allergens. The resident's medical record was updated to reflect these allergies on 4/30/25, and the allergy was included in the May 2025 allergy report. Despite this, the resident was served potato salad and a tuna fish sandwich, both of which typically contain mayonnaise, as well as a ham salad sandwich made with mayonnaise. The resident reported being served foods containing allergens on multiple occasions and attempted to address the issue with nurse aides and nurses, but was told it was a kitchen issue. Facility staff interviews revealed that the process for communicating food allergies involved nursing staff alerting the kitchen, with dietary aides responsible for reading dietary tickets to avoid serving allergens. However, the allergy was not initially listed on the resident's record, and even after the record was updated, the resident continued to receive inappropriate meals. Observations confirmed the resident was served a sandwich containing mayonnaise, which was only removed after intervention by the Food Service Director. The Director of Nursing confirmed that it was the charge nurse's responsibility to resolve food issues by contacting the kitchen, and acknowledged the resident should not have been served foods they were allergic to.

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 the facility failed to ensure the availability and administration of prescribed pain medication for a resident with chronic pain and significant medical needs, including a stage four pressure ulcer and a surgical abdominal wound. The resident had physician orders for Oxycodone oral solution and Tylenol for pain management, with pain monitoring every shift. Documentation showed that the resident's pain was frequently assessed and ranged from zero to eight on the pain scale, with high pain levels recorded over several shifts. Despite these assessments, there was a gap in the administration of Oxycodone from the afternoon of one day until the early morning two days later, and no alternative pain medication was documented as given during this period. Records indicated that the facility ran out of the resident's prescribed Oxycodone, and the emergency backup supply was only used once during the shortage. Interviews with staff confirmed the medication was unavailable, and the resident reported experiencing significant pain during this time. The Director of Nursing acknowledged the resident's complaint and stated that medications should be reordered when seven doses remain, and that it is against policy to document a medication as given when it was not administered. Facility policy also requires nurses to notify supervisors if a medication is unavailable and to document such occurrences, which was not consistently done in this case.

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 meals that were palatable, attractive, and served at an appetizing temperature for all residents, as evidenced by clinical record reviews, observations, and interviews. One resident with severe protein malnutrition, a stage four pressure ulcer, and a surgical wound was noted to have a care plan that included dietary interventions and supplements. Despite this, observations revealed that meals lacked seasoning, had unappealing presentation, and were sometimes difficult to identify. The rice was described as gummy, vegetables as soggy and waterlogged, and sandwiches on the nourishment cart contained minimal filling. Residents reported that hot foods were often served cold, portion sizes were small, and meal service was sometimes delayed until late in the evening. Resident Council and Food Committee meeting minutes documented ongoing concerns about food quality, lack of condiments, decreased food presentation, and menu inconsistencies, including missing bread and wrong orders. The Administrator and Director of Food Service were frequently absent from these meetings, and requested documentation of dietary audits and meeting minutes was not provided. Interviews with residents and staff confirmed persistent dissatisfaction with food temperature, flavor, and appearance, as well as inconsistent attendance by key staff at meetings intended to address these issues.

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 the misappropriation of their controlled medications, specifically Oxycodone, as evidenced by missing doses, incomplete documentation, and lack of proper destruction procedures. For several residents with significant medical conditions such as osteomyelitis, polyneuropathy, cancer, and chronic pain, there were discrepancies in the controlled substance distribution records (CSDR) and medication administration records (MAR). In several instances, tablets were documented as removed from the supply but were not accounted for as administered, destroyed, or wasted according to facility policy. Required co-signatures for destroyed or wasted medications were missing, and in some cases, the CSDR sheets themselves were not available for review. The report details that an LPN was involved in multiple discrepancies, including popping or dropping tablets without obtaining a second nurse's signature, as required by policy. The facility's audits and investigations revealed missing CSDR sheets, illegible or obscured signatures, and a lack of proper documentation for the administration or destruction of controlled substances. The LPN in question admitted to diverting Oxycodone for personal use during an external investigation by the Department of Consumer Protection. The facility was unable to provide complete records for several residents, further indicating a breakdown in the required controls for handling controlled substances. Facility policy mandates that all controlled drugs be subject to special handling, storage, and record keeping, including immediate documentation of administration or destruction with two nurse signatures when necessary. Despite these policies, the facility did not ensure proper accounting for controlled medications, resulting in unaccounted-for doses and missing documentation for several residents. These failures directly led to the misappropriation of resident medications and a violation of residents' rights to be free from wrongful use of their property.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper controlled drug accountability records (CDSR) for multiple residents, as required by policy and regulation. In several cases, CDSR forms were missing, illegible, or incomplete, making it impossible to accurately track the administration and disposition of controlled substances such as Oxycodone, Tramadol, and Hydrocodone. For example, for one resident with osteomyelitis and contractures, CDSR forms were either missing, had signatures obscured by spills, or lacked required co-signatures for destroyed medication. In another case, a resident with polyneuropathy and diabetes had a significant discrepancy between the number of narcotic tablets received, administered, and remaining, with the required CDSR sheet missing and unaccounted doses. Additional deficiencies included instances where controlled substances were documented as dropped or popped in error without the required co-signature to verify destruction, as well as CDSR forms with smudged or illegible signatures that prevented accurate tracking. Several residents with chronic pain, cancer, or a history of opioid abuse had missing CDSR forms for their prescribed narcotic medications, and in some cases, the forms were never located despite requests. Interviews with the prior Director of Nursing Services (DNS) confirmed the missing or illegible forms and the lack of required documentation, with suspicions raised about possible drug diversion. Facility policy required that all controlled drugs be subject to special handling, storage, and record keeping, including immediate documentation of administration, destruction in the presence of two licensed nurses, and retention of records for at least five years. Despite these requirements, the facility was unable to provide complete and accurate CDSR documentation for at least nine residents reviewed, resulting in a failure to ensure proper accountability and control of controlled substances.

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 timely notification to the State Agency regarding allegations of misappropriation of resident medications, specifically suspected drug diversion incidents involving controlled substances. In multiple cases, including five residents with significant medical conditions such as osteomyelitis, polyneuropathy, cancer, and chronic pain, discrepancies were identified in the administration and documentation of narcotic pain medications. These discrepancies included missing co-signatures for destroyed or wasted medications, missing controlled substance distribution records, and unaccounted-for doses of Oxycodone. In several instances, medication administration records did not match the controlled substance logs, and required documentation to track the disposition of narcotics was missing or incomplete. Despite these findings, the facility did not notify the State Agency's Facility Licensing & Investigation Section (FLIS) as required by policy and regulation. The Director of Nursing Services (DNS) acknowledged that an internal investigation was conducted and that the suspected staff member was reported to the Department of Consumer Protection (DCP), but was unaware that such incidents constituted abuse or misappropriation requiring immediate reporting to the State Agency. The facility's own policy defined misappropriation of resident property as the wrongful use of a resident's belongings and required prompt reporting to the Department of Public Health within two hours of an allegation. The failure to report these incidents in a timely manner was confirmed through review of facility documentation, interviews, and the absence of required notifications on the State Agency's reportable events website. The deficiency was further substantiated by the facility's inability to provide key documentation for the controlled substances in question and the lack of co-signatures for wasted medications, all of which are necessary to ensure accountability and resident safety.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to ensure complete and accurate documentation regarding a resident's behaviors and the administration and effectiveness of a prescribed medication. The resident, who had diagnoses including dementia, schizophrenia, and anxiety disorder, was noted to have a moderate cognitive impairment and a history of behavioral issues such as paranoia, delusions, restlessness, and running in the hallway. On the evening in question, the resident was observed running uncontrollably in the hallway and sustained a significant hand injury, later determined to be a partial traumatic amputation. Although the resident was administered Ativan 2 mg as ordered for anxiety or agitation, the administration was not documented on the Medication Administration Record (MAR), and the effectiveness of the medication was also not recorded. Additionally, the resident's behaviors were not documented on the Behavior Intervention Flow Record for the relevant shift, despite a facility policy requiring such documentation. Interviews with the LPN involved and the Director of Nursing Services confirmed that the required documentation was not completed due to the busy and chaotic nature of the shift. The LPN acknowledged administering the medication and failing to document both the administration and the resident's behaviors, as well as not recording the medication's effectiveness. The facility's policy on behavior monitoring required licensed nurses to document behavioral episodes by shift, but this was not followed. Furthermore, the facility was unable to provide a policy on nursing documentation when requested.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe and sanitary environment, as evidenced by several deficiencies observed during the survey. Toilets in two shower rooms were not maintained properly; one toilet had its seat on the floor and was not cleaned, while another was skewed and not securely attached to the base. Staff members, including an RN and a housekeeper, were unaware of these conditions until they were pointed out during the survey. Additionally, the facility's maintenance director admitted to not conducting comprehensive assessments of each room during environmental rounds, leading to unaddressed issues such as holes in walls and peeling paint in resident rooms. Resident #79, who had dementia and was frequently incontinent, was found to have a bathroom with peeling paint and a missing outlet cover, which exposed old paint surfaces. The maintenance director suggested that the peeling paint might be due to the placement of a soap dispenser without a tray. Despite the maintenance director's rounds, these issues were not addressed, and staff were not consistently reporting maintenance needs through the facility's system. Resident #193, who was cognitively intact and valued personal belongings, experienced issues with the facility's laundry process. The resident's clothes were not labeled as requested, resulting in missing items. The social worker and laundry director were not fully aware of the situation, and there was no clear process communicated to staff for labeling residents' clothing. The facility's policy did not provide specific guidance on managing residents' clothing, leading to confusion and unresolved grievances regarding missing personal items.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During the initial tour and subsequent observations, numerous deficiencies were identified, including marred mirrors, broken tiles, stained ceilings, and missing baseboards in various rooms. Additionally, a strong smell of urine was detected in one room, which permeated the hallways despite cleaning efforts. The Director of Maintenance acknowledged responsibility for conducting environmental rounds but admitted that some areas of concern might be missed due to oversight. The facility also failed to ensure proper handling and disposal of sharps containers. An overfilled sharps container with protruding razors was found in a locked shower room, and there was confusion among staff regarding who was responsible for changing the containers. Interviews revealed that nursing staff were responsible for this task, but a lack of communication and oversight led to the containers being neglected. Furthermore, resident chart binders were found to be soiled, with no clear assignment of responsibility for their cleaning. Additional issues included a resident's room with a towel draped over a light fixture and items hanging from window shades, which posed safety concerns. Despite being informed of these issues, the Maintenance Director did not communicate them to the nursing supervisor or administrator. The facility also faced challenges with residents who urinated on the floor, contributing to foul odors and damaged flooring. Despite frequent cleaning, the odors persisted, and the facility struggled to address the underlying behavioral issues of the residents involved.

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 timely response to call bells for a resident with chronic respiratory conditions. Resident #133, who has chronic respiratory failure, COPD, and anxiety, reported that staff took a long time to respond to call bells when she/he needed breathing medication. On one occasion, the resident had to yell for help due to the delay. During a demonstration with a surveyor present, the resident's call bell was not answered for 23 minutes. Staff interviews revealed that the assigned nurse aide did not see the call bell light, and the LPN was unaware of any specific time limit for answering call bells, although it was generally expected to be within five minutes. Additionally, the facility failed to ensure that the call bell was accessible to another resident with COPD, morbid obesity, and chronic respiratory failure. Resident #140's call bell was observed to be out of reach, wrapped around an overbed table and dangling to the side, making it inaccessible despite the resident's attempts to reach it. An LPN confirmed that the expectation was for the call bell to be within reach but could not explain why it was not. The facility's call light policy did not specify staff expectations for the proximity of the call bell to the resident.

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 a comprehensive care plan for a resident with severe cognitive impairment, depression, and bipolar disorder, specifically regarding dental care. The resident had a history of dental issues, including broken and discolored teeth, and was awaiting a tooth extraction. Despite the resident's complaints of a toothache, the facility did not have a current dental care plan in place. The last documented dental visit attempt was in 2018, which the resident refused, and no subsequent visits were recorded until the survey date in 2024. Interviews with facility staff and review of the clinical records revealed that the care plan for dental care was not developed or updated in the new electronic documentation system, despite being identified as necessary during the Care Area Assessments (CAA) process. The facility's policy required the interdisciplinary team to develop and revise care plans within seven days of completing the MDS and CAAs, but this was not done. The MDS Nurse acknowledged the oversight, noting that the care plan was overdue and not available in the system or in printed form on the units.

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 revise the care plans of residents in a timely manner, as required by their policy. Resident #12, who has a diagnosis of depression and bipolar disorder, was identified as severely cognitively impaired. Despite the Care Area Assessments (CAA) process indicating the need for a dental care plan, no such plan was found in the resident's records, both paper and electronic, until 16 days after the CAA completion. This delay was acknowledged by the MDS Coordinator Nurse, who confirmed that the dental care plan should have been written and revised in the new system during the CAA completion. For Resident #25, who has hemiplegia and other conditions, the care plan was not updated promptly after a physical altercation with a roommate. Although interventions were reportedly done immediately, the DNS admitted to possibly forgetting to update the care plan on the same day. Similarly, Resident #460, with a diagnosis of Major Depressive Disorder and other conditions, had a care plan that was not updated in a timely manner following an incident. Interviews with staff indicated that each discipline is responsible for updating their part of the care plan, but this was not done as required by the facility's policy.

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 proper storage and labeling of oxygen supplies for three residents. Resident #65, who has morbid obesity with alveolar hypoventilation, was observed with a nebulizing mask and oxygen tubing improperly stored and not labeled with the current date. Similarly, Resident #69, diagnosed with chronic obstructive pulmonary disease (COPD), had a nebulizer mask placed directly on the bedside table without a storage bag or date label. Resident #129, with congestive heart failure and COPD, had oxygen tubing without a current date label, and humidification tubing was dated from the previous month. Interviews with nursing staff and the Director of Nursing Services confirmed that the facility's expectations for storage and labeling were not met. The facility also failed to provide tracheal suctioning in accordance with professional standards for Resident #196, who was in a persistent vegetative state and required tracheostomy care. An LPN was observed using clean gloves instead of sterile gloves and reusing a suction catheter throughout her shift, contrary to the facility's policy, which requires a new sterile suction catheter for each procedure. The LPN used non-sterile water to clear the catheter, and the suction catheter was stored in a non-sterile bag after use. The Director of Nursing Services indicated that sterile gloves were not deemed necessary, although the facility policy required them. The facility's policies for oxygen administration and tracheal suctioning were not adhered to, leading to deficiencies in respiratory care. The lack of proper storage, labeling, and adherence to sterile procedures for respiratory equipment compromised the standard of care provided to the residents. Interviews with staff revealed a misunderstanding or disregard for the facility's policies, contributing to the deficiencies observed during the survey.

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 staff were competent in providing tracheal suctioning for a resident in a persistent vegetative state who required tracheostomy care and suctioning. During an observation, an LPN was seen using clean gloves instead of sterile gloves, reusing a suction catheter, and using non-sterile water to clear the catheter, which contradicts the facility's policy that requires sterile equipment and procedures. The LPN admitted to learning suctioning from nursing supervisors and a respiratory therapist at the facility, rather than through formal education, and was unaware of the need for sterile procedures. Interviews with the nursing supervisor, DNS, and the Director of Respiratory Therapist revealed inconsistencies in understanding the sterility requirements for tracheal suctioning. The Director of Respiratory Therapist confirmed that tracheal suctioning is a sterile procedure, requiring sterile gloves, catheters, and water. However, the facility lacked documentation of staff competencies related to tracheal suctioning prior to the surveyor's inquiry, and the training provided did not include hands-on practice of suctioning through a tracheostomy.

Penalty

No penalty information released

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

Summary

The facility failed to maintain proper hygiene and organization in its food storage and preparation areas. During a tour of the kitchen, surveyors observed hard black matter in the corners of a refrigerator, indicating a lack of cleanliness. The Director of Food Service acknowledged that all staff are responsible for cleaning and maintaining the refrigerator area, but it was not adequately done. Additionally, the dry food storage area was found to be disorganized, with stacks of boxes, both empty and filled, on the floor and some falling over, which blocked access to emergency stock. The Director of Food Services confirmed that boxes should not be stored in this manner and that the Dietary Aide responsible for stocking should ensure proper organization. Furthermore, a Dietary Aide with facial hair was observed preparing breakfast juice and coffees without wearing a beard guard, which is a requirement for staff handling food items. The Director of Food Services admitted that staff with facial hair should wear a beard guard while in the kitchen or handling food, but could not explain why the staff member was not compliant. These observations highlight deficiencies in the facility's adherence to food safety and hygiene standards.

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 proper use of Personal Protective Equipment (PPE) during tracheostomy care for a resident in a persistent vegetative state with a tracheostomy. Despite the presence of an orange sign indicating enhanced barrier precautions, which required the use of gloves and a gown for high-contact care, an LPN was observed performing tracheal suctioning wearing only gloves. The LPN was unaware that a gown was necessary for this procedure, indicating a lack of communication or training regarding the enhanced barrier precautions for residents with tracheostomies. The Nursing Supervisor confirmed the requirement for gown and gloves during such procedures. Additionally, the facility did not maintain sanitary conditions for linen storage. Soiled towels were observed on the floor outside the shower room in the hallway, several feet from a laundry bin designated for soiled laundry. The charge nurse on duty acknowledged that the previous shift staff likely left the towels on the floor, and subsequently instructed a nurse aide to place them in the laundry bin. This incident highlights a lapse in maintaining sanitary conditions and proper handling of soiled linens.

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 timely notification to the responsible party of a resident regarding the end of Medicare coverage and potential liability for services not covered. The resident in question, who was diagnosed with dementia and schizophrenia, was identified as severely cognitively impaired. The Prospective Payment System (PPS) Part A Discharge Minimum Data Set (MDS) indicated that the resident's Medicare stay ended on May 9, 2024. However, the facility did not provide adequate evidence that the responsible party received the necessary notification of Medicare non-coverage and the Skilled Nursing Facility Advanced Beneficiary Notification (SNFABN). The MDS Nurse (RN #9) stated that the notification was dated and emailed to the responsible party on May 7, 2024, but there was no response or signed acknowledgment from the responsible party. Although there was electronic verification of email delivery, there was no follow-up via phone or registered letter to ensure receipt of the notification. Consequently, the facility could not provide evidence that the responsible party was informed of their right to appeal the decision, resulting in a deficiency in the facility's notification process.

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 Medical Director attended the monthly Quality Assessment and Performance Improvement (QAPI) meetings for the years 2022, 2023, and 2024. During an interview and document review with the Administrator, it was identified that although the Medical Director was a member of the QAPI Committee, they did not attend the monthly meetings and therefore did not sign the attendance sheets for these years. The Administrator noted that the Medical Director was present in the facility weekly and was kept updated on the QAPI meetings conducted monthly. However, the facility could not provide any documentation with the Medical Director's signature indicating attendance at meetings that included QAPI discussions. The facility's policy stated that the QAPI Committee should include the Medical Director or a designee, among other members, and meet at least quarterly, but this requirement was not met.

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

Two residents with severe cognitive impairment, one diagnosed with paranoid schizophrenia and the other with encephalopathy, were observed seated near the nurse's station. Both required significant assistance with activities of daily living (ADLs) and had care plans specifying the need for explanation of care and reporting of any decline in ADLs. During this time, a social worker exited a resident's room and, in a loud voice within close proximity to the residents, used inappropriate and profane language. The incident was witnessed by a psychiatric practitioner who confirmed hearing the inappropriate comment while charting at the nurse's station. The social worker acknowledged using swear words in the presence of residents, attributing her outburst to frustration over a resident's discharge process. The Director of Nursing also confirmed that the language used was inappropriate. Facility policy and the Resident's Bill of Rights require that residents be treated with respect and dignity, and the observed behavior failed to meet these standards.

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 diagnoses of anxiety disorder, mood disorder, and dementia, and a BIMS score indicating impaired cognition, was involved in an incident where a staff member was observed holding the resident by the wrists while both were screaming at each other. The resident alleged that the staff member twisted their wrists and pulled their hair, resulting in complaints of wrist pain. The incident was witnessed by an LPN who responded to the commotion and observed the staff member holding the resident's wrists. The resident was subsequently assessed, and x-rays were ordered, which showed no fractures. Interviews with the involved staff revealed that the staff member claimed to have been responding to the resident's yelling and attempted to change the resident's soiled brief. The staff member reported that the resident became upset, began to hit and scratch, and that she held the resident's arms to prevent further scratching. The staff member denied twisting the resident's wrists or pulling their hair, stating she was only trying to protect herself. The LPN and other staff confirmed the sequence of events, with the LPN noting that the staff member was holding the resident's wrists when she entered the room. The facility's policy prohibits any form of abuse, including physical abuse, by anyone. Despite the resident's history of hitting and scratching staff, the staff member's action of holding the resident's wrists during the altercation was not in accordance with the policy to protect residents from abuse. The facility ultimately unsubstantiated the abuse allegation, citing the staff member's intent to protect herself, but the incident demonstrated a failure to ensure the resident was free from physical abuse as required by facility policy.

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 a comprehensive care plan for a resident with refusals of care, specifically for medications and wound care treatment. The resident, who had diagnoses including non-pressure chronic ulcers, diabetes mellitus, and dysphagia, was identified as having moderately impaired cognition and required assistance with certain activities of daily living. Despite these needs, the resident's care plan did not address their repeated refusals of medications and wound care, which were documented multiple times over several months. The Director of Nursing (DON) was unaware of the resident's refusals and acknowledged that the care plan should have included interventions for these refusals. The facility's Care Plan Policy mandates the development of a comprehensive person-centered plan of care, which was not adhered to in this case. The lack of a care plan addressing the resident's refusals represents a deficiency in the facility's care planning process.

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 timely reweighting and notification of significant weight loss for a resident with multiple health conditions, including diabetes mellitus, severe protein-calorie malnutrition, and dysphagia. The resident was admitted with a weight of 148.6 lbs, which dropped to 134 lbs within four days, indicating a 10.33% weight loss. Despite the facility's policy requiring reweighting and notification of the dietician and physician for weight variances of 5% or more, there was no documentation of a reweight or notification to the relevant healthcare professionals. Interviews with the Director of Nursing (DON), Registered Dietician (RD), and Advanced Practice Registered Nurse (APRN) revealed a lack of communication and follow-up regarding the resident's significant weight loss. The DON admitted to not notifying the dietician or physician and was unsure of whom the task was delegated to. The RD was on leave during the incident and was not informed of the weight loss, while the APRN confirmed no notification or progress notes addressing the weight loss were made. The facility's failure to adhere to its weight policy and ensure proper communication contributed to the deficiency.

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 clinical record for a resident was complete and accurate, specifically regarding the documentation of wound care treatments. The resident, who had diagnoses including non-pressure chronic ulcers, diabetes mellitus, and dysphagia, required specific wound care treatments for bilateral heel wounds as per physician and APRN orders. However, the Treatment Administration Record (TAR) for December 2023 and January 2024 did not reflect that the required treatments were provided on several dates. Interviews with nursing staff revealed that treatments may have been performed but were not documented, indicating lapses in record-keeping. Additionally, the facility lacked a documentation policy, which contributed to the inconsistency in maintaining accurate records. Furthermore, the facility was unable to provide the Medication Administration Record (MAR) for December 2023 for the resident. Interviews with the Director of Nursing Services (DNS) and a registered nurse confirmed that the MAR could not be located, although it should have been available. The absence of a documentation policy was again noted, highlighting a systemic issue in the facility's record management practices. These deficiencies in documentation and record accessibility compromised the facility's ability to ensure timely and accurate medical record access for the resident.