New Castle Health And Rehabilitation Center

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 adequately assess, monitor, and manage tube feeding and fluid needs for a resident with a gastrostomy tube, and to intervene appropriately when repeated aspiration events occurred. The resident was admitted with a diagnosis of feeding tube (gastrostomy status) and had a care plan directing staff to administer tube feeding and hydration as ordered, maintain the head of bed elevation during and after feeding, and flush the tube with specified amounts of water before and after medications and feedings. Dietary progress notes documented that the resident’s weight was stable and overweight by standard, with tube feeding ordered as Nutren 1.5 at 70 mL/hr for 18 hours and free water flushes (FWF) of 65 mL/hr for 18 hours, providing 1890 calories and 1170 mL of water per day. However, review of the Medication Administration Record (MAR) showed that staff documented providing tube feeding and FWF volumes far in excess of the ordered daily amounts on multiple days, with recorded totals of tube feeding and water flushes that greatly exceeded the prescribed 1260 mL of tube feeding and 1170 mL of FWF in 24 hours. The resident experienced multiple episodes of tube feeding formula oozing from the mouth and nares, along with respiratory compromise, that were documented in progress notes but were not followed by documented reassessment or adjustment of tube feeding orders by the dietitian or medical providers. On one occasion, the resident was found unresponsive with low oxygen saturation and tube feeding seen oozing from the mouth; CPR was initiated, suctioning was performed, and the resident was sent to the hospital. The resident was later readmitted with the same tube feeding and water flush rates, and a subsequent note indicated treatment for aspiration pneumonia. Later MAR entries again showed staff-documented tube feeding and FWF volumes that exceeded the ordered amounts. Another nursing note described the resident with labored breathing, crackles in both lungs, and milky secretions pooling from both nares and mouth, with suctioning performed and an order obtained to send the resident to the hospital via 911. A hospital history note documented concern for overfeeding and aspiration, with admission for septic shock, pneumonia, and urinary tract infection. Despite these events, dietary notes continued to state that the resident’s weights were stable or that weight gain was being evaluated for accuracy, and that no nutritional interventions were needed at that time, even when a dietary note recorded a net weight gain of 22.6% over seven months. A later dietary progress note indicated that the resident remained NPO and continued on the prescribed tube feeding regimen, with concurrent water flushes providing a total of 2132 mL of fluid per day. Nursing progress notes in a subsequent month documented repeated observations of Nutren feed coming out of the resident’s mouth, coarse crackles bilaterally, dyspnea, and the need for frequent suctioning, with the NP initially instructing staff to monitor the resident. Another note described fluid from the mouth, crackles, and continued monitoring, followed by a note that the resident was aspirating from the mouth with shortness of breath and lung crackles, leading to a recommendation from the NP to send the resident to the hospital. Interviews with the NP and dietitians revealed that the NP documented the resident as tolerating tube feeding after aspiration incidents, that the dietitian was not notified of earlier aspiration events or the hospital note about overfeeding, and that the dietitian acknowledged an assessment of tube feeding and water flush rates should be conducted after aspiration incidents. The facility’s own enteral nutrition policy required the RDN to assess energy, protein, and fluid requirements, compare them to ordered formula and flushes, and monitor weight, labs, and physical symptoms, and required nursing to communicate changes such as vomiting and high residuals, but the documented care and communication did not reflect consistent adherence to these requirements for this resident. The facility’s leadership, including the DON, Medical Director, NP, Regional Registered Dietitian, and facility dietitian, acknowledged in interview that the resident had chronic encephalopathy and aspirated off and on, and that dietary staff usually changed orders and tracked tube feeding, aspiration, and labs. However, the Medical Director responded to a question about tube feeding coming out of the resident’s nose by stating that people vomit when they are sick, and there was no documentation that the tube feeding regimen was reassessed or modified in response to the repeated documented episodes of tube feeding formula oozing from the resident’s mouth and nares, the excessive volumes recorded on the MAR, or the significant weight gain. The survey findings concluded that the facility failed to ensure that the resident was assessed and monitored for nutritional and fluid needs and failed to implement interventions when the resident aspirated tube feeding multiple times and gained a significant amount of weight, resulting in harm including cardiac arrest during an aspiration event and multiple hospitalizations after aspiration of tube feeding.

Removal Plan

• Transferred the affected resident to the hospital
• Assessed all tube-fed residents for tolerance, weights, and aspiration signs
• Registered Dietitian and clinical leadership reviewed tube-fed residents’ status
• Convened a QAPI meeting
• Provided education to the dietitian and nursing staff on the enteral feeding policy with completion
• Implemented a structured audit and monitoring process of MARs and progress notes to ensure ongoing compliance and early identification of tube feeding intolerance

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 consistently implement fall-prevention interventions and adequate supervision for a resident with a history of traumatic brain injury, dementia with agitation, and multiple prior falls. The resident was admitted with significant cognitive impairment, as evidenced by an incomplete BIMS due to poor cognition, and was assessed as high risk for falls with a fall risk score of 19. The quarterly MDS documented that the resident was dependent on staff for transfers and had experienced two or more falls with no or minor injury since the prior assessment. The resident’s care plan, updated after multiple falls and a hip fracture, identified the resident as high risk for falls and included interventions such as close supervision when in the wheelchair/Broda chair, frequent monitoring when in bed, and getting the resident out of bed to a Broda chair or common area when awake at night. Despite these identified risks and care-planned interventions, facility documentation and staff practices did not reflect consistent monitoring or supervision. Review of the MARs, TARs, and CNA documentation from October through December showed no entries indicating that the resident was being monitored to prevent falls, and monitoring was not listed as a fall intervention in those records. Incident/accident reports revealed a pattern of unwitnessed and unsupervised falls on numerous occasions, often in the hallway or near the nurse’s station, with the resident unable to explain how the falls occurred. These falls included multiple events from the resident’s wheelchair or Broda chair and culminated in a fall resulting in a left hip fracture, after which the resident was hospitalized and later returned to the facility. Direct observations by surveyors further demonstrated lapses in supervision inconsistent with the care plan and staff expectations. On several observed occasions, the resident was in a Broda chair in hallways, common areas, and even stuck in a staff office, propelling himself and at times attempting to stand, without staff present to monitor him. Staff interviews confirmed that the resident was known to be at high risk for falls, was impulsive, and was supposed to remain within line of sight of staff at all times when up in the Broda chair. The DON, Administrator, Regional VP of Operations, and Regional Nurse all confirmed that the resident was expected to be in line of sight when up in the Broda chair due to his high fall risk. The facility’s fall prevention policy required assessment of fall risks and implementation of preventative measures when risks were identified, but the repeated unwitnessed falls and lack of documented monitoring showed that these measures were not consistently carried out, resulting in a fall with major injury (hip fracture).

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

Surveyors found that the facility failed to ensure food was discarded and stored according to professional food service safety standards in the kitchen. During observations of the dry storage area, two 19.5-ounce plastic squeeze bottles of chocolate syrup were noted with a manufacturer’s expiration date of 5/16/25. In the walk-in refrigerator, three 19.5-ounce bottles of chocolate syrup and three 19.5-ounce bottles of vanilla syrup were found opened, all displaying the same expiration date of 5/16/25. The Dietary Manager confirmed that these chocolate and vanilla syrups were past the manufacturer’s use-by date and should not have been available for use, and stated that these items were used during activities and should have been checked by dietary staff, who were ultimately responsible for ensuring food items were not expired. During an interview, the Administrator reported that the facility had no policy that directly addressed manufacturer use-by dates or expiration dates displayed on food items. Review of the existing policy titled “Equipment Cleaning and Sanitation Policy,” dated 08/25/20, showed it only addressed maintaining a clean and sanitary environment in food service areas and did not include food storage policies or procedures. All 109 residents received food from this kitchen, and the deficiency was based on the presence and potential use of expired food items and the lack of a specific policy addressing food expiration and storage.

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 provide and implement an adequate infection prevention and control program in two key areas: water management and wound care practices. Surveyors reviewed a facility document titled "Premise Plumbing System" and found it contained only a diagram of the facility’s water system without any documentation identifying high‑risk areas where water pathogens might develop. During an interview, the Maintenance Director stated he had not previously seen a water flow diagram of the facility’s water system and confirmed that the diagram did not identify high‑risk areas for pathogen development. Review of ASHRAE guidance on managing the risk of legionellosis indicated that building water systems should be described using flow diagrams and written descriptions that include details such as where the building connects to the municipal water supply, how water is distributed and used, and the locations of water‑related equipment, highlighting that the facility’s existing water management program was incomplete and not consistent with this guidance. The report also identifies a deficiency in hand hygiene and glove use during wound care for one resident. The resident was admitted with a history of stroke and had a quarterly MDS showing a BIMS score of 0/15, indicating severe cognitive impairment. The assessment documented that the resident had a stage IV pressure ulcer, an unstageable pressure ulcer, and a venous stasis ulcer, and was receiving hospice services. Physician orders directed multiple daily wound treatments to several sites, including the left ischium, left lateral foot, left groin, left trochanter, right lateral foot, and sacrum, and the resident’s care plan indicated that wound care orders were to be followed. During observation of wound care, an LPN and the ADON were seen providing treatment to the resident. The LPN removed all existing dressings, then donned a single pair of gloves and used the same gloves while moving from wound to wound to cleanse each site with normal saline. After cleansing, the LPN changed gloves and sanitized her hands once, then applied the ordered treatments to all of the resident’s wounds while wearing the same pair of gloves, and repositioned the resident while still wearing those gloves before finally removing them and sanitizing her hands upon leaving the room. In a subsequent interview, the LPN stated she believed she only needed to change gloves and sanitize her hands between dirty and clean processes and was not aware she should change gloves and sanitize hands when moving from one wound to another to avoid cross‑contamination. The ADON stated she was unsure of the facility’s infection control process for wound care, while the DON stated her expectation was that infection control processes be maintained during wound care to prevent cross‑contamination and confirmed the LPN should have removed gloves and sanitized hands between wounds. The facility’s "Clean Dressing Change" policy indicated that, where sterile technique is not ordered, wounds are to be dressed using clean technique that avoids direct contamination of materials and supplies.

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 residents or their representatives were informed of the risks and benefits of psychotropic medications prior to their use, as required by resident rights. For one resident with traumatic brain injury and dementia with agitation, records showed ongoing administration of trazodone, risperidone, and buspirone per physician orders, with the MDS indicating significant cognitive impairment and use of antidepressant, antianxiety, and antipsychotic medications. However, there was no documentation that risks and benefits were discussed before these psychotropic medications were administered. Another resident with severe cognitive impairment, emotional lability, and dementia had an order for trazodone 50 mg twice daily with medication monitoring, but the EMR contained no record of any risk-versus-benefit discussion with the resident or representative prior to starting the medication. A third resident, cognitively intact with a diagnosis of depression, was started on sertraline 25 mg daily, yet the EMR lacked documentation that risks and benefits were reviewed before initiation. A fourth resident with severe cognitive impairment, multiple neurological and psychiatric diagnoses, and existing use of antipsychotic and antianxiety medications had a care plan noting risk for adverse reactions related to psychotropic use and a physician order for risperidone 0.5 mg twice daily for dementia with severe agitation. Despite this, there was no documentation that the risks and benefits of this psychotropic medication were reviewed with the responsible party prior to initiation. During an interview, the Administrator, DON, and Regional President of Operations confirmed that risk-versus-benefit discussions for psychotropic medications had not been conducted for at least one of the residents, despite the facility’s resident rights document stating that residents have the right to be fully informed of the risks and benefits of proposed treatments.

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 reporting of multiple allegations and incidents of potential abuse and neglect, contrary to its policy requiring immediate reporting to the Administrator/DON and the State Agency. For one resident with traumatic brain injury and dementia with agitation, a nurse’s note documented that the resident attempted to enter two female residents’ rooms, tried to get into bed with one of them, and that the resident threatened to call 911 if the behavior recurred. The note stated the DON was notified and a room change was recommended, but there was no corresponding entry on the Incident and Accident Report Log, and no evidence in the facility or resident records that this potential resident‑to‑resident abuse was reported to administration or to the State Agency. During interview, the Administrator and DON confirmed such incidents should be logged and reported within two hours, and the DON denied being notified as documented. The facility also failed to promptly report a resident‑to‑resident incident involving two other residents. One resident, cognitively intact and ambulatory, attempted to propel his wheelchair around another resident who used a front‑wheeled walker and was moderately cognitively impaired. When the second resident refused to move, the first resident grabbed the wheelchair handles and pulled back, causing the second resident to fall and sustain a skin tear on the right elbow, for which nursing provided assessment and Tylenol. Although the incident occurred on one date, the Facility Reported Incident form showed it was not reported to the State Survey Agency until two days later. In interview, the Administrator stated that the RN involved failed to report this resident‑to‑resident incident to her immediately, despite the expectation that staff notify her right away of any alleged resident‑to‑resident abuse. In another case, the facility delayed reporting an allegation of staff roughness made by a cognitively intact resident with multiple medical conditions, including sepsis history, muscle weakness, COPD, chronic pain, depression, and diabetes, who used a wheelchair and required assistance with ADLs. During a shift, a CNA checked the resident’s brief after the resident stated she was not wet and would notify staff if needed; the CNA continued the check, and the resident struck the CNA’s arm, stating the CNA was being too rough and causing pain. The CNA told the resident not to put hands on her and left the room, and the nurse present documented the resident’s statements that the CNA was rough and had an attitude, and that she would call her children to remove her from the facility. The Facility Reported Incident indicated the Administrator was not notified until the following day, constituting a delay in notification under the facility’s abuse policy, which requires immediate reporting of all allegations of abuse, neglect, injuries of unknown origin, and misappropriation to the Administrator/DON and State Agency, and reporting of abuse or serious bodily injury to the Department of Health no later than two hours after the allegation is made.

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 conduct thorough abuse investigations for multiple resident-to-resident incidents as required by its own Abuse, Neglect and Exploitation policy. For one incident, the facility’s Incident Online Submission Form documented that one resident attempted to propel himself around another resident who did not move, then grabbed the other resident’s wheelchair handles and pulled him back, causing the resident to fall to the ground and sustain a skin tear on his right elbow. Although the facility initiated an investigation that included staff and resident interviews, the questioning of staff was limited to whether they had ever witnessed the resident redirecting other residents in wheelchairs, rather than asking if they had ever seen him attempt to hurt other residents. In an interview, the Administrator confirmed that the investigation into this resident-to-resident incident was incomplete because staff were not asked about possible abuse. In a separate incident, a progress note documented that CNA staff reported a resident with a history of traumatic brain injury and dementia with agitation had attempted to enter the rooms of two unnamed female residents, with one female resident reporting that he tried to get into bed with her and stating she would call 911 if the behavior recurred. The note indicated no injuries were observed and both residents were within normal limits on assessment, and the DON was notified with a room change recommended. However, this incident was not entered on the facility’s Incident and Accident Report Log, and there was no documentation in facility or resident records that any investigation of potential abuse was initiated or completed related to this event. The Administrator and DON confirmed that an investigation of potential abuse was expected for any such incident, including this potential resident-to-resident abuse, but none was documented, contrary to the facility’s policy requiring interviews of the resident, the accused, and all potential witnesses and, if needed, expanded interviews when there are no 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

Surveyors identified a deficiency in the facility’s failure to provide appropriate care to maintain or improve range of motion (ROM) for a resident who required a hand splint. The resident was admitted with diagnoses including anoxic brain damage and persistent vegetative state and was unable to participate in a BIMS assessment due to poor cognition and inability to communicate. The resident’s care plan, dated 10/01/25, documented a need for a splint/brace related to a contracture of the right hand, with instructions for the splint/brace to be applied every day and removed at night. However, review of the physician’s orders dated 12/13/25 showed no provider order for a splint/brace, and review of the record revealed no documentation that the splint/brace was being applied per the care plan. During multiple observations over several days, the resident was seen lying in bed in a vegetative state and unable to move her body, and on each occasion the splint/brace was not applied to the right hand; instead, it was observed lying on the bedside table. In an observation with a CNA, the CNA confirmed that the splint/brace was not applied and acknowledged it was supposed to be applied during the day every day according to the care plan. In an interview, the DON stated her expectation was that the splint would be applied according to the plan of care to prevent further decline in ROM. The facility’s Splint Issuance Policy required that splints be issued or fabricated with a provider’s order, that a therapist evaluate the patient to determine need, fit, and issuance, and that the splint schedule be communicated to the multidisciplinary team and documented in the care plan, but the resident’s record and observations did not show that the splint was routinely applied as planned.

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 provide consistent and comprehensive nutritional management for one resident identified as being at risk for significant weight loss. The resident, who had a history of traumatic brain injury and dementia with agitation and demonstrated poor cognition with short- and long-term memory deficits, required set-up assistance for meals. A quarterly MDS indicated no weight-loss interventions were in place at that time. The resident’s care plan identified risk for significant weight loss related to altered mental status and combative behaviors, with interventions limited to providing diet and weights per physician orders. Physician orders specified a regular diet and weekly weights, with no active orders for nutritional supplements or other interventions to prevent weight loss. Weight records showed a decrease from 162 lbs to 145 lbs between 11/11 and 12/03, representing a 10.49% loss in less than 30 days, with no documented re-weight after the significant loss. A dietary progress note dated 12/06 documented that the resident had experienced significant unintentional weight loss and stated that oral nutritional supplements (Boost 8 oz twice daily) were being used, and that staff were encouraging fluids. However, review of the MAR/TAR from 12/01 through 12/12 showed no evidence that any nutritional supplements were administered during that period. Interviews with an LPN responsible for the resident’s care and the unit manager confirmed they could not find any orders or documentation showing the supplement was provided or that a re-weight was obtained after the documented weight loss, and both indicated the supplement order had not been re-entered after the resident’s hospital readmission. The RD and DON stated their expectations that the resident receive the recommended supplement and that a re-weight be obtained within 24 hours of significant weight loss. The facility’s resident weight policy referenced routine weights to monitor nutritional health, and requested nutritional health policies were not provided to surveyors before survey exit.

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 bed rails in use were necessary for one resident reviewed for accidents. The resident was admitted with diagnoses including anoxic brain damage and persistent vegetative state and was documented on the admission MDS as totally dependent on staff for all ADLs, including bed mobility and transfers, with no bed rails indicated. Review of the physician’s orders and the comprehensive care plan showed no orders or care plan addressing the use of bed rails, and the record contained no documentation of informed consent for bed rail use. The facility’s bed rail policy required that bed rails be used only to treat a medical condition and enhance functional abilities, and that risks and benefits be evaluated and reviewed with the resident or representative, with informed consent obtained prior to installation. Despite the absence of orders, care plan, or consent, multiple observations over several days showed the resident lying in bed in a vegetative state, unable to move, with grab bars (short bed rails) raised on both sides of the bed during each observation. During an observation with an LPN, the LPN confirmed that the grab bars were raised on both sides, that the resident was unresponsive and unable to move at all, and that the resident was completely dependent on staff for all ADLs, noting the grab bars were usually in the raised position. In an interview, the DON confirmed the resident was unresponsive, unable to use the grab bars in any way, and stated the grab bars should not have been installed on the resident’s bed. These findings demonstrated that the facility did not follow its own policy requirements to assess necessity, evaluate risks and benefits, review them with the resident/representative, and obtain informed consent before installing and using bed rails for this 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

Surveyors identified a deficiency in medication administration when the facility failed to maintain a medication error rate below five percent, with two errors occurring out of 25 observed opportunities, resulting in an eight percent error rate. During a medication pass, an LPN administered Basaglar (long-acting insulin) and Insulin Lispro (short-acting insulin) via insulin pens to a resident without priming either pen prior to injection. The resident had Type 2 Diabetes, was cognitively intact with a BIMS score of 15, and had physician orders for Basaglar 10 units SC each morning and Insulin Lispro 14 units SC three times daily before meals, which were being administered as ordered per the MAR. During observation, the LPN did not prime the insulin pens before administering the doses. In a subsequent interview, the LPN stated she was not aware that insulin pens needed to be primed and reported she had never primed the resident’s pen prior to insulin administration. The DON stated that facility expectations were that insulin pens be primed with two units of insulin before each injection to ensure an appropriate dose, consistent with the facility’s “Using Insulin Pen Delivery Systems” document, which instructs staff to prime the pen before each injection to remove air bubbles and ensure the needle is open and working.

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

Surveyors identified a deficiency in the facility’s implementation of pneumococcal vaccination practices for one resident. The resident, over 65 years of age at the time of admission on 08/09/23, had documentation in the electronic medical record (EMR) under the Preventive Health section showing receipt of PPSV23 on 08/18/23. However, there was no evidence in the clinical record that the resident or the resident’s representative participated in shared clinical decision-making regarding the option to receive an additional pneumococcal vaccine dose with PCV15, PCV20, or PCV21 after the PPSV23 vaccination. During an interview on 12/12/25, the Infection Preventionist confirmed that she missed offering this resident the PCV15, PCV20, or PCV21 vaccination. Review of the facility’s Resident Vaccination Policy dated 03/04/25 showed that it required staff to ask residents or responsible parties about prior vaccinations at admission and to document prior pneumococcal and other vaccines in the immunization portal of the EMR. However, the policy did not include the CDC recommendations for pneumococcal vaccinations, which state that, based on shared clinical decision-making, adults 65 years or older who have received PCV13 and PPSV23 at or after a specified age may opt to receive PCV20 or PCV21 or decline additional pneumococcal vaccines. The absence of documentation of shared decision-making and the missed offer of PCV15, PCV20, or PCV21 for this resident constituted the identified 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 deficiency involves the facility’s failure to assess, obtain orders for, and accurately document the use of bed rails for a resident, as well as failure to inspect bed rails at installation and routinely thereafter as required by facility policy. The resident, admitted with diagnoses including anoxic brain damage and persistent vegetative state, was totally dependent on staff for all ADLs, including bed mobility and transfers, and was unable to communicate or move her body. On multiple observations over several days, grab bars/bed rails were found raised on both sides of the resident’s bed while she lay in a vegetative state and unable to move. During a joint observation with an LPN, it was confirmed that bed rails were in the raised position on both sides of the bed. Review of the resident’s admission MDS showed that a BIMS was not completed due to poor cognition and inability to communicate, and the assessment indicated the resident did not have bed rails in place. The physician’s orders contained no orders for bed rail use, and facility documentation showed no assessment had been conducted prior to installation of the bed rails. The Maintenance Director stated that while beds were routinely inspected for overall safety, rails applied to residents’ beds were not inspected at the time of installation or routinely thereafter. The Regional Director of Operations confirmed that bed and rail safety assessments were expected when rails were initiated and then routinely thereafter. The facility’s Bed Rail Policy required evaluation of risks prior to installation using a Bed Rail Safety Checklist, ensuring appropriate bed dimensions, correct installation per manufacturer’s recommendations, correct use, and scheduled maintenance, but these steps were not documented or carried out for this resident’s bed rails.

Penalty

Fine: $18,524

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 safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents with cognitive impairment and high risk for elopement and injury. One resident, with a history of dementia, seizure disorder, and behavioral symptoms including aggression and elopement attempts, was placed on 1:1 supervision for safety. Despite this, there were documented gaps in 1:1 supervision, including periods where no staff were present to monitor the resident. During one such period, the resident exhibited altered mental status, was found with bloody drainage from the ear, and was later diagnosed at the hospital with a right temporal hemorrhagic contusion, temporal bone fracture, and epidural hematoma. Staff interviews and documentation confirmed lapses in supervision and incomplete handoff between shifts, contributing to the resident's harm. Another resident with moderate to severe cognitive impairment and a history of wandering was care planned to wear a wander guard device. The resident repeatedly removed the device, and there were multiple documented instances where the device was not in place. The facility failed to reassess the resident's elopement risk after significant changes in condition and after the resident was assigned a legal guardian due to incapacity. The resident ultimately eloped from the facility through an alarmed front door, remaining unsupervised outside for approximately 50 minutes before being located and returned by police. Staff interviews revealed that the door alarm system did not function as intended, and the wander guard device did not reliably trigger the alarm or lock the door as required. Facility policies required continuous supervision for residents on 1:1 monitoring and regular checks of wander guard devices, but these were not consistently followed. Documentation and staff statements indicated that assigned staff were not always present, handoffs were incomplete, and monitoring tools were not properly utilized. The combination of inadequate supervision, failure to reassess risk, and malfunctioning safety equipment directly contributed to the residents' exposure to harm and, in one case, actual injury.

Penalty

Fine: $18,524

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

Summary

The facility failed to conduct a thorough investigation into injuries of unknown origin sustained by a cognitively impaired resident. After a witnessed fall, which was documented as resulting in no injury, the resident was later found with blood and tissue in his ear, slurred speech, and increased weakness, leading to a hospital transfer. Hospital evaluation revealed multiple injuries, including a right temporal hemorrhagic contusion, right temporal bone fracture, small epidural hematoma, and right hip bruise. The facility's five-day follow-up report to the State Agency did not include all of these injuries, only mentioning the hemorrhagic contusion. The investigation documentation provided by the facility was limited to an event report and statements from the LPN and assigned CNA, as well as phone interviews with eight staff. There was no evidence that the investigation included interviews with other staff who may have cared for or observed the resident during the relevant period, nor was there a review of timecards to confirm 1:1 observation coverage. Additionally, there was no review or identification of missing CNA documentation, such as the Point of Care Report and 1:1 Observation/Monitoring Tool, from the time of the fall through the resident's hospital transfer.

Penalty

Fine: $18,524

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 allow a resident, who was hospitalized, to return to the facility and did not provide a required 30-day discharge notice to the resident's family representative. The resident, who had vascular dementia with psychotic disturbances and a history of behavioral symptoms including aggression and elopement attempts, was transferred to the hospital for evaluation due to increased confusion, unsteady gait, and other medical concerns. The facility sent a bed hold notice and transfer paperwork to the resident's brother but did not include discharge paperwork in the mailing. After the resident was medically cleared for return and met the facility's stated requirements (restraint-free for 24 hours), the hospital case manager repeatedly contacted the facility regarding bed availability. The facility declined the resident's return, citing lack of available beds, specifically a private room near the nurse's station, despite documentation that there were two empty male beds and a private room under bed hold. The facility also communicated to the hospital and the Ombudsman that they could not meet the resident's care needs and considered the resident a danger to others, but did not initiate the formal 30-day discharge process as required. Throughout the process, the facility's staff confirmed that the resident was a Medicaid recipient and that the facility's policy allowed for a seven-day bed hold. Despite the expiration of the bed hold, the facility did not provide the required 30-day discharge notice to the resident's representative and continued to decline the resident's return, leaving the resident hospitalized. The surveyor confirmed these findings during interviews and record review.

Penalty

Fine: $18,524

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 registered nurses (RNs) completed and documented required admission and post-fall assessments for two residents, as mandated by the Delaware State Board of Nursing Scope of Practice. For one resident admitted with dementia, all admission observations and assessments—including those related to language, hearing, speech, vision, and multiple body systems—were completed and documented by LPNs, with no evidence of RN involvement in the admission assessment process. The Director of Nursing confirmed that the documentation in question was part of the admission assessment, and the facility was unable to provide any RN-completed admission assessment for this resident. In a separate incident, another resident experienced a fall, and the post-fall assessment and documentation were completed solely by an LPN. The nurse's note and event report detailed the fall, observations, and follow-up, but there was no documentation of RN assessment or involvement. Interviews with staff confirmed that LPNs performed these assessments, which is outside their scope of practice according to state regulations.

Penalty

Fine: $18,524

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 and safeguard resident-identifiable information and medical records in accordance with accepted professional standards for one resident. During the resident's admission, although a DNR order was entered and signed in the electronic medical record (EMR), there was no evidence that the resident's completed DMOST (Delaware Medical Orders for Scope of Treatment) form or financial power of attorney (POA) documentation was present in the EMR. Staff interviews confirmed that the advanced directive and POA documents were not obtained from the hospital or assisted living facility at admission, and the business office manager stated that a copy of the POA was never received, despite being informed that the financial POA was handling billing and applying for guardianship. The resident had a history of dementia and moderate cognitive impairment at the time of admission.

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 adhere to professional standards for food service safety, as observed during a survey of the kitchen. In the dry storage area, several items were improperly stored: a box containing a plastic bag of powdered thickener had a large hole and was surrounded by debris and food wrappers, with no date indicating when it was opened. Additionally, a package of prepared tart crusts was left open and unsealed, exposing the crust directly. A large bag of panko breadcrumbs was folded but not sealed, and a can of applesauce was found with a large dent near the top seal. In the walk-in refrigerator, packages of croissants, sliced provolone cheese, and sliced ham were left open and unsealed. In the food preparation area, two squirt bottles containing yellow liquid were not labeled or dated, and two boxes of corn starch were opened and unsealed. During a follow-up observation with the Dietary Manager, it was confirmed that the issues identified in the initial observation persisted. The Dietary Manager acknowledged the open and unsealed bag of thickener, the open tart crust package, and the unsealed bag of panko breadcrumbs. The dented can of applesauce was also noted, with the Dietary Manager stating that dented cans should be stored on the top shelf for return to the supplier, not in the middle of the rack for use. The Dietary Manager confirmed that all foods should be sealed and labeled with dates indicating when they were opened, highlighting a failure to comply with 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

The facility failed to ensure that all pureed foods listed on the menu were served to the seven residents who required pureed diets. The menu for the lunch meal on the specified date included pureed roast beef, pureed creamed spinach, pureed egg noodles, pureed bread, and pureed spice cake. However, during the meal service, it was observed that pureed noodles and pureed bread were not present on the tray line, and the residents on pureed diets were only served pureed roast beef, pureed creamed spinach, and pureed cake. Interviews conducted during the investigation revealed that the Dietary Manager confirmed the absence of pureed noodles and bread on the tray line and acknowledged that these items should have been prepared and served according to the menu. The cook responsible for preparing the pureed foods admitted to not preparing the pureed noodles or bread for the lunch meal, serving only the meat, spinach, and cake. The Dietary Manager noted that the cook was new to the position and typically did not work the breakfast and lunch shift, indicating a need for additional training.

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 properly assess a resident for self-administration of medication, which led to a deficiency in medication safety. The resident, who was admitted with chronic obstructive pulmonary disease, cognitive communication deficit, and dementia, had a BIMS score indicating severe cognitive impairment. Despite this, the resident was found with a medicine cup containing several pills on her bedside table, which she did not recognize or understand the purpose of. The resident expressed that she would take the medication when she wanted, indicating a lack of understanding and oversight in medication administration. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) confirmed that the resident was not supposed to have medications at her bedside due to her cognitive impairment and the facility's policy against self-administration for safety reasons. The ADON removed the medication and informed the resident that the nurse would return to administer it properly. The Director of Nursing (DON) and the Administrator acknowledged that the resident should not have been allowed to self-administer medication, citing her low BIMS score and the facility's process for assessing and approving self-administration, which was not followed 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 ensure that a resident had access to a call light, which is essential for requesting assistance from staff. During an observation and interview, it was noted that the call light was placed on the opposite side of the bed, out of the resident's reach. The resident, who was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of nine out of 15, confirmed that she could not reach the call light to call for help. The resident had been admitted with diagnoses including atrioventricular block, muscle weakness, and osteoarthritis. The Director of Nursing (DON) acknowledged that the call light should have been within the resident's reach and subsequently attached it to the resident's lapel.

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 residents from physical abuse by other residents, which was identified through observations, interviews, and record reviews. In the first incident, a resident with severe cognitive impairment was found with his hands around the neck of another resident, who was also severely cognitively impaired and a hospice patient. The altercation was witnessed by a CNA who intervened and separated the residents. The aggressor admitted to the act, stating he 'just snapped.' The victim was assessed for injuries, and none were found. In the second incident, a resident with moderate cognitive impairment was reported to have physically assaulted another resident with severe cognitive impairment. The assaulted resident was found on the floor, and it was reported that the aggressor had hit and pushed her, resulting in her fall. The incident was reported to the nurse supervisor and the DON, and the police were called at the request of the assaulted resident's family. Both incidents highlight the facility's failure to protect residents from abuse, as required by their policy. The facility's policy clearly states that abuse, neglect, and exploitation of residents will not be tolerated, yet these incidents occurred, indicating a lapse in adherence to the policy and procedures designed to prevent such occurrences.

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 report allegations of abuse to the appropriate authorities for two residents, which could potentially affect resident safety. For the first resident, who was severely cognitively impaired with a BIMS score of 0, the facility did not report bruising on the resident's thighs to the state agency or police. The Director of Nursing (DON) determined the bruising was caused by the resident's pants bunching up and did not consider it necessary to report or investigate further. The DON and Administrator were responsible for reporting such incidents, and the facility's policy required immediate reporting of abuse allegations, including injuries of unknown origin. For the second resident, who was also severely cognitively impaired with a BIMS score of 3, staff observed the resident being hit by his wife with a hanger. The facility's follow-up involved educating the wife not to hit or yell at the resident, but the incident was not reported to the authorities. The Administrator stated she was informed that reporting was not necessary. The facility's policy required all allegations of abuse to be reported immediately to ensure resident safety, but this was not adhered to in these cases.

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 conduct a thorough investigation into an allegation of physical abuse involving a resident, identified as R216, who was observed being hit by his wife with a hanger. The facility's policy mandates that all allegations of abuse must be immediately reported to the Administrator/Abuse Coordinator, who is then responsible for initiating an investigation and notifying the relevant local and state agencies. However, in this case, the facility did not provide documentation of an investigation into the reported abuse incident. R216 was a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of three out of 15. The resident had multiple diagnoses, including metabolic encephalopathy, dementia, and other health conditions. Despite the report of abuse, the facility's follow-up only involved speaking to and educating the wife, without further investigation or reporting to authorities. The resident was subsequently discharged to a hospital, but the concern form related to the incident was signed by the Administrator without a date, and no investigation documentation was provided.

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 update the care plan for a resident, identified as R89, to include the use of palm guards for managing hand contractures. R89, who was admitted with diagnoses including traumatic subdural hemorrhage and bilateral hand contractures, was observed multiple times without palm guards in place, despite their presence on the nightstand. The facility's policy requires that splint schedules be communicated to the multidisciplinary team and documented in the care plan, but this was not done for R89. The care plan only included passive range of motion exercises and therapy consults, with no mention of palm protectors. Interviews with facility staff revealed a lack of communication regarding the use of palm guards for R89. A Certified Nurse Aide indicated that palm protectors should be used at all times, but the Clinical Reimbursement Coordinator stated she had not received any communication from therapy staff about the need for palm guards for R89. Consequently, there was no physician order, care plan entry, or profile update regarding the use of palm guards, leading to inconsistent application and potential risk for 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 ensure proper nephrostomy tube care for a resident, leading to a potential risk of urine backflow, blockage, and infection. The resident, who was admitted with multiple diagnoses including dysphagia, gastric ulcer disease, immobility, incontinence, colostomy, and sepsis, had an order to monitor output from a nephrostomy tube. During an observation, the resident's nephrostomy bag was found in the bed near her arm and uncovered, with the urine appearing yellow and clear. The Assistant Director of Nursing (ADON) noted that the urine bag should be hanging at the level of the bed, but it was not properly positioned. The ADON attempted to hang the bag correctly but realized a clip was needed, which was not initially available. After retrieving a clip, the ADON hung the nephrostomy bag from the bed rail below the resident's waist, as expected by the Director of Nursing (DON). The DON confirmed that nephrostomy bags should be placed below the resident's waist to ensure proper drainage. This oversight in nephrostomy tube care was identified during observations and interviews, highlighting a deficiency in the facility's care practices for residents with nephrostomy tubes.

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) and hand hygiene during wound care for a resident identified as R92. The resident was admitted with diagnoses including a stage four pressure ulcer on the right hip, unspecified protein-calorie malnutrition, and schizoaffective disorder. The resident was on Enhanced Barrier Precautions (EBP) due to requiring a feeding tube related to dysphagia. During an observation, a registered nurse (RN2) performed wound care without washing or sanitizing her hands before donning gloves, and she did not change gloves or sanitize hands after touching various surfaces and items, including an ink pen, light switch, bed linens, and the resident's adult brief. RN2 entered the resident's room with EBP and wound care supplies, placing them on the resident's dresser and rolling bedside table. She donned a gown and gloves without hand hygiene, labeled and dated a bottle of normal saline solution (NSS), and prepared gauze pads without changing gloves or sanitizing hands. During the wound care procedure, RN2 touched multiple surfaces and items without changing gloves or performing hand hygiene, including turning on the overbed light, removing bed linens, and handling the resident's adult brief. She proceeded to cleanse the wound and apply a new dressing without proper hand hygiene or glove changes. Interviews with RN2, the Infection Preventionist (IP), the Director of Nursing (DON), and the Administrator revealed that staff were trained in EBP and infection control practices, and there was an expectation for staff to follow these protocols to ensure resident and staff safety. RN2 acknowledged the failure to perform hand hygiene and change gloves as required by the facility's infection control policy. The DON and Administrator reiterated the importance of adhering to infection control policies to prevent the spread of infection.

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 each resident's clinical record was complete, accurately documented, and readily accessible. For eight residents, the clinical records lacked documented evidence of physician progress notes despite notes indicating that the patients were seen and examined. Specific instances include missing progress notes for residents on various dates, such as 8/21/23, 12/8/23, 11/3/23, 4/18/23, 7/24/23, 10/19/23, 12/2/23, and 6/5/23. Additionally, there were discrepancies in physician orders and progress notes regarding INR checks for one resident, and incomplete evaluations for continence and retraining schedules for another resident. These findings were confirmed during interviews with the physician, nurse practitioner, and nursing home administrator. One resident's clinical record revealed an incident where the resident was found on the floor and later transferred to the hospital due to low blood sugar. The change in condition evaluation inaccurately stated that the resident was not on anticoagulant medication, despite being on rivaroxaban and clopidogrel. This discrepancy was also confirmed during an interview with the nursing home administrator and director of nursing. The facility's failure to maintain accurate and complete clinical records for these residents highlights significant deficiencies in documentation and record-keeping practices.

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 offer the opportunity to formulate an advance directive for six residents (R25, R29, R31, R43, R56, and R119). Each resident's clinical record lacked documented evidence that they were offered to formulate an advance directive upon admission or during their stay. Interviews with the Regional (E6) and Social Worker (E7) confirmed that the facility was not offering residents the opportunity to formulate an advance directive. This was corroborated by the residents' BIMS scores, which indicated that they were cognitively intact and capable of making such decisions. Specifically, R25, R29, R31, R43, R56, and R119 were all admitted to the facility at various times, and their admission MDS assessments documented BIMS scores ranging from 11 to 15, indicating varying levels of cognitive function. Despite this, there was no documented evidence in their clinical records that they were offered to formulate an advance directive. Additionally, R56 explicitly stated during an interview that she was not offered to formulate an advance directive, and E7 confirmed that she did not coordinate with the Ombudsman's office regarding this matter. The findings were reviewed with the Nursing Home Administrator (E1) and the Director of Nursing (E2).

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 residents were seen for the required physician visits. For Resident 29, the clinical record showed that after an initial comprehensive visit by the physician, the resident was not seen again until approximately 104 days later, missing the required 90-day visit. Similarly, Resident 43 was not seen by a physician for approximately 324 days, despite multiple hospitalizations and evaluations by a nurse practitioner. The clinical record lacked evidence of a comprehensive visit upon readmission to the facility after hospitalization for COPD exacerbation and urinary tract infection. Resident 43 was also not seen by a physician every 120 days as required. Resident 99's clinical record revealed that after being seen by a nurse practitioner for follow-up on mood and Parkinson's, the resident was not seen again for approximately 170 days, missing two 60-day visits. During an interview, the physician and nurse practitioner acknowledged the missed visits and stated that they are catching up on their visits and plan to keep a log to ensure that required visits are completed in the future. The findings were reviewed with the Nursing Home Administrator and Director of Nursing.

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 proof of annual performance reviews for five certified nurse's aides (CNAs). Specifically, the facility lacked evidence of yearly performance evaluations for CNAs hired on 6/27/22, 8/1/22, 7/12/22, 8/1/18, and 8/3/22. This deficiency was confirmed during interviews with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). The findings were reviewed and confirmed by the NHA and DON on two separate occasions.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the start dates were documented when over-the-counter medications were opened in four out of four medication carts reviewed during medication administration. During observations, multiple opened bottles of over-the-counter medications were found in the medication drawers without the dates they were opened. An LPN stated that they were unaware of the requirement to put start dates on the medications. A pharmacist reviewed the medication carts and reported the issue to the administration, but the problem persisted. The findings were reviewed with the Nursing Home Administrator and the Director of Nursing.

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 a resident's discharge needs regarding wound care were identified and communicated. The resident was admitted for a five-day respite stay and developed a skin tear under the right third toe. A physician ordered specific wound care, but at the time of discharge, no nursing education was provided to the resident's daughter, and the wound was not shown to her. Subsequently, the resident's daughter took the resident to the hospital due to swelling and pain in the wound, where antibiotic medication was prescribed. The lack of documentation and communication regarding the wound care at discharge led to this 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 provide adequate pain management for two residents, R525 and R274. For R525, who was admitted with multiple diagnoses including osteoarthritis and severe kidney disease, the facility did not document consistent post-pain assessments using a numerical scale after administering Tylenol. Despite experiencing high pain levels, there was no evidence that the facility contacted the medical provider for further guidance on managing R525's pain. The pain levels recorded for R525 were 6 out of 10, 9 out of 10, and 8 out of 10, but the post-pain scale was either not documented or noted as effective without a numerical value, indicating a lack of proper pain reassessment and follow-up. For R274, who was admitted with cervical disc degeneration, a wedge compression fracture of the thoracic vertebra, and chronic low back pain, the facility's baseline care plan did not identify an acceptable pain level or pain scale. The resident's pain was frequently assessed using a numerical scale for pre-pain but was inconsistently documented as effective, ineffective, or unchanged for post-pain assessments. Over several months, numerous doses of PRN pain medications were administered without consistent post-pain numerical documentation, indicating a failure to monitor pain with a consistent scale. Interviews with staff confirmed the inconsistency in pain assessment documentation.

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 routine pharmaceutical services for a resident (R274) who was admitted with diagnoses of cervical disc degeneration, wedge compression fracture of thoracic vertebra, and chronic low back pain. An updated physician order was written for hydromorphone 2 mg to be given every eight hours as needed for severe pain. Despite the pharmacy delivering the medication on multiple occasions, the controlled substance log revealed that the resident received doses resulting in a zero quantity count, indicating a lack of medication availability. The resident was without the prescribed hydromorphone from one evening until the following evening, as confirmed by both the LPN and the Director of Nursing (DON). The pharmacy also confirmed that the backup hydromorphone was expired and was replaced later. Interviews with the pharmacist, LPN, and DON confirmed the medication delivery dates and the unavailability of hydromorphone for the resident during the specified period. The facility's failure to ensure the timely ordering and receiving of the medication resulted in the resident being without the necessary pain management medication for an extended period. This deficiency was reviewed with the Nursing Home Administrator (NHA) and the DON.

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 promote the dignity of a resident (R2) by not keeping R2's urinary collection bag in a privacy bag. R2 was admitted to the facility on 7/1/15 and had a care plan indicating the need for a urinary catheter due to retention with incomplete bladder emptying and obstructive uropathy. On 12/28/23, physician orders specified that the Foley bag should be covered every shift. However, on 1/17/24, R2 was observed lying in bed at 8:30 AM, 10:30 AM, and 12:30 PM with the urinary collection bag visible from the hallway and not in a privacy bag. These findings were confirmed with the Unit Manager (E52) and later reviewed with the Nursing Home Administrator (E1) and the Director of Nursing (E2).

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 a resident, identified as R106, was free from the use of physical restraints, specifically side rails, which were not required for medical treatment. R106 was admitted to the facility with diagnoses including muscle weakness and seizure disorder. Both the admission side rail assessment and the quarterly nursing side rail assessment documented that R106 had no medical needs for bed rails and did not benefit from their use. Despite this, observations on multiple occasions in January 2024 revealed that R106 was lying in bed with two long bed rails in the raised position. There were no physician's orders for the use of these side rails documented in R106's records. Interviews with staff, including the Unit Manager (UM) and the Nursing Home Administrator (NHA), confirmed that R106 did not use the side rails for bed mobility or transfers and was completely dependent on staff for all care. The presence of the bed rails was acknowledged by the staff, yet no medical justification or physician's orders were provided for their use. The findings were reviewed with the NHA and the Director of Nursing (DON).

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 accurately document a resident's use of side rails on the MDS assessments. The resident, admitted with diagnoses including muscle weakness and seizure disorder, had side rails requested by his sister and documented in his care plan. However, the MDS assessments for multiple dates inaccurately recorded that the resident did not have bed rails. Interviews with staff revealed that the resident had side rails for the duration of the staff's employment, but the LPN responsible for the MDS assessments was unaware of their presence. The findings were reviewed with the Nursing Home Administrator and Director of Nursing.

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 referral for a new PASARR screening after changes to a resident's mental health diagnoses. The resident had a Level II PASARR completed on 10/8/20. However, on 10/2/22, a progress note documented new mental health diagnoses, including adjustment disorder with depressed mood, major depressive disorder severe with recurrent symptoms, and delusional disorders. Despite these changes, the resident did not have an updated PASARR evaluation. This was confirmed during interviews with the social worker and the nursing home administrator, as well as through email correspondence with the PASARR State Authority. The findings were reviewed with the nursing home administrator and the director of nursing on 1/29/24.

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 accurately develop and implement a comprehensive person-centered care plan for a resident's use of bed rails. The resident, admitted with diagnoses including muscle weakness and seizure disorder, had bed rails installed at the request of their sister. Despite this, the care plan lacked documentation for the use of bed rails. Observations over several days showed the resident consistently using bed rails, but interviews with staff revealed a lack of awareness and documentation regarding the bed rails. The Unit Manager acknowledged the long-term presence of the bed rails, while the LPN responsible for care planning was unaware of their existence. The findings were reviewed with the Nursing Home Administrator and Director of Nursing.

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 a resident (R31) was appropriately assessed on admission to promote continence of bladder and bowel. Upon admission, R31's bowel and bladder assessment lacked documentation of bowel continence, and the bladder assessment indicated no altered bladder elimination. However, the Kardex noted the need for incontinence care as needed. Despite being cognitively intact with a BIMS score of 13, R31's care plan later documented frequent incontinence of bowel and bladder without any trial of a toileting program. Interviews with CNAs revealed a lack of awareness about any toileting programs, and the Director of Nursing (DON) confirmed the absence of a policy for bowel and bladder assessment for new residents or those with changes in continence status. The DON stated that nurses use bowel and bladder records for the first three days post-admission to form a care plan, but this was not effectively implemented for R31. Further review of R31's bowel and bladder records over a 27-day period showed significant episodes of incontinence, with 14 episodes of bowel continence versus 42 episodes of incontinence, and 23 episodes of bladder continence versus 58 episodes of incontinence. Interviews with the MDS LPN indicated that assessments and care plans are based on these flowsheets, but the findings suggest that R31's continence needs were not adequately addressed. The deficiency was reviewed with the Nursing Home Administrator (NHA) and the DON, highlighting the facility's failure to provide appropriate continence care and assessment for R31.

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 accurately assess a resident's medical condition for the necessary use of two bed rails and did not ensure the bed rail padding was provided as documented in the resident's medical records. The resident, admitted with diagnoses including muscle weakness and seizure disorder, had multiple assessments indicating no medical need for bed rails. Despite this, the resident was observed on several occasions lying on a concave mattress with two long bed rails in the raised position, without the required bed rail padding. The facility's policy stated that bed rails should only be used to treat a medical condition and enhance the resident's functional abilities, which was not adhered to in this case. Additionally, the resident's physician's orders and Kardex lacked documentation for the use of bed rails, bed rail padding, and the concave mattress. Interviews with the Unit Manager and Nursing Home Administrator confirmed that the resident did not use the bed rails for bed mobility or transfers and was completely dependent on staff for all care. Both staff members also confirmed the absence of the required bed rail padding. The findings were reviewed with the Nursing Home Administrator and Director of Nursing.

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 PRN orders for psychotropic medications were limited to 14 days for two residents. One resident, admitted with diagnoses including muscle weakness, dementia, and major mood disorder, had a PRN order for lorazepam gel that remained active for 27 days. Another resident, admitted with anxiety disorder and depression, had a PRN order for alprazolam that remained active for 23 days. The Director of Nursing confirmed that both residents' clinical records lacked the required 14-day stop date for the PRN antianxiety medications.

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 right to self-determination for a resident (R474) who was cognitively intact and had expressed a strong preference for choosing the type of bathing. Despite being scheduled to receive two showers a week, the resident's clinical records showed that they received only three showers in June 2022, one shower in July 2022, and two showers in August 2022. During an interview, the Director of Nursing (DON) confirmed that the resident did not receive the scheduled showers. This deficiency was confirmed during a review of findings with the Nursing Home Administrator (NHA) and the DON.

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 adequate supervision during a transfer for a resident (R476) who was documented to require the assistance of two staff members. The resident's care plan, last reviewed on 3/17/22, indicated the need for two-person assistance during transfers. Despite this, a physical therapy discharge summary on 4/4/22 noted that staff reported consistent one-person transfers, but there was no documented change in the resident's clinical record to reflect this. Subsequent assessments on 8/29/22 and 11/21/22 confirmed that the resident was cognitively impaired and required the assistance of two staff members for transfers due to impairment on one side. On 11/28/22, the resident complained of pain and swelling in the right knee after being transferred by a CNA (E20) alone, contrary to the care plan instructions. The CNA confirmed during an interview that he transferred the resident alone, believing the resident to be a one-person assist. The Director of Nursing (E2) confirmed that the resident's orders and care plan required two-person assistance for transfers. The physical therapist (E12) also stated that residents should be transferred according to the Kardex and care plan. The incident was reported to the State Agency, and the aides involved were suspended pending an investigation to rule out abuse. The findings were reviewed with the Nursing Home Administrator (E1) and the Director of Nursing (E2).

Penalty

No penalty information released

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

Summary

The facility failed to implement interventions related to the risk of weight loss for one resident (R475) out of four reviewed for nutrition. The resident, who had multiple diagnoses including dementia and dysphagia, was admitted to the facility with a weight of 118 pounds and a poor appetite. Despite a care plan and physician's orders to monitor weight weekly and provide nutritional supplements, the facility did not obtain a weekly weight on 3/2/23 and did not document the percentage of supplement consumed in February 2023. The resident's weight dropped from 118 pounds on 2/16/23 to 101 pounds on 3/6/23, indicating a significant weight loss that was not adequately monitored or addressed by the facility staff. During an interview, the Registered Dietitian (RD) confirmed that the supplement intakes for the resident should have been recorded and acknowledged that one weekly weight was missed. The findings were reviewed with the Nursing Home Administrator (NHA) and the Director of Nursing (DON), who were made aware of the deficiencies in monitoring the resident's nutritional status and weight as per the facility's policy and physician's orders.