Avante At Boca Raton, Inc.

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 necessary care and services for two residents. For one resident, an error occurred during the admission process when the Admissions Director entered the dosage of an IV antibiotic incorrectly into the pharmacy system, using milligrams instead of grams. This mistake prevented the pharmacy system from flagging the medication as expensive, delaying the identification of the need for special compounding and shipment. As a result, the resident missed five doses of the antibiotic between admission and transfer back to the hospital, where treatment was continued. For another resident, documentation and monitoring were inadequate during an episode of epistaxis (nosebleed). The resident, who was on antiplatelet medications (Ticagrelor and Aspirin), experienced a nosebleed late in the evening. The nurse instructed the resident on first aid and notified the DON and physician, but did not document ongoing observations throughout the night. Certified Nursing Assistants reported significant bleeding, requiring multiple changes of towels, clothing, and cleaning of the resident's environment. The resident became lethargic and was later transferred to the hospital with low blood pressure. The lack of thorough monitoring and documentation contributed to the deficiency in care.

Penalty

No penalty information released

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

Summary

The facility failed to store, serve, and prepare food in a sanitary manner in accordance with professional food safety standards. During the initial kitchen tour, surveyors observed residue on oven handles, dust and debris on pipes over cooking equipment and a food preparation table, raw chicken stored on a shelf directly above raw ground beef in the walk-in cooler, peeling paint with dust and rust in the vents of the air handler over the area storing coffee and single-service condiments, condensation in the opening between the processing area and the room where the air handler was located, and food debris on the exterior of the mechanical ware washing machine doors. Additional observations in the kitchen showed utensils in the three-compartment sink with handles that appeared melted and no longer easily cleanable, along with a cracked wall and a window frame coming apart over the sanitizer basin. On the follow-up kitchen tour, a Dietary Aide was observed handling cleaned and sanitized utensils with a bare thumb in direct contact with food-contact surfaces, drying the utensils with a paper napkin before wrapping them for lunch, and wearing a watch while handling the wares. Another Dietary Aide was observed handling dirty wares on the dirty side of the mechanical ware washing machine and then handling cleaned and sanitized wares with the same gloved hands after the machine backed up. Portions of the shelf used to support trays while staff plated meals were held together with duct tape.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment in 18 resident rooms, the 200-unit nursing station, the entrance in front of the kitchen, and the smoking patio. Survey observations identified multiple environmental and maintenance concerns, including overwhelming urine odors in several rooms, emergency pull cords in bathrooms wrapped around grab bars or hanging too low, missing wall tile behind a toilet, and an air conditioning unit that was not blowing cold air. In one room, a resident was observed in a wheelchair in the bathroom doorway with the emergency pull cord wrapped around the grab bar. Additional observations showed poor upkeep of resident furnishings and equipment. Surveyors observed loose AC console covers with visible dust in vents, a bed that did not go up and down with a cut cord on the floor beneath it, a broken half bedrail hanging off the bed, and recliner chairs with tattered and torn surfaces. Other rooms had worn wheelchair arm covers with exposed foam, residue on wheelchair brakes and overbed tables, torn chair seats, overflowing waste baskets, and reddish-brown marks on privacy curtains and furniture. One resident stated the AC needed to be cleaned because it was dusty, and facility leadership later confirmed the dust and loose AC cover observations during side-by-side observations. The environmental concerns also extended to common areas. The wall in the corridor between the 200 and 300 units, near where food trolleys are stored at the kitchen entrance, was damaged in a manner consistent with repeated impact from the trolleys. There was dust accumulation on the air vent over the 200-unit nursing station, and the outside smoking patio had cigarette butts scattered on the patio and in the landscaping along with trash. The Director of Maintenance stated staff could report maintenance issues through the TELS system, log books at the nursing stations, or a manager group chat, and that maintenance checked the log books minimally every morning.

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 follow the approved menu and approved recipe for lunch served on 09/02/25. The approved menu documented that residents were to receive Ginger-Barbecue chicken, and the approved recipe specified boneless and skinless chicken thighs. During lunch observation in the dining room on the 200 unit and in resident rooms, residents were served one bone-in chicken leg instead. When the Surveyor asked the Dietary Manager how much protein residents were to receive, the Dietary Manager stated they should receive three ounces. The Dietary Manager then placed a piece of the bone-in chicken leg on the kitchen scale, and it weighed 2 ounces, half of which was non-edible bone and cartilage. The Dietary Manager acknowledged that the chicken leg was not enough protein per the menu and stated the facility had been using boneless and skinless chicken thighs until residents requested the bone-in chicken leg, but the recipe and menu were not updated to reflect that request. The facility also failed to follow the posted lunch menu on 09/04/25. The menu posted outside the second-floor dining room documented a choice of roll, but during the kitchen tour staff were observed plating two pieces of sliced bread with the meal instead of rolls. When asked, the Dietary Manager stated the rolls did not come in on the most recent food delivery received on 09/01/25. The Dietary Manager acknowledged that the menu was not changed so residents could be notified of the change in the menu.

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 reasonably accommodate a resident’s needs and preferences when an incontinent resident was sent to an outside medical appointment without extra incontinence supplies. Resident #80 had severe cognitive impairment, was dependent on staff for all ADLs except eating, used a manual wheelchair for ambulation, and was always incontinent of urine and bowel without a device. The record documented that the resident left the facility for a scheduled appointment accompanied by a CNA and transportation attendee, and staff noted the resident was appropriately dressed and without signs of incontinence at departure. However, the resident’s son later reported that when he met the resident at the appointment, the resident was wet, had a strong urine odor, and had to be cleaned and changed using makeshift supplies because no briefs had been brought. Staff later acknowledged that the resident should have gone with an extra brief and that none were taken with her. The facility also failed to follow up after specialist appointments for a resident with a left femur fracture and ongoing pain. Resident #72 was admitted with diagnoses including a nondisplaced fracture of the left greater trochanter, pain in the left hip, spinal stenosis, difficulty walking, and other conditions. The resident’s care plans addressed pain and the need for assistance with self-care and mobility, and the resident had a BIMS score of 13. The record showed follow-up appointments were scheduled with orthopedic and neurosurgery specialists, and the resident reported persistent severe pain and stated that he had been taken to both appointments but was not seen because the facility had not obtained the required HMO referral. Interviews and record review showed the facility scheduled transportation and documented that the resident was picked up and taken to the appointments, but staff did not verify whether the specialist offices had received the needed referral or whether the resident was actually seen. The medical records/credentialing coordinator stated she did not confirm referral requirements when scheduling, and nursing staff stated they were not aware that the resident had not been seen and did not follow up with the offices afterward. One orthopedic office later reported the appointment had been cancelled, and the weekend nursing supervisor documented that the resident returned from the orthopedic appointment stating he was not seen because he did not have the correct referral and that his pain was not managed.

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 honor residents’ right to organize and participate in resident and family groups by not resolving grievances voiced through the Resident Council and Food Committee in a timely manner. The facility policy stated that it would quickly act on concerns or grievances and make prompt efforts to resolve them, including concerns about the behavior of other residents. Despite repeated council discussions, the same concerns remained active over multiple meetings and were still being voiced by residents at the time of survey review. Resident Council minutes showed recurring complaints about staff cell phone and earbud use in front of residents during care and at the desk, foreign language being heard in halls and during care, slow call bell response, rude or short CNA behavior, staff on the 3-11 shift and weekends taking breaks at the same time, and differences in care when management was not present. The council also repeatedly raised concerns about food carts arriving late, trays being cold, CNAs not passing trays to rooms outside their assignment, and medications sometimes running out because they were not ordered far enough in advance. These concerns were documented in April, June, July, and August and were still listed as continuing or unresolved. During interviews, active council members confirmed the concerns had not been resolved. Residents with intact cognition or limited impairment described cold, flavorless food, missing condiments, small portions, and the need to sign up for food deliveries. One resident stated that staff cell phone use and foreign language use remained unresolved, and another described a prolonged incident where someone banged on a door for an hour and a half because no one was available to redirect the person. The Activities Director acknowledged that weekend food was often not hot and that supervision was less on weekends. The Administrator and DON stated they were not aware of the food concerns, and the DON said the issues had been brought up about a month earlier.

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 make prompt efforts to resolve residents’ grievances related to missing property for 2 of 2 sampled residents. The facility’s grievance policy stated that it was intended to support each resident’s right to voice concerns and grievances, including lost clothing, and that the facility would quickly act on concerns or grievances and arrive at an appropriate resolution. However, review of the grievance records from December 2024 through August 2025 did not document grievances for either resident’s missing items. One resident, admitted with seizures and COPD and assessed with a BIMS score of 15, reported that after returning from a hospital transfer, his room had been emptied and his belongings were gone. He also stated that brand new labeled clothing sent to laundry was lost, and that a new cell phone had water poured on it while on his table; he said he filed complaints, left messages for the Social Worker, and received no response or reimbursement. Another resident, admitted and readmitted with diagnoses including primary generalized osteoarthritis and anxiety disorder and a BIMS score of 15, reported that her pearls valued at $3,000 were stolen from her purse and that she never heard back after reporting it to the previous administrator. Interviews with the Administrator and Social Worker Assistant confirmed the absence of written grievances for these concerns, and the Administrator stated the facility had not checked prior messages and later completed a federal report related to the missing 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 follow physician orders for scheduled specialist appointments in a timely manner for two residents. The facility policy stated residents must receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, and that the facility should assist the resident in making appointments. For one resident with seizure disorder and COPD, the record showed an active order for a Neurology consult for seizure disorder and an order for levetiracetam for seizures. The resident, who had a BIMS score of 15, told surveyors he had continued seizures, had been transferred to a hospital after a seizure at the facility, had sustained injuries, and had not been seen by a neurologist despite requesting the consult. Facility staff stated the resident had requested to be seen by a neurologist and that an order was written, but the resident had not been seen as of the survey date. The MRCC documented on the order that she could not make the appointment because no provider was taking Medicaid, and staff stated there were insurance issues and difficulty finding a provider. For the second resident, the record showed a fall with major injury resulting in a left ankle and tibia/fibula fracture. The resident was sent to the hospital the same day and later seen by a Foot and Ankle Surgeon, who recommended surgery and requested medical clearance. Surveyors found no written documentation explaining why the surgery was not scheduled or completed as recommended. Facility staff, including the DON, ADON, and NP, stated they were not aware the surgery had not been done or that the resident needed surgery until the survey process, and the resident stated she did not want surgery because she feared losing her bed. Later, the resident stated she would want the surgery done and reported ongoing pain and limited ability to straighten the leg.

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 professional standards were followed for a resident with an indwelling urinary Foley catheter during catheter care and peri-care. The resident was admitted with diagnoses including obstructive and reflux uropathy, retention of urine, benign prostatic hyperplasia, and Parkinson's disease, and had a BIMS score of 13. His care plan identified the need for catheter care and Enhanced Barrier Precautions (EBP) related to the urinary catheter, including wearing gown and gloves during high-contact resident care activities. Observation of Foley catheter and peri-care showed that the resident had no signage or indication at or near the room door that he was on EBP, and there was no PPE container or caddy at or near the door. During the procedure, the CNA wore clean gloves only and did not don a protective gown before or during care. The resident's Foley catheter and tubing were also observed not properly secured and anchored in place. The physician's order documented catheter care every shift and as needed, with catheter changes and irrigation parameters as needed. Interviews after the observation confirmed the breakdown in care. The CNA stated she did not know the resident was on EBP because there was no sign on the door and said she does not wear a gown when performing Foley catheter and peri-care unless a sign is posted. The nurse and another staff member acknowledged the resident should have had an EBP order, staff should have worn a gown during catheter care, and the Foley catheter should have been anchored with a strap. The DON also stated that an EBP order should have been obtained, signage placed on the door, PPE worn during care, and the catheter properly secured.

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 follow the physician’s ordered tube feeding regimen for one sampled resident with a gastrostomy/J-tube. The resident had diagnoses including other seizures, encounter for attention to gastrostomy, and aphasia, and the MDS documented that a BIMS could not be completed because the resident was rarely or never understood. The physician’s order dated 07/17/25 directed Isosource 1.5 or Jevity 1.5 at 80 mL for 20 hours via J-tube, from 2:00 PM off to 10:00 AM, for a total of 1600 mL per 24 hours. The care plan addressed tube feeding related to dysphagia and included providing tube feeding and water flushes according to current MD orders. On 09/02/25, observations showed the resident receiving Isosource 1.5 via pump at 75 mL/hr at 9:55 AM and again at 5:00 PM. During the later observation, the tube feeding bag was labeled with 09/02/25 and listed a rate of 85 mL/hr, with no time documented. In interview on 09/03/25, the RN stated she had cared for the resident the previous day and acknowledged the tube feeding was running at the wrong rate in the morning and late afternoon. She stated she stopped the tube feeding at 10:00 AM and restarted it at 2:00 PM per the physician’s orders, but also stated she did not really look at the rate and only verified it when a new bag was hung because she trusted the nurses before her to do the right thing.

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 attempt appropriate alternatives and obtain informed consent before installing bedside rails, and it failed to provide regular inspection and maintenance to identify areas of possible entrapment for Resident #90. The resident was admitted with diagnoses including Budd-Chiari Syndrome, obesity, and weakness, and the MDS documented a BIMS score of 15, indicating intact cognition. The physician’s order dated 12/03/22 included bilateral enablers/side rails for use as a mobility aid for positioning, and the Side Rail Evaluation dated 12/03/22 documented that the rails were requested by the resident and recommended for anytime use. Record review showed no additional Side Rail Evaluations for the resident. The Side Rail Informed Consent and Release form did not include the resident’s name, only a date of birth, and it was signed by a nurse assessor but not by the resident or a family representative. The care plan review also showed no care plan specifically for side rails/enablers, although there were care plans that included side rails/enablers as an intervention. The facility policy required assessment for entrapment risk, review of risks and benefits with the resident or representative, informed consent prior to installation, and correct installation and maintenance of bedrails. During observations on 09/02/25 and 09/03/25, Resident #90’s bed had loose side rails on each side, with the right rail very loose and at an approximate 30-degree angle. The resident stated the side rails had been on the bed since admission and that he used them to get in and out of bed. Staff interviews indicated the RN believed consent could be obtained from the family or patient if able, that maintenance inspected the rails, and that reassessment was ongoing. The Director of Maintenance stated the rails were attached when beds were delivered unless the resident refused, that inspections were done monthly without a log, and that loose rails were tightened immediately; during the tour, he acknowledged the loose rails on Resident #90’s bed.

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 currently dated posting for the Nurse Staffing Information. During an entrance tour on 09/02/25 at 8:30 AM, surveyors observed the staffing information posted at the front desk was not dated correctly and displayed Saturday 08/30/25, which was two calendar days earlier than the start of the survey. The facility policy stated that nurse staffing information must be posted daily, include the current date, and be placed in a prominent location readily accessible to residents, staff, and visitors. During an interview on 09/03/25 at 12:30 PM, the Staffing Coordinator/Scheduler stated she posts the daily Nurse Staffing Information every weekday at 8:30 AM and prepares the weekend document for the Weekend Day Supervisor/Manager on Duty or receptionist to post on Saturday or Sunday. She stated the receptionist forgot to change the posting over the holiday weekend and acknowledged that the form dated 08/30/25 was incorrect and that the current form should have been posted. On 09/04/25 at 10:00 AM, the Administrator and DON acknowledged that the Nurse Staffing Information Form must be posted daily with the current date.

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 attending physician documented in residents’ medical records that consultant pharmacist-identified irregularities had been reviewed and, when no medication change was made, the physician’s rationale was recorded. The deficiency was identified during interview and record review and involved 2 of 5 sampled residents reviewed for unnecessary medications, Resident #14 and Resident #142. The facility policy titled Medication Regimen Review stated that the consultant pharmacist would provide MRRs to designated facility personnel and that the attending physician/prescriber should address the pharmacist’s recommendations no later than the next scheduled visit. For Resident #14, the record showed diagnoses including COPD, polyneuropathy, major depressive disorder, generalized anxiety disorder, primary insomnia, drug-induced subacute dyskinesia, and fibromyalgia, with an MDS documenting a BIMS score of 15. Physician orders included amiodarone 200 mg daily, zolpidem 10 mg daily, and phenazopyridine, which had been discontinued. The consultant pharmacist recommended monitoring for amiodarone and recommended discontinuing phenazopyridine after prolonged use, but the report stated there was no response from the physician or ARNP for either recommendation. For Resident #142, the record showed diagnoses including left lower extremity fracture, head injury, COPD, pleural effusion, mood disorders, GAD, major depressive disorder, implantable cardiac defibrillator, DVT of the left upper extremity, insomnia, CHF, hypoglycemia, and hypothyroidism. Active orders included amiodarone 200 mg daily, Eliquis 5 mg every 12 hours, and zolpidem 10 mg at bedtime. The consultant pharmacist recommended a GDR for Ambien and monitoring related to amiodarone and Eliquis; one June recommendation was documented as accepted by the physician, but staff later confirmed that the GDR for Ambien and the accepted monitoring recommendations had not been completed, and no supporting documentation was available for the pharmacist recommendations carried out.

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 only authorized staff had access to medication cart keys. During observation, an RN handed the first-floor medication cart keys to a CNA so the CNA could open the smoking room, and the CNA walked away from the RN with the keys before returning them. In a separate observation, the DON accepted medication cart keys from an LPN and stated that only nurses can have the medication cart keys. The RN later stated she had given the keys to the CNA because she was busy, but another nurse told her not to give the key to a CNA. The facility also failed to ensure that medications were properly supervised during administration for one resident. During a medication pass for a resident with constipation and Parkinson's disease, an LPN poured lactulose, carbidopa-levodopa, and entacapone into a cup, placed the tray on the resident's bedside table, and walked away to the bathroom to wash hands. The medications were left unattended and out of the nurse's sight while the resident was sitting in a wheelchair in the room. The LPN later stated he should not have left the medications out of his sight and should have washed his hands first. In the medication storage rooms on both floors, surveyors found expired and improperly stored items in treatment carts, including opened and undated wound care supplies, bottles with missing or expired dates, and items that staff said should not have been in the carts. The first-floor medication storage room also lacked soap or hand sanitizer for hand hygiene, had an accumulation of ice in the refrigerator freezer, and contained an unidentified plastic bag with dirty boots. In the second-floor medication storage room, surveyors found a labeled plastic bag containing a resident's personal belongings, including a cell phone, charger, and wallet, as well as an unlocked treatment cart with expired Xeroform dressing. Staff confirmed that residents' personal belongings should not be in the medication storage room and that the treatment cart should have been locked.

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 food in the correct form, as ordered, for Resident #56. The resident was admitted to the facility with diagnoses including cancer, hypertension, hyperlipidemia, thyroid disorder, malnutrition, and chronic lung disease, and the most recent assessment showed a BIMS score of 13, indicating the resident was cognitively intact. The physician diet order dated 08/27/25 specified a regular diet with mechanical soft texture, but during lunch observation in the dining room on the 200 unit, the resident was served a piece of bone-in chicken with skin on it and was seen attempting to eat it with a fork. The resident ate very little of the chicken, approximately one quarter of the serving. The SLP later stated that the bone-in chicken leg with skin was not appropriate because the resident had left-sided weakness and left-sided droop and could not masticate food properly, which was why mechanical soft was needed.

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 an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Surveyors observed that three residents who had orders and care plans for Enhanced Barrier Precautions (EBP) did not have EBP implemented as documented. Resident #20 had diagnoses including seizures, gastrostomy care, and aphasia, and had an order for EBP every shift related to a feeding tube. Although the care plan directed staff to wear gowns and gloves during high-contact activities, surveyors observed the resident receiving tube feeding on multiple occasions with no EBP sign on or near the room and no gowns available in or near the room. The Assistant DON/Infection Preventionist acknowledged the resident should have had EBP in place long before the observation period. Resident #77 had diagnoses including osteomyelitis of the lower leg and obstructive/reflux uropathy, with a suprapubic catheter and chronic wound. The resident had an order for EBP related to the chronic wound and suprapubic catheter, and the care plan directed staff to wear gown and gloves during high-contact care. During observation, the resident was in bed with the urinary drainage bag at the side of the bed, but there was no EBP sign outside or inside the room and no gowns in the room or nearby. Resident #14 had diagnoses including UTI, Parkinson’s disease, and obstructive/reflux uropathy, with orders for Foley catheter care and EBP every shift. During observation, an RN entered the room, applied gloves, and touched the catheter tubing and drainage bag without putting on a gown. There was no EBP sign on the door or inside the room and no gowns available nearby. Staff interviews showed inconsistent understanding of EBP requirements, including where PPE should be located and when gowns were needed. The facility also failed to disinfect reusable equipment between residents during medication administration observations. For one resident, an LPN entered the room, performed handwashing and donned gloves, used a blood pressure machine with cuff and a pulse oximeter, then returned the equipment to the medication cart without disinfecting it. The same LPN then used the same reusable equipment for another resident without disinfecting it between uses. The LPN later stated he cleans reusable equipment after every resident and confirmed he did not clean or disinfect the equipment between those two residents during the observation. In addition, the facility failed to perform hand hygiene during medication administration observation for two residents. During care for one resident, an LPN assisted the resident after a difficult transfer, exited the room without performing handwashing, discarded medication, and then went to the nurse’s station to use the computer and telephone without hand hygiene before preparing medications for another resident. The LPN stated handwashing was important and said she used hand sanitizer, but she was not observed performing hand hygiene during the sequence of care and medication preparation.

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 thoroughly investigate an allegation of neglect related to wound care for a resident with multiple medical conditions, including a wedge compression fracture, diabetes, bacteremia, and a history of falls. The resident had an indwelling catheter and an unstageable pressure ulcer, and was discharged to the hospital after experiencing profuse bleeding. The facility's investigation into the neglect allegation included a review of the resident's diagnosis, a skin check evaluation, a previous hospitalization, and interviews with other residents regarding neglect. However, the investigation did not include interviews with staff directly involved in the resident's care, nor did it review records related to the resident's wounds or the care provided for those wounds. Additionally, the investigation lacked documentation explaining the circumstances surrounding the resident's wounds and did not identify procedures to prevent similar occurrences in the future. When questioned, the Administrator stated that a thorough investigation had been conducted, but was unable to provide information regarding the resident's wounds or the connection to the neglect allegation. The only staff interview conducted was with a nurse supervisor present during the resident's transfer to the hospital, and there was no evidence of a comprehensive review of wound care practices or staff actions related to the incident.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report highlights lapses in following established protocols for pressure ulcer prevention and care, contributing to the occurrence and worsening of pressure ulcers among 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 enter and implement physician orders for indwelling catheter care for a resident who was admitted with an indwelling Foley catheter. The resident, who had diagnoses including a lumbar vertebra fracture, type 2 diabetes mellitus, bacteremia, and overactive bladder, was admitted with a Foley catheter in place. Although there were orders for changing the catheter as needed and for irrigation in case of blockage, there was no order entered for routine catheter care every shift and as needed. Review of the Certified Nursing Assistant (CNA) documentation also showed no evidence that catheter care was performed during the resident's stay. Interviews with nursing staff revealed that the admitting nurse and others involved in entering orders did not ensure that the required catheter care order was entered into the system. The Director of Nursing and Administrator confirmed that the resident did not have orders for routine Foley catheter care and was not receiving the appropriate care for the indwelling catheter as required by facility policy. The deficiency was identified through record review and staff interviews, which confirmed the lack of both orders and documentation of catheter care 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 that a physician-ordered gynecological consult and related procedure were scheduled and performed for a resident with significant medical needs. The resident, who was admitted with multiple diagnoses including limited mobility and cognitive impairment, had a history of fungal rashes in the perineal area that were previously treated and resolved. Despite a physician's order for a gynecological consult and a specific procedure, there was no evidence in the medical record that the order was carried out, and nursing staff were unaware of the order. Interviews with nursing staff confirmed they had not seen or received the order, nor had they observed any ongoing issues in the affected area during their care of the resident. The resident's family member reported not being informed by the facility about the fungal issues or the need for the gynecological procedure, only learning about it during an external gynecologist visit. The family member stated that he had been waiting for almost a month for the facility to schedule the procedure and had not received any updates despite repeated inquiries. The facility administrator acknowledged the delay and lack of communication, citing the procedure's special nature as a reason for the scheduling delay, but provided no timeline or further information to the family.

Plan Of Correction

F684 Quality of Care A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On was scheduled for at 4pm for Resident #1. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit of physician order to ensure any outsource diagnostic testing has been ordered. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of nursing/designee to complete education with the nurses to ensure any outsource diagnostic testing has been submitted to the coordinator. b. On education provided to the coordinator to ensure are scheduled timely for outsource diagnostics and transportation if needed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of nursing/designee will complete audit of residents who have outsource diagnostic testing scheduled in a timely manner and transportation if needed, compliance with federal regulation F684 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined. F 684

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 physician-ordered procedure was scheduled and performed for one resident. The resident, who had significant cognitive impairment and required substantial to maximal assistance with hygiene and toileting, had a history of fungal rashes that were treated and resolved. A physician order for a gynecological consult and a specific procedure was documented, but there was no evidence that the procedure was scheduled or completed. Interviews with nursing staff revealed they were unaware of the order, and there was no documentation indicating the procedure had been arranged. The resident's family member reported not being informed about the resident's condition or the scheduling of the ordered procedure, despite repeated inquiries to the facility's administrator. The administrator acknowledged the delay, attributing it to the special nature of the procedure and the need for additional coordination, but was unable to provide a scheduled date. This lack of follow-through resulted in the resident not receiving timely, physician-ordered care as required by regulation.

Plan Of Correction

N201 Right To Adequate and Appropriate Health Care A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On [date] was scheduled for [procedure] for Resident #1 at 4pm. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On [date], the Director of Nursing/designee completed an audit of physician orders to ensure any outsource diagnostic testing has been ordered. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of Nursing/designee to complete education with the nurses to ensure any outsource diagnostic testing has been submitted to the coordinator. b. On education provided to the coordinator to ensure [specific actions] are scheduled timely for outsource diagnostics and transportation if needed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of Nursing/designee will complete an audit of residents who have outsource diagnostic testing scheduled in a timely manner and transportation if needed, compliance with federal regulation N201 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.

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 clean and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. The shower room on the second floor had brown-colored matter on the floor, rust-colored stains on the wall above the grab bar, and black stains on the shower walls. Additionally, the paint on the floor was peeling in several areas. The first-floor shower room had gaps between the floor and walls, and both the floors and walls had black markings. The floor tiles on the south wing of the second floor were cracked in several places. Furthermore, a bed rail was observed with peeling paint and rust-colored staining, privacy curtains had black stains, and a blanket was found with holes. Photographic evidence was obtained to support these findings.

Plan Of Correction

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. **Physical Environment** A) What corrective action will be accomplished for those residents found to have been affected by this practice? a. On __, the second floor shower room was cleaned of brown colored matter. On the wall above the grab bar, as well as, the grab bar was removed of rust colored stains. On __, the black stains on the shower room walls were removed. On __, epoxy flooring project started by Custom Group, Inc., with an estimated completion date of __, to address the peeling paint on the floor of the shower stall. b. On __, epoxy flooring project started by Custom Group Inc., with an estimated completion date of __, to address the floor gaps and black markings in the first floor shower room stalls. On __, the black stains on the shower room walls were removed. c. On __, VCT material for floor tile repairs throughout the building were ordered. Commencement of work to be completed within 30 days of __ by Holiday Carpet Service. d. On __, the bed rails in __ were replaced. e. On __, privacy curtains in __ were replaced. f. On __, the blanket in __ was immediately replaced. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On __, audit completed of the second floor shower room to ensure that it was clean, rust-free, and free of black stains on the walls. b. On __, audit completed of the first floor shower room to ensure that it was clean, rust-free, and free of black stains on the walls. c. On __, audit completed of floor tiles to identify cracks in floor tiles in need of repair. d. On __, audit completed of bed rails to ensure none had peeling paint with rust colored stains. e. On __, audit completed of privacy curtains to ensure curtains are free from stains. f. On __, audit completed of resident blankets to ensure blankets are in good condition. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By __, the ED/designee educated the environmental services supervisor and maintenance director on ensuring that the facility shower room stalls, floors, and walls are maintained in good, clean condition. b. By __, the ED/designee educated the maintenance director on ensuring that cracks in floor tiles are repaired within a timely manner. c. By __, the ED/designee educated staff on identifying and timely reporting environmental concerns in TELS. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. ED/designee to randomly audit shower rooms to ensure that they are clean and in good repair. b. ED/designee to randomly audit 6 resident rooms to ensure resident bed rails are rust-free, bedding is free of holes, and privacy curtains are in good, clean condition. c. ED/designee to randomly audit floor tiles to ensure tiles are in good condition. d. Audits will be conducted weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.

Penalty

No penalty information released

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

Summary

The facility failed to provide a clean, homelike environment for its residents, as evidenced by several deficiencies observed during the survey. On the second floor, the shower room had brown-colored matter on the floor of the shower stall, rust-colored stains on the grab bars, and black stains on the walls. Additionally, the paint on the floor was peeling in several locations. The first-floor shower room also exhibited gaps between the floor and walls, along with black markings on both the floors and walls. Furthermore, the floor tiles on the south wing of the second floor were found to have noticeable cracks. Additional deficiencies included a bed rail with peeling paint and rust-colored staining, privacy curtains with black stains, and a blanket with holes. These observations indicate a failure to maintain a sanitary, orderly, and comfortable interior, as required by the regulations. The facility did not ensure that the environment was safe, clean, and homelike, which is a fundamental right of the residents.

Plan Of Correction

Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. **Physical Environment** A) What corrective action will be accomplished for those residents found to have been affected by this practice? a. On __, the second floor shower room was cleaned of brown colored matter. On __, the wall above the grab bar, as well as, the grab bar was removed of rust colored stains. On __, the black stains on the shower room walls were removed. On __, epoxy flooring project started by Custom Group, Inc., with an estimated completion date of __, to address the peeling paint on the floor of the shower stall. b. On __, epoxy flooring project started by Custom Group Inc., with an estimated completion date of __, to address the floor gaps and black markings in the first floor shower room stalls. On __, the black stains on the shower room walls were removed. c. On __, VCT material for floor tile repairs throughout the building were ordered. Commencement of work to be completed within 30 days of __ by Holiday Carpet Service. d. On __, the bed rails in __ were replaced. e. On __, privacy curtains in __ were replaced. f. On __, the blanket in __ was immediately replaced. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On __, audit completed of the second floor shower room to ensure that it was clean, rust-free, and of black stains on the walls. b. On __, audit completed of the first floor shower room to ensure that it was clean, rust-free, and of black stains on the walls. c. On __, audit completed of floor tiles to identify cracks in floor tiles in need of repair. d. On __, audit completed of bed rails to ensure none had peeling paint with rust colored stains. e. On __, audit completed of privacy curtains to ensure curtains are free from stains. f. On __, audit completed of resident blankets to ensure blankets are in good condition. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By __, the ED/designee educated the environmental services supervisor and maintenance director on ensuring that the facility shower room stalls, floors, and walls are maintained in good, clean condition. b. By __, the ED/designee educated the maintenance director on ensuring that cracks in floor tiles are repaired within a timely manner. c. By __, the ED/designee educated staff on identifying, and timely reporting environmental concerns in TELS. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. ED/designee to randomly audit shower rooms to ensure that they are clean and in good repair. b. ED/designee to randomly audit 6 resident rooms to ensure resident bed rails are rust-free, bedding is of holes and privacy curtains are in good, clean condition. c. ED/designee to randomly audit floor tiles to ensure tiles are in good condition. d. Audits will be conducted weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen/food service sanitation tour, several deficiencies were noted, including a soiled and rust-covered exhaust hood system, heavily soiled ceiling-mounted commercial light fixtures, broken and missing floor tiles, and a walk-in refrigerator with a dust and black mold-covered internal fan cover. Additionally, the walk-in freezer door was rust-laden and ajar, and expired yogurt was found in the walk-in refrigerator. The Trauleson reach-in refrigerator had soiled and rusted internal food storing shelves, and the chemical levels in the 3-compartment sink and cleaning rag buckets did not meet regulatory requirements. The dish machine hood system was also rust-laden and had a build-up of a black mold type substance. The Certified Dietary Manager (CDM) stated that numerous requests had been made to maintenance over the past three months to address these issues, but no action had been taken. During a follow-up kitchen/food service sanitation tour, additional deficiencies were observed, including a full and overflowing trash container in the food preparation/serving area, a heavily soiled oven back splash with a large build-up of black carbon matter, and a coffee cart located in the chemical room. A wall-mounted fire sprinkler was rusted and draining on the dish room wall, and soiled cleaning rags were left unattended on clean preparation and serving surfaces. The floor of the pantry room had large areas of peeling paint. These observations were made in the presence of the Corporate Food Service Director, and photographic evidence was obtained during both tours.

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 an adequate food supply necessary to meet the nutritional needs of 111 out of 120 residents. During an initial kitchen/food service tour, it was observed that there was a significant shortage of various food supplies, including frozen foods, dairy products, canned foods, fresh fruits and vegetables, juices, and daily pantry items. The Certified Dietary Manager (CDM) mentioned that she was under monthly food budget restrictions and that numerous requests for emergency food orders were not approved by the new Administrator, leading to the shortages. The CDM was later suspended for failing to perform her duties, and the Corporate Food Service Director (CFSD) took over the oversight of the kitchen operations temporarily. Despite an emergency food delivery, numerous items were still not in supply, and residents continued to experience food shortages and lack of menu alternatives, leading to multiple complaints about the quality and availability of food. Additionally, it was noted that two residents were not provided meals or nutritious snacks before their dialysis appointments, leaving them hungry during their treatments. The survey also revealed that the facility failed to provide physician-ordered thickened liquids and dietary supplements for at least one resident, further highlighting the inadequacies in food supply management. Interviews with residents indicated ongoing issues with the approved menu not being followed, running out of foods regularly, lack of meal substitutions, poor food quality, and unavailability of between-meal snacks. These issues were repeatedly voiced to the administration without resolution.

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 housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for multiple resident rooms and common areas. During the survey, it was observed that 12 of 27 resident rooms on the first floor and 11 of 31 rooms on the second floor had various issues such as dust-laden A/C filters, damaged walls, loose or missing fixtures, and mold build-up. Additionally, the second-floor dining room was found to have heavily soiled floors, walls with large scuff marks, and live bugs present. These deficiencies were confirmed during an environment tour with the Corporate Maintenance Director and the Administrator. The Corporate Maintenance Director acknowledged that staff have access to a computerized system to report maintenance and housekeeping issues but stated that staff are not utilizing the system effectively. Specific issues noted included loose bathroom fixtures, damaged ceiling tiles, rusted bed rails, and heavily stained bathroom floors. The dining room also had an oxygen concentrator with a dust-laden filter and a serving table that was heavily soiled and worn. These findings indicate a significant lapse in maintaining a clean and safe environment for the 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 provide two residents, who regularly attend dialysis appointments, with a nourishing, palatable, well-balanced meal or snack. Resident #60, who has been residing in the facility for three years and attends dialysis three times a week, reported not receiving a breakfast meal or snack before leaving for dialysis. Additionally, when a bagged snack was provided, it contained only a package of crackers and a warm, undrinkable House Shake. The resident's clinical records confirmed his dependence on dialysis and the absence of documented interventions for providing meals before or during dialysis appointments. Interviews with the facility's Registered Dietetic Technician and Corporate Food Service Director could not confirm if meals were being provided as required. Similarly, Resident #23, who also attends dialysis three times a week, reported not receiving a nourishing bagged lunch or snack for the past year. Despite multiple requests, the issue remained unresolved. The resident's clinical records indicated no cognitive impairment and independent eating ability, yet there was no confirmation from the facility staff regarding the provision of meals or snacks for dialysis appointments. The facility's failure to ensure these residents received appropriate nutrition during their dialysis appointments constitutes a significant deficiency in care.

Penalty

No penalty information released

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

Summary

The facility failed to follow its approved menu, which potentially affected 111 residents. During a review of the facility's menu for the week of 04/28/24, it was noted that 2% milk and skim milk were supposed to be served to various diets, but only whole milk was available due to a lack of supply for the past two days. Additionally, there was no supply of orange juice for the past seven days. The Certified Dietary Manager (CDM) confirmed these shortages and stated that an emergency order for whole milk was placed, but no such order was made for orange juice. During the lunch meal observation on 04/29/24, it was found that rolls, pureed rolls, and blueberry shortbread were not available, and substitutions were not properly planned or communicated. The Breakfast/Lunch Cook was unaware of certain menu items that needed to be prepared, indicating a lack of communication and planning. For the dinner meal on 04/29/24, it was observed that several items, including potato salad, pureed potato salad, cinnamon applesauce, baked potatoes, and noodles, were either not purchased or not prepared. The Dinner Cook confirmed the unavailability of these items and the lack of planned substitutions. The CDM mentioned that food purchasing was under budget restraints and that she needed emergency permission from the Administrator to place orders. However, the Administrator stated that the CDM had not notified her of the need for emergency food orders in the past seven days. Interviews with 15 residents revealed issues such as failure to follow the approved menu, lack of alternate menu options, and failure to provide between-meal snacks, further highlighting the deficiencies in the facility's food service management.

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 prepare food by methods that conserve nutritive value, flavor, and appearance, potentially affecting 111 residents. During an initial kitchen/food service observation, it was noted that approximately 11 pans of food were covered with aluminum foil and left on the stove top without heat being applied. The breakfast/lunch cook stated that these pans contained lunch foods that were fully cooked and would remain on the stove top or in the steam table for the next three hours until the lunch tray line began. The cook was unaware that prolonged cooking and holding of foods could compromise their nutritive value, taste, flavor, and appearance. The Certified Dietary Manager (CDM) was also interviewed and stated she was unaware that foods were being completely cooked and held hours prior to meal service. She confirmed that foods are required to be prepared as close to meal time as possible and that the early cooking was done for convenience. The deficiency potentially affected 111 residents on various diets, including regular, mechanically altered, and therapeutic diets.

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 food preferences and options of similar nutritive value to potentially 111 residents. During an observation of the lunch meal, it was noted that the approved menu items were being served without any alternate hot entree, hot starch food, or hot vegetable prepared and available. Staff A mentioned that baked chicken, which is supposed to be always available, had not been available for over 7 days. The Certified Dietary Manager (CDM) confirmed that the facility was under budget restraints and had not ordered many foods without emergency permission from the Administrator. The Administrator stated that the CDM had not notified her of the need for an emergency food order in the past 7 days. The facility's Alternate Menu Ticket listed several items that were supposed to be always available, but many were not. For example, baked boneless chicken, tuna salad sandwich, and fresh fruit had not been available for several days. Additionally, residents reported issues such as failure to follow the approved menu, failure to provide an alternate menu, and failure to provide between-meal snacks. Interviews with 15 sampled residents revealed these food issues, indicating a significant deficiency in the facility's food service management.

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 suitable, nourishing snacks to potentially 111 residents who wanted to eat at non-scheduled times or outside of scheduled meal service times. During an initial food service tour, it was noted that the facility had low levels of food supplies, including frozen, canned, dairy, and daily pantry foods. The Resident Snack Menu listed various items that were supposed to be always available, but many of these items, such as puddings, gelatins, cookies, and crackers, were not available for at least the last seven days. Additionally, there was no documentation of the times when scheduled snacks were to be provided to residents with specific nutritional care plans, and the facility could not verify if these snacks were being prepared and served as required. Interviews with the Certified Dietary Manager, Registered Dietetic Technician, and Corporate Food Service Director revealed that they were unaware of the availability and distribution of scheduled snacks. Furthermore, individual interviews with 15 residents indicated issues such as failure to follow the approved menu, failure to provide an alternate menu, failure to provide food substitutions, and failure to provide between-meal snacks. These deficiencies affected residents with specific nutritional needs, including those with diabetes, underweight conditions, and those undergoing dialysis.

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 fingernail grooming for two residents, leading to deficiencies in personal hygiene and care. Resident #26, who has severe cognitive impairment and multiple health issues, was observed with elongated fingernails and black matter underneath them. Despite the resident's statement that he did not refuse care, no staff had offered to clean his nails. Interviews with CNAs and the DON revealed inconsistencies in the responsibility and scheduling for nail care, with some staff unaware of the procedures and others incorrectly stating that a CNA was assigned weekly for this task. The DON admitted to scheduling a CNA for nail care only when multiple residents needed it, and there was no documentation of the resident refusing care or any attempts to address his nail hygiene issues. Resident #43, who has no cognitive impairment but suffers from left-sided hemiplegia and other health conditions, also had elongated and jagged fingernails. The resident reported asking for nail care but stated that only one person usually performed it. Observations confirmed the resident's nails were in poor condition, and he mentioned that his left hand's spasms caused his hand to get into his soiled brief, leading to potential hygiene issues. Interviews with staff revealed a lack of clarity on who was responsible for nail care, with some staff unaware of the procedures and others incorrectly stating that a CNA was scheduled for this task. The DON was not aware of any refusals of care and admitted there was no documentation of the resident refusing nail grooming. The report highlights a systemic issue in the facility's approach to nail care, with inconsistencies in staff responsibilities and a lack of proper documentation and follow-up. Both residents' conditions and the observations made during the survey indicate a failure to provide necessary grooming services, as required by the facility's policies and the residents' care plans.

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 address a significant weight loss in a timely manner for a resident admitted with malnutrition and other medical conditions. The resident experienced a notable weight loss from 182.8 lbs to 162.6 lbs over a short period, which was documented but not adequately addressed. Despite the Diet Tech's assessment and recommendation for a Medpass protein supplement twice a day, the order was not placed, and the resident did not receive the necessary nutritional support. Additionally, the resident's lunch tray was observed without the prescribed Health Shake or frozen nutritional treat, further indicating a lapse in nutritional care. The resident was readmitted to the facility with a urinary tract infection and continued to show signs of malnutrition and weight loss. The Diet Tech acknowledged the significant weight loss and the development of a pressure ulcer on the resident's sacrum. Despite recognizing the need for additional nutritional support, the necessary orders were not implemented promptly, leading to further deterioration in the resident's condition. The failure to provide adequate nutrition and hydration contributed to the resident's declining health and the development of a pressure ulcer.

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 dialysis communication forms were completely and accurately documented for a resident requiring dialysis services. During the review of the clinical record of a resident with End Stage Renal Disease, it was found that 24 out of 25 dialysis communication forms from February 6, 2024, through April 30, 2024, were improperly documented. The forms, which are divided into three sections to be completed by the facility and the dialysis center, were missing required information in various sections. Specifically, Section #1, which includes pre-dialysis information such as medications administered, vital signs, and examination of the shunt site, was incomplete on multiple dates. Section #2, to be completed by the dialysis center, and Section #3, to be completed by the facility upon the resident's return, were also found to be lacking necessary documentation on several occasions. The deficiency was confirmed during a review with the Director of Nursing, who acknowledged that numerous required sections of the forms were not being documented by both facility nursing staff and dialysis center staff. This lack of proper documentation could potentially impact the monitoring and care of the resident before and after dialysis treatments. The resident involved had been admitted to the facility originally in 2017 and re-admitted in December 2023, with a diagnosis of End Stage Renal Disease and current physician's orders for dialysis three times a week. The failure to document critical information on the dialysis communication forms indicates a significant lapse in the facility's protocol for ensuring safe and appropriate dialysis care 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 provide liquids in a Nectar Thick form for a resident with physician-ordered thickened liquids. During the review of the clinical record of a resident with diagnoses including Chronic Kidney Disease Stage 4, Acute Kidney Failure, Type 2 Diabetes, Protein-Calorie Malnutrition, Dysphagia, and Dependence on Dialysis, it was noted that the resident had a physician order for a Renal Diet, Mechanical Soft Meat, and Nectar Consistency liquids. However, during the observation of the breakfast meal, the resident was served non-thickened coffee, cranberry juice, and milk, totaling 660 ml of non-thickened fluids, which exceeded the breakfast fluid restriction of 180 ml. The surveyor discussed the fluid restriction and nectar thickened liquids with the facility's Registered Diet Technician (DTR), who confirmed that the physician-ordered fluid restriction and thickened liquids were not followed for the breakfast meal. The DTR acknowledged that the resident was served an additional 480 ml of fluids over the breakfast allotment and that the tray liquids were not thickened to the physician's orders for Nectar Thick Liquids.

Penalty

No penalty information released

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

Summary

The facility failed to provide a physician-ordered therapeutic diet for a resident with chronic kidney disease and dependence on dialysis. The resident was prescribed a fluid restriction of 1500 ml per day, with specific allocations for dietary and nursing fluids. However, during a breakfast meal observation, the resident was served a total of 660 ml of non-thickened fluids, which exceeded the prescribed breakfast fluid allotment of 180 ml. Additionally, the fluids were not thickened to the physician's order of nectar consistency. The deficiency was confirmed through interviews and record reviews. The facility's Registered Diet Technician acknowledged that the fluid restriction and thickened liquid orders were not followed. The resident's meal tray included 6 ounces of non-thickened coffee, 8 ounces of non-thickened cranberry juice, and 8 ounces of milk, totaling 660 ml of fluids, which was 480 ml over the prescribed breakfast fluid limit. This failure to adhere to the physician's orders for fluid restriction and thickened liquids constitutes a significant deficiency in the resident's care.