Aviata At Saint Lucie

Penalty

No penalty information released

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

Summary

A deficiency was identified when the facility failed to provide and document shower services for a resident with cancer who was admitted with functional limitations in both upper and lower extremities. The resident was assessed as cognitively intact and required substantial to maximal assistance with showering, bathing, dressing, and personal hygiene, and was dependent on staff for footwear. According to the resident's care plan, showers were scheduled three times a week during the day shift. However, a review of Certified Nursing Assistant (CNA) task records over a 30-day period revealed no documented evidence that showers were provided on multiple scheduled dates. During interviews, the resident stated he had never received a shower since admission and did not refuse showers when offered, only receiving bed baths. Staff confirmed that showers or refusals should be documented in the shower books, but a review of these records with both a CNA and the Interim DON found no documentation of showers or refusals for the resident. The lack of documentation and the resident's statements indicated that the facility failed to provide the ordered care and services as required.

Penalty

No penalty information released

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

Summary

A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to ensure that the resident's pain was properly addressed according to their needs.

Penalty

No penalty information released

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

Summary

The facility failed to implement appropriate transmission-based precautions for a resident suspected of having C-Diff, a contagious intestinal infection. Resident #83, who was cognitively intact and dependent on activities of daily living, was admitted to the facility and later developed diarrhea. Despite being care planned for antibiotic therapy and having a change in condition noted, the resident was not placed on contact or special isolation precautions to prevent the spread of the suspected infection. Additionally, the resident's roommate also experienced diarrhea, further highlighting the need for proper infection control measures. During medication administration observations, several lapses in infection control standards were noted. For Resident #193, an LPN placed a box of eye drops directly on the resident's chair without using a tray or barrier, potentially contaminating the medication. Similarly, for Resident #10, an RN placed a plastic bag containing eye drops on the resident's over-the-bed table without a barrier, and then returned the contaminated bag to the medication cart. Furthermore, for Resident #65, an RN administered a transdermal patch without wearing gloves, contrary to the facility's policy, and handled medication pills directly with her hands before placing them in a medication cup. The facility also failed to maintain laundry practices that prevent the spread of infection. Laundry staff were observed handling overflowing bins of soiled linens without appropriate personal protective equipment, such as gloves, and the bins were not properly covered. Additionally, the laundry area was found to have cleanliness issues, including a dried substance inside a dryer, a stained handwashing sink, and debris around the washing machines. These observations indicate a lack of adherence to infection control policies and procedures in the facility's laundry 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 honor a resident's right to self-determination by not providing showers as per the resident's schedule and request. Resident #2, who was cognitively intact with a BIMS score of 15, expressed a preference for receiving showers twice a week. However, the facility's records showed that the resident did not receive showers on the scheduled dates of 02/25/25 and 03/01/25, and the last documented shower was on 03/18/25. The care plan indicated that the resident required maximum assistance with bathing due to an ADL self-care performance deficit related to disease process, impaired balance, and weakness. Interviews revealed discrepancies in the documentation and the actual care provided. Resident #2 reported not receiving showers as often as desired and stated that he had communicated his preferences to the staff without any changes being made. Staff B, a CNA, claimed to have provided a bed bath, which she documented as a shower, but the resident contradicted this by stating he had not received a bed bath. This inconsistency highlights a failure in communication and documentation, leading to the resident's dissatisfaction with the care 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 notify the family of a resident in a timely manner regarding the end of Medicare Part A coverage. The review of the SNF Beneficiary Protection Notification for the resident showed that Medicare Part A skilled services began on 11/25/24 and the last covered day was 12/16/24, as initiated by the facility. The SNF Advanced Beneficiary Notice of Non-Coverage and the Notice of Medicare Non-Coverage were signed by the resident's son on 12/16/24, which was the last day of covered services. During an interview, the Social Service Director acknowledged that the resident or family should have been notified at least two days before the coverage ended and could not find any documentation indicating that the family was notified before 12/16/24.

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 provide personal privacy for three residents due to issues with bedroom doors not closing completely. Observations revealed that the main door to the bedroom of one resident could not close because the bed was protruding into the door space, and the privacy curtain was knotted, preventing privacy during personal care. This resident reported that the door had been in this condition since admission. The Director of Nursing and the Executive Director were informed of the issue, and it was noted that bed bumpers were preventing the bed from being positioned closer to the wall. Similar issues were observed in the rooms of two other residents, where the beds also obstructed the doorways, preventing them from closing. These deficiencies were identified during observations and interviews conducted by surveyors.

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 accurate Minimum Data Set (MDS) assessments for several residents, leading to multiple deficiencies. Resident #5, who was admitted with hemiplegia, exhibited a contracture of the left hand, which was not documented in the MDS assessment. Despite observations confirming the contracture, the MDS coordinator acknowledged the lack of documentation. Resident #107 and Resident #64 were both prescribed opioids, yet their MDS assessments inaccurately reflected no opioid use. The MDS coordinator confirmed these inaccuracies upon review. Resident #139 was transferred to a hospital due to respiratory failure, but the MDS assessment incorrectly documented the resident as deceased in the facility. The MDS coordinator and the Regional MDS nurse provided conflicting explanations, with no documentation supporting the facility death status. Additionally, Resident #32's MDS assessment inaccurately indicated anticoagulant use, despite no evidence of such medication in the resident's records. The MDS coordinator acknowledged the error after reviewing the records.

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 obtain a PASARR Level II in a timely manner for a resident who was admitted with a mental disorder or intellectual disability. The resident was admitted to the facility, and a PASARR Level I screening indicated that a Level II assessment was necessary. Although the Level II was initially submitted, it was closed due to an incomplete signature for the resident. The Regional Social Services Director confirmed that the Level II had not been resubmitted with the missing information, resulting in a deficiency in the facility's compliance with PASARR requirements.

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 baseline care plans were completed within 48 hours of admission for three residents. Resident #32 was admitted to the facility and readmitted from the hospital, but the baseline care plan was not completed until eight days after admission. For Resident #103 and Resident #117, the facility was unable to locate any baseline care plans, indicating that they were not completed as required. Interviews with facility staff revealed confusion and miscommunication regarding the location of the baseline care plans. The Social Service Director and the MDS Coordinator provided conflicting information about where the care plans were stored, with the MDS Coordinator eventually admitting that she misunderstood the question and was unable to locate the care plans for Resident #103 and Resident #117. Despite efforts by the Regional Nurse Consultant to find the missing documents, they were not located, indicating a failure in the facility's process for managing and storing baseline 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 provide necessary assistance with activities of daily living (ADLs) for a resident, specifically in the areas of dental care and mobility. Observations revealed that the resident was consistently left in bed without being offered the opportunity to get up, despite his requests to do so. The resident, who has been in the facility since October 2024, reported that he had only been out of bed twice. Additionally, the resident's teeth were observed to have food caked between them, and he stated that his teeth were not being brushed by the staff, despite his inability to do so himself due to limited hand function caused by diabetes. The resident's care plan indicated that he required substantial assistance for oral hygiene and mobility, yet these needs were not being met. Interviews with staff revealed inconsistencies in the care provided. A CNA admitted to only getting the resident out of bed on specific days and not offering to do so on others. The resident expressed frustration with this arrangement and disagreed with the CNA's claim that she offered to brush his teeth. Furthermore, there was a discrepancy regarding the storage of the resident's wheelchair, with conflicting statements from the CNA and the occupational therapist. The resident's care plan was updated only after the surveyor's intervention, indicating a lack of proactive care management. The resident expressed happiness when finally assisted out of bed and having his teeth brushed, highlighting the deficiency in consistent care provision prior to the surveyor's involvement.

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 encourage and assist two residents, identified as Resident #32 and Resident #243, to participate in activities, as observed and documented by surveyors. Resident #32, who has a history of aortic stenosis, type 2 diabetes, pulmonary disease, heart failure, reflux disease, hydronephrosis, anemia, restless leg syndrome, and kidney disease, was observed multiple times in his bed either playing on his phone or doing nothing. Despite his care plan indicating a preference for activities such as watching television, playing the harmonica, listening to classical music, and attending religious services, the facility did not facilitate his participation in these activities. Interviews revealed that Resident #32 expressed a desire for more engagement, including having a chaplain visit him, but reported that the facility did not assist him in attending activities or provide in-room activities. Resident #243, who has a history of acute myocardial infarction, heart failure, kidney failure, hypotension, anemia, muscle weakness, dysphagia, and atrial flutter, was similarly observed spending most of his time in his room, either eating meals or lying in bed. His care plan highlighted his interest in social activities, music, news, and religious services, yet the facility did not adequately support his participation in these activities. Interviews with Resident #243 indicated that he wanted to attend activities, including church services, but was not assisted in getting out of bed to participate. The Community Life Director and Activities Assistant failed to document or facilitate his involvement in activities, despite his expressed interest. The facility's documentation and communication regarding the residents' activity preferences and participation were inadequate. The Community Life Director admitted to recording activity participation but was unable to retrieve the records, and the Activities Assistant did not actively engage with Resident #243 to encourage his participation in activities. The surveyor's observations and interviews highlighted a lack of proactive measures by the facility to ensure that the residents' activity preferences and needs were met, resulting in a deficiency in providing adequate activity engagement 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 adhere to physician's orders for several residents, leading to medication administration errors. Resident #103, diagnosed with Essential Hypertension, had specific blood pressure parameters for administering Metoprolol and Midodrine. However, the Medication Administration Record (MAR) showed multiple instances where these parameters were not followed, resulting in incorrect administration of the medications. Despite in-service training for nurses, the Director of Nursing acknowledged that the issue persisted. Resident #242, with a diagnosis of Adrenocortical Insufficiency, was prescribed Levothyroxine for Hypothyroid. The resident reported receiving only one pill instead of the prescribed two, and photographic evidence supported this claim. Interviews with staff revealed discrepancies in medication administration, with one nurse admitting to discarding pills without verifying if they were taken. The MAR and blister pack counts confirmed that the resident did not receive the correct dosage on multiple occasions. Resident #66, who was prescribed methocarbamol for muscle spasms, did not receive the medication at the correct intervals. The Medication Administration Audit Report indicated that the medication was administered outside the scheduled 8-hour intervals on several occasions. Additionally, Resident #83, who was supposed to have a stool sample collected for C-Diff testing, did not have the sample collected as ordered. The Director of Nursing confirmed these deficiencies during an interview.

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 timely urology appointment for a resident with a suprapubic urinary catheter. The resident was admitted with an indwelling urinary catheter, and a physician ordered a urology consult on March 4, 2025. However, the record showed no evidence of an upcoming or completed appointment. Observations on March 17 and 18, 2025, revealed very cloudy urine in the resident's catheter drainage tube, indicating a potential issue that required medical attention. Interviews with staff revealed a breakdown in the process for scheduling the urology appointment. Staff M, an RN, explained that the Medical Transportation Coordinator, Staff L, was responsible for making appointments but was unaware of any appointment for the resident. Staff L confirmed she had not made the appointment, citing a lack of information about the reason for the consult. Despite having the order, Staff L did not reach out to obtain the necessary details to proceed with scheduling, resulting in the failure to secure the required medical consultation 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 maintain the nutritional status of a resident receiving dialysis therapy by not ensuring the ordered nutritional supplement was consumed. The resident, who was cognitively intact and dependent on activities of daily living, was at nutritional risk due to End Stage Renal Disease and a history of significant weight change. The care plan included providing supplements as ordered and having a Registered Dietician (RD) evaluate and make dietary recommendations. However, the resident reported not consuming the Nepro supplement at night due to stomach upset and expressed dissatisfaction with the facility's food, noting that no one had inquired about his food preferences. The RD was unaware that the resident was not consuming the ordered supplements and had not followed up on the resident's food preferences. The dietary progress note indicated the resident was at risk for malnutrition and underweight for age, with a need to encourage additional calories. Despite documentation in the Medication Administration Record of the resident consuming varying amounts of Nepro daily, the resident's refusal and the lack of follow-up on dietary preferences contributed to the deficiency in maintaining the resident's nutritional status.

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 safe and appropriate respiratory care for three residents, leading to deficiencies in oxygen therapy management. For one resident with a respiratory disorder, the nebulizer mask was improperly stored on personal items without protective covering, contrary to the facility's protocol of storing it in a bag. Despite the Director of Nursing's awareness and the presence of a respiratory therapist, the nebulizer set was not replaced as required. Another resident used oxygen without a physician's order, which was only entered after surveyors noted the deficiency. The Director of Nursing confirmed that oxygen should be used per physician's orders, which was not adhered to in this case. Additionally, a third resident with COPD and other health issues was observed using oxygen at a higher rate than prescribed. The resident's care plan indicated a continuous oxygen flow of 3 liters per minute, but observations showed the concentrator set at 4.5 liters per minute. A nurse acknowledged the discrepancy but attributed it to the resident adjusting the machine, despite no documentation supporting this claim. These actions and inactions demonstrate a failure to follow physician orders and ensure proper respiratory care, as evidenced by the discrepancies in oxygen therapy management for the residents involved.

Penalty

No penalty information released

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

Summary

The facility failed to ensure proper administration of pain medication for a resident, leading to inadequate pain management. Resident #109, who was admitted with a diagnosis including depression and an arterial stasis ulcer on the left lower leg, was prescribed tramadol for moderate to severe pain. The physician ordered 50 mg tramadol to be administered as two tablets orally every eight hours as needed. However, the resident reported instances where the medication was not provided as prescribed, including receiving only one tablet instead of two, which resulted in inadequate pain relief. On March 17, 2025, Resident #109 expressed concerns about the pain management, reporting a pain level of eight that could escalate to ten when seated in a wheelchair. The resident's left leg was wrapped in kerlix, and the left foot appeared swollen, indicating ongoing pain issues. A review of the medication monitoring control record confirmed that on March 19, 2025, the resident received only one tablet of tramadol instead of the prescribed two. The regional nurse consultant confirmed these findings, highlighting the facility's failure to administer pain medication as ordered.

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 dialysis care and communication for a resident requiring hemodialysis. The resident, who was cognitively intact and dependent on activities of daily living, had a care plan indicating dialysis on Mondays, Wednesdays, and Fridays. However, the facility did not complete the required dialysis communication forms on several occasions, specifically on 03/03/25, 03/07/25, 03/10/25, 03/17/25, and 03/19/25. This lapse was confirmed by a Registered Nurse who stated that the forms were not kept in the designated narcotic book but in a binder at the nursing station. Additionally, the facility did not timely implement the Hemodialysis Dietitian's recommendations. The dietitian had advised discontinuing Tums and holding Cinacalcet based on lab values from 02/05/25. However, Tums was only discontinued 15 days later, and Cinacalcet was never held, as confirmed by the resident's Medication Administration Record. The Registered Dietitian acknowledged these discrepancies during an interview.

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 with PTSD was properly assessed and had an individualized care plan. The resident, who was cognitively intact and independent in activities of daily living, was admitted with a diagnosis of PTSD. The care plan for the resident, dated 03/18/24, addressed behaviors related to PTSD and Obsessive Compulsive Disorder but lacked specific details about the resident's trauma, behaviors, or triggers. During an interview, the resident confirmed the PTSD diagnosis, attributing it to an abusive childhood and adult experiences, and identified crowds as a trigger. The Social Service Director acknowledged that the care plan was generic and not tailored to the resident's personal experiences and triggers.

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 sufficient staffing to manage the timely uploading of physician progress notes for a resident with diarrhea and to obtain a urology consult for another resident. Resident #83, who was cognitively intact and dependent on assistance for daily activities, had no physician progress notes uploaded for the year 2025. The medical records staff acknowledged the delay, citing increased census and high staff turnover as reasons for the backlog. The Director of Nursing recognized the need for additional training to assist with the uploading process, as a large stack of notes awaited processing. Resident #60, who had a suprapubic urinary catheter, did not have a timely urology consult appointment scheduled despite a physician's order. Observations revealed cloudy urine in the catheter's drainage tube, indicating a potential issue. The Medical Transportation Coordinator, responsible for scheduling appointments, had not made the appointment due to not receiving the necessary information and being overwhelmed with multiple responsibilities, including central supply duties. This lack of coordination and communication resulted in the failure to secure the necessary medical consultation 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 documentation of narcotic removal in the medication administration records (MARs) for three residents during a medication storage review. Resident #39 had discrepancies in the documentation of Tramadol removal, with missing entries for specific times on March 11 and March 12, 2025. Similarly, Resident #69's records showed missing documentation for Tramadol removal on March 17, 2025, at two different times. Additionally, Resident #71's records revealed missing documentation for Lorazepam removal on March 17 and March 18, 2025. These discrepancies were identified during a review of the medication binder on cart 1, where the medication control records were compared against the March 2025 MARs. The Director of Nursing (DON) was informed of these issues during an interview conducted on March 20, 2025. The lack of documentation for narcotic removal indicates a failure in maintaining accurate medication administration records, which is essential for ensuring the safe and effective management of residents' 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 adequate monitoring of side effects and behaviors for psychotropic medications for a resident diagnosed with Generalized Anxiety, Major Depressive Disorder, Bipolar Disorder, Schizoaffective Disorder, and Diabetes Mellitus. The resident was prescribed multiple medications, including Venlafaxine, Quetiapine, and Divalproex Sodium, for their mental health conditions. However, upon review, it was found that there was no behavioral monitoring documented for the resident after their return from the hospital on two separate occasions. This lack of documentation was confirmed during interviews with facility staff, including an LPN and the Regional Nurse Consultant. The LPN interviewed was unaware of the behavioral monitoring procedures for the resident and could not find any documentation of such monitoring in the system. The Regional Nurse Consultant acknowledged that the resident should have had behavioral monitoring documented, especially since it was previously in place before the resident's hospitalizations. The oversight occurred because the resident was not put back on behavioral monitoring after returning from the hospital, leading to a deficiency in the facility's care 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 medication error rate at the facility was found to be 14.81 percent, significantly exceeding the acceptable threshold of 5 percent. During a medication pass observation, an LPN administered medications to a resident incorrectly. The resident was supposed to receive two eye drops in each eye, one docusate sodium tablet, and hydralazine only if the systolic blood pressure was greater than 160. However, the LPN administered only one eye drop in each eye, two docusate sodium tablets instead of one, and gave hydralazine despite the resident's systolic blood pressure being 156, which did not meet the criteria for administration. Additionally, the resident was supposed to receive two Senna 8.6 mg tablets, which were not administered because the LPN did not have them on the medication cart and had not retrieved them from central supply. The LPN acknowledged the errors upon review of the medication administration record and the physician's orders, admitting to the oversight in administering the incorrect dosages and failing to provide the necessary medication.

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 proper storage of medications for two residents during a medication pass observation. For one resident, an LPN left a box of artificial tears unattended on top of a medication cart while she went into the resident's room to obtain his blood pressure. During this time, another resident was observed self-propelling down the hallway in front of the unattended medication cart, posing a risk of access to the unsecured medication. The LPN later acknowledged leaving the eye drops unsecured. In another instance, a resident with a diagnosis of Adrenocortical Insufficiency was observed with a pill cup containing medications left on his bedside table. The resident reported that a nurse had left the cup there after waking him up to take his thyroid medication, which was supposed to be taken before a meal. The resident noted that he was supposed to receive two Levothyroxine pills but was only given one, along with a Docusate Sodium capsule. The surveyor confirmed the presence of the medications in the pill cup on the bed tray, and photographic evidence was obtained.

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 complete and current medical records for several residents, as evidenced by missing physician progress notes and unscanned documentation. Resident #83's medical record was incomplete, with the last documented physician progress note dating back to November 2024, despite being admitted on an unspecified date. The medical records person admitted to not uploading any physician progress notes for the current year, acknowledging the incompleteness of Resident #83's records. Similarly, Residents #37, #60, #64, and #79 had missing or outdated physician visit documentation, with some records lacking any recent physician visits. The medical records person found unscanned physician visit notes for these residents, confirming that the records were not current. Additionally, the facility failed to document a dietitian consult for Resident #60, who was receiving nutrition and fluids via a feeding tube. The resident's current Minimum Data Set (MDS) assessment indicated the need for increased water flushes due to elevated blood urea nitrogen (BUN) levels, suggesting a potential need for more fluids. However, the Registered Dietitian (RD) did not document the consult or the decision not to increase fluids further, despite discussing it with a nurse practitioner. This lack of documentation contributed to the incomplete medical records for Resident #60.

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 portable fire extinguishers in accordance with NFPA 101 standards. During a facility tour conducted on March 17, 2025, between 11:30 AM and 2:30 PM, it was observed that several fire extinguishers were improperly installed. Specifically, the fire extinguishers located by room 20, room 8, the main lobby, room 30, the Emerald Nurses Station, room 45, and room 25 were all found in cabinets with the top of the handle positioned above 60 inches from the floor. This placement does not comply with the required standards for accessibility and safety. The observations were made in the presence of the Maintenance Director, who confirmed the findings during the tour. These findings were subsequently reviewed with the administrator and the Maintenance Director during an exit conference held on the same day at 3:00 PM. The report does not mention any corrective actions or plans to address the deficiency, focusing solely on the improper installation of the fire extinguishers.

Plan Of Correction

This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. The fire extinguishers noted in the fire extinguisher (FE) cabinets by room 20, by room 8, in the main lobby, by room 30, by the Emerald Nurses Station, by room 45, and by room 25 will be remounted to the required height. 2. Additional fire extinguisher locations will be reviewed for placement at the required height. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Portable Fire Extinguishers specific to maintaining fire extinguisher placement at the required height and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review. This plan of correction is submitted as required under Federal and State regulations and statutes applicable to long term care providers. This plan of correction does not constitute an admission of liability on the part of the facility, and such liability is hereby specifically denied. The submission of this plan does not constitute agreement by the facility that the surveyors findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope or severity regarding any of these deficiencies cited are correctly applied. 1. The fire extinguishers noted in the fire extinguisher (FE) cabinets by room 20, by room 8, in the main lobby, by room 30, by the Emerald Nurses Station, by room 45, and by room 25 will be remounted to the required height. 2. Additional fire extinguisher locations will be reviewed for placement at the required height. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Portable Fire Extinguishers specific to maintaining fire extinguisher placement at the required height and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.

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 their corridor doors in accordance with NFPA 101 standards. During a facility tour conducted on March 17, 2025, between 11:30 AM and 2:30 PM, it was observed that the patient room corridor door to room 47 would not completely close. This issue was caused by the bottom of the door rubbing against the floor, which prevented the door from closing properly. This deficiency was identified during observations made by the surveyors in the presence of the Maintenance Director. The findings were confirmed through an interview with the Maintenance Director, who was present during the observations. The issue was further discussed and reviewed at an exit conference with the administrator and the Maintenance Director on the same day at 3:00 PM. The deficiency was noted as a failure to comply with the requirements set forth in NFPA 101 (2012 and 2021 editions) and NFPA 80 (2010 and 2019 editions), which specify the standards for corridor doors to resist the passage of smoke and ensure proper closure.

Plan Of Correction

1. The resident room corridor door to room 47 was repaired to properly close. 2. Additional resident room corridor doors will be reviewed for proper closing. 3. The Executive Director/ designee will educate the Maintenance Director on the importance of NFPA 101 Corridor- Doors specific to maintaining resident room corridor doors to properly close and will continue to monitor in accordance with NFPA standards. 4. Any findings will be reported to the monthly QAPI Committee for further review.

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 evidence that staff adhered to professional standards of quality care, specifically in medication administration, for 8 out of 12 residents reviewed. This deficiency was identified through clinical record reviews and interviews, revealing that staff did not follow physician orders for medication administration. The Director of Nursing acknowledged that after the evacuation of residents from another facility due to a storm, the Medication and Treatment Administration Records were initially taken by the departing staff. However, the records were later accessed and printed to ensure continuity of care. For Resident #8, the Medication Administration Record (MAR) showed multiple instances where medications were not signed as administered, despite the availability of the medications. This included several oral and intravenous medications prescribed for conditions such as BPH, depression, ALS, hypotension, and osteomyelitis. Similar issues were found for Resident #9, who had diagnoses including acute respiratory failure and a persistent vegetative state, with numerous missed doses of medications administered via G-tube and intravenously. Other residents, such as Residents #13, #11, #15, #12, #7, and #14, also experienced missed doses of critical medications for various conditions, including neuropathy, heart disease, diabetes, Parkinson's disease, and glaucoma. The MARs for these residents showed that nurses failed to document the administration of prescribed medications, indicating a systemic issue in medication management and documentation within the facility.

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 consistent with the prescribed treatment plan for two residents. For one resident, the staff did not perform or document essential treatments such as tracheostomy care, skin integrity checks, wound dressing changes, and catheter care. This resident had complex medical needs, including a tracheostomy, a stage 4 pressure ulcer, and required total care for daily activities. The Treatment Administration Record showed multiple instances where nurses did not initial the completion of these treatments, indicating they were missed. Another resident, who also remained in the facility after a storm, did not receive proper skin checks, PICC line dressing changes, or arm circumference measurements as prescribed. This resident had diagnoses including Amyotrophic Lateral Sclerosis and a stage 4 pressure ulcer. The PICC line dressing was observed to be outdated, further indicating a lapse in care. The Director of Nursing acknowledged that the Medication and Treatment Administration Records were initially taken by another facility's staff, but she later accessed and printed them to ensure care continuity.

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 staff failed to provide necessary oral hygiene care for a resident who was unable to perform activities of daily living. The resident, who remained in the facility after a storm, had multiple diagnoses including seizures, persistent vegetative state, acute respiratory failure with hypoxia, a Stage 4 pressure ulcer in the sacral region, and essential hypertension. The resident required total care, had a tracheostomy, received tube feeding via a gastrostomy tube, used a wound vac for the sacral wound, and had a Foley catheter. During an observation, the resident was found lying in bed with a copious amount of dry yellowish-brown crusty substance inside her mouth and lips, indicating a lack of necessary mouth care. A registered nurse, who had just taken over the shift, was unaware of the care that had been provided to the resident.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the proper care and maintenance of a PICC line for a resident, as evidenced by the staff's failure to change the PICC line dressing for multiple weeks. The facility's policy requires that a sterile dressing change using transparent dressings be performed at least weekly, or if the integrity of the dressing is compromised. An observation revealed that the resident's PICC line dressing was dated 20 days prior, indicating that the dressing had not been changed as required. Interviews with the Regional Consultant Nurse and the Director of Nursing confirmed that the dressing should be changed weekly, but the Treatment Administration Record (TAR) showed that the weekly PICC dressing change was not completed. Additionally, the staff failed to document the weekly monitoring of the PICC line by not placing their initials in the appropriate box. The resident involved had significant medical conditions, including Amyotrophic Lateral Sclerosis, a Stage 4 pressure ulcer, and Osteomyelitis, and was prescribed intravenous medications for treatment. The Medication Administration Record (MAR) indicated that the resident was prescribed DAPTomycin and Ertapenem Sodium Injection for infections, but the nurses failed to document the administration of these medications for several doses. The MAR also noted that the medication was unavailable on certain dates. This lack of documentation and failure to administer prescribed medications contributed to the deficiency identified by the surveyors.

Penalty

Fine: $55,322

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 a newly admitted resident requiring dialysis treatments from neglect, resulting in serious harm and potentially contributing to the resident's death. The resident, who had multiple medical conditions including end-stage renal disease and was dependent on hemodialysis, did not receive dialysis for seven days after admission. This lapse in care led to the resident being transferred to a hospital emergency department with critically high serum potassium levels, a condition that can lead to severe cardiac issues. The deficiency was primarily due to a breakdown in communication between the facility and the dialysis provider. The facility's admissions personnel failed to ensure that the necessary documentation and communication were completed to arrange for the resident's dialysis. Despite having physician orders for dialysis, the resident was not taken for treatment because the dialysis provider did not receive the required information. Interviews with facility staff revealed a lack of awareness and understanding of the process for managing new admissions requiring dialysis, contributing to the oversight. The facility did not have a specific policy for dialysis services or a process for new admissions requiring such services, which further compounded the issue. Staff interviews indicated that there was confusion and a lack of communication regarding the resident's dialysis needs. The resident's condition deteriorated due to the absence of dialysis, leading to a hospital transfer where the resident was diagnosed with severe hyperkalemia and uremia. The resident passed away shortly after being admitted to the hospital.

Removal Plan

• The facility submitted appropriate reporting through the AHCA portal.
• Staff education was initiated for all nursing personnel, therapy staff, dietary staff, housekeeping/laundry staff, and administrative and department heads.
• A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Executive Director, Medical Director, Director of Clinical Services, Plant Operations, Registered Dietician, MDS Coordinator, Business Development Director, Business Office Manager, Activities Director, and Admissions Director to review the data, root cause analysis, and plan for improvement.
• Staff interviews were conducted with the staff involved with the event.
• The facility installed a communication box outside the dialysis room as an additional way to communicate with the nurses in the dialysis unit.
• Nursing and Admission staff were educated on the improved communication process.
• The plan for improvement consisted of education/training for all staff providing care to residents and the Executive Director will complete a random audit of 10% of all residents to ensure no concerns related to abuse/neglect are identified.
• The findings will be reviewed by the QAPI committee until substantial compliance is identified.
• All newly hired staff will receive education in orientation regarding abuse/neglect.
• A full house audit was completed on all residents to determine any concerns for abuse/neglect.
• A certified letter was sent to those who did not attend advising that they could not work at the facility until the education was completed.
• The monthly QAPI meetings were held to discuss and review the corrective action plan.
• Education sign-in sheets were reviewed and verified with random staff interviews.
• All audits were reviewed and have been completed as stated.
• Random resident interviews were conducted and there were no allegations/complaints of abuse or neglect.
• The facility has changed dialysis companies to do in-house dialysis.
• The admission process has changed with the new company. Everything is done electronically through email from the admission personnel at the facility directly to admission personnel at the dialysis company.
• Electronic confirmations are obtained to verify the communication is complete.
• A paper communication is given to the executive director as well as placed in the communication box outside the dialysis door for the dialysis nursing staff.
• The facility CNA staff are now responsible for transporting their residents to and from dialysis to avoid any confusion as to where the residents are.
• All residents have assigned chair times for dialysis, which was reviewed and verified during the survey.
• Audits are being done weekly now and have been in 100% compliance.
• The nursing staff are aware of notifying the dialysis nurses if they have a resident that requires dialysis, and they are not on the list for that day.
• The External Business Development/Interim Admission Coordinator stated the process was to email admissions at the new dialysis company with all clinical info they need for admission. If she doesn't hear back, she reaches out to them again.
• A bright colored form and one goes to dialysis, and one goes to the executive director.
• The box outside the dialysis door is used for every resident so nurses are aware of a new patient.

Penalty

Fine: $55,322

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 newly admitted resident received timely dialysis services, resulting in the resident being transferred to a higher level of care. The resident, who had multiple medical conditions including chronic kidney disease, end-stage renal disease, and dependence on renal dialysis, was admitted to the facility with specific physician orders for hemodialysis. Despite these orders, the resident did not receive dialysis for seven days, leading to a critically high serum potassium level and other severe health issues. The deficiency was primarily due to a lack of communication and coordination between the facility and the dialysis provider. The facility's Director of Nursing (DON) and admissions personnel failed to ensure that the necessary documentation and communication were completed to arrange dialysis services for the resident. Interviews with staff revealed that there was confusion and a lack of awareness regarding the resident's dialysis needs, and the facility did not have a policy in place for managing new admissions requiring dialysis. As a result of these failures, the resident was sent to the emergency department with severe hyperkalemia and uremia, conditions that required immediate dialysis. The resident's condition was further complicated by sepsis and other infections, and the resident ultimately passed away in the hospital. The facility's lack of a structured process for handling dialysis admissions and ensuring timely communication with the dialysis provider contributed to the resident's deterioration and subsequent death.

Removal Plan

• The facility submitted appropriate reporting through the AHCA portal.
• Staff education was initiated for all nursing personnel, therapy staff, dietary staff, housekeeping/laundry staff, and administrative and department heads.
• A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Executive Director, Medical Director, Director of Clinical Services, Plant Operations, Registered Dietician, MDS Coordinator, Business Development Director, Business Office Manager, Activities Director, and Admissions Director to review the data, root cause analysis, and plan for improvement.
• Staff interviews were conducted with the staff involved with the event.
• The facility installed a communication box outside the dialysis room as an additional way to communicate with the nurses in the dialysis unit.
• Nursing and Admission staff were educated on the improved communication process.
• The plan for improvement consisted of education/training for all staff providing care to residents and the Executive Director will complete a random audit of 10% of all residents twice weekly for 4 weeks, then weekly for 8 weeks to ensure no concerns related to abuse/neglect are identified.
• The findings will be reviewed monthly by the QAPI committee until substantial compliance is identified.
• All newly hired staff will receive education in orientation regarding abuse/neglect.
• A full house audit was completed on all residents to determine any concerns for abuse/neglect.
• A certified letter was sent to those who did not attend advising that they could not work at the facility until the education was completed.
• The monthly QAPI meetings were held to discuss and review the corrective action plan.
• Education sign-in sheets were reviewed and verified with random staff interviews.
• All audits were reviewed and have been completed as stated. There have been no further concerns regarding neglect for newly admitted dialysis residents or current dialysis residents receiving dialysis care.
• Random resident interviews were conducted over the course of the survey, and there were no allegations/complaints of abuse or neglect.
• The facility has changed dialysis companies to do in-house dialysis.
• The admission process has changed with the new company. Everything is done electronically through email from the admission personnel at the facility directly to admission personnel at the dialysis company.
• Electronic confirmations are obtained to verify the communication is complete.
• A paper communication is given to the executive director as well as placed in the communication box outside the dialysis door for the dialysis nursing staff.
• The facility CNA staff are now responsible for transporting their residents to and from dialysis to avoid any confusion as to where the residents are.
• All residents have assigned chair times for dialysis, which was reviewed and verified during the survey.
• Audits are being done weekly now and have been in 100% compliance.
• The nursing staff are aware of notifying the dialysis nurses if they have a resident that requires dialysis, and they are not on the list for that day.
• The process was to email admissions at the new dialysis company with all clinical info they need for admission. If she doesn't hear back by the following morning, she reaches out to them again.
• A bright colored form and one goes to dialysis, and one goes to the executive director.
• The box outside the dialysis door is used for every resident so nurses are aware of a new patient.

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 newly admitted resident, who was dependent on dialysis, received timely dialysis services. The resident, who had multiple complex medical conditions including end-stage renal disease, was admitted with a physician's order for hemodialysis three times a week. Despite this, the resident did not receive dialysis for seven days, leading to an emergency transfer to a higher level of care. The deficiency arose from a breakdown in communication and procedural lapses within the facility. The admissions personnel claimed to have sent the necessary information to the dialysis provider, but the dialysis provider did not receive it until the resident's condition became critical. Interviews with various staff members revealed a lack of awareness and understanding of the process for managing new admissions requiring dialysis, contributing to the oversight. As a result of the facility's failure to communicate and coordinate dialysis services, the resident developed severe hyperkalemia and uremia, necessitating emergency medical intervention. The resident was diagnosed with additional complications, including sepsis and a large stage 3 pressure injury, and ultimately passed away shortly after being transferred to the hospital.

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 the food preferences of two residents regarding portion sizes, following a change in ownership. Resident #1 expressed dissatisfaction with the smaller portion sizes provided after the new company took over, stating that the portions were insufficient for his needs. Despite his repeated requests for larger portions, the facility maintained that they could only provide larger or double portions when deemed medically necessary. The Certified Dietary Manager (CDM) confirmed this policy change and stated that the resident's previous preference for larger portions was no longer honored. Similarly, Resident #4 reported that he no longer received his preferred large portions after the change in ownership. The facility's policy now requires a medical reason for providing larger portions, as confirmed by the CDM and the Dietitian. The Dietitian, who was new to the facility, explained that a nutritional assessment must be completed to determine if a resident meets the criteria for medically necessary larger portions. This policy shift has resulted in the facility not accommodating the residents' preferences for larger portion sizes unless there is a documented medical need.

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 by serving and storing milk beyond the manufacturer's expiration date. This deficiency was identified during an observation of the kitchen refrigerator, where a red crate containing over 30 individual chocolate milk cartons with expired dates was found. Additionally, two cartons of expired chocolate milk were noted on a tray with lunch items. The Certified Dietary Manager confirmed that the milk was out of date and acknowledged that the milk was delivered in this condition, indicating a failure to check expiration dates upon delivery and before serving to residents. Resident #5, who has a preference for chocolate milk, reported being served expired milk on multiple occasions and provided photographic evidence of the expired milk cartons and corresponding tray tickets. The issue of expired milk was previously raised during a Resident Council meeting, yet the facility did not develop a plan to prevent recurrence. The Resident Council President was unaware that the problem persisted, despite previous efforts to address it by obtaining fresh milk from the supplier.

Penalty

Fine: $10,039

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

Summary

The facility failed to provide adequate supervision and functioning wanderguard doors for a resident identified as at risk for elopement. Resident #1, admitted with severe cognitive impairment and a BIMS score of 0, was care planned for elopement risk with an electronic monitoring device in place. Despite this, Resident #1 exited the facility undetected, walking 1.4 miles away and being found by the police displaying confusion. The facility's Policies and Procedures required daily checks of the wander monitoring system device, but the resident was able to leave without staff knowledge. An investigation revealed that Resident #1 likely exited through unlocked/disalarmed emergency exit doors in a unit under construction. The facility lacked security cameras covering these doors, hindering the ability to track the resident's movements. Staff interviews indicated gaps in monitoring and response, with the primary nurse unaware of the resident's whereabouts upon starting their shift. The Assistant Maintenance Director confirmed issues with the wanderguard sensors, as the door could be opened without alarming when tested by surveyors and facility staff. The deficiency resulted in Immediate Jeopardy, with the resident exposed to hazards such as a 4-lane road with high-speed limits during their unsupervised walk. The facility's failure to prevent elopement for a resident at high risk highlights systemic issues in supervision, monitoring, and door security. Despite the resident's known elopement risk and the presence of monitoring devices, lapses in staff awareness, door functionality, and surveillance contributed to the incident, posing serious risks to the resident's safety and well-being.

Penalty

Fine: $10,039

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 for wandering behaviors. Resident #1, who was admitted to the facility on an unspecified date, exhibited exit-seeking and wandering behaviors, leading to a room change on 03/18/24. The resident was care planned for elopement risk on 03/19/24, with an intervention of an electronic monitoring device placed on the right ankle. However, a comprehensive assessment dated an unspecified date documented that the resident had severe cognitive impairment and did not exhibit any wandering behaviors, indicating a discrepancy in the resident's assessment.