Aviata At The Bay

Penalty

Inspection fine: $17,225

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

Summary

The deficiency involves the facility’s failure to protect a resident from neglect related to elopement. A cognitively impaired resident with dementia, severe disorientation, and a history of wandering exited the building from the fourth floor to the outside, unnoticed by staff. The resident was ambulatory, able to walk significant distances independently with a steady gait, and had documented wandering behaviors, including going into other residents’ rooms and requiring frequent redirection for safety. Despite these characteristics and prior identification as an elopement risk on risk evaluations, the resident did not have an active electronic monitoring device in place at the time of the incident. The resident’s records showed that she had previously been identified as an elopement risk and had an elopement-focused care plan that included use of an electronic monitoring device and monitoring of that device for function. Physician orders for checking the electronic monitoring device each shift had been in place earlier in the year but had ended months before the elopement. The care plan, however, still reflected interventions related to an electronic monitoring device. Staff interviews revealed that the resident typically wandered on the fourth floor, was easily redirected, and had not been seen off the unit before. Multiple clinical providers, including the primary care provider, ARNP, PMHNP, and therapy staff, described the resident as ambulatory, oriented only to person, unable to care for herself, and at risk for following others toward exits or elevators. On the day of the incident, staff on the unit saw the resident around change of shift and redirected her to her room, but they were unaware that she had left the floor and the building. An alarm sounded from a stairwell exit door on the lower level, but staff did not initially know why it was sounding or whether a resident had gone out. Another cognitively intact resident, who was outside on a leave of absence, observed the confused resident walking around the west side of the building in a hospital gown and blanket, approached her, and brought her to sit on a bench at the front of the building, where a staff member then saw them and assisted the resident back inside. Facility leadership and staff were unable to determine how the resident traveled from the fourth floor to the first floor or how she accessed a stairwell door that should have been locked with a keypad. The facility’s own abuse/neglect policy defined neglect to include failure to adequately supervise a resident known to wander from the facility without staff knowledge, and the surveyors determined that this failure resulted in a situation that created a likelihood for serious injury or death and constituted Immediate Jeopardy. Interviews with the NHA and DON indicated that the resident had initially been considered an elopement risk earlier in the year, then was viewed as not at risk after a hospital stay when she was non-ambulatory. They acknowledged that an Elopement Risk Assessment completed in May was incorrect because it was based on pre-hospital information, and that the resident was not listed in the elopement binders at the time of the incident. They also confirmed that although the resident’s mobility improved and she began walking well again and wandering, an electronic monitoring device was not reapplied because she was not perceived as exit seeking. Resident representatives reported that the resident had “bounced back” after her decline, was always wandering, tried to get to doors and elevators, and had been described by staff as trying to get out of the building. These documented conditions, combined with the absence of an active monitoring device and the lack of staff awareness of her departure from the unit and building, led to the neglect finding related to elopement.

Removal Plan

• Returned Resident #5 to the facility.
• Completed a skin assessment, pain assessment, and change of condition assessment for Resident #5 with no negative findings.
• Notified Resident #5’s attending physician and obtained new orders for labs; obtained urine culture results showing ESBL and implemented new medication orders.
• Completed psychiatric services via telehealth for Resident #5 with no new orders received.
• Placed Resident #5 on 1:1 supervision and completed an elopement assessment with an electronic monitoring device applied to her lower extremity; maintained 1:1 supervision until discharge.
• Checked electronic monitoring device function and placement for all current residents at risk for elopement with no negative findings.
• Verified all residents’ demographics were in each resident elopement binder at the nurse station, receptionist area, and therapy gym.
• Added Resident #5’s demographics and picture to the elopement binder.
• Completed door checks to ensure all doors worked properly with no negative findings.
• Completed a 100% head count to ensure all residents were in the facility with no negative findings.
• Re-assessed 100% of residents for elopement risk with no new residents identified.
• Completed an elopement drill; reviewed and documented results on the Elopement Drill QAPI worksheet with no negative findings.
• Gathered witness statements from residents and staff.
• Notified DCF and police of an allegation of neglect.
• Arranged for psychiatric services evaluation for Resident #5.
• Discharged Resident #5 to a memory care unit as planned with the IDT, family, and Medical Director.
• Placed a door guard to ensure no one was able to leave the facility until screamers were installed.
• Completed elopement drills every day, three times per day, randomly.
• Completed elopement drills once per week on random days.
• Completed monthly elopement drills on random shifts and days, with results reviewed with the QAPI team.
• Verified screamers were shipped from the manufacturing company.
• Installed cameras and new secure care boxes.
• Completed door checks to ensure doors were functioning properly.
• Met with the IDT and Clinical Consultant to discuss removal of the door guard and removed it.
• Assessed for a possible amber alarm system and installed the system.
• Set up security cameras in the facility with the main station located in the NHA office.
• Held IDT meetings (including the Medical Director) to review the ad hoc/QAPI plan; the Medical Director reviewed and recommended no changes.
• Provided education to 100% of staff (including contract employees) regarding abuse/neglect, missing persons policy, elopement policy (including care plans and Kardex for those at risk), and staff response to door alarms.
• Initiated elopement drills for 100% of staff (including contracted employees).

Penalty

Inspection fine: $17,225

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

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one cognitively impaired resident who was known to be at risk for wandering. The resident had diagnoses including unspecified dementia, psychosis, depression, and anxiety, and was consistently described as alert only to self, confused at baseline, and unable to care for herself. Quarterly MDS data showed she could ambulate 150 feet with supervision or touching assistance, and therapy notes documented that she could ambulate 275 feet without an assistive device. Progress notes and staff interviews described ongoing wandering behavior throughout the unit, frequent need for redirection for safety, and episodes of verbal and physical aggression during care. The resident’s psychiatric and primary care providers, as well as her representatives, characterized her as ambulatory, severely cognitively impaired, and unable to care for herself outside the facility. Despite this history, the resident did not have an active electronic monitoring device at the time of the incident, even though prior physician orders and the active care plan documented use of such a device earlier in the year and identified her as an elopement risk. Elopement Risk Evaluations in February and May identified her as at risk, and her care plan included interventions related to elopement risk and monitoring of an electronic monitoring device. The DON later stated that the May Elopement Risk Assessment was incorrect because it was completed based on pre-hospitalization information, and the resident was not listed in the elopement binders as an elopement-risk resident on the date of the event. Facility leadership and nursing staff reported that when the resident returned from the hospital she was initially not an elopement risk due to being unable to get out of bed, and that when she later regained mobility and began walking well again, an electronic monitoring device was not reapplied because she was not considered exit seeking. On the day of the incident, the resident was observed by staff on the fourth floor earlier in the shift, wandering as usual, and was redirected to her room. Approximately 10–15 minutes later, staff became aware that a door alarm was sounding from a stairwell exit on the west side or backside of the building, but they did not initially know why the alarm was going off or whether a resident had gone out. During this time, another cognitively intact resident, who was outside on a leave of absence, saw the confused resident walking around the west side of the building near generators, wearing a hospital gown and blanket, and appearing headed somewhere. He approached her, noted her confusion, and directed her to sit on a bench in front of the building, where a staff member saw them and helped bring her back inside. Staff interviews and the facility’s own investigation confirmed that no staff member observed the resident leaving the fourth floor, using the elevator or stairs, or exiting the building, and that staff did not know she had left the unit until she was brought to the front entrance by the other resident. The facility determined that she had exited through a stairwell door that should have been locked and that the alarm associated with that door could only be heard in or just outside the stairwell, not at the front reception area. This sequence of events, combined with the lack of an active electronic monitoring device and failure to recognize and manage her ongoing elopement risk, led to the resident’s unsupervised exit from the building and the determination of Immediate Jeopardy. Resident representatives reported that the resident had "bounced back" and was up and moving weeks after her May hospitalization, and that she was always wandering, trying to escape, and attempting to get to doors and elevators. They stated that staff had told them multiple times that she tried to get out of the building and that she wandered in and out of other residents’ rooms, taking items. Clinical staff, including the OT, PMHNP, ARNP, and PCP, consistently described her as ambulatory, oriented only to person, confused, easily redirected, and not capable of caring for herself outside the facility, with some specifically stating they considered her an elopement risk. Nonetheless, she was not being monitored with an electronic device at the time of the event, and staff on the unit were unaware she had left the floor until after she had already been outside and was returned by another resident. These actions and inactions regarding risk assessment, care planning, and supervision directly contributed to the elopement event that formed the basis of the cited deficiency and Immediate Jeopardy determination.

Removal Plan

• Returned Resident #5 to the facility.
• Completed a skin assessment, pain assessment, and change of condition assessment for Resident #5 with no negative findings.
• Notified Resident #5’s attending physician and obtained new orders for labs; obtained urine culture results showing ESBL and implemented new medication orders.
• Completed psychiatric services via telehealth for Resident #5 with no new orders received.
• Placed Resident #5 on 1:1 supervision, completed an elopement assessment, and applied a wanderguard to her lower extremity; maintained 1:1 supervision until discharge.
• Completed wanderguard function and placement checks for all current residents at risk for elopement with no negative findings.
• Confirmed all residents’ demographics were included in each resident elopement binder at the nurse station, receptionist area, and therapy gym.
• Added Resident #5’s demographics and picture to the elopement binder.
• Completed door checks to ensure all doors worked properly with no negative findings.
• Completed a 100% head count to ensure all residents were in the facility with no negative findings.
• Re-assessed 100% of residents for elopement risk with no new residents identified.
• Completed an elopement drill and reviewed and documented results on the Elopement Drill QAPI Worksheet with no negative findings.
• Gathered witness statements from residents and staff.
• Notified DCF and police of an allegation of neglect.
• Ensured Resident #5 was evaluated by psychiatric services and confirmed no injuries or complaints related to the event.
• Discharged Resident #5 to a memory care unit as planned with the IDT, family, and Medical Director.
• Placed a door guard at the door to ensure no one was able to leave the facility until additional alarm measures were installed.
• Completed elopement drills multiple times per day on random schedules.
• Completed weekly elopement drills on random days.
• Completed monthly elopement drills on random shifts and days and reviewed results with the QAPI team.
• Verified shipment of screamers from the manufacturing company.
• Installed cameras and new secure care boxes.
• Completed door checks to ensure doors were functioning properly.
• Met with the IDT and Clinical Consultant to discuss removal of the door guard and reached agreement.
• Completed a security company assessment for a possible amber alarm system and installed the system.
• Set up security cameras in the facility with the main station located in the NHA office.
• Held IDT meetings to review the ad hoc/QAPI plan with no negative findings and obtained Medical Director review with no recommended changes.
• Provided education to 100% of staff (including contract employees) related to abuse and neglect, missing persons policy, elopement policy (including care plans and KARDEX for those at risk for wandering/elopement), and staff response to door alarms.
• Initiated elopement drills for 100% of staff (including contracted employees).

Penalty

Inspection fine: $17,225

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

Summary

The deficiency involves the facility’s failure to provide dinner meals in a timely manner and in accordance with its own meal service timeframes for the majority of dinners reviewed. Fourteen of seventeen dinner meal services in January 2026 were documented as being late, with tray carts leaving the kitchen anywhere from several minutes to over an hour and a half after the scheduled delivery times listed on the Dining Services Cart Delivery Log. The facility’s posted Meal Cart Delivery Schedule in the kitchen showed earlier dinner delivery times than those used in practice, but the Dietary Manager stated staff generally followed the later times on the Dining Services Cart Delivery Log. There was no specific policy and procedure related to honoring meal service times, although the Nursing Home Administrator acknowledged that residents have the right to receive their meals timely and per the meal service schedule. Multiple cognitively intact residents reported that their meals, particularly dinner, were routinely late. One resident who chose to eat breakfast and dinner in his room stated that for the past few months his dinner, expected around 5:00 p.m., was often delivered 30 minutes to two hours late, and that he had reported this to the DON and Nursing Home Administrator without resolution. Another resident, serving as Resident Council President, reported hearing repeated complaints at resident meetings that all three meals were late to rooms, sometimes by almost two hours, and confirmed that his own meals were routinely 45 minutes to two hours late despite his complaints to the Dietary Manager. Additional residents reported similar experiences, including one who said dinner was supposed to arrive around 5:00 p.m. but frequently came 30 to 45 minutes late and sometimes up to two hours late, and another who stated that since admission he often did not receive dinner until 7:00 p.m. or after 8:00 p.m., despite an expected delivery time around 5:00 p.m., and that he had complained to aides, nurses, the social worker, and the Dietary Manager many times. Interviews with dietary leadership and the Nursing Home Administrator revealed ongoing staffing problems in the kitchen that contributed to the late meal service. The Regional Dietary Manager, who stated he usually assists at the facility twice a week, reported that kitchen staff are contracted, that the facility has been unable to retain cooks and dietary aides, and that he has been filling in for various tasks including cooking, prepping, plating trays, delivering carts, cleaning, and paperwork. The Dietary Manager, who works six days a week and attempts to cover all three meal shifts, confirmed he employs a limited number of cooks and dietary aides, has had persistent staffing issues—especially with cooks—and that about half or more of the dinner meals in January 2026 were sent out late, sometimes over an hour to an hour and a half late. He acknowledged that meal delays had been occurring mainly during dinner since around November 2025, that he lacked documentation of supervisory audits of meal service, and that he was unsure whether residents had been informed about the kitchen’s inability to provide meals timely on a consistent basis. The Nursing Home Administrator confirmed awareness of the contracted kitchen’s staffing problems and ongoing efforts to hire staff, but there was no indication in the report that these issues had resolved the pattern of late meal delivery.

Penalty

Inspection fine: $64,581

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 the rights of four residents to be free from neglect, as evidenced by the lack of access to wheelchairs, assistance in getting out of bed, and proper activities of daily living (ADL) care. Resident #114, who has multiple complex diagnoses including quadriplegia and aphasia, was observed to be in bed continuously over several days, with her custom wheelchair unused in the closet. Her family member reported that the facility staff did not facilitate her use of the wheelchair, citing various reasons, including the absence of a seatbelt, which was later found to be present. Resident #47 expressed a desire to get out of bed but reported that no one would assist her. She had been in bed for an extended period and was concerned about her mental health due to the lack of mobility and interaction. Her care plan indicated she was dependent on staff for transfers, requiring assistance from two staff members with a mechanical lift, yet she remained confined to her bed. Resident #124 and Resident #126 also experienced neglect in their care. Resident #124, who was cognitively intact, reported that staff did not assist her with ADLs or getting out of bed, despite her repeated requests. She expressed distress over being confined to bed for three months. Resident #126, who was unable to brush her hair, was observed with matted hair and expressed a desire to go outside, but did not ask for help due to perceived staff shortages. Interviews with staff revealed systemic issues, including a lack of wheelchairs and inadequate staff response to residents' needs, which were known to the administration but not addressed effectively.

Penalty

Inspection fine: $64,581

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 organized kitchen environment, as evidenced by multiple observations during a survey. The initial tour revealed a blue lighter on the handwashing sink, a silver pan with a brown substance under the sink, and dirty dishes in the three-compartment sink. Additionally, frozen chicken was improperly defrosting in the sink with dirty dishes. In the reach-in cooler, there were several food items without proper labeling or dates, including a pan of sauce, a block of unknown food, and open instant mashed potatoes. The water heater under the dish machine was missing its front panel, exposing wires and insulation, and there was a rust-like substance on the dish machine. Further inspection with the Regional Certified Dietary Manager (CDM) revealed additional issues, such as a mop bucket with gray water touching clean dish racks, an unlabeled bag of mashed potatoes on the AC unit, and an opened bag of grits under the stove. The AC vent above clean dishes had black bio growth, and personal items like a windbreaker jacket and shoes were improperly stored near food preparation areas. The facility's kitchen cleaning schedule showed missing entries, and policies regarding food labeling, storage, and equipment maintenance were not followed. Interviews with the CDM and Regional CDM confirmed these deficiencies, as they were unaware of the lighter's presence and the improper thawing of chicken, and they acknowledged the lack of adherence to food labeling and storage policies.

Penalty

Inspection fine: $64,581

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

Summary

The facility failed to maintain a safe and homelike environment across all three units and shower rooms, as evidenced by multiple observations of soiled privacy curtains, unpainted and unfinished wall repairs, foul odors, and unclean bathrooms. During a facility tour, surveyors noted dirty privacy curtains with gray staining in several rooms, peeling paint and plaster around windows and air conditioning units, and unpainted wall repairs. These conditions persisted throughout the survey period. The facility's procedure for cleaning cubicle curtains, which requires immediate removal of stained curtains, was not followed due to a shortage of replacement curtains, as confirmed by the Director of Housekeeping. Further observations revealed additional deficiencies, including a strong odor of stale urine in certain rooms, a toilet with brown stains, and a bathroom with brown residue on the floor. The Maintenance Director acknowledged these issues, stating that he was in the process of addressing them but had not yet completed the necessary repairs. The facility's policy on cleaning and disinfection, which mandates regular cleaning and disinfection of environmental surfaces, was not adequately implemented, contributing to the unsanitary conditions observed. Additional issues included a missing ceiling light shade, a missing receptacle cover, a rusty and uncleanable shower chair, and a fallen wire shelf in a closet. The Director of Maintenance confirmed these issues and noted that parts had to be ordered due to a lack of petty cash for immediate repairs. The Housekeeping Director reported that two residents were known to urinate on the floor, causing urine to seep under the tiles, and that this issue had been communicated to the Nursing Home Administrator. Despite these reports, the facility did not provide a policy regarding maintaining a homelike environment by the end of the survey.

Penalty

Inspection fine: $64,581

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 Level I Preadmission Screening and Resident Review (PASRR) for residents with mental disorders or intellectual disabilities. This deficiency was identified for six residents, with one resident not having a required Level II PASRR initiated. The PASRR forms for several residents were found to be incomplete or incorrect, with qualifying diagnoses not checked or missing entirely. For instance, Resident #394's PASRR was blank, and Resident #135's PASRR did not have the necessary diagnoses marked. Resident #114's PASRR Level I Screen did not include several of their diagnoses, such as depressive disorder and autism, and indicated that a Level II PASRR evaluation was required. However, no Level II PASRR was found in the resident's medical record. Interviews with facility staff revealed a lack of proper review and training regarding PASRR processes. The Social Services Director admitted to not having access to the PASRR system until recently and acknowledged that many residents' PASRRs needed corrections. The facility's policy requires that PASRR screenings be conducted and results obtained prior to admission, but this was not adhered to. The Admission Director and Director of Nursing confirmed that the PASRRs were not reviewed pre-admission, and the Admission Director was not trained on PASRRs. The facility's failure to conduct accurate PASRR screenings and ensure proper documentation led to the admission of residents who may not have been eligible for the facility, as evidenced by the incomplete and incorrect PASRR forms.

Penalty

Inspection fine: $64,581

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 life-enriching activities for three residents, leading to deficiencies in meeting their social and emotional needs. Resident #79, who has severe cognitive impairment and requires substantial assistance with mobility, was not informed about scheduled activities and lacked a wheelchair to participate. Despite expressing interest in activities like the Ice Cream Social, the resident remained in bed without access to a television remote or a means to move around. The Activities Coordinator acknowledged the resident's lack of independence in social needs and noted the absence of a wheelchair, which hindered the resident's participation in activities. Resident #57, also with severe cognitive impairment, reported not being aware of any activities and expressed willingness to participate if informed. The resident's care plan indicated minimal community life involvement due to poor adjustment and required staff to encourage participation. However, the Activities Coordinator admitted to not providing any activities to the resident and noted the absence of a wheelchair, which further limited the resident's ability to engage in social activities. Additionally, scheduled activities like Taco Tuesday and Trivia did not occur as planned due to logistical issues, such as lack of petty cash and staff availability. Resident #124, who is cognitively intact but dependent on staff for mobility, expressed a desire to participate in activities and socialize with other residents. However, the resident remained in bed, as staff did not assist in getting her up. The Activities Coordinator confirmed the resident's interest in socializing and getting her hair done but failed to report these desires to other staff members. The facility's policies on social and individual activities were not effectively implemented, as residents were not provided with adequate opportunities for socialization and engagement, leading to unmet needs for love and belonging.

Penalty

Inspection fine: $64,581

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

Summary

The facility failed to ensure that residents with limited mobility received restorative services to maintain or improve their mobility and range of motion. This deficiency was observed in three residents who were assessed for the facility's restorative program but did not receive the necessary services. Resident #129, who had difficulty walking and required orthopedic aftercare, was not included in the restorative program despite recommendations for active range of motion exercises and ambulation. Resident #31, who was legally blind and had polyneuropathy, was also not receiving the recommended exercises for upper body mobility. Similarly, Resident #102, with chronic pain syndrome, was not provided with the prescribed active range of motion exercises for maintaining functional mobility. The deficiency was further highlighted during interviews with staff members. Staff T, a Certified Nursing Assistant and Restorative Aide, was not aware of Resident #129 being on her assignment, indicating a lack of communication and coordination in implementing restorative therapy orders. The Director of Rehabilitation acknowledged that Resident #129 had been transitioned to restorative therapy, but the nursing staff failed to follow through with the orders. The Assistant Director of Nursing (ADON) admitted to not setting up the necessary training for managing the restorative program and was unaware of her responsibility to input the orders for the aides. The Director of Nursing confirmed that the restorative program had not been implemented for newly assigned residents since the previous ADON left. The Nursing Home Administrator recognized the lapse in transitioning residents to the restorative program and attributed it to the new ADON not being familiar with the process. The facility's policy on Restorative Nursing Services outlined the procedure for transitioning residents to restorative care, but the lack of communication and training led to the failure in executing the program, affecting the residents' therapeutic goals.

Penalty

Inspection fine: $64,581

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

Summary

The facility failed to ensure proper storage and labeling of medications, leading to several deficiencies. An unlocked medication cart was observed on the 4th floor with no staff present, and a pill was found on the floor of a resident's room. Staff acknowledged the cart should have been locked and the pill on the floor was a safety concern. Additionally, medications were found at the bedside of residents without proper orders, including bottles of Zinc, Wild Omega, and Quercetin immune formula, and an Albuterol Sulfate inhaler on a resident's walker. Further observations revealed undated insulin vials and an unlocked medication cart, indicating a lack of adherence to storage protocols. The 300 High medication cart contained undated vials of Novolog, Lantus, Fiasp insulin, and Latanoprost Ophthalmic solution, while the 200 Low cart had an opened undated vial of Insulin Glargine and Insulin Aspart. The facility's policy requires medications to be stored in a locked area and dated according to manufacturer instructions, which was not followed. Interviews with staff, including the DON, confirmed the expectation for medication carts to be locked and medications to be dated. The facility's policy mandates central storage of medications and supervision during administration, which was not consistently practiced. The presence of unsecured medications and undated insulin vials highlights a significant lapse in medication management and storage protocols.

Penalty

Inspection fine: $64,581

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 confidentiality of Protected Health Information (PHI) for a resident on the 200 Unit. During a facility tour, an IV label containing the resident's PHI, including their name, medication name, prescription number, and medication administration schedule, was found discarded in a trash can by the resident's bed. This action was contrary to the facility's policy, which mandates that sensitive information should never be thrown in the trash and should only be destroyed by shredding. Interviews with staff members revealed an awareness of the breach in protocol. A Registered Nurse acknowledged that PHI should not be disposed of in the trash, and a Licensed Practical Nurse identified the IV label in the trash, attributing the error to a nurse possibly being in a hurry. The LPN retrieved the IV information from the trash bag, which was about to be removed by a Certified Nursing Assistant, and stated she would dispose of it properly. The facility's policy on confidentiality and privacy, dated 11/30/2014, was reviewed and confirmed the requirement to protect residents' PHI in compliance with HIPAA regulations.

Penalty

Inspection fine: $64,581

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 grievance from a resident regarding the malfunctioning air conditioning (A/C) unit in his room. The resident, who was admitted with a primary diagnosis of wedge compression fracture of the fourth lumbar vertebra, expressed discomfort due to the heat and the inability to use a plug-in fan due to a lack of available outlets. Despite notifying the facility staff, including CNAs and nurses, about the issue, the resident's grievance was not documented in the facility's Grievance Log. Interviews with staff revealed that the resident's roommate consistently turned off the A/C unit, and the resident had requested a room change due to the ongoing issue. The Director of Maintenance acknowledged the conflict between the residents but did not take further action. Staff members, including an LPN and a CNA, confirmed the resident's complaints and the roommate's behavior. The Assistant Social Services Director stated that a grievance should have been initiated, but nursing staff failed to notify the Social Services department. The Director of Nursing confirmed that the staff should have documented the resident's concerns, as per the facility's policy, which mandates prompt efforts to resolve grievances and document them appropriately.

Penalty

Inspection fine: $64,581

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

Summary

The facility failed to develop and implement effective care plans for three residents, leading to deficiencies in their care. Resident #57 was observed with matted hair, and despite her refusal to allow staff to comb her hair, the care plan did not address this issue or the family's refusal to assist. The resident's care plan included interventions for other behaviors but lacked specific strategies for managing her hair care needs. Resident #75, who had highly impaired vision, reported that his glasses did not work, and he struggled to see and read. Despite this, his care plan did not include any focus areas or interventions related to his vision loss. Staff interviews confirmed that he required assistance with reading and other activities due to his vision impairment, yet these needs were not addressed in his care plan. Resident #114, diagnosed with autistic disorder among other conditions, did not have any focus areas or interventions in his care plan related to autism. The MDS Coordinator acknowledged that autism affects behavior and should be care planned, but this was not done. The facility's policy requires individualized, person-centered care plans to address residents' medical, nursing, mental, and psychosocial needs, but this was not adhered to for these residents.

Penalty

Inspection fine: $64,581

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 an effective discharge planning process for a resident who wished to transfer to another facility. The resident, who was cognitively intact and had a history of acute embolism, thrombosis, bipolar II disorder, major depressive disorder, anxiety, and adjustment disorder, expressed dissatisfaction with the care received, including lack of assistance with activities of daily living and missed therapy sessions. Despite the resident and her family member's request for a transfer, the Social Services Director (SSD) did not assist them, citing the resident's Medicaid pending status as a barrier to finding another facility willing to accept her. The Business Office Manager (BOM) revealed that the facility had a Medicaid specialist responsible for applications, but the resident's application had not been processed since March, as it was not pulled from the system. The SSD admitted to not assisting the resident in finding another facility due to her belief that no facility would accept a Medicaid pending resident. The facility did not provide a policy related to discharge planning by the end of the survey, indicating a lack of structured guidance in handling such situations.

Penalty

Inspection fine: $64,581

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 functional communication system for two residents, leading to deficiencies in their care. Resident #393, who was non-verbal following a stroke, was observed without any alternate communication tools in her room. Staff members, including LPNs and CNAs, were unsure of the resident's preferred communication methods, relying on body language and facial expressions to interpret her needs. The Director of Nursing acknowledged that a communication board should have been provided and documented in the care plan, but this was not done. The MDS Coordinator also confirmed that the baseline care plan did not reflect the resident's non-verbal status or appropriate communication methods. Similarly, Resident #97, who was unable to verbally communicate due to medical conditions, was observed trying to express herself through gestures. Despite having a board to write on, she was unable to use it effectively. The MDS Coordinator noted that the resident's care plan, created in April, may have been incorrectly coded as the resident being usually understood, which did not trigger the creation of a communication care plan. This oversight resulted in the absence of a communication care plan to assist Resident #97 with her needs. The facility's policy on care plans requires an individualized, person-centered plan to be established and updated in accordance with regulatory requirements. However, the lack of proper communication tools and documentation for both residents indicates a failure to adhere to this policy. The staff's inability to effectively communicate with these residents highlights a significant deficiency in the facility's care planning and communication systems.

Penalty

Inspection fine: $64,581

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 activities of daily living (ADLs) were completed and maintained for two residents, leading to deficiencies in their care. Resident #126 was observed in bed with matted and unkempt hair, expressing a desire to go outside but feeling unable to ask for help due to perceived staff shortages. Despite requiring substantial assistance for personal hygiene and mobility, staff interviews revealed a lack of familiarity with her care needs and a failure to offer necessary assistance, such as brushing her hair or helping her out of bed. Resident #97, who is severely cognitively impaired, was observed in bed wearing the same nightgown throughout the day, unable to communicate her needs verbally. Her care plan indicated a need for substantial assistance with dressing and bathing, yet observations showed she remained in bed without receiving the necessary care. Staff interviews indicated a reliance on residents to request assistance, which was not feasible for Resident #97 due to her communication limitations. The facility's staff, including CNAs and LPNs, acknowledged issues with providing adequate care, particularly for residents who do not speak Spanish. The Director of Nursing stated that residents were reportedly refusing assistance, but the observations and interviews suggest a systemic issue with staff not proactively offering or providing necessary ADL support, contributing to the deficiencies noted in the care of Residents #126 and #97.

Penalty

Inspection fine: $64,581

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 trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who also has bipolar disorder, unspecified intellectual disabilities, anxiety disorder, major depressive disorder, and autistic disorder, was admitted with these diagnoses. However, the resident's care plan did not include a focus area or interventions related to PTSD, despite the diagnosis being noted in the Quarterly Minimum Data Set (MDS). An observation noted the resident lying in bed and yelling out repeatedly, with a Licensed Practical Nurse (LPN) nearby, indicating a lack of appropriate intervention. Interviews with facility staff revealed gaps in the implementation of trauma-informed care. The MDS Coordinator, who had only been at the facility for a few months, was unaware of the resident's specific needs and confirmed that there was no specific PTSD care plan in place. The Nursing Home Administrator acknowledged that the resident was not being followed by psychiatry or psychology, and that the primary care nurse practitioner, who has mental health training, managed the resident's medications. The facility's policy on trauma-informed care requires evaluation for trauma, triggers, and cultural preferences, and the development of resident-centered interventions, which were not adequately implemented for this resident.

Penalty

Inspection fine: $64,581

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 medications were administered as ordered for a resident on the 200 Unit. The resident, who was admitted with multiple diagnoses including traumatic hemorrhage of the cerebrum and acute respiratory failure, was prescribed Cephalexin 500 mg to be taken four times a day for a urinary tract infection. However, the Medication Administration Record (MAR) showed that the resident did not receive the medication as ordered. On several occasions, the resident received only partial doses, and from June 10 to June 13, the resident did not receive the medication at all. Interviews with staff, including the Licensed Practical Nurse (LPN)/Unit Manager, the Director of Nursing (DON), the Regional Nurse Consultant (RNC), and the Advanced Registered Nurse Practitioner (ARNP), revealed that the facility ran out of the medication from the Emergency Drug Kit (EDK) and failed to follow up with the pharmacy for a timely delivery. The DON confirmed the missed doses and acknowledged that the nurse should have contacted the pharmacy and notified the unit manager and DON about the medication shortage. The facility's policy on physician orders emphasized the importance of timely documentation and verification of orders, which was not adhered to in this case.

Penalty

Inspection fine: $64,581

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 critical laboratory results for a resident were reported to the ordering physician in a timely manner. Resident #393, who had a history of traumatic hemorrhage of the cerebrum, acute respiratory failure, aphasia, hemiplegia, and hemiparesis, had labs collected on June 10th. The results, which included high readings for glucose serum, BUN, sodium serum, chloride, and osmolarity, were reported to the facility later that day. However, there were no progress notes indicating that the physician was notified of these critical results. The resident was later sent to the emergency room on June 13th with abnormal labs and was admitted to the ICU. Interviews with the facility's ARNP, DON, and an LPN revealed that there was a communication issue within the facility, as the physician was not notified of the critical lab results. The ARNP and DON both stated that the nurse should have called the physician immediately upon receiving the results and documented the notification. The facility's policy also required that critical values be communicated to the ordering practitioner promptly, but this procedure was not followed in this instance.

Penalty

Inspection fine: $64,581

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 promptly provide dental services for a resident who complained of chewing difficulties related to tooth pain. The resident, who had severe cognitive impairment and multiple health conditions, reported having no teeth and experiencing chewing problems. Despite notifying the Nurse Practitioner and obtaining an order for a dental consult and Acetaminophen, the resident did not receive timely dental care. The Social Service Assistant (SSA) and Director of Nursing (DON) were involved in attempts to address the resident's dental needs. The SSA reported that the dentist visits the facility once a month and was unsure if the resident had been seen. The DON and Regional Nurse Consultant (RNC) were also involved in trying to arrange a dental appointment, but there was a lack of documentation to confirm that the resident had been seen by dental services in May or June. Ultimately, the resident was observed waiting to leave for a dental appointment 32 days after initially reporting tooth pain. The facility's policy required prompt referral to dental services within three days for residents with dental issues, but this was not adhered to, resulting in a significant delay in addressing the resident's dental pain.

Penalty

Inspection fine: $64,581

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 accuracy of the medical record for a resident concerning the application and removal of an orthotic device. The resident, who was diagnosed with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, was observed multiple times without the prescribed right-hand splint or brace. Despite physician orders indicating the splint should be applied in the morning and removed in the evening, the resident was not wearing the device during several observations over consecutive days. The resident's medical records, including the Treatment Administration Record (TAR) and Medication Administration Record (MAR), indicated that the splint was administered daily, except for one day. However, interviews with staff revealed inconsistencies. A Restorative Certified Nursing Assistant (RCNA) reported that the resident did not have a splint and only received range of motion (ROM) exercises when allowed by the resident. The RCNA also mentioned that the splint had been discontinued, contradicting the documentation. A Registered Nurse (RN) confirmed signing the TAR for the splint application but acknowledged that the resident often removed it after a short period. The Director of Nursing (DON) reviewed the physician orders and stated that the splint orders should be discontinued if the resident did not have the device, and staff should not document its application inaccurately. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment, yet the resident was able to answer questions appropriately during the survey process. The facility's failure to accurately document and apply the prescribed orthotic device led to the deficiency noted in the report.

Penalty

Inspection fine: $64,581

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 post correct infection control signage in resident rooms on two of its three floors, leading to confusion among staff regarding the necessary precautions to prevent cross-contamination of infections. Specifically, Resident #37's room was incorrectly labeled with an Airborne Precautions sign, despite the resident being on Enhanced Barrier precautions for Colonized Candida Auris. Observations revealed that staff were not following the correct precautions, as evidenced by a CNA wearing inappropriate PPE and the Director of Nursing (DON) confirming that no residents were on Airborne precautions. Interviews with staff indicated reliance on incorrect signage, contributing to the improper use of PPE. On the fourth floor, several rooms were incorrectly labeled with contact precaution signs, while only two rooms were actually on contact precautions. A room had a precaution sign in Spanish but not in English, and a staff member delivered a lunch tray without donning PPE, contrary to the posted contact precaution sign. The DON and other staff confirmed that the signage did not match the actual precaution orders, leading to further confusion. Resident #77, who had a wound culture positive for MRSA, was not correctly placed on contact precautions until a day after the lab results were reported, and the signage remained incorrect even after the order was entered. The facility's infection control policy, revised in October 2018, outlines the need for proper signage and PPE use, but the implementation was flawed. The Assistant Director of Nursing (ADON), responsible for placing precaution signs, admitted to potential confusion caused by posting multiple signs in different languages. Despite conducting rounds to check signage, errors persisted, such as the unexplained presence of an Airborne precaution sign. The DON acknowledged that incorrect signage could lead to staff confusion and improper infection control practices.

Penalty

Inspection fine: $64,581

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 pest-free environment, as evidenced by the presence of small flying gnat-like insects in two of the four residential units and the kitchen. Observations were made of these insects in various locations, including a resident's bedside dresser, a medication cart, and the facility's conference room. The Director of Maintenance acknowledged the issue, noting that bug zapping lights were sometimes unplugged by staff to charge their phones, and that the problem was exacerbated by residents who hoarded food. The Nursing Home Administrator confirmed that there had been ongoing complaints about gnats, and the facility had increased pest control visits in response. In the kitchen, standing water around missing tiles was observed, along with flies hovering near the trash can and food carts. The Certified Dietary Manager attributed the fly problem to the standing water and noted that maintenance was supposed to address the issue. The Director of Maintenance stated that pest control contractors visited weekly and that staff were inconsistent in reporting pest sightings. The facility's pest control policy outlined the need for routine inspections and immediate reporting of unusual insect sightings, but the report indicated that these procedures were not consistently followed.