Charlotte Bay Rehab And Care Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure safe storage of medications in accordance with its own Clinical Medication Administration policy and accepted professional standards. The policy, revised 12/10/25, states that residents deemed appropriate to self-administer and who wish to keep medications at bedside will be provided with a locked container or drawer to house the medication when not in use. On 3/16/2026 at 9:53 a.m., surveyors observed one resident’s room where a Dulera inhaler and four vials of Ipratropium-Albuterol nebulizer solution were left unsecured and unattended on the bedside table while the resident was not in the room. Review of the resident’s March 2026 MAR showed the Dulera inhaler was ordered twice daily and the Ipratropium-Albuterol solution was administered via nebulizer on 3/14/26. At 9:58 a.m., an LPN confirmed that these medications were not locked and had been left unattended at the bedside, and stated that the resident always self-administered her inhaler and knew how to do it. This sequence of events demonstrates that the facility did not provide a locked container or otherwise secure the resident’s medications at bedside as required by its policy, resulting in unsecured medications accessible in the resident’s room when the resident was absent.

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 and appropriate care and services to prevent complications from urinary catheters for several residents. Resident #1, who had a diagnosis of prostatic hyperplasia, experienced significant issues due to improper catheter management. The nursing staff did not document the free flow of urine to verify the proper positioning of the catheter, and there was a delay in notifying the practitioner about the lack of urine output. This resulted in Resident #1 becoming unresponsive and requiring emergency transfer to an acute care hospital. The report highlights that the facility did not have processes in place to ensure ongoing assessment of residents to prevent complications from urinary catheters. This lack of proper monitoring and documentation was evident in the discrepancies between the Treatment Administration Record (TAR) and the Certified Nursing Assistants' (CNAs) documentation of urine output. The facility's failure to monitor and document urine output as ordered by the physician was also noted for other residents, such as Residents #4, #61, and #8, who had similar issues with catheter management. Additionally, Resident #999, who was incontinent, reported that staff did not respond to her requests for toileting assistance, and her daughter filed a grievance after finding her mother in soiled conditions. The facility's failure to address these issues and ensure proper care and monitoring of residents with catheters and incontinence led to the determination of Immediate Jeopardy, indicating a likelihood of serious harm or injury to the residents.

Plan Of Correction

1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 no longer resides in the facility. • Residents #4, #5, #8, & #61 had an RN assessment completed. • Resident #999 was provided with care at the time of grievance. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • Current residents had an evaluation completed. • Current residents had an RN assessment completed including a set of vital signs and observation for output and patency. Any changes identified were communicated to the provider and family notification completed. • Facility residents with a score of 13 or greater were interviewed regarding the facility's provision of goods and services. • Facility residents with a score of 12 or less had skin evaluations completed. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Staff Development Coordinator/Designee completed competencies with CNAs on emptying and measuring output for residents with. This competency was conducted using a mannequin with an to simulate the actual emptying of the. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Staff Development Coordinator/Designee completed competencies with licensed nurses on the proper insertion of with return demonstrations. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the requirement of detailed communication during shift to shift report to include any changes in condition, any new physician orders, and review of any new or existing devices including. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education with CNAs on completing the required ADL documentation. • The facility's Staff Development Coordinator/Designee completed education with Nurse Unit Managers and RN Weekend Supervisor on monitoring the completion of ADL documentation. System Change: • Output was added to the MAR to ensure nursing documentation. • CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. • The facility added to the orientation agenda that all newly hired licensed nurses will complete competencies on the proper insertion of with return demonstration prior to providing resident care. • The facility implemented staff huddles led by Nurse Unit Managers to address ADL documentation completion. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee.

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 and appropriate care and services to prevent complications for several residents, including Resident #1, who had a diagnosis of prostatic hyperplasia. The facility did not adequately monitor and document the urinary output of Resident #1, leading to a situation where the resident had no output for an extended period. Despite a physician's order to change the catheter monthly and as needed, there was a lack of documentation regarding the size of the re-inserted catheter, observation of flow, or how the resident tolerated the procedure. The staff failed to communicate effectively about the resident's condition, resulting in a delay in sending the resident to the emergency room. Resident #1 experienced a critical situation where clots were present, and there was no urinary output for more than eight hours. The APRN was informed late about the resident's condition, and the order to send the resident to the ER was not transcribed promptly. The resident was eventually sent to the hospital after being found unresponsive, with symptoms including a high temperature, rapid breathing, and low oxygen saturation. The facility's documentation and communication failures contributed to the delay in addressing the resident's urgent medical needs. Additionally, the facility failed to monitor and document the urinary output for other residents, including Residents #4, #5, #8, and #61, as per physician orders. The Director of Nursing was unaware of these lapses in monitoring, indicating a systemic issue in the facility's adherence to care plans and physician orders. The lack of documentation and timely intervention highlights significant deficiencies in the facility's care and monitoring processes.

Plan Of Correction

1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: > Resident #1 no longer resides in the facility. > Residents #4, #5, #8, & #61 had an RN assessment completed. > Resident #999 was provided with care at the time of grievance. 2) How you will identify other residents: > Securement device, care Qshift, and to record the output Qshift. > The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A.B.C. & D. > The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. > The facility's Staff Development Coordinator/Designee completed education with CNAs on completing the required ADL documentation. > The facility's Staff Development Coordinator/Designee completed education with Nurse Unit Managers and RN Weekend Supervisor on monitoring the completion of ADL documentation. System Change: > Output was added to the MAR to ensure nursing documentation. > CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. > The facility added to the orientation agenda that all newly hired licensed nurses will complete competencies on the proper insertion of with return demonstration prior to providing resident care. > The facility implemented staff huddles led by Nurse Unit Managers to address ADL documentation completion. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: > The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. > The facility initiated the completion of audits seven days a week including output documentation for all residents with. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. > The daily clinical meeting form was edited to include: > - Review of 24-hour report for change in condition. > - The review of vital signs and the timely transfer of all residents that returned to the hospital. > - The review of all new admissions and existing residents with output to ensure orders to monitor are in place. > - The review of vital signs and the review of the nurses' change of condition evaluation for all residents that had a change in condition. > - The review of vital signs for all residents per physician order. > - The review of PCC ADL Documentation.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's right to be free from neglect by not appropriately monitoring the resident's condition after the insertion of a catheter. The resident, who was admitted with diagnoses including prostatic hyperplasia, had a catheter inserted to drain urine. However, there was no documentation that the resident was monitored to ensure the catheter was properly inserted and draining. On a particular day, the resident had no urine output, and the catheter was removed, revealing copious amounts of blood and clots. Despite this acute change in condition, there was no documentation of the resident's status being monitored, including vital signs or output. The facility's records show that the resident was emergently transferred to an acute care hospital later that evening, unresponsive and with no urine output. Interviews with staff revealed that there was a lack of communication and documentation regarding the resident's condition throughout the day. The APRN had given orders to monitor the resident and send them to the hospital if there was no urine output or if clots continued, but these orders were not transcribed or followed in a timely manner. The resident's spouse had also reported concerns about the lack of urine output to the staff, but these concerns were not adequately addressed. The facility's investigation into the incident noted that the care provided was in adherence to physician orders, but the documentation and monitoring of the resident's condition were insufficient. The investigation revealed that staff failed to take necessary actions, such as obtaining vital signs and ensuring timely communication with the physician, which contributed to the neglect of the resident's care needs. The lack of proper monitoring and documentation led to a determination of Immediate Jeopardy, indicating a likelihood of serious harm to the resident.

Plan Of Correction

1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 is no longer a resident. An AHCA Federal Immediate Report with a corresponding investigation was completed by the facility prior to this survey. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • Facility residents with a score of 13 or greater were interviewed regarding the facility's provision of goods and services. • Facility residents with a score of 12 or less had skin evaluations completed. • Current residents had an RN assessment completed including a set of vital signs and observation for output and patency. Any changes identified were communicated to the provider and family notification completed. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Administrator and Director of Nursing were reeducated by Regional Nurse Consultant on: o The components of the regulation: F600 Free from and Neglect o Neglect, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) with indicators of neglect. o Facility standard and guideline P&P Neglect and Investigations to include: o Screening o Training o Prevention o Identification o Investigation o Protection o Reporting • The facility's Staff Development Coordinator/Designee completed education with facility staff on Neglect with an emphasis on the following F600 noncompliance: The facility failed to protect resident rights to be free from neglect by failing to appropriately monitor the resident's output and failure to monitor the resident when the was discontinued. On at approximately 4:30 p.m. resident's was discontinued. Resident experienced copious and was passing clots through his penis. The facility neglected to monitor resident's status including vital signs with a significant change in condition. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs on emptying and measuring output for residents with . This competency was conducted using a mannequin with an to simulate the actual emptying of the . • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs and licensed nurses on the proper obtaining of resident vital signs including temperature, , and , and on a live member of staff. Vital signs obtained for an identified change in condition will be documented in the and vitals tab in PCC. This allows for these vitals to populate accurately in the SBAR/Change in Condition evaluation. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, or status. o This may include life-threatening conditions, or clinical complications and changes in output including color, consistency, and output. o Circumstances that may require a need to alter treatment. This may include new treatment and/or discontinue of current treatment due to an acute condition or a worsening of a condition. o A complete nursing evaluation must be conducted and documented in the medical record of systems including but not limited to functional status, evaluation, evaluation/evaluation, evaluation, skin evaluation, evaluation, and vital signs. o The physician/NP shall be made aware of pertinent evaluation findings. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on vital sign documentation, and on following timely transfer to a higher level of care upon directive from physician. • The facility's Staff Development Coordinator/Designee completed residents that returned to the hospital. o The review of all new admissions and existing residents with monitor output to ensure orders to include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. o The review of vital signs and the review of the nurse's change of condition evaluation for all residents that had a change in condition. o The review of vital signs for all residents per physician order. • Licensed Nurses and CNAs will complete competencies on care at the time of orientation and annually with the facility's Staff Development Coordinator. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. • The facility initiated the completion of audits seven days a week including weekends documentation of output for all residents with . These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee.

Penalty

No penalty information released

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

Summary

The facility failed to protect a resident's right to be free from neglect, as evidenced by inadequate monitoring and care following the insertion of a catheter. The resident, who was admitted with diagnoses including prostatic hyperplasia, had a catheter inserted to drain urine. However, after the catheter was changed, there was no documentation to confirm that the catheter was properly inserted and draining. The resident subsequently experienced no urine output, and the catheter was removed, revealing a copious amount of blood and clots. Despite the acute change in the resident's condition, there was no documentation of monitoring the resident's status, including vital signs or urine output. The resident was eventually found unresponsive and was emergently transferred to an acute care hospital. The facility's failure to provide necessary care and services to prevent neglect created a likelihood of serious harm, as the resident was found to be unresponsive and required life support upon hospital admission. Interviews with staff and review of the clinical record revealed that the facility did not adequately monitor the resident's condition or follow up on the lack of urine output. The APRN's orders to monitor the resident and send him to the hospital if the condition did not improve were not transcribed in a timely manner. Additionally, there was a lack of communication among staff regarding the resident's condition, contributing to the delay in addressing the resident's acute change in condition.

Plan Of Correction

1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 is no longer a resident. An AHCA Federal Immediate Report with a corresponding investigation was completed by the facility prior to this survey. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • Facility residents with a score of 13 or greater were interviewed regarding the facility's provision of goods and services. • Facility residents with a score of 12 or less had skin evaluations completed. • Current residents had an RN assessment completed including a set of vital signs and observation for output and patency. Any changes identified were communicated to the provider and family notification completed. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Administrator and Director of Nursing were reeducated by Regional Nurse Consultant on: o The components of the regulation: F600 Free from and Neglect o Neglect, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) with indicators of neglect. o Facility standard and guideline P&P Neglect and Investigations to include: - Screening - Training - Prevention - Identification - Investigation - Protection - Reporting • The facility's Staff Development Coordinator/Designee completed education with facility staff on Neglect with an emphasis on the following F600 noncompliance: The facility failed to protect resident rights to be free from neglect by failing to appropriately monitor the resident's output and failure to monitor the resident when the was discontinued. On at approximately 4:30 p.m. resident's was discontinued. Resident experienced copious and was passing clots through his penis. The facility neglected to monitor resident's status including vital signs with a significant change in condition. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs on emptying and measuring output for residents with. This competency was conducted using a mannequin with an to simulate the actual emptying of the. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs and licensed nurses on the proper obtaining of resident vital signs including temperature, and on a live member of staff. Vital signs obtained for an identified change in condition will be documented in the and vitals tab in PCC. This allows for these vitals to populate accurately in the SBAR/Change in Condition evaluation. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, and measuring output for residents with. This competency was conducted using a mannequin with an to simulate the actual emptying of the. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs and licensed nurses on the proper obtaining of resident vital signs including temperature, and on a live member of staff. Vital signs obtained for an identified change in condition will be documented in the and vitals tab in PCC. This allows for these vitals to populate accurately in the SBAR/Change in Condition evaluation. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, or status. o This may include life-threatening conditions, or clinical complications and changes in output including color, consistency, and output. o Circumstances that may require a need to alter treatment. This may include new treatment and/or discontinue of current treatment due to an acute condition or a worsening of a condition. o A complete nursing evaluation must be conducted and documented in the medical record of systems including but not limited to functional status, evaluation, evaluation/ evaluation, skin evaluation, evaluation, and vital signs. o The physician/NP shall be made aware of pertinent evaluation findings. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on vital sign documentation, and on following timely transfer to a higher level of care upon directive from physician. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on care to include insertion, monitoring output, and proper documentation of output, including documenting this output on the resident's MAR. The licensed nurse must perform a visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. System Change: • The facility reviewed all orders. Output was added to the MAR to ensure nursing documentation. • CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. • The daily clinical meeting form was edited to include: o Review of 24-hour report for change in condition. o The review of vital signs and the timely transfer of all residents that returned to the hospital. o The review of all new admissions and existing residents with to ensure orders to monitor output are in place. o The review of vital signs and the review of the nurse's change of condition evaluation for all residents that had a change in condition. o The review of vital signs for all residents per physician order. • Licensed Nurses and CNAs will complete competencies on care at the time of orientation and annually with the facility's Staff Development Coordinator. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. The facility initiated the completion of audits seven days a week including weekends documentation of output for all residents with. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. F 600

Removal Plan

• The facility completed education for almost all of the nursing staff, with remaining staff to be educated before their next scheduled shift.
• Re-education of Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and Licensed Practical Nurses (LPNs) was conducted.
• The facility Administrator and Director of Nursing were re-educated on the components of the regulation F600 Free from and Neglect.
• Staff education on neglect with emphasis on failure to protect resident rights to be free of neglect by failing to monitor output and to monitor the resident when the catheter was discontinued.
• A facility-wide audit of 155 residents was completed to ensure that all residents have physician's orders to take vital signs and that these were transcribed to the medication administration record (MAR).
• Review of all catheter orders and addition of output monitoring to the MAR to ensure nursing documentation.
• CNA education was initiated to ensure any changes in output for residents with catheters and any residents experiencing a change in condition must be reported immediately to the nurse.
• Vital sign assessment competencies including temperature, pulse, and respiration were initiated for staff members.
• The facility initiated audits of residents to ensure the nursing staff completed proper documentation of vital signs.
• An audit for residents with catheters was completed to ensure measuring and documenting of the output was completed on each shift.
• An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done.
• Re-education of nurses was completed, with the remaining nurses to be educated prior to working their next shift.
• Review of random resident records was completed to ensure accurate assessment and interventions were in place to prevent neglect related to the care of residents with catheters and for those who experience a change in condition.

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 licensed nurses possessed the necessary skills and competencies to safely care for residents, particularly in the management of urinary catheters. This deficiency was highlighted by the case of a resident who experienced significant complications due to improper catheter management. The resident, who had a history of prostatic hyperplasia and was admitted with a catheter, suffered from a lack of urine output and the presence of clots, which were not adequately monitored or addressed by the nursing staff. On one occasion, an LPN changed the resident's catheter but failed to verify its proper insertion and drainage, leaving the resident with no urine output. Despite receiving an order to monitor the resident and send him to the hospital if the condition persisted, the LPN did not transcribe the order promptly, resulting in a delay in care. The resident eventually became unresponsive and required emergency transfer to a hospital, where he was intubated. The investigation revealed that the nursing staff lacked proper training and competency evaluations for catheter management. The facility's orientation and competency checklists did not include essential skills such as catheter insertion and monitoring for complications. This oversight contributed to the failure to recognize and respond to the resident's deteriorating condition, ultimately placing the resident at risk of significant harm.

Plan Of Correction

1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 no longer resides at the facility. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • Current residents had an RN assessment completed including a set of vital signs and observation for output and patency. Any changes identified were communicated to the provider and family notification completed. • Current residents with an had an evaluation completed. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, or status. o This may include life-threatening conditions, or clinical complications and changes in output including color, consistency, and output. o Circumstances that may require a need to alter treatment. This may include new treatment and/or discontinuation of current treatment due to an acute condition or a worsening of a condition. o A complete nursing evaluation must be conducted and documented in the medical record of systems including but not limited to functional status, evaluation, evaluation, evaluation/evaluation, skin evaluation, evaluation, and vital signs. o The physician/NP shall be made aware of pertinent evaluation findings. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on vital sign documentation, and on following timely transfer to a higher level of care upon directive from physician. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on care to include insertion, output, and proper monitoring documentation of output, including documenting this output on the resident's MAR. The licensed nurse must perform a visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs and licensed nurses on the proper obtaining of resident vital signs including temperature, and on a live member of staff. Vital signs obtained for an identified change in condition will be documented in the and vitals tab in PCC. This allows for these vitals to populate accurately in the SBAR/Change in Condition evaluation. • The facility's Staff Development Coordinator/Designee completed competencies with licensed nurses on the proper insertion of with return demonstrations. • The facility added to the orientation agenda that all newly hired licensed nurses will complete competencies on the proper insertion of with return demonstration prior to providing resident care. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the requirement of detailed communication during shift to shift report to include any changes in condition, any new physician orders, and review of any new or existing devices including. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. • The facility's Staff Development Coordinator/Designee completed competencies with CNAs on emptying and measuring output for residents with. This competency was conducted using a mannequin with an to simulate the actual emptying of the. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. System Change: • The daily clinical meeting form was edited to include: o Review of 24-hour report for change in condition. o The review of vital signs and the timely transfer of all residents that returned to the hospital. o The review of all new admissions and existing residents with to monitor output to ensure orders are in place. o The review of vital signs and the review of the nurse's change of condition evaluation for all residents that had a change in condition. o The review of vital signs for all residents per physician order. o Output was added to the MAR to ensure nursing documentation. • CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. • Licensed Nurses and CNAs will complete competencies on care at the time of orientation and annually with the facility's Staff Development Coordinator. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. • The facility initiated the completion of audits seven days a week including weekends documentation of output for all residents with. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee.

Removal Plan

• Educated licensed nurses on completing a Change in Condition Assessment on residents.
• The education included identifying conditions that required an assessment including: Accidents resulting in injury; significant change in the resident's physical or mental condition, deterioration in health, mental or status; life threatening conditions or clinical complications including changes in output including color, consistency and output; circumstances that require an alteration in treatment including acute and conditions.
• A complete nursing evaluation must be conducted and documented in the medical record of systems.
• The nurses were educated to obtain a new set of vital signs and document in the electronic record in that the Change in Condition Assessment would contain the most recent and relevant vital signs.
• The provider shall be notified of pertinent evaluation findings.
• Nurses must visualize amount of output, color and clarity during each shift.
• Educated all remaining licensed nurses prior to working their next scheduled shift.
• Began CNA and licensed nurse competencies on obtaining vital signs.
• Vital signs obtained for a change in condition are to be documented in the electronic record under the and vitals tab, so they populate in the change in condition assessment.
• Completed audits including weekends and off hours to ensure the proper documentation of vital signs for all residents.
• Initiated the completion of audits 7 days a week and off hours to include output for all residents.
• Edited the daily clinical meeting form to include review of the 24-hour report for change in condition; vital signs and timely transfer to a higher level if necessary: for new and existing residents to ensure orders to monitor output were in place; review of the nurses' Change in condition Assessment to include current vital signs during the change, and review of the vital signs for all residents per the physician's orders.
• The RN assessed all residents currently at the facility for vital signs and output if indicated. Any changes were communicated to the provider and family.
• Began competencies on the proper insertion of licensed nurses. The remaining licensed nurses would complete the competency prior to working their next scheduled shift.
• Added to the orientation agenda for newly hired licensed nurses. They will complete competency on the proper insertion of with return demonstration prior to resident care.
• Began education with licensed nurses on the requirement of detailed communication during shift-to-shift report to include any changes in condition, new orders, and review any existing devices.
• The education was also added to the orientation for all newly hired nurses.
• Began educating nurses on ensuring new orders for will include placement, patency/draining, irrigation, securement, care every shift and recording of output on the MAR.
• Verified through observation and interview, nurses were educated prior to working their next shift.
• Verified through interview with the DON and review of audits completed, interviews with CNAs, nurses and review of random residents records to ensure proper nursing care and services for residents with and those experiencing changes in condition.
• An ad hoc QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities Director, Minimum Data Set nurse, Nurse, CNA.

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's administration failed to ensure that nursing staff were adequately trained and competent in the care of residents with specific medical needs, leading to the neglect of a resident with a diagnosis of prostatic hyperplasia. The resident had a catheter inserted to drain urine, but nursing staff did not ensure the catheter was properly inserted and draining. The staff failed to notify the physician in a timely manner when the resident had no urine output for an extended period, resulting in a significant delay in addressing the resident's condition. The nursing staff also neglected to monitor the resident's vital signs and condition after the catheter was removed, despite the presence of blood clots and a lack of urine output. The resident was eventually found unresponsive and was transferred to the hospital in a critical state. The facility's documentation of the resident's urine output was inconsistent and inaccurate, further complicating the assessment of the resident's condition. Interviews with facility staff revealed that there was a lack of competency assessments for nursing staff regarding catheter care and monitoring. The Director of Nursing admitted that the facility had not been conducting necessary competency evaluations, and the staff educator confirmed that the competency checklist was not properly utilized. This lack of oversight and training contributed to the inadequate care provided to the resident, ultimately resulting in immediate jeopardy to the resident's health and safety.

Plan Of Correction

1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 no longer resides in the facility. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • The VP of Operations re-reviewed the job description of the Administrator with Nursing Home Administrator. During this review, it was discussed in detail that the administrator must ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental, and wellbeing consistent with the resident's comprehensive assessment and plan on care. • The VP of Operations and NHA re-reviewed the job description of the Director of Nursing with the Director of Nursing. During this review, it was discussed in detail that the purpose of her position is to plan, organize, develop, and direct the overall operation of the nursing services department in accordance with federal, state, and local standards, guidelines, and regulations to ensure the highest degree of quality care is maintained at all times. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Staff Development Coordinator/Designee completed competencies with licensed nurses on the proper insertion of with return demonstrations. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, or status. o This may include life-threatening conditions, or clinical complications and changes in output including color, consistency, and output. o Circumstances that may require a need to alter treatment. This may include new treatment and/or discontinuation of current treatment due to an acute condition or a worsening of a condition. o A complete nursing evaluation must be conducted and documented in the medical record of systems including but not limited to functional status, evaluation, evaluation/evaluation, evaluation, skin evaluation, evaluation, and vital signs. o The physician/NP shall be made aware of pertinent evaluation findings. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on vital sign documentation, and on following timely transfer to a higher level of care upon directive from physician. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on care to include insertion, monitoring output, and proper documentation of output, including documenting this output on the resident's MAR. The licensed nurse must perform a visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Administrator and Director of Nursing were reeducated by Regional Nurse Consultant on: o The components of the regulation: F600 Free from and Neglect o Neglect, Misappropriation, Mistreatment, and injury of Unknown Origin (ANEMMI) with indicators of neglect. o Facility standard and guideline P&P Neglect and Investigations to include: - Screening - Training - Prevention - Identification - Investigation - Protection - Reporting • The facility's Staff Development Coordinator/Designee completed education with facility staff on Neglect with an emphasis on the following F600 noncompliance: The facility failed to protect resident rights to be free from neglect by failing to appropriately monitor the resident's output and failure to monitor the resident when the was discontinued. On approximately 4:30 p.m. resident's was discontinued. Resident experienced copious and was passing clots through his penis. The facility neglected to monitor resident's status including vital signs with a significant change in condition. • The DON and Nurse Management Team were educated by the Regional Nurse Consultant on the components of the management of with an emphasis on output monitoring and ANEMI. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the requirement of detailed communication during shift to shift report to include any changes in condition, any new physician orders, and review of any new or existing devices including. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. System Change: • The daily clinical meeting form was edited to include: o Review of 24-hour report for change in condition. o The review of vital signs and the timely transfer of all residents that returned to the hospital. o The review of all new admissions and existing residents with to monitor to ensure orders are in place. output o The review of vital signs and the review of the nurse's change of condition evaluation for all residents that had a change in condition. o The review of vital signs for all residents per physician order. • Licensed Nurses and CNAs will complete competencies on care at the time of orientation and annually with the facility's Staff Development Coordinator. • The Director of Nursing/designee will operate as the lead investigator on all clinical investigations to ensure that the review of the care provided to facility residents meets standards. • The Administrator and Director of Nursing will complete a comprehensive investigation to include a 72-hour look of events to ensure no deprivation of care or services occurred. On the Administrator and Director of Nursing were educated by the regional nurse consultant on utilizing an investigation checklist to ensure all elements and facts are thoroughly reviewed and completed. • All facility investigations related to ANEMI will be reviewed in detail with the facility's Medical Director to ensure all areas of the investigation were completed and that the facility has identified the root cause of the incident. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee. • The facility initiated the completion of audits seven days a week including weekends documentation of output for all residents with. These audits will be monitored by DON/designee and reviewed by the QAPI committee. These audits will be completed weekly x 4 weeks, biweekly x 2 months, then monthly thereafter until substantial compliance is determined by the QAPI committee.

Removal Plan

• The Vice President of Operations reviewed their job descriptions with the Nursing Home Administrator (NHA) and Director of Nursing (DON) to ensure that the administrator must ensure that each resident receives necessary care and services to attain and maintain the highest practical physical, mental and well-being consistent with the resident's comprehensive assessment and plan of care.
• The Vice President of Operations and NHA re-reviewed the job description of the DON with the DON to ensure the purpose of her position is to plan, organize, develop, and direct the overall operation of the nursing services department in accordance with regulations and standards, guidelines, and to ensure the highest degree of care is maintained at all times.
• The DON will be lead investigator on all clinical investigations to ensure resident care met all accepted standards. This investigation will include a 72-hour look in time to include additional information on the events leading to the event.
• Investigations on Neglect, Misappropriation, and Injury will be reviewed in detail with the medical director to ensure all areas of the investigation were completed and that the facility has identified the root cause analysis of the incident.
• The NHA and DON will complete a comprehensive investigation to include a 72-hour look on events to ensure no deprivation of care or services occurred. The NHA and DON were educated by the regional nurse consulted on utilizing an investigation checklist to ensure all elements and facts are thoroughly reviewed and completed.
• The facility conducted an unplanned QAPI (Quality Assurance and Performance Improvement) meeting and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities, Director, Minimum Data Set nurse, Nurse, CNA. The meeting addressed the adequate monitoring of output for residents and the adequate monitoring of vital signs for residents with changes in condition. The DON rereviewed the facility assessment and identified the facility's clinical capabilities included caring for residents without nurse competency for completed.
• The facility initiated training to the nurses for insertion and return demonstration for 42 of 50 nurses with all nurses to be retrained prior to working their next shift. Verified the retraining and return demonstration for Staff A, LPN, Staff C, LPN, Staff B, LPN, and Staff D.
• The facility added to the orientation plan of all newly hired nurses to include complete competencies on the proper insertion of with return demonstration prior to providing resident care.
• CNA education was initiated to ensure the following: any notable changes in output for residents and those residents experiencing a change in condition must be reported immediately to the nurse. CNAs were educated by all remaining CNAs are to be educated prior to working their next shift.
• The facility educated their licensed nurses on completing a Change in Condition Assessment on residents. The education included identifying conditions that required an assessment including: Accidents resulting in injury; significant change in the resident's physical or mental condition, deterioration in health, mental or output status; life threatening conditions or clinical complications including changes in including color, consistency and output: circumstances that require an alteration in treatment including acute and conditions. A complete nursing evaluation must be conducted and documented in the medical record of systems. The nurses were educated to obtain a new set of vital signs and document in the electronic record in that the Change in Condition Assessment would contain the most recent and relevant vital signs. The provider shall be notified of pertinent evaluation findings. Nurses must visualize for amount of output, color and clarity during each shift.
• Nurses were re-educated. The remaining nurses will be educated prior to working their next shift.
• The facility initiated audits of residents in the facility to ensure the nursing staff was recording vital signs and proper documentation of those vital signs.
• The facility initiated audits of residents to ensure the measuring and documenting of the output each shift.
• The facility edited the daily clinical meeting to include the review of all residents with changes in condition to ensure vital signs and a timely transfer was completed; review of all new and existing residents with had monitoring and documenting of output amount in place, review of vital signs for all residents per physician order.
• The Nursing Home Administrator (NHA) and Director of Nursing (DON) were re-educated on the policy and procedure for Neglect, and by the Regional Clinical Nurse. The education included screening, training staff to prevent neglect and all allegations of neglect are to be reported to the NHA or the person in charge immediately. Investigation, protection, and reporting to follow.
• The facility began staff in-service training and education on and Neglect with the emphasis on failure to protect resident rights to be free of neglect by failing to monitor output and to monitor the resident when the was discontinued. The resident experienced copious amounts of and clots through his penis. The facility failed to monitor vital signs with a significant change in condition. 141 of 171 staff members received this education by all remaining staff would be educated prior to working their next shift.
• The DON and nurse management team was re-educated by the regional clinical director on the components of the management of with an emphasis on Neglect, Misappropriation, and Injury.
• The facility initiated education with licensed nurses to ensure new orders for included placement, patency/draining, irrigation, securement, care each shift and recording of output on the MAR.
• 37 nurses out of 50 were educated. The surveyor verified through interviews that the nurses were educated prior to working their next shift.
• The facility educated nurses on the requirement of detailed communication during shift-to-shift report will include any changes in condition, any new orders, and review any new or existing devices including verified the training of 39/50 nurses by all remaining licensed nurses will be educated prior to working their next shift. This education has also been added to the orientation agenda for all newly hired licensed nurses to be provided prior to resident care.
• A QAPI (Quality Assurance and Performance Improvement) meeting was held, and a root cause analysis of the incident was done. Attendees of the QAPI included the Medical Director, Director of Nursing, Administrator, Human Resources, Social Service, Activities. Director, Minimum Data Set nurse. Nurse. CNA.
• The surveyor verified through interviews with the DON and facility staff, review of the audits, and review of 6 random resident records to ensure accurate assessment of resident vital signs, obtaining and documenting output and proper documentation for residents experiencing a change in condition.

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

Complaint #2025003458 was substantiated with a citation at N201, and Complaint #2025002491 was substantiated with citations at N201 and N204. A male resident was admitted to the facility with a condition related to prostatic hyperplasia. On a specific morning, the resident's condition was not adequately monitored after a change in his medical device, leading to a lack of output being observed. Later that day, the device was removed due to no output, and the resident experienced a significant medical event involving copious amounts of fluid and clots. The facility failed to monitor the resident's condition, including vital signs, which resulted in the resident being emergently transferred to the hospital. Upon arrival at the hospital, the resident was unresponsive to painful stimuli, had low blood pressure, and a fever, leading to intubation and hospital admission. The facility's failure to adequately monitor the resident with a significant change in condition resulted in neglect and created a likelihood of serious harm or injury.

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 procedures to identify the risk for elopement and adequately monitor a cognitively impaired resident who left the facility without staff knowledge. The resident, who had a history of severe cognitive impairment, was found outside the facility by the Assistant Director of Nursing (ADON) and was followed in a car until stopped. The resident had previously been assessed as not at risk for elopement, despite having a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment and expressing a desire to leave the facility. The resident's care plan was updated to include a wander alert bracelet only after the incident occurred. The facility's policy on missing residents and elopement was not followed, as there was no formal investigation conducted, and the incident was not considered an elopement by the Director of Nursing (DON) and the Regional Nurse. The Maintenance Director was unaware of any issues with the door alarms, and the facility did not determine through which door the resident exited. Interviews with staff revealed that the resident was not familiar to the DON, and the incident was not reported as an elopement because the resident was followed by the ADON. The Occupational Therapist had previously recommended distant supervision for the resident's use of an electric scooter, but no elopement evaluation was conducted when the resident began using the scooter. The facility's failure to recognize and address the resident's elopement risk contributed to the deficiency.

Plan Of Correction

1) Resident #1 elopement evaluation completed. 2) Current residents had elopement evaluations completed. 3) Systematic Change: Residents will be evaluated for elopement on admission, readmission, quarterly, and with a change in conditions. Residents identified for an electric scooter will have an elopement evaluation completed prior to receiving the scooter. The Regional Director of Clinical Services reeducated the DON regarding the completion of a thorough investigation. The DON educated staff regarding nursing communication for residents receiving electric scooters. The ADON reeducated current staff regarding identifying residents at risk of elopement. New staff will be educated during orientation. 4) The Facility DOR/Designee will conduct a quality review of residents receiving electric scooters for assessment of use to ensure nursing communication is completed so that the completion of elopement evaluations can be initiated weekly for 4 weeks, then every 2 weeks for 2 months, then monthly. Results of these audits will be presented to the QAPI committee until the committee determines substantial compliance has been achieved. The Facility ADON/Designee will conduct a quality review of 10 residents for completion of elopement evaluations on admission, readmission, quarterly, significant change, and prior to approval of electric scooters weekly for 4 weeks, then every 2 weeks for 2 months, then monthly. Results of these audits will be presented to the QAPI committee until the committee determines substantial compliance has been achieved.

Penalty

Inspection fine: $274,053

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

Summary

The facility failed to provide appropriate care for a resident with a urinary catheter, leading to a deficiency in catheter management and infection control. The resident, admitted for rehabilitation after pacemaker surgery, had a urinary catheter placed due to urinary retention. However, the catheter was not secured to the resident's thigh, causing discomfort and potential friction at the insertion site. Observations revealed that the catheter drainage bag and tubing were often on the floor, contrary to the facility's policy for infection control. Interviews with staff indicated a lack of awareness regarding the necessity of the catheter and proper securing techniques. The resident expressed discomfort and a desire for the catheter's removal, stating it was uncomfortable and unnecessary. Despite the resident's ability to void, there was no follow-up or voiding trial conducted to assess the need for continued catheter use. The facility's comprehensive assessment listed a diagnosis of obstructive uropathy, but staff interviews revealed uncertainty about the justification for the catheter. The lack of proper securing and infection control measures, along with inadequate assessment of the catheter's necessity, contributed to the deficiency.

Penalty

Inspection fine: $274,053

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 staff followed safety precautions in the care plan for a resident, leading to an avoidable fall and fracture. The resident, who had intact cognition and was dependent on staff for activities of daily living, was at risk for falls due to general weakness, decreased mobility, and other health conditions. The care plan specified that the resident required the assistance of two staff members for bed mobility. However, during a bed bath, a CNA provided care independently, contrary to the care plan instructions. During the incident, the CNA was drying the resident and changing sheets when the resident used the assist bar to roll over, resulting in her legs sliding off the bed and causing a fracture. The CNA's failure to follow the care plan, which required two-person assistance, was identified as the cause of the fall. The facility's investigation concluded that the injury could have been avoided if the care plan had been followed, and the CNA was suspended pending further investigation.

Penalty

Inspection fine: $274,053

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 urinary catheters in a sanitary manner for four residents, leading to potential infection risks. Observations revealed that catheter drainage bags for these residents were in contact with the floor, contrary to the facility's policy which mandates that catheter tubing and drainage bags be kept off the floor to prevent catheter-associated urinary tract infections. Photographic evidence confirmed these observations, and staff interviews corroborated the improper handling of catheter equipment. Additionally, the facility did not ensure that intravenous (IV) access devices were dated and secured properly for two residents. One resident's IV dressing was not dated, and the transparent dressing was rolled up on the edges, making it impossible to determine when it was last changed. Another resident's IV dressing was outdated, with the date on the dressing not matching the date recorded in the medication administration record. The Infection Preventionist confirmed these discrepancies, highlighting a failure to adhere to the facility's policy for changing IV dressings every seven days or as needed. The deficiencies were further supported by staff interviews, where it was acknowledged that the catheter drainage bags should not be in contact with the floor and that IV dressings should be changed regularly to prevent infection. The report indicates a lack of adherence to established infection control protocols, which are critical in preventing infections in residents with indwelling catheters and IV access devices.

Penalty

Inspection fine: $274,053

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 to maintain personal hygiene for two residents, leading to deficiencies in their activities of daily living (ADLs). Resident #252, who required substantial to maximum assistance with personal hygiene, was observed with significant facial hair growth and untrimmed, dirty fingernails. Despite being scheduled for showers twice a week, the resident only received one shower over a period of several weeks, with the rest being bed baths. The resident expressed a desire for a shave and a shower but was not provided with these services consistently. Resident #61, who was dependent on staff for all ADLs due to dementia and functional decline, was also found with long, dirty fingernails and facial hair. The resident's care plan required assistance from two staff members for showering, but documentation showed missed scheduled showers. The resident reported not receiving oral care and experiencing discomfort due to a curled hand, which was supposed to be managed with a splint. Observations confirmed the lack of personal hygiene care, including dry and peeling lips. Interviews with staff revealed inconsistencies in the provision of care, with CNAs acknowledging the residents' needs but failing to meet them. The facility's policy aimed to ensure residents' needs were met to promote quality of life, but the observed deficiencies indicated a failure to adhere to this policy, resulting in unmet personal hygiene needs for the residents involved.

Penalty

Inspection fine: $274,053

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 limited range of motion (ROM) received appropriate treatment and services to prevent further decline. The facility's policy required that residents with limited ROM should receive treatment to increase or prevent further decrease in ROM. However, Resident #61, who had limitations in ROM on one side of the upper body and both sides of the lower body, was not provided with the necessary interventions as outlined in their care plan. The care plan specified the use of a palm guard for the left hand, but observations revealed that the resident was not wearing the palm guard, and the hand was curled into a tight fist. Interviews with the resident and staff indicated a lack of adherence to the care plan. The resident expressed an inability to open the left hand and reported pain, while staff interviews revealed confusion about the use of a splint. The Unit Manager and a Certified Nursing Assistant (CNA) acknowledged that the resident was supposed to wear a splint, but it was not being used as required. The CNA Kardex also indicated the need for a palm guard, but this was not consistently implemented, leading to the deficiency in care for Resident #61.