Dade City Health And Rehabilitation Center

Penalty

Inspection fine: $26,685

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

Summary

The facility failed to honor a resident's Do Not Resuscitate (DNR) order, resulting in the initiation of Cardiopulmonary Resuscitation (CPR) against the resident's documented wishes. On the date of the incident, a registered nurse (RN) found the resident unresponsive and without a pulse. The RN instructed a certified nursing assistant (CNA) to call a code and began chest compressions. After performing two compressions, the RN was informed that the resident had a DNR order in place and discontinued CPR. The DNR order was present in the resident's medical record and in the code status binder at the nurses' station, and the resident's care plan clearly indicated the existence of a DNR order. The resident involved had significant medical conditions, including dementia with severe cognitive impairment, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, chronic kidney disease, anxiety, depression, insomnia, hypertension, and Hodgkin's Lymphoma. The resident's DNR order was fully executed and documented in both the electronic health record and the physical code status binder. Despite these clear directives, staff failed to verify the resident's code status before initiating CPR, which was contrary to the resident's end-of-life wishes and facility policy. Interviews with staff revealed gaps in training and knowledge regarding code status verification and DNR procedures. The RN involved reported that orientation did not include education on Code Blue or DNR procedures, nor was she trained on how to locate a resident's code status in the electronic health record. Other staff members confirmed that the code status was not checked prior to the initiation of CPR. Facility policy required verification of code status by two nurses before starting CPR, but this protocol was not followed, resulting in the resident's DNR wishes not being honored.

Removal Plan

• Audit of the code status binders to validate DNR forms are in the appropriate binder.
• Audit to verify residents' DNR forms are present in the electronic medical record, physician orders are in place, and care plans are reflective of residents' code status.
• Staff education instructing licensed nurses to evaluate residents for absence of vital signs, and if vital signs are absent, to follow residents' Advanced Directive. If the resident has DNR orders, notify the provider for further orders.
• Staff education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
• Education completed by all staff, excluding those on leave from work.
• Process initiated for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
• Quality Assurance and Performance Improvement (QAPI) committee meeting conducted with the Medical Director, Administrator, Director of Nursing, and Interdisciplinary team members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.
• QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results.
• QAPI committee reviewed education completion rates for licensed nurses and all other staff; staff on leave will be educated upon return.
• QAPI committee discussed ongoing monitoring audits including education validation; all staff interviewed answered questions appropriately.
• Code Blue drills continue until all nursing staff participate.
• QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
• QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.
• Completed audits titled 'Code staff education validation' observed; no issues identified.
• Licensed nurses received additional education regarding two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text, for orders and to clearly document in the medical record.
• Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
• All nurses received an electronic copy of the education. Licensed nurses are required to sign the education acknowledgment sheet before working.
• Verification of the facility's removal plan conducted by the survey team through interviews with CNAs and licensed nurses to verify education related to their role during a Code Blue, the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.
• In-service attendance signature sheets and a log of electronic communications reviewed, which confirmed that nurses received the in-service training about the new processes.

Penalty

Inspection fine: $26,685

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

Summary

A deficiency occurred when staff failed to honor a resident's Do Not Resuscitate (DNR) order during a medical emergency. The resident, who had severe cognitive impairment and multiple medical diagnoses including dementia, diabetes, and chronic kidney disease, was found unresponsive and without a pulse. Despite the presence of a valid DNR order in both the medical record and the facility's designated binder, a registered nurse initiated chest compressions before being informed of the resident's DNR status and subsequently discontinued resuscitation efforts. Interviews revealed that the nurse involved had not received adequate training on CPR or DNR procedures, nor on how to locate a resident's code status in the electronic health record or the physical binder. Other staff members, including CNAs and LPNs, were unclear about their roles during a code situation and the process for verifying code status. The facility's policy required two nurses to verify code status before initiating CPR, but this protocol was not followed in this incident. Documentation confirmed that the resident's care plan and medical orders clearly indicated a DNR status, and the facility's policies emphasized the right of residents to refuse treatment and have their advance directives honored. However, the failure to verify and adhere to the resident's DNR order resulted in the initiation of unwanted resuscitative measures, constituting neglect as defined by the facility's own policies and federal regulations.

Removal Plan

• Audit of the code status binders to validate DNR forms are in the appropriate binder.
• Audit to verify residents' DNR forms are present in the electronic medical record, physician orders are in place, and care plans are reflective of residents' code status.
• Staff education provided instructing licensed nurses to evaluate residents for absence of vital signs, and if vital signs are absent, to follow residents' Advanced Directive. If the resident has DNR orders, notify the provider for further orders.
• Staff received education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
• Process initiated for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
• Ad hoc Quality Assurance and Performance Improvement (QAPI) committee meeting conducted with the Medical Director, Administrator, Director of Nursing, and additional IDT members to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.
• QAPI committee reviewed the plan viability of the advance directives process, code process, code status binder process, and audit results.
• QAPI committee reviewed education completion rates.
• QAPI committee discussed ongoing monitoring audits including education validation.
• Code Blue drills continue until nursing staff participate.
• QAPI committee reviewed ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
• QAPI committee continued review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.
• Completed audits titled 'Code staff education validation' observed.
• Licensed nurses received additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text, for orders and to clearly document in the medical record.
• Director of Nursing and Unit Manager designees began educating licensed nurses on evaluating residents for the absence of vital signs. Staff instructed that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified for further orders. Staff are also required to notify the DON when a resident is noted to be absent of vital signs. Education emphasized that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
• Nurses received an electronic copy of the education. Licensed nurses must complete the education prior to starting their next shift.
• Licensed nurses are required to sign the education acknowledgment sheet before working.
• Interviews conducted with CNAs working across all shifts to verify education related to their role during a Code Blue, the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.
• Licensed nurses received additional education on two nurses confirming the absence of vital signs, notifying a physician by telephone, do not text for orders, and to clearly document in the medical record.
• Licensed nurses received additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to notify the physician or Medical Director for additional orders.
• Interviews conducted with licensed nurses working across all shifts to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills.
• In-service attendance signature sheets and a log of electronic communications reviewed, which confirmed that nurses received the in-service training about the new processes.

Penalty

Inspection fine: $26,685

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

Summary

The facility failed to honor a resident's Do Not Resuscitate (DNR) order when staff initiated cardiopulmonary resuscitation (CPR) without first verifying the resident's code status. The incident involved a resident with severe cognitive impairment and multiple comorbidities, including dementia, diabetes, vascular implants, osteoarthritis, chronic kidney disease, anxiety, depression, insomnia, hypertension, and Hodgkin's Lymphoma. The resident had a fully executed DNR order documented in both the medical record and the facility's code status binder, as well as a valid state DNR form. On the day of the incident, the resident was found unresponsive and without a pulse. A registered nurse (RN) instructed a certified nursing assistant (CNA) to call a code and began chest compressions before being informed by staff that the resident had a DNR order. The RN discontinued compressions after performing one or two chest compressions. Multiple staff interviews confirmed that the code status was not checked prior to initiating CPR, and that the expectation was for two nurses to verify code status in both the electronic health record (EHR) and the code status binder before starting resuscitative measures. Facility policy required adherence to residents' advance directives and DNR orders, with clear procedures for verifying and documenting code status upon admission and during care. Despite these policies, staff failed to follow the established process, resulting in the resident's wishes not being honored at the time of death. The deficiency was identified as Immediate Jeopardy due to the failure to respect the resident's advance directive.

Removal Plan

• Audit of the code status binders to validate DNR forms are in the appropriate binder.
• Audit to verify residents' DNR forms are present in the electronic medical record, physician orders are in place, and care plans are reflective of residents' code status.
• Provide staff education instructing licensed nurses to evaluate residents for absence of vital signs, and if vital signs are absent, to follow residents' Advanced Directive. If the resident has DNR orders, notify the provider for further orders.
• Provide staff education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
• Initiate a process for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
• Conduct ad hoc Quality Assurance and Performance Improvement (QAPI) committee meetings to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.
• QAPI committee to review the plan viability of the advance directives process, code process, code status binder process, and audit results.
• QAPI committee to review education completion rates and ongoing monitoring audits including education validation.
• Continue Code Blue drills until 100% of nursing staff participate.
• QAPI committee to review ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
• Provide licensed nurses with additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text, for orders and to clearly document in the medical record.
• Director of Nursing and Unit Manager designees to educate licensed nurses on evaluating residents for the absence of vital signs.
• Instruct staff that if vital signs are absent, they must follow the residents' Advanced Directive. For residents with DNR orders or if death occurs in the facility, the physician must be notified for further orders.
• Require staff to notify the DON when a resident is noted to be absent of vital signs.
• Emphasize in education that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
• Provide 100% of the nurses with an electronic copy of the education. Require licensed nurses to sign the education acknowledgment sheet before working.
• Conduct verification of the facility's removal plan.
• Conduct interviews with CNAs to verify education related to their role during a Code Blue, the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.
• Provide licensed nurses with additional education on confirming the absence of vital signs and for residents with a DNR order nurses are required to notify the physician or Medical Director for additional orders.
• Conduct interviews with licensed nurses to verify training and knowledge about the new policies and processes, completed code status competencies, and participation in code blue drills.
• Review in-service attendance signature sheets and a log of electronic communications to confirm nurse training completion.

Penalty

Inspection fine: $26,685

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

Nursing staff failed to verify and honor a resident's Do Not Resuscitate (DNR) order when the resident was found unresponsive and without a pulse. Despite the presence of a valid DNR order in the medical record and code status binders, a registered nurse initiated chest compressions before being informed of the resident's DNR status, at which point resuscitation efforts were discontinued. The incident occurred after the nurse instructed a CNA to call a code and began CPR, only stopping after being notified of the DNR order. The resident involved had multiple diagnoses, including dementia, Type 2 Diabetes Mellitus, vascular implants, osteoarthritis, chronic kidney disease, anxiety, depression, insomnia, hypertension, and Hodgkin's Lymphoma. The resident's care plan and medical record clearly indicated a DNR order, and the resident was severely cognitively impaired, as evidenced by a low BIMS score. Staff interviews revealed that the nurse involved had not received specific training on CPR or DNR procedures, nor on how to locate code status information in the facility's systems or binders during orientation. Further review of facility policies, job descriptions, and orientation materials showed that while procedures and competencies regarding code status and DNR orders existed, they were not effectively communicated or implemented with all staff. The nurse involved was unaware of the location of DNR documentation and the process for verifying code status, leading to the failure to honor the resident's advance directive at the time of the emergency. This deficiency resulted in the determination of Immediate Jeopardy.

Removal Plan

• Audit code status binders to validate DNR forms are in the appropriate binder.
• Audit to verify residents' DNR forms are present in the electronic medical record, physician orders are in place, and care plans are reflective of residents' code status.
• Provide staff education instructing licensed nurses to evaluate residents for absence of vital signs and to follow residents' Advanced Directive if vital signs are absent.
• If the resident has DNR orders, staff are to notify the provider for further orders.
• Provide staff education on Abuse and Neglect, with emphasis on the importance of following residents' wishes regarding code status.
• Initiate a process for newly hired facility staff to receive the above education during orientation and prior to working any assignment.
• Conduct QAPI committee meetings to review adherence to policy and procedure for advance directives, code status in the electronic health record, code status binders, following physician orders, and results of the root cause analysis.
• QAPI committee to review the plan viability of the advance directives process, code process, code status binder process, and audit results.
• QAPI committee to review ongoing monitoring audits including education validation; ensure staff interviewed answer questions appropriately.
• Continue Code Blue drills until all nursing staff participate.
• QAPI committee to review ongoing audits, including validation of code status for new/re-admissions and staff education during general orientation.
• QAPI committee to continue review of ongoing monitoring audits including education validation, code status validation for new/re-admissions, and orientation education.
• Provide licensed nurses additional education on two nurses confirming the absence of vital signs and notifying the health care provider by telephone, not text, for orders and to clearly document in the medical record.
• Director of Nursing and Unit Manager designees to educate licensed nurses on evaluating residents for the absence of vital signs and following the residents' Advanced Directive.
• For residents with DNR orders or if death occurs in the facility, notify the physician for further orders.
• Require staff to notify the DON when a resident is noted to be absent of vital signs.
• Emphasize in education that, per the Nurse Practice Act, only a physician may pronounce death; a licensed nurse (RN or LPN) cannot do so.
• Distribute an electronic copy of the education to all nurses.
• Require licensed nurses to sign the education acknowledgment sheet before working.
• Conduct interviews with CNAs and licensed nurses to verify education related to their role during a Code Blue, the Stop, Think, and Perform process, resident rights, participation in Code Blue drills, and education on resident rights.
• Review in-service attendance signature sheets and a log of electronic communications to confirm training completion.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate supervision and implement appropriate interventions to prevent falls for three residents with known fall risks. For one resident with dementia and muscle weakness, multiple falls occurred, including incidents where the resident attempted to transfer without assistance and sustained injuries such as a bruised elbow and a laceration above the eyebrow. Documentation revealed that post-fall assessments and neuro checks were inconsistently completed, with missing times for monitoring and lack of new neuro checks after subsequent falls. The Interdisciplinary Team (IDT) did not review fall events promptly, and care plan interventions were either vague or not updated to address the specific circumstances of each fall. Another resident with a history of cerebral infarction, muscle weakness, and lack of coordination experienced a witnessed fall after rolling out of bed while drowsy. The post-fall evaluation noted poor lighting as an environmental factor and documented a significant bruise. However, the IDT post-fall review was delayed by several days, and the care plan interventions were not clearly documented or tailored to the resident's needs at the time of the fall. There was also confusion in the documentation regarding whether the fall was witnessed or unwitnessed, and staff education provided as an intervention was not recorded in the medical record. A third resident with Huntington’s disease, dementia, and a history of falls was found on the bathroom floor with abrasions and redness after an unwitnessed fall. The post-fall evaluation and IDT review contained discrepancies in the timing of the fall, and no new interventions were added to the care plan following the incident. The recommended medication regimen review was not documented as completed, and there was no evidence that neuro checks were performed as required. These deficiencies demonstrate a lack of timely assessment, documentation, and individualized intervention following fall events, contrary to the facility’s own policies for accident prevention and supervision.

Penalty

No penalty information released

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

Summary

The facility failed to properly hold, secure, and manage each resident's personal money that was deposited with the nursing home. This deficiency indicates that the required procedures for safeguarding and accounting for residents' funds were not followed as specified.

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 promptly resolve a grievance submitted by the family member of a resident with dementia, muscle weakness, and a need for personal care. The family member, who held power of attorney for financial and care matters, raised concerns regarding the resident's patient trust account, including a $400 deposit, an $1800 refund, and the monthly posting of a $160 personal allowance. These concerns were first communicated in February and continued through multiple emails and a formal grievance submitted in June. Despite repeated requests for an accounting of the resident's funds and documentation of specific transactions, the issues remained unresolved as of mid-July. Interviews with facility staff, including the Social Service Director, Assistant Business Office Manager, and Business Office Manager, confirmed that the grievance was ongoing and had not been addressed. The grievance form indicated that the Business Office Manager was assigned to investigate the matter, but there was no evidence of an investigation or a plan to resolve the complaint. The facility's own policy required prompt efforts to resolve grievances, but documentation and staff statements showed that the family member's concerns about the resident's trust account were not resolved in a timely manner.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accurate and complete documentation of resident medical records, specifically regarding skin and wound care, for four residents. Resident #1's records showed discrepancies between physician orders and LTC notes, with a noted absence of wound documentation despite the presence of a stage 4 pressure ulcer. This inconsistency highlights a lack of adherence to professional standards in maintaining accurate medical records. Resident #2's documentation was incomplete and inconsistent, with missing progress notes and delayed initiation of wound care. Despite being admitted with multiple skin issues, including a pressure ulcer, the records lacked detailed descriptions and timely wound care orders. The baseline care plan was also incomplete, missing crucial information about the resident's skin integrity and necessary interventions. For Resident #3, the facility's records showed a delay in starting ulcer care and a lack of consistent documentation in the Skilled Nursing Notes. The Weekly Skin Evaluations were inconsistent with the actual condition of the resident's skin, failing to address existing wounds. Similarly, Resident #4's records were missing necessary LTC Nurse Notes, and the documentation did not adequately address the resident's wounds. These deficiencies indicate a systemic issue in the facility's documentation practices, impacting the quality of care provided to residents.

Penalty

No penalty information released

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

Summary

The facility failed to obtain timely wound care orders and perform wound care for a resident, leading to a deficiency in care. The resident was admitted with multiple diagnoses, including congestive heart failure, chronic obstructive pulmonary disease, and diabetes, and had existing skin issues such as a deep tissue injury to the left buttocks and scabs on the bilateral lower extremities. Despite these conditions, the facility did not start the prescribed wound care until three days after the resident's admission, even though the orders were received earlier. The facility's documentation practices contributed to the deficiency. The Treatment Administration Record (TAR) showed inconsistencies in documenting wound care, with some treatments not recorded on the day they were performed due to system limitations. Additionally, the Skilled Nursing Notes lacked documentation of the resident's wounds, and the care plans did not adequately address pressure ulcer interventions. Interviews with staff revealed that the facility's policy did not require wound measurements until the consultant wound nurse's visit, which could be delayed by several days. The Director of Nursing (DON) acknowledged the lapses in documentation and care, noting that the wound care should have started on the day of admission and that the lack of documentation could lead to negative outcomes. The facility's policy on wound treatment management emphasized the importance of evidence-based treatments and timely documentation, but these guidelines were not followed, resulting in a failure to provide appropriate care according to the resident's needs and physician orders.

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 timely pressure ulcer care for a resident, leading to a deficiency in care. The resident was admitted with multiple skin issues, including a stage III pressure ulcer on the sacrum, red heels, and a skin tear on the left elbow. Despite these conditions being noted upon admission, the facility did not obtain wound care orders or start treatment until several days later. The Treatment Administration Record (TAR) showed no care was provided for the sacrum pressure ulcer, bilateral heels, or skin tear on the left elbow on the initial days following admission. The facility's documentation was inconsistent and incomplete, contributing to the deficiency. The Weekly Skin Evaluation and Skilled Nurse Notes failed to accurately document the resident's wounds and the care provided. For instance, the Weekly Skin Evaluation on 10/31/2024 did not describe the open areas, and the Skilled Nurse Notes repeatedly indicated no wounds were present, despite the resident having documented pressure ulcers and a skin tear. The Director of Nursing (DON) confirmed that wound care was not started until 11/03/2024, and there were no progress notes for the initial days of the resident's stay. Interviews with staff revealed a lack of communication and follow-through on wound care protocols. Staff A, an LPN, acknowledged that wound care orders should have been obtained on 10/31/2024, but they were not. The DON also verified that the care plans were not followed, and the admission documentation did not include a description of the resident's wounds. The facility's policy on pressure injury prevention and management was not adhered to, as evidenced by the lack of timely assessment, treatment, and documentation of the resident's pressure ulcers.

Penalty

Inspection fine: $28,197

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

Summary

The facility failed to honor the advance directives of two residents, leading to inappropriate medical interventions. Resident #109, who had a signed Do Not Resuscitate (DNR) order, was subjected to cardiopulmonary resuscitation (CPR) for three minutes before the staff realized and confirmed the DNR status. The incident occurred because the nurse on duty, Staff AA, RN, did not verify the resident's code status before initiating CPR and insisted that the DNR order was pending despite being informed otherwise by another nurse, Staff DD, LPN. The Director of Nursing (DON) confirmed the timeline of events, which showed a delay in stopping CPR due to the miscommunication and failure to check the resident's medical records promptly. Resident #212, who was legally blind and had expressed a wish to be a DNR, did not have a DNR order documented in his medical record. Despite the resident wearing a purple bracelet indicating his DNR status and verbally expressing his wishes, the staff failed to obtain the necessary physician order. Staff F, LPN, admitted to flagging the progress note but did not follow through with obtaining the order immediately, believing it could wait until the next day. The DON confirmed that the admitting nurse should have verified the resident's wishes and obtained the physician's order promptly. The facility's policy on advance directives and code status was not followed correctly in both cases. The policy requires the admitting nurse to verify the resident's code status upon admission and obtain the necessary physician orders. In the case of Resident #109, the failure to check the code status before initiating CPR led to unnecessary resuscitation efforts. For Resident #212, the lack of timely documentation and verification of the resident's DNR wishes resulted in a failure to honor his advance directive. These deficiencies highlight significant lapses in communication and adherence to established protocols within the facility.

Penalty

Inspection fine: $28,197

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 Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for ten residents. For instance, Resident #16 was admitted with diagnoses including Alzheimer's Disease, major depressive disorder, and generalized anxiety disorder. However, the PASRR did not reflect the anxiety disorder diagnosis. Similarly, Resident #34's PASRR did not include diagnoses of epilepsy and generalized anxiety disorder, which were present in the medical record. The Director of Nursing (DON) acknowledged that these PASRRs were incorrect and should have been updated to reflect the residents' current status. Resident #48 was admitted with diagnoses including bipolar disorder and generalized anxiety disorder, but the PASRR failed to include the bipolar disorder diagnosis. Resident #13's PASRR did not indicate any qualifying diagnoses, despite the resident having schizoaffective disorder and major depressive disorder. The DON confirmed that these PASRRs were inaccurate and should have been corrected upon admission. Additionally, Resident #33, #78, and #97 had PASRRs that did not reflect their respective diagnoses of dementia, major depressive disorder, and bipolar disorder. The facility's policy mandates that all applicants be screened for serious mental disorders or intellectual disabilities in accordance with the State's Medicaid rules. The policy also requires that any resident who experiences a significant change in status be referred for a Level II PASRR evaluation. Despite this, the facility failed to maintain accurate PASRR documentation for multiple residents, as evidenced by the discrepancies found during the survey. The DON admitted that the PASRRs were not updated as required, leading to the deficiencies noted in the report.

Penalty

Inspection fine: $28,197

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

Summary

The facility failed to store, prepare, and appropriately document food temperatures in accordance with professional standards for food service safety. During an observation, a walk-in refrigerator contained unlabeled and undated food items, including a bag of orange shredding solid substance, a metal container of fruit-like half-moon shaped substance, a head of lettuce that was brownish/red in color, and a mushy cucumber. Additionally, a bag of lettuce was left open and not properly sealed. Staff H, a Dietary Aide, confirmed that all food in the walk-in refrigerator should be labeled and dated, and acknowledged that the head of lettuce and cucumber were rotting and should have been discarded. In the East Dietary Pantry, a pizza box was found unlabeled and undated, and a container of prune juice had a use-by date that had already passed. Photographic evidence was obtained for these observations. Further observations revealed that Staff J, the Dietary Manager, did not document food temperatures while preparing residents' food trays. Although Staff J stated the temperatures of the food items, the lunch food temperature log showed no recorded temperatures. Staff I, the Regional Dietary Consultant, confirmed that not recording food temperatures in the log book was not best practice and mentioned that Staff J had only been recently hired. The facility's policies on food brought in by family or visitors and food storage were reviewed, indicating that all food items should be labeled, dated, and stored properly to prevent cross-contamination. The facility's failure to adhere to these policies led to the identified deficiencies in food storage and temperature documentation.

Penalty

Inspection fine: $28,197

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 medication administration error rate of less than five percent. During an observation of medication administration, a Licensed Practical Nurse (LPN) incorrectly primed insulin injector pens without attaching an insulin needle, resulting in a medication administration error rate of 20%. The LPN was unaware that a needle needed to be applied to the injector pen prior to priming and had not received proper education on the use of insulin pens. This error was observed in the administration of insulin to a resident with type 2 diabetes mellitus and other serious health conditions, including diabetic chronic kidney disease and metabolic encephalopathy. Additionally, the facility failed to ensure proper storage, labeling, and dating of food and beverages in accordance with professional standards for food service safety. Observations revealed multiple instances of improperly stored and labeled food items in the facility's kitchen and dietary pantries. Items such as lettuce, milk, bread, and various other food products were found without proper labeling or with expired dates. The Certified Dietary Manager (CDM) acknowledged these deficiencies and discarded the improperly stored items. Interviews with facility staff, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), revealed that the facility's Interdisciplinary Team (IDT) had discussed the findings and areas of concern identified by the survey team. However, the facility's Quality Assessment and Assurance (QAA) committee failed to identify, monitor, and implement effective action plans to correct these deficiencies, leading to repeated issues in medication administration and food storage practices.

Penalty

Inspection fine: $28,197

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 proper infection prevention and control measures, leading to several deficiencies. Staff did not provide hand hygiene to residents before meal service, as observed during breakfast and lunch tray passes. Multiple residents confirmed that they had never been offered hand hygiene before meals. Interviews with CNAs revealed inconsistent practices regarding hand hygiene, and the Director of Nursing confirmed that all residents should be provided hand hygiene prior to meals. The facility's policy on hand hygiene was not followed, contributing to the spread of infections among residents with various medical conditions, including Type II Diabetes Mellitus, Chronic Respiratory Failure, and Chronic Obstructive Pulmonary Disease. The facility also failed to properly identify and manage residents on isolation precautions. Resident #416, who had a physician order for contact isolation due to ESBL in urine, did not have transmission-based precautions signage or PPE available at the room entrance. Staff interviews revealed a lack of adherence to the facility's policy on transmission-based precautions, which requires signage and PPE for residents on contact precautions. Additionally, Resident #214's room lacked proper signage indicating the type of precautions, and the PPE caddy was inadequately stocked. The resident's urinary catheter drainage bag was found lying on the floor, contrary to infection control standards. Furthermore, the facility did not ensure the proper storage of nebulizer masks and the cleaning of reusable equipment. Observations showed that nebulizer masks for two residents were not stored in appropriate storage bags, and staff interviews indicated a lack of compliance with the facility's policy on nebulizer therapy. Additionally, a staff member failed to clean a manual blood pressure cuff and stethoscope between uses for different residents, increasing the risk of cross-contamination. The facility's policies on infection control and equipment cleaning were not followed, leading to multiple deficiencies in maintaining a safe and sanitary environment for residents.

Penalty

Inspection fine: $28,197

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

Summary

The facility failed to adhere to the smoking assessment and policy for Resident #79, who was observed smoking unsupervised at the main entrance of the facility. The resident had a history of moderate cognitive impairment and multiple respiratory conditions, yet was found with a pack of cigarettes and reported that staff had become lax about enforcing the smoking policy. The resident also mentioned that it sometimes took 45-60 minutes to be let back into the facility after smoking outside, indicating a lack of adequate supervision and timely assistance from staff. Resident #9, who had intact cognition and was the Resident Council President, was found to possess personal cigarettes and a lighter, despite the facility's policy requiring supervision while smoking. The resident admitted to keeping these items due to previous instances of missing cigarettes when stored by the facility. The resident was observed smoking in the designated smoking area but acknowledged not being supposed to have a lighter. Resident #213, who had intact cognition and chronic respiratory failure, was found with a pack of cigarettes on the bedside dresser. The resident reported not having been outside to smoke since admission and stated that the belongings were recently brought over. The facility's policy required all smoking materials to be kept by nursing staff for residents needing supervision, yet this was not adhered to. Staff P, the Activities Assistant, admitted to allowing residents to keep their smoking materials to avoid arguments, further indicating a lack of enforcement of the smoking policy.

Penalty

Inspection fine: $28,197

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 medication error rate was less than 5%, resulting in a 20% error rate based on observations, record reviews, and interviews. Thirty medication administration opportunities were observed, and six errors were identified for four residents. These errors included improper insulin priming techniques, incorrect documentation of vital signs, and failure to administer medications within the prescribed time frame. One incident involved a Licensed Practical Nurse (LPN) administering insulin to a resident without properly priming the insulin pen, as per the manufacturer's guidelines. The LPN held the pen at a 45-degree angle instead of upright, leading to potential air bubble injection. Another LPN administered medications to a resident and documented vital signs that were actually from the resident's roommate, failing to ensure the resident rinsed their mouth after a nebulizer treatment as required. Additional errors included administering insulin to a resident more than an hour late and holding a medication without notifying the physician, despite the absence of parameters to hold the medication. The facility's policies on medication administration and nebulizer therapy were not followed, contributing to the high medication error rate observed during the survey.

Penalty

Inspection fine: $28,197

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 two residents were assessed for self-administration of treatments and medications. Resident #79, who has diagnoses including Type 2 Diabetes Mellitus with diabetic chronic kidney disease, cellulitis of the left lower limb, and End Stage Renal Disease, was observed with various treatment items at the bedside, including nasal spray, wound cleanser, and Betadine. The resident had dressed an open wound on the left upper leg by themselves. The Director of Nursing (DON) acknowledged the presence of these items but did not remove them after the resident refused. The resident's care plan did not indicate an assessment for self-administration of medications or treatments, nor did it authorize keeping medications at the bedside. Resident #213, who has diagnoses including encounter for orthopedic aftercare following surgical amputation and Type 2 Diabetes Mellitus with hyperglycemia, was observed with an opened bottle of Nystatin Topical Powder and a medication cup with a powder substance on a bedside bookcase. The treatment administration record indicated the use of the antifungal powder, but there was no documentation of an assessment for self-administration of medications. The DON confirmed awareness of the antifungal powder at the resident's bedside. The facility's policy requires an interdisciplinary team assessment and proper documentation for residents to self-administer medications, which was not followed in these cases.

Penalty

Inspection fine: $28,197

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 complete the smoking assessment for one resident out of four sampled. An observation revealed the resident actively smoking on the designated smoking patio during a specified smoking time. Interviews with the resident and the Director of Nursing (DON) confirmed that the smoking assessment was not completed at the time of admission, as required by the facility's policy. The DON acknowledged that the assessment was overlooked and should have been completed immediately upon admission to ensure resident safety and provide education on safe smoking practices. The resident was admitted with multiple diagnoses, including Bipolar Disorder, generalized anxiety, major depressive disorder, cellulitis of the right lower limb, lymphedema, and unspecified cirrhosis of the liver. Despite being listed as a smoker in the facility records, the resident's medical record lacked a completed smoking assessment. The care plan indicated that the resident must smoke with supervision and had been revised to reflect this requirement. The facility's smoking policy mandates that each resident be evaluated upon admission to determine their smoking status and ability to smoke safely, which was not adhered to in this case.

Penalty

Inspection fine: $28,197

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 assess, obtain physician orders, and provide treatments for a resident with skin conditions unrelated to pressure injuries. The resident was observed with wound care supplies within reach and undated foam dressings on the upper left arm and left thigh. The resident reported self-dressing the wounds and expressed dissatisfaction with the facility's wound care nurse. A review of the resident's medical record revealed a noted skin tear but no further information or physician orders for the dressings. The facility's incident log did not document any skin tear incidents for the resident during the specified period. Interviews with staff revealed a lack of awareness and follow-up on the resident's wounds. The wound care nurse stated that the assigned nurse would have assessed the area, notified the physician, obtained treatment orders, and performed the treatments. However, the wound care nurse admitted to not following up on the resident's wounds. An agency LPN confirmed that no dressings were scheduled for the resident's shift. Observations with the Director of Nursing confirmed the presence of undated dressings and an open area on the resident's left thigh, which appeared to be infected. The resident's care plan included interventions for skin breakdown and actual skin breakdown related to surgical sites, but the facility failed to monitor and document the resident's skin conditions adequately. The facility's policies on skin assessment and clean dressing changes were not followed, leading to a lack of proper wound care and documentation for the resident. The Director of Nursing attempted to remove wound care supplies from the resident's room, but the resident refused to allow it, further complicating the situation.

Penalty

Inspection fine: $28,197

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 a pressure ulcer received necessary care and services to promote healing, prevent infection, and prevent new ulcers from developing. During an interview, the resident reported that their heel hurt and they requested a bandage and pressure ulcer medicine from an LPN, who refused due to being too busy and understaffed. Observations confirmed that the resident's right heel pressure ulcer was not bandaged, and photographic evidence was obtained. The resident's medical history included Type II Diabetes Mellitus, Chronic Respiratory Failure, and other conditions, and a physician's order required daily cleaning and dressing of the pressure ulcer, which was not followed as observed during the survey. Further interviews revealed that the LPN admitted to not replacing the bandage due to time constraints and being the only nurse on duty. The Director of Nursing stated that it was expected for the nurse on duty to complete the care or at least pass the information to the morning shift nurses. The facility's policy on Pressure Injury Prevention and Management emphasized the commitment to preventing avoidable injuries and providing treatment to heal pressure ulcers, which was not adhered to in this case.

Penalty

Inspection fine: $28,197

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 physician-ordered lab work was completed accurately and in a timely manner for a resident with a history of recurrent urinary tract infections (UTIs). The resident's Power of Attorney (POA) alerted nursing staff about the resident's unusual behavior and requested a urinalysis (UA). Despite this, it took over a week to complete the UA, and the culture and sensitivity (C&S) test was not initially requested as ordered, causing further delays in treatment. The Director of Nursing (DON) acknowledged that the order was missed and should have been addressed immediately upon receipt on 04/05/24. Interviews with staff revealed that the process for handling physician orders involves immediate entry into the system and scheduling lab pick-ups within 24 hours. However, in this case, the UA was not completed until 04/11/24, and the C&S test was only done on 04/16/24. The resident's medical record showed signs of confusion and agitation, and the resident was eventually treated with Macrobid for Enterococcus faecalis. The facility's policy mandates that all physician orders be followed as prescribed and documented if not followed, which was not adhered to in this instance.

Penalty

Inspection fine: $28,197

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 documentation for refrigerator/freezer temperature logs in two dietary pantries. Observations revealed incomplete temperature logs with blank spaces for multiple dates in April 2024. Specifically, the [NAME] Dietary Pantry had missing entries from 04/05/24 to 04/14/24 and 04/16/24 to 04/21/24, while the East Dietary Pantry had missing entries on 04/06/24, 04/12/24, 04/13/24, 04/17/24, 04/18/24, and 04/19/24. Photographic evidence was obtained to support these findings. Subsequent observations showed that the logs were later fully completed with no blank spaces, indicating that the entries were filled in after the initial observation. During an interview, the DON confirmed that the nursing staff was responsible for completing the temperature logs daily. The DON reviewed the photographic evidence and acknowledged that the logs should not have been retroactively completed. The facility's policy on employee conduct emphasizes the importance of honest communication and adherence to professional standards, which was not followed in this instance. The nursing staff's failure to complete the logs daily and the subsequent filling in of blank spaces led to the deficiency.