Highland Pines Rehabilitation 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 implement and enter physician orders for wound care and infection treatment in a timely manner for a resident with a right fifth finger injury. The resident had multiple significant medical diagnoses, including bilateral below-knee amputations, chronic congestive heart failure, Type 2 diabetes mellitus with diabetic chronic kidney disease, muscle wasting and atrophy, altered mental status, and delusional disorder. A skin evaluation dated 10/20/2025 documented bruising and an open area on the right hand pinky, identified as a new in-house skin tear. Progress notes from that date showed the nurse observed an open area on the right pinky finger, notified the unit manager and wound care team, and documented that the resident reported his finger had become tangled in the wheelchair wheel. However, no treatment orders were documented or implemented at that time for the finger wound. Staff interviews revealed that on 10/20/2025, an LPN observed the resident’s right pinky finger as swollen, necrotic, with pus and a blister, and stated she could tell the finger was infected and that it appeared to have been developing for a few days. She acknowledged that no treatment was provided until 10/22/2025 and that she should have immediately notified the provider but did not. On 10/21/2025, the wound care nurse and unit manager saw the resident for other wound care and noted the right pinky as swollen, discolored, with drainage and a blister, but the skin issue entry for the finger remained “not evaluated,” and there was no documentation of treatment orders being obtained or initiated that day. The DON and regional nurse consultant both stated that facility expectations were that any open area should prompt immediate provider notification, with documentation of that notification and prompt entry of any resulting orders. Record review showed that the resident’s primary care provider saw the resident in person on 10/20/2025 and, according to an untitled document later signed by the provider, gave orders for an x-ray of the right hand, Doxycycline, and topical Bacitracin for the right fifth digit on that date. However, these orders were not entered into the facility’s system until 10/22/2025 and 10/23/2025, when an x-ray order dated 10/22/2025 and medication orders dated 10/23/2025 appeared in the physician orders. A late entry progress note dated 10/22/2025 documented a call placed to the physician regarding the infected, swollen, and bruised right pinky finger and indicated the physician would examine the resident while rounding. The regional nurse consultant and DON confirmed that orders should be added as soon as they are given and that the facility’s policy requires noting, dating, signing, and confirming the accuracy of physician orders, with daily review to identify errors of omission. The failure to promptly enter and implement the provider’s wound care and antibiotic orders resulted in the resident going without ordered infection treatment for two days before further diagnostic testing and transfer occurred. Radiology records showed that an x-ray of the right hand, performed on 10/22/2025 and reported on 10/23/2025, demonstrated subtle bone loss at the fifth DIP joint with swelling, with a conclusion suggesting osteomyelitis and recommending an MRI. The DON stated that the primary care provider suspected osteomyelitis related to the right pinky finger and that the x-ray results revealed osteomyelitis. Hospital records documented that the resident presented for evaluation of the right small finger injury, with initial hand x-rays demonstrating signs of cellulitis and osteomyelitis, and that IV antibiotics were initiated. The resident subsequently underwent resection (amputation) of the right small finger. Throughout this sequence, the survey findings focused on the gap between the provider’s in-person assessment and orders on 10/20/2025 and the facility’s failure to timely enter and implement those orders, despite multiple staff observations and documentation of the injured, infected right pinky finger.

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 provide urinary catheter care and services in accordance with professional standards for two residents. For one resident with chronic kidney disease (Stage 4) and obstructive uropathy, surveyors repeatedly observed the urinary catheter drainage bag detached from the bed and resting directly on the floor, with urine that appeared slightly cloudy. These observations occurred multiple times on the same day, despite the treatment administration record indicating catheter care was provided and a care plan directing staff to keep the drainage bag below bladder level and off the floor. During interviews, a CNA and an LPN both stated that catheter bags should be kept off the floor to prevent infection and that they routinely check catheter tubing, drainage bag placement, and urine characteristics, yet the resident’s catheter bag remained on the floor during the LPN’s visit to the room. The DON also confirmed that CNAs are responsible for catheter care and that catheter bags should not be on the floor. For another resident with obstructive uropathy, renal disease, communicating hydrocephalus, altered mental status, dementia, and acidosis, the care plan identified use of a urinary catheter with risk for infection and complications and directed staff to change the drainage bag routinely and as needed and to provide daily catheter care. Daily skilled nursing notes documented clear, yellow urine and normal abdominal findings on several days. However, the resident was later found lethargic and not responding to verbal stimuli, and was sent to the hospital, where records showed admission for severe sepsis secondary to UTI, life-threatening hypernatremia, and acute kidney injury. A CT scan revealed the catheter balloon was inflated in the urethra rather than the bladder, causing a significantly distended bladder and bilateral hydroureteronephrosis. Despite this change in condition, there was no documented assessment of urinary catheter patency, and interviewed staff, including an LPN and CNAs, had no recollection of the resident’s catheter status, though they described general practices of frequent rounding, monitoring, and emptying catheter bags.

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 provide and document pain management as ordered for two cognitively intact residents with documented pain. One resident, admitted with conditions including a right knee contusion, muscle weakness, and need for assistance with personal care, had an MDS showing a BIMS score of 15 and an average pain intensity of 7/10 over the prior five days. This resident had a physician’s order for Hydrocodone-Acetaminophen 5-325 mg, one tablet by mouth every 8 hours for chronic pain, but the MAR for January showed missed scheduled doses on two occasions. In interview, the resident reported not receiving pain medication as scheduled and stated that when this occurred, she experienced pain for the rest of the day. The Activities Director recalled that this resident had filed a grievance a few months earlier about not receiving medications, but did not know the outcome. The second resident, admitted with diagnoses including generalized anxiety disorder, age-related osteoporosis, and unspecified abdominal pain, had an MDS showing a BIMS score of 13 and an average pain intensity of 7/10 over the prior five days. This resident had a physician’s order to monitor and record pain every shift on a 0–10 scale, but the MAR showed a missing pain assessment on one night shift and documented severe pain (10/10) and moderate pain (5/10) on other shifts. The resident also had multiple scheduled pain medication orders, including oxycodone 5 mg every 8 hours and Hydrocodone-Acetaminophen 5-325 mg and 7.5-325 mg via G-tube every 6 hours, with the MAR showing missed doses on several dates and unclear entries such as “NA” and “9 (see progress notes)” without corresponding progress note documentation. In interview, this resident reported sometimes not receiving scheduled pain medication, resulting in severe pain. The Regional Nurse Consultant acknowledged that both residents should have received medications as ordered and that any omitted doses should have been accompanied by appropriate documentation, consistent with the facility’s medication administration policy requiring administration per prescriber orders, timely administration within 60 minutes of scheduled time, and immediate documentation on the MAR.

Penalty

Inspection fine: $182,782

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 residents' rights to be free from neglect, specifically in the area of medication management and follow-up laboratory orders for medication therapeutic levels. Eleven residents were affected, with serious harm occurring to one resident whose medication levels were not monitored, and consultation was not obtained as requested by the provider. This resident experienced a significant medical event and had to be transferred to a higher level of care due to the facility's failure to monitor and manage medication levels appropriately. The report details multiple instances where residents' medication levels were not checked as ordered, and abnormal lab results were not communicated to the appropriate medical providers. For example, one resident had low medication levels that were not reported to the physician, leading to a severe medical event. The facility's process for managing lab orders and results was inadequate, with orders not being transcribed correctly, and lab results not being reviewed or acted upon in a timely manner. Interviews with staff, including the DON and medical providers, revealed systemic failures in the facility's processes for lab management and physician notification. The DON admitted to not having a primary person assigned to oversee labs and review results, leading to missed lab draws and unreported critical lab values. The facility's lack of a structured process for ensuring lab orders were executed and results communicated contributed to the neglect of residents' medical needs.

Plan Of Correction

Free from & Neglect/N204 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How you will identify other residents who have the potential to be affected by the same deficient practice and what corrective actions will be taken. A facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and that consultation orders for were completed as indicated. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put in place or what systematic changes you will make to ensure that the deficient practice does not recur. Director of Nursing/Designee will educate licensed nursing staff on the lab monitoring process to include ensuring that residents on medication receive proper lab monitoring, physician notification of abnormal lab values or refused labs, documentation of physician notification and new orders is recorded in the resident clinical record, and consultation orders for are properly executed. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur. What quality assurance program will be put into place. Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.

Removal Plan

• The Regional Nurse Consultant educated the Administrator and Director of Nursing on neglect, and as they relate to ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal labs, and follow-up procedures and resident condition change related to laboratory results. Education is 100% complete.
• The Consultant Physician provided education to facility Medical Director and physician extender on neglect, and as they relate to ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, and follow-up procedures related to laboratory results.
• The Director of Nursing or designee educated 100% of staff on neglect, and as they relate to ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal lab values, and follow-up procedures related to laboratory results.
• Process Change: Director of Nursing is responsible for reviewing consultation log(s) and making sure that consultation orders were executed, monitoring the laboratory monitoring processes for medications that require lab levels, reviewing progress notes to ensure physician notification has taken place, and ensuring complete follow-through with relation to laboratory results.
• All education and in-service sign-in sheets were reviewed and validated 53 out of 93 employees had received neglect, and training as they relate to ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal labs, and follow-up procedures and resident condition change related to laboratory results.
• Interviews were conducted with 53 staff members across various shifts, the Nursing Home Administrator, the Assistant Director of Nursing, the DON, and the Medical Director. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.

Penalty

Inspection fine: $182,782

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 competent physician services for the treatment and monitoring of diagnoses for eleven residents. This deficiency was evidenced by the lack of monitoring and consultation for medication levels, which led to serious harm for one resident. The resident's medication levels were not monitored, and consultation was not obtained as requested by the provider, resulting in the resident experiencing a severe medical event and requiring transfer to a higher level of care. The report details multiple instances where residents' lab results were not properly monitored or communicated to the appropriate medical personnel. For example, one resident had low medication levels that were not reported to the physician, and another resident's critical lab results were not communicated in a timely manner. Additionally, there were failures in ensuring that lab orders were entered into the lab portal, leading to missed or delayed lab draws. Interviews with facility staff, including the Director of Nursing (DON), revealed systemic issues in the lab process, such as the lack of a designated person to oversee lab results and ensure follow-up. The DON acknowledged that the facility's process for managing lab orders and results was broken, contributing to the failure to provide adequate medical supervision and care for the residents.

Plan Of Correction

Residents Care Supervised by a Physician. 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #5 and #10 no longer reside in facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. Facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and consults have been completed as indicated. Any residents identified without lab monitoring orders were reported to physician and new orders transcribed as indicated. Any prior consultation orders not properly executed were scheduled. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. Director of Nursing/Designee will educate licensed nursing staff on ensuring appropriate physician oversight of resident care related to the lab monitoring process, ensuring that residents on medication receive proper lab monitoring, physicians are notified of abnormal lab values or refused labs, outside providers are consulted as indicated, and documentation of physician notification and new orders is recorded in the resident clinical record. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur i.e. what quality assurance program will be put into place. Director of Nursing/Designee will randomly audit residents on medications to ensure that the results of lab orders for monitoring medication levels have been reported to the physician, new orders are transcribed as indicated, and consultation orders for outside providers are completed as indicated. Audits will be performed weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.

Removal Plan

• The Regional Nurse Consultant educated the Administrator and Director of Nursing on ensuring a competent physician process is in place for residents with diagnoses.
• A consulting was credentialed with Point Click Care access and on site.
• The Consultant Physician provided education to facility Medical Director and physician extender on the process for monitoring therapeutic lab levels for residents with diagnoses and the medication prescribing standards for such.
• The Director of Nursing or designee educated 100% of licensed nursing staff on the process for ensuring that consultation orders are completed, lab work is ordered for residents on medications, abnormal lab results are reported to physicians, and new orders are transcribed appropriately.
• Process Change: The Director of Nursing is responsible for making sure that a competent physician process is in place for residents with diagnoses.
• Education and in-service sign-in sheets were reviewed and validated with 12 out of 18 licensed nursing staff on the process for ensuring that consultation orders are completed, lab work is ordered for residents on medications, abnormal lab results are reported to physicians, and new orders are transcribed appropriately.
• Interviews were conducted with 10 licensed nurses across various shifts, the Assistant Director of Nursing, the DON, and the Medical Director. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.

Penalty

Inspection fine: $182,782

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 nursing staff were competent in caring for residents, particularly in the areas of laboratory monitoring, following through with orders, processing consultations, and communicating with physicians. This deficiency was evident in the case of a resident whose medication levels were not adequately monitored, leading to a serious medical event. The resident's medication levels were found to be low, and despite orders for consultation and lab tests, there was no evidence that these were completed or that the physician was notified of the results. The report highlights multiple instances where lab results were not communicated to the appropriate medical personnel, and orders were not followed through. For example, several residents had lab orders that were either not entered into the lab portal or not completed, resulting in missed or delayed lab tests. In some cases, critical lab results were not reported to the physician in a timely manner, if at all. This lack of communication and follow-through contributed to the deterioration of residents' conditions. Interviews with staff revealed systemic issues in the facility's lab process, including a lack of access to the lab portal for some nurses, insufficient training on lab procedures, and unclear responsibilities for ensuring lab orders were completed. The Director of Nursing acknowledged these failures, noting that there was no assigned person to oversee lab processes and that the system for managing lab orders and results was broken. This systemic failure in managing lab processes and communication with physicians led to the determination of Immediate Jeopardy.

Plan Of Correction

Competent Nurse staffing 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken? A facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that medications residents on had appropriate lab monitoring orders in place and that any consults that were previously ordered were scheduled. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur? Director of Nursing/Designee will educate licensed nursing staff on the care of residents with a diagnosis to include ensuring that lab orders are in place to monitor medication levels, physicians are notified of abnormal lab values or refused labs, documentation of physician notification of lab levels and new orders is recorded in the resident clinical record, and that consultation orders for or other outside providers are executed appropriately. 4. How the corrective action(s) will monitor to ensure the practice will not recur, i.e., what quality assurance program will be put in place(s); will be accomplished for those residents: Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place and consultation orders for outside providers are completed weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.

Removal Plan

• Regional Nurse Consultant educated the Administrator and Director of Nursing on ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal lab values, and follow-up procedures and resident condition change related to laboratory results.
• Current resident audit conducted by Director of Nursing/designee for review of residents taking medications with no concerns identified.
• Consultant Physician provided education to facility Medical Director and physician extender regarding standards of practice for monitoring and treating residents with related diagnoses.
• Director of Nursing or designee educated 100% of licensed nursing staff on ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal lab values, and follow-up procedures related to laboratory results.
• Process Change: Director of Nursing is responsible for ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification, and follow-up procedures related to laboratory results.
• All education and in-service sign-in sheets were reviewed and validated 10 out of 18 licensed nursing staff on ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, physician notification of abnormal lab values, and follow-up procedures related to laboratory results.
• Interviews were conducted with 10 licensed nurses across various shifts, the Assistant Director of Nursing, the DON, and the Medical Director. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.

Penalty

Inspection fine: $182,782

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 laboratory orders were properly entered into the electronic medical record and laboratory portal, resulting in incomplete lab tests and delayed notification of abnormal results to providers. This deficiency affected eleven residents, all of whom were sampled in the survey. For instance, one resident experienced serious harm due to unmonitored medication levels and lack of timely consultation, leading to a worsened condition and transfer to a higher level of care. The resident's medication levels were consistently low, and there was no evidence that the physician was notified of these critical results. The facility's Director of Nursing (DON) acknowledged a systemic failure in the lab process, including the lack of a primary person to oversee lab orders and results. Interviews with staff revealed that lab results were often not communicated to providers unless they were critical, and even then, the process was inconsistent. The DON admitted that the facility's process for managing lab orders and results was broken, with no assigned responsibility for ensuring that labs were drawn and results were reviewed and communicated to the appropriate providers. Multiple residents had lab orders that were not completed or documented, and there was no evidence of provider notification for abnormal results. The facility's failure to manage lab orders and results led to residents not receiving necessary medical interventions in a timely manner. The DON and other staff members confirmed that the facility did not have a policy for laboratory processes or for managing changes in residents' conditions, contributing to the deficiencies identified in the survey.

Plan Of Correction

F773 lab services 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Resident #5 and #10 no longer reside in facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. Facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and that any consults that were previously ordered were scheduled. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur. Director of Nursing/Designee will educate licensed nursing staff on the lab process to include ensuring that lab orders are in place to monitor medication levels, physicians are notified of abnormal lab values or refused labs, and documentation of physician notification of lab levels and new orders is recorded in the resident clinical record. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur i.e. what quality assurance program will be put into place. Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.

Removal Plan

• On the Regional Nurse Consultant educate the Administrator and Director of Nursing on ensuring proper follow-through with consultation orders, laboratory monitoring of therapeutic levels for medications, lab process with morning meeting process review compared to lab binder by clinical leadership, physician notification of abnormal labs, and follow-up procedures related to laboratory results.
• On the Consultant Physician provide education to facility Medical Director and physician extender on ensuring proper and timely monitoring and treating of residents with -related diagnoses.
• On the Director of Nursing or designee educated 100% of licensed nursing staff on making sure that consultation orders are properly executed, labs are in place to monitor therapeutic levels for medications, physicians are notified of abnormal lab results, and lab monitoring guidelines are followed related to laboratory results.
• Process Change: Effective the Director of Nursing is responsible for making sure that consultation orders are properly executed, labs are in place to monitor therapeutic levels for medications, physicians are notified of abnormal lab results, and lab monitoring guidelines are followed related to laboratory results.
• On all education and in-service sign-in sheets were reviewed and validated with licensed nursing staff on making sure that consultation orders are properly executed, labs are in place to monitor therapeutic levels for medications, physicians are notified of abnormal lab results, and lab monitoring guidelines are followed related to laboratory results.
• On interviews were conducted with licensed nurses across various shifts, the Assistant Director of Nursing, the DON, and the Medical Director. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.

Penalty

Inspection fine: $182,782

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 effectively monitor adverse events, specifically in the management of medication levels for multiple residents. This deficiency was highlighted by the case of a resident whose medication levels were not adequately monitored, leading to a significant medical event. The resident was admitted with various medical diagnoses and had specific medication orders that were not consistently followed. Laboratory results indicating low medication levels were not communicated to the physician, and necessary consultations were not obtained, resulting in the resident experiencing a severe medical episode that required transfer to a higher level of care. The report details multiple instances where the facility did not maintain effective systems for monitoring and reporting adverse events. Several residents had medication levels that were either not checked or not reported to the appropriate medical personnel, leading to suboptimal management of their conditions. The facility's process for handling lab orders and results was inadequate, with orders not being entered into the lab portal, results not being communicated to providers, and critical lab values not being addressed in a timely manner. Interviews with facility staff, including the Director of Nursing and other medical personnel, revealed systemic failures in the lab process and medication management. There was a lack of accountability and oversight in ensuring that lab results were reviewed and acted upon. The facility's Quality Assurance and Performance Improvement (QAPI) plan did not adequately address these issues, leading to a breakdown in the monitoring and management of residents' health care needs.

Plan Of Correction

QAPI/N 901 QA Program 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken? A facility-wide audit of current residents on medications was conducted by the Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and that any consults that were previously ordered were scheduled. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur? The Regional Nurse Consultant educated the Nursing Home Administrator and Director of Nursing on ensuring that an effective Quality Assurance program is in place as it pertains to the care of residents with a diagnosis, ensuring that lab orders are in place to monitor medication levels, physicians are notified of abnormal lab values or refused labs, documentation of physician notification of lab levels and new orders is recorded in the resident clinical record, and that consultation orders for or other outside providers are executed appropriately. 4. How the corrective action(s) will monitor to ensure the practice will not recur, i.e., what quality assurance program will be put in place(s); will be accomplished for those residents: Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place and consultation orders for outside providers are completed weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.

Removal Plan

• Regional Nurse Consultant educated the Administrator and Director of Nursing on ensuring that an effective Quality Assurance and Performance Improvement Plan is in place to ensure the safety of all residents.
• Administrator educated 100% of the members of the Quality Assurance and Assessment Committee on ensuring that an effective Quality Assurance and Performance Improvement Plan is in place to ensure the safety of all residents.
• Adhoc meeting held with interdisciplinary team and Medical director related to lab process monitoring and MD notification. Another Adhoc meeting was held on lab process/lab monitoring, following physician orders, clinical morning meeting process with review of lab binder, lab access availability audit.
• Daily audits were conducted on lab process with no new findings.
• Process Change: Administrator is responsible for ensuring that an effective Quality Assurance and Performance Improvement Plan is in place to ensure the safety of all residents.
• All education and in-service sign in sheets were reviewed and validated for 13 out of 13 members of the Quality Assurance and Assessment Committee on ensuring that an effective Quality Assurance and Performance Improvement Plan is in place to ensure the safety of all residents.
• Interviews were conducted with the Nursing Home Administrator, members of the interdisciplinary team, the Assistant Director of Nursing, and the DON. The staff members were able to verbalize they had been trained and were knowledgeable about the new policies.

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 nursing staff were competent in managing the care of residents, particularly in the areas of laboratory monitoring, following through with orders, processing consultations, and communicating with physicians. This deficiency was evident in the case of a resident who experienced serious harm due to inadequate monitoring of medication levels and failure to obtain a necessary consultation as requested by the provider. The resident was admitted with multiple medical diagnoses, including generalized idiopathic conditions, and required specific medication management. However, the facility did not monitor the resident's medication levels appropriately, leading to a significant medical event that necessitated transfer to a higher level of care. The report highlights multiple instances where the facility's processes for managing laboratory orders and results were inadequate. For several residents, including the one who suffered serious harm, there were repeated failures to notify physicians of critical lab results, to follow up on lab orders, and to ensure that consultations were scheduled and completed. Interviews with staff, including the Director of Nursing (DON), revealed systemic issues in the facility's lab process, such as the lack of a designated person to oversee lab results and ensure follow-up actions were taken. The DON acknowledged that the facility's process for managing labs was broken, leading to missed lab draws and unreported critical results. The deficiency was further compounded by communication breakdowns among staff and between the facility and external providers. Staff interviews indicated confusion and inconsistency in the lab process, with some staff lacking access to the lab portal and others unclear about their responsibilities in managing lab orders and results. The facility's failure to maintain a reliable system for lab management and communication resulted in significant lapses in care for multiple residents, as evidenced by the lack of documentation and follow-up on critical lab results and physician notifications.

Plan Of Correction

F 726 Competent Nurse staffing 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken? Facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and that any consults that were previously ordered were scheduled. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put into place or what systematic changes will you make to ensure that the practice does not recur? Director of Nursing/Designee will educate licensed nursing staff on the care of residents with a diagnosis to include ensuring that lab orders are in place to monitor medication levels, physicians are notified of abnormal lab values or refused labs, documentation of physician notification of lab levels and new orders is recorded in the resident clinical record, and that consultation orders for or other outside providers are executed appropriately. 4. How the corrective action(s) will monitor to ensure the practice will not recur, i.e., what quality assurance program will be put in place(s); will be accomplished for those residents: Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place and consultation orders for outside providers are completed weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.

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 the residents' right to be free from neglect, particularly in the area of medication management and follow-up laboratory orders for medication therapeutic levels. Eleven residents were affected, with serious harm occurring to one resident whose medication levels were not monitored, and consultation was not obtained as requested by the provider. This resident experienced a significant medical event and had to be transferred to a higher level of care. The report details multiple instances where residents' medication levels were not properly monitored, and laboratory results were not communicated to the appropriate medical personnel. For example, one resident's medication levels were consistently low, yet there was no evidence that the physician was notified of these results. Additionally, there were lapses in ensuring that lab orders were entered into the lab portal, leading to missed or delayed lab draws. The Director of Nursing acknowledged a system failure in the facility's lab process, which contributed to these deficiencies. Interviews with staff revealed a lack of clear responsibility for overseeing lab orders and results. The facility's process for managing lab work was described as broken, with no designated person to ensure that lab results were reviewed and communicated to providers. This systemic issue resulted in residents not receiving the necessary medical oversight, leading to potential harm and inadequate care.

Plan Of Correction

1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practices? Residents #5 and #10 no longer reside in the facility. Laboratory orders for medication management were received for residents #1, #2, #3, #4, #6, #7, #8, #9, and #11. Results of labs were reported to resident physicians, documented in the clinical record, and new orders were transcribed as indicated. Consult was for resident #1 as requested by physician. 2. How you will identify other residents who have the potential to be affected by the same deficient practice and what corrective actions will be taken. A facility-wide audit of current residents on medications was conducted by Director of Nursing/designee to ensure that residents on medications had appropriate lab monitoring orders in place and that consultation orders were completed as indicated. Any residents identified without lab monitoring orders or fully executed consults were reported to physician and new orders transcribed as indicated. 3. What measures will be put in place or what systematic changes you will make to ensure that the deficient practice does not recur. Director of Nursing/Designee will educate licensed nursing staff on the lab monitoring process to include ensuring that residents' medication receive proper lab monitoring, physician notification of abnormal lab values or refused labs, documentation of physician notification and new orders is recorded in the resident clinical record, and consultation orders for are properly executed. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur. Director of Nursing/Designee will randomly audit residents on medications to ensure that appropriate lab orders for monitoring medication levels are in place weekly for four weeks and then monthly for two months. Results of the audits will be submitted by the Director of Nursing/designee to the Quality Assessment, Assurance, and Compliance Committee monthly for three months for further recommendations and guidance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that the Preadmission Screening and Resident Reviews (PASRRs) for residents with mental disorders and intellectual disabilities were updated appropriately. This deficiency was identified for five residents who had qualifying mental health diagnoses. For instance, Resident #9 was admitted with a primary diagnosis of dementia and other diagnoses including schizophrenia and major depressive disorder. However, the PASRR documentation was incomplete, missing page 2, and did not reflect the updated primary diagnosis of dementia or consider the diagnosis of schizophrenia. The deficiency was further highlighted in the cases of other residents. Resident #7's PASRR did not have the qualifying diagnoses checked, and the need for a level II PASRR was not identified. Similarly, Resident #22's PASRR did not reflect the diagnosis of dementia, and Resident #39's PASRR also failed to identify the need for a level II PASRR. Additionally, Resident #23's medical record lacked a level I PASRR entirely, and the facility was unable to locate it. Interviews with facility staff revealed systemic issues in the PASRR process. The Director of Nursing (DON) and the Social Services Director (SSD) both indicated they lacked access to the PASRR web-based submission program, which hindered their ability to update PASRRs. The facility's policy required PASRR screenings to be conducted prior to admission, but the process was not effectively managed, leading to the oversight of necessary updates and reviews for residents with serious mental illnesses or intellectual disabilities.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a clean and sanitary environment in resident rooms across three halls, as observed during a four-day survey. A strong urine odor was noted in the secured unit of hall 300, confirmed by staff interviews. Rooms were found with various cleanliness issues, including stained floors, walls, and curtains, grime on baseboards, and broken furniture. Interviews with staff revealed that the foul odor and unclean conditions were ongoing issues, exacerbated by residents urinating on the floors and a lack of accountability in housekeeping duties. Housekeeping staff from sister facilities were brought in to assist, indicating a shortage of regular staff due to illness. The facility's housekeeping manager admitted to the lack of cleanliness and the need for more frequent cleaning, especially in the mornings. Observations also noted missing door handles, moldy and musty smells, and a smoking area with safety hazards such as a fallen fence and insect infestations. The facility's maintenance director acknowledged the ventilation issues and the need for room repairs, including painting and furniture replacement. The facility's policy and procedure review highlighted the expectation of a safe, clean, and homelike environment for residents. However, the observed conditions and staff interviews indicated a failure to adhere to these standards. The maintenance director and nursing home administrator confirmed the presence of ongoing maintenance issues, prioritizing leaks over other concerns. The housekeeping manager outlined the daily cleaning procedures, but the observed deficiencies suggested these were not effectively implemented.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate below 5%, as evidenced by observations of medication administration for two residents, resulting in an 18.75% error rate. During the observation, a registered nurse administered insulin and Cyanocobalamin to one resident and several medications, including Amlodipine and Naloxegol Oxalate, to another resident. In both cases, the medications were administered late, as indicated by the electronic medication administration records (eMAR) highlighted in red. The scheduled times for these medications were not adhered to, leading to the errors being identified. Interviews with the registered nurse and the Director of Nursing (DON) revealed that medications should be administered within one hour before or after the scheduled time. However, the nurse admitted to consistently administering medications after 10:00 a.m. The facility's policy on medication administration specifies that medications should be given according to the prescriber's written orders and within 60 minutes of the scheduled time. Despite notifying the physicians about the late administration, there were no documented orders to administer the medications late for the residents involved.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to proper PPE protocols when entering rooms of residents under transmission-based precautions. Observations revealed that staff members, including CNAs and housekeeping managers, entered rooms with contact isolation signage without donning the required PPE such as gloves, gowns, and masks. Interviews with staff indicated a lack of awareness and understanding of the isolation status of residents and the necessary precautions to be taken. Specific incidents included staff entering rooms of residents who were on isolation for COVID-19 without the appropriate PPE. For instance, a housekeeping manager entered and exited a resident's room multiple times without donning or doffing PPE, despite the presence of a contact isolation sign. Additionally, staff members were observed assisting residents without using PPE, and some staff were unsure of the isolation requirements or the reasons for the posted signage. This lack of compliance was further highlighted by the presence of outdated isolation orders and inconsistent signage. The facility's infection prevention and control policies were not effectively implemented, as evidenced by the discrepancies between the expected PPE protocols and the actions of the staff. The Infection Control Preventionist confirmed that there was a lack of oversight regarding PPE supply and signage, contributing to the confusion and non-compliance observed. The facility's failure to ensure adherence to infection control protocols posed a risk of transmission of infections among residents and staff.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an ongoing antibiotic stewardship program for two out of three months reviewed, specifically for July and August 2024. The infection prevention documentation lacked any records related to the surveillance of resident infections and antibiotic orders during these months. Interviews revealed confusion regarding the responsibility for infection control, with the Nursing Home Administrator initially stating that the Infection Control Preventionist was the Registered Nurse Unit Manager. However, the RN Unit Manager clarified that she was not responsible for infection control, indicating a lack of clarity in role assignments. Further interviews with the Director of Nursing and the Infection Control Preventionist, who was also the Unit Manager, revealed that both were new to the facility and not engaged in any surveillance or audits related to infection control practices. They were unable to provide monthly antibiotic stewardship program reports for July and August 2024. The facility's policy required ongoing tracking of antibiotic prescribing and use, but this was not being implemented. Additionally, neither the DON nor the ICP knew the contact for the Department of Health in case of an outbreak, highlighting a gap in communication and preparedness.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a dignified living environment for several residents, notably Resident #56, who was exposed to inappropriate sexual behavior by his roommate. Despite having a care plan that emphasized promoting dignity and ensuring privacy, there were no specific interventions to address the roommate's behavior. Staff members, including CNAs and LPNs, acknowledged the ongoing issue but did not take effective measures to protect Resident #56 from exposure. Observations showed Resident #56 attempting to shield himself from his roommate's actions, indicating distress and discomfort, yet staff responses were inadequate and delayed. Additionally, the facility did not maintain the dignity of Residents #264 and #266, as their urinary catheter bags were left uncovered and visible from the hallway on multiple occasions. This lack of privacy was observed over two days, with staff acknowledging the absence of covers but failing to provide an explanation or remedy the situation. The facility's policy on resident rights emphasizes dignity and privacy, yet these were not upheld in practice. Interviews with various staff members, including CNAs, LPNs, and the Nursing Home Administrator, revealed a lack of awareness and action regarding the residents' rights to privacy and dignity. The Social Services Director and the Psychiatric Physician Assistant also expressed concerns but had not been informed of the issues. The facility's failure to address these deficiencies highlights a significant gap between policy and practice, impacting the residents' quality of life.

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 call lights were within reach for residents in eight rooms across two halls, specifically halls 200 and 300. During multiple facility tours, surveyors observed call lights on the floor in several rooms, indicating that residents did not have immediate access to them. Interviews with staff, including CNAs and LPNs, revealed that while they acknowledged the importance of having call lights within reach, they did not consistently ensure this was the case. Staff members admitted to not noticing the call lights on the floor and expressed intentions to rectify the situation when it was brought to their attention. The Director of Nursing (DON) confirmed that the facility lacked a formal policy and procedure for call light placement, although it was understood that call lights should be accessible to residents. Despite staff education on the importance of call light accessibility, the deficiency persisted, as evidenced by the repeated observations of call lights on the floor. This oversight suggests a gap in the implementation of practices to ensure resident safety and prompt access to assistance.

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 privacy for a resident with severe cognitive impairment, who was observed performing sexual acts on himself in his room without the privacy curtain being drawn. This resident, who had a history of dementia, schizophrenia, major depressive disorder, and age-related cognitive decline, was exposed to other residents, visitors, and staff due to the lack of privacy measures. The care plan for this resident did not adequately address the dignity and privacy concerns for him and his roommate, despite the resident's known behavioral issues, including public disrobing and inappropriate sexual behavior. During multiple observations, the resident was seen engaging in sexual acts with the privacy curtain open, exposing him to the public and his roommate. Staff interviews revealed that the resident's behavior was a known issue, and while staff attempted to redirect him and pull the curtain, these measures were inconsistently applied. The roommate was observed trying to pull the curtain for privacy, and other residents were seen reacting to the behavior, indicating a lack of consistent privacy measures. Interviews with staff, including CNAs, LPNs, and the Social Services Director, highlighted a recognition of the need for privacy but also revealed lapses in ensuring it was provided. The facility's policy on resident rights emphasized the importance of dignity and privacy, yet the implementation was lacking, as evidenced by the repeated exposure of the resident during inappropriate behavior. The resident's guardian and psychiatric physician assistant also acknowledged the need for privacy and monitoring of the resident's behavior, underscoring the deficiency in maintaining the resident's dignity and privacy.

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 communication accommodations for two residents with limited English proficiency. Resident #61, who is Vietnamese-speaking with intact cognition, was observed using a personal cell phone translation app to communicate with staff. Despite having a care plan that acknowledged the resident's primary language as Vietnamese, the facility did not provide access to interpreting services, relying instead on the resident's personal resources. Interviews with staff revealed that while a communication board was available, it was not utilized, and staff anticipated the resident's needs without formal language support. Resident #25, who is Spanish-speaking with severe cognitive impairment and visual disturbance, had a care plan that included utilizing Spanish-speaking staff for communication. However, it was unclear if Spanish-speaking staff were consistently available. A CNA mentioned using written notes to communicate, despite the resident's visual impairment. The facility's policy stated that language assistance should be provided without cost, but interviews indicated that staff did not have access to interpreting services, contradicting the facility's policy on communication with persons with limited English proficiency.

Penalty

No penalty information released

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

Summary

The facility failed to address a change in condition for a resident with severe cognitive impairment, who was on multiple psychotropic medications. The resident was observed to be lethargic and unresponsive, with staff noting increased sleepiness and difficulty in arousing him. Despite these observations, there was a lack of timely communication with the physician or PA regarding the resident's condition and potential medication side effects. The resident had recently experienced a significant increase in the dosage of Seroquel and Ativan, which may have contributed to his altered mental status and increased sedation. Staff failed to document any concerns related to sedation or drowsiness in the resident's electronic medical record, and there was no evidence that the PA was notified of these changes. The facility's monitoring of the resident's medication side effects was inadequate, as indicated by the lack of detailed documentation and communication with the healthcare provider. The Director of Nursing acknowledged the need for a review of the resident's medication dosages and response, noting that the monitoring should include specific documentation of behaviors or side effects. The facility did not have a clear policy for documenting changes in condition, and the Regional Nurse Consultant confirmed the absence of a CIC policy. This lack of documentation and communication contributed to the deficiency in addressing the resident's change in condition effectively.

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 vision services for a resident with a detached retina, resulting in a significant delay in receiving medical attention. The resident, who was admitted to the facility with intact cognition, reported waiting since June for transportation to an eye doctor. Despite multiple orders and notes indicating the need for an ophthalmology consultation as soon as possible, the resident did not receive timely care. The resident's care plan, initiated in July, acknowledged impaired visual function related to a detached retina, with interventions including a vision consult as needed. However, progress notes revealed repeated failures to schedule and secure transportation for the resident's ophthalmology appointments. Attempts to send the resident to the emergency room for evaluation were unsuccessful, as the resident was returned to the facility without treatment. Throughout June and July, there were numerous documented attempts to arrange appointments and transportation, but these efforts were consistently unsuccessful. The resident missed several scheduled appointments due to transportation issues, and despite being aware of the need for urgent medical attention, the facility did not ensure the resident received the necessary care 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 adequately monitor medication-related side effects and behaviors for two residents, leading to a deficiency in ensuring each resident's drug regimen was free from unnecessary drugs. Resident #10, who was admitted with multiple diagnoses including epilepsy, mood disturbance, and schizoaffective disorder, was prescribed several medications such as Levetiracetam, Escitalopram Oxalate, and Olanzapine. Despite having a care plan that required documentation of behaviors and responses to interventions, there was no documentation of Resident #10's behaviors in the medication and treatment administration records for August 2024. A Licensed Practical Nurse indicated that behaviors were documented by exception in the progress notes, which was insufficient for monitoring purposes. Similarly, Resident #73, admitted with dementia and anxiety disorder, was prescribed Donepezil, Trazodone, and initially Risperdal, which was discontinued shortly after admission. The facility's records showed no orders for behavior monitoring, and the August 2024 Medication Administration Record lacked documentation of behavior monitoring. The Director of Nursing acknowledged that the resident should be reviewed for appropriate medication dosage and response, noting that the resident appeared lethargic. The facility's policy required behavior monitoring for residents on psychoactive medications, but this was not followed, as evidenced by the lack of documented behavior monitoring and side effects in the electronic medical record.

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 appropriately store and secure medications, as observed in the case of a resident and in two medication rooms. Resident #20, who was readmitted to the facility with diagnoses including mood disorder and neutropenia, was found to have two bottles of eye drops in the drawer of his nightstand. The resident, who had a BIMS score indicating moderate cognitive impairment, stated that the eye drops were his and that he received them from a local hospital. A registered nurse confirmed that the resident should not have had medications accessible to him, as he was not assessed to administer them independently. In the Birch Unit medication room, a grey plastic shopping bag containing medication bottles was found stored in a cabinet. Staff members present during the observation were unaware of the contents of the bag or the reason for its storage in the medication room. Additionally, a container with a broken seal containing resident-specific medications and over-the-counter eye medications was found. Staff acknowledged that the resident-specific medications should have been disposed of. In the 200-hall medication room, a plastic bag with medication bottles labeled for expired and discharged residents was found, along with loose pills. Staff confirmed that these medications should have been disposed of properly. The facility's policy on medication storage requires that medications be stored properly and only accessible to authorized personnel. Medications belonging to expired or discharged residents should be destroyed or sent to the pharmacy. The Director of Nursing confirmed that medications should not be stored in residents' nightstands or inappropriately in medication rooms. The policy also mandates that medication storage areas be clean, organized, and free of clutter, which was not adhered to in this instance.

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 dental care and services for two residents. Resident #78, who was admitted with diagnoses including Major Depressive Disorder and Kyphosis, had broken and missing teeth, and the remaining teeth were brown in color. Despite having a care plan indicating the need for dentures, there was no documentation of dentures or partials being provided. The Social Service Director (SSD) acknowledged that the resident wanted dentures, but the in-house dental vendor did not accept his insurance. Additionally, the resident missed three appointments with the oral surgeon due to various reasons, including a canceled appointment, transportation issues, and a missing medical clearance form. Resident #84, admitted with Major Depressive Disorder and Generalized Anxiety, also had broken and discolored teeth but lacked a care plan addressing dental needs. The resident reported never having his teeth cleaned, and there was no documentation of dental cleaning from April to August 2024. The SSD mentioned that the resident often refused services and then complained about not receiving them. Although the SSD stated that the resident was seen by the hygienist every six months, there was no documentation to support this claim.

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 effectively collaborate and coordinate care with hospice services regarding the code status of a resident receiving hospice care. The resident, who was admitted with diagnoses including cerebral infarction, emphysema, unspecified dementia, and major depressive disorder, had conflicting orders regarding resuscitation status. The resident's physician orders indicated hospice care for a terminal diagnosis of cerebrovascular disease, with a full resuscitation order dated later. Additionally, the hospice plan of care in the resident's chart showed an advanced directive of full code, while the facility's order listing report indicated a DNR order that was later discontinued. Interviews with facility staff, including a Licensed Practical Nurse/Unit Manager and the Social Services Director, revealed a lack of hospice documentation at the facility, except for the initial visit. The staff were unable to locate a current hospice care plan or communication sheets for the resident. The Nursing Home Administrator later provided hospice notes, which confirmed the advanced directive of full code during several hospice visits. The facility's policy on advance medical directives required that current directives be placed in the medical record and the care plan updated, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident had access to his wheelchair during the survey. On the day of the survey, the resident was heard yelling for his wheelchair, which he needed to ambulate and go outside for a cigarette. The resident, who had an acquired absence of the left leg below the knee and other mobility impairments, was dependent on his wheelchair for mobility. Despite his repeated requests, the resident did not have access to his wheelchair all night, which caused him significant distress. Interviews with staff revealed that the wheelchair had been removed for cleaning the previous night and was not returned promptly. The CNA and LPN confirmed the resident's dependency on the wheelchair, and the LPN admitted to not hearing the resident's calls due to the noise. The DON and DOR acknowledged that an alternate wheelchair should have been provided and that the housekeeping staff should have communicated with therapy to ensure a safe replacement. The NHA confirmed that wheelchair cleaning was scheduled at night and that residents should not be left without their wheelchairs for extended periods. The facility's policy on resident rights emphasized the importance of ensuring residents' access to necessary services and mobility aids.