Kensington Gardens Rehab And Nursing 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 an effective antibiotic stewardship program, specifically in tracking infections and ensuring antibiotic use met established infection criteria. Review of the December 2025 Infection and Antibiotic Tracking Tool showed a resident identified as having a UTI with symptoms documented only as "urinary tract symptoms" and leukocytosis. Although a urine test was obtained, there was no documentation of WBC count, colony count, or culture results, and the urinalysis was negative, yet the resident received a 7‑day course of Ceftriaxone. The tracking tool did not specify which urinary symptoms were present. In January 2026, the Infection and Antibiotic Tracking Tool was found to be incomplete, with symptoms not listed and no indication whether cultures or tests had been obtained for five of nineteen facility-acquired conditions treated with antibiotics. One resident was treated with Nitrofurantoin for a facility-acquired UTI, but the tool did not document symptoms, whether testing was obtained, or test results. Progress notes showed this resident reported not feeling like herself, had an order for a urinalysis, and later had a urine culture with >100,000 CFU of E. coli and many bacteria, but there was no evidence that infection surveillance criteria were completed to determine the necessity of antibiotic use. Another resident was treated with doxycycline for a facility-acquired skin and soft tissue infection of a lower extremity wound, but the tracking tool did not document symptoms, test or culture results, or whether any tests were obtained. An SBAR noted a new skin wound or ulcer with no observed changes in skin and no applicable pain, and the infection surveillance criteria for cellulitis showed that the condition did not meet the required criteria for infection (no pus and only three of four required signs/symptoms). Despite this, the resident received antibiotics. Interviews with the IP and DON confirmed that line listings were incomplete, surveillance criteria were not consistently completed, antibiotic tracking was not reliably performed (especially for hospital-initiated antibiotics), and that the facility’s policies did not address completion of tracking and surveillance tools, even though the infection control program policy required surveillance data and antibiotic usage reviews as part of antibiotic stewardship.

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 an effective infection prevention and control program, including proper hand hygiene and appropriate use of Enhanced Barrier Precautions (EBP). During observation, a restorative aide removed gloves in one resident’s room, left without performing hand hygiene, crossed the hallway, and entered another resident’s room before later acknowledging that hand hygiene should have been performed after glove removal and between residents. This conduct occurred despite a facility hand hygiene policy requiring staff to perform hand hygiene after each direct resident contact and after removing gloves. Surveyors also reviewed the facility’s infection surveillance line listings for December and January and found that, while no residents were listed with Candida auris (C. auris), there were entries for skin and soft tissue infections. The January listing contained multiple incomplete sections regarding symptoms, whether cultures or testing had been done, and the results of such testing. The December listing included generalized symptoms such as pain, acute functional decline, and urinary tract symptoms, without clear, complete documentation. The Infection Preventionist (IP) reported not tracking or maintaining a list of residents diagnosed with C. auris on the line listing and stated that residents with C. auris should be on EBP indefinitely, but that C. auris cases were not added to the line listing because those residents were not receiving antibiotics. Further observations and record reviews showed that a resident with an active physician order for EBP related to C. auris, IV, and wound care did not have any precaution signage posted on or near the room door. Staff assigned to this resident, including CNAs, reported that there were no precautions in place and believed the resident only had a wound. The IP later confirmed that all residents on the C. auris list should have signs posted and that the resident in question had been readmitted and should have been on precautions at that time. Facility policies on infection prevention and control, transmission-based precautions, and EBP specified that residents colonized or infected with MDROs, including C. auris, require EBP and appropriate isolation measures, but these were not consistently implemented or communicated to 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 deficiency involves the facility’s failure to maintain a comprehensive grievance policy and to properly implement grievance procedures for multiple residents. The written Grievances – Resident Rights policy, last revised 07/2024, did not include required notification to the State Survey Agency and the State Long-Term Care Ombudsman program. Although the policy stated that the Grievance Officer would investigate grievances within five working days, coordinate with appropriate state and federal agencies as needed, and inform the resident or representative of the investigation findings and corrective actions, the facility did not follow these procedures as written. Surveyors found no documentation that residents or their representatives were informed of the results of grievance investigations for four sampled residents. One cognitively intact resident with necrotizing fasciitis, Type 2 DM, chronic combined systolic and diastolic CHF, difficulty in walking, muscle weakness, and colostomy status filed two grievances received on the same date. One grievance concerned waiting too long for call light response related to a colostomy bag that had broken open with feces on the resident’s abdomen. During interview, the resident reported waiting three hours for the call light to be answered while worried about wound integrity and stated that no one came to talk to him after he filed the grievance. The Social Services Assistant (SSA) reported she gave the grievance to the ADON and that staff were trained on call lights, but she did not know how long the call light had gone unanswered and did not confirm whether a resident statement had been obtained. The DON, who was also the Abuse Coordinator, acknowledged that no resident interview or statement was attached to the grievance and stated she did not know how long the resident had waited, while also acknowledging that a three-hour wait would be a problem. Another cognitively intact resident with chronic pain syndrome, heart failure, bipolar disorder, generalized muscle weakness, and neuromuscular bladder dysfunction filed a grievance about call light response time. The DON confirmed she completed this grievance after receiving it from staff, but there was no statement from the resident to show the concern had been directly discussed with the resident. A third cognitively intact resident with a displaced comminuted fracture of the left femur, lack of coordination, and need for assistance with personal care had a grievance filed by a family member, with the SSA listed as the investigator. A fourth cognitively intact resident with chronic pain syndrome, cervical disc degeneration, and generalized muscle weakness filed a grievance investigated by the ADON. For all four residents’ grievances, the section of the grievance forms designated for resident or responsible party notification of resolution, including name and signature, was left blank. Staff H stated that follow-up should have occurred with these residents, indicating that the facility did not document or demonstrate that residents were informed of the investigation findings or resolution of their grievances. Overall, the survey findings showed that the facility’s written grievance policy lacked required elements for external notification, and the implemented grievance process did not include complete investigations or documented resident interviews for key complaints, particularly those involving call light response and customer service. The facility also failed to document that residents or their representatives were informed of the results of the grievance investigations and any actions taken, despite policy language requiring verbal and/or written notification with rationale. These omissions affected at least four cognitively intact residents who had filed grievances or had grievances filed on their behalf, and the staff directly involved in grievance handling were unable to provide basic investigative details such as the length of call light delays or evidence of resident interviews.

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 appropriate assessment and care in response to changes in condition and to consistently provide and document ordered wound treatments for two residents with complex medical needs. For one resident with COPD, CHF, diabetes, peripheral vascular disease, and a below-knee amputation, the record showed he was cognitively intact, on continuous oxygen, and had PRN orders for ProAir inhaler and albuterol nebulizer for shortness of breath. On the day of his death, the MAR documented administration of ProAir at 11:02 p.m. and an albuterol nebulizer at 11:18 p.m., both marked as ineffective. The progress note by the LPN on duty stated she received report that the resident was not easily waking up, found him restless and congested, administered the inhaler and nebulizer, and called 911; EMS arrived and the resident expired at 11:59 p.m. Interview with the LPN revealed that she was told by the outgoing nurse that the resident was not doing well and that the outgoing aide and the resident’s roommate reported he had been more sleepy and not eating throughout the day. The LPN stated that when she assessed him, he was wheezing, had a pulse oximetry reading in the 80s, and elevated respirations, but she did not check his blood pressure. She reported that she believed he improved after the treatments and called another LPN to check on him, and that the resident had a pulse and was breathing when EMS arrived. The DON confirmed there was no SBAR, no documented assessment or vital signs after the morning vitals at 8:39 a.m., and no documentation that the resident’s emergency contact was notified of the change in condition. The DON also stated she did not know whether oxygen was applied, did not account for the 40-minute interval between the last PRN treatment and the time of death, and verified that the facility’s change-in-condition policy requires physician and representative notification and documentation of changes in condition. For a second resident with CHF, heart transplant status, ESRD on dialysis, diabetes, lymphedema, chronic venous hypertension, multiple chronic leg ulcers, and a left buttock pressure ulcer, the facility failed to consistently provide and document ordered wound care and weekly wound assessments. Physician orders directed daily wound care to the left buttock and right lower extremity using Santyl, Manuka honey, calcium alginate, and absorbent dressings, with additional orders after hospitalization for continued daily treatments to the buttock and extensive right lower leg venous ulcers. Review of the TARs for two consecutive months showed multiple days where ordered wound treatments were not documented as performed, with some days marked as out of facility or refused, but several days left blank with no indication of care provided. Weekly wound evaluations were incomplete or missing for multiple dates, and some wound evaluation entries for different dates were documented as written on the same later date. Additional documentation showed that the resident had large, full-thickness venous ulcers on the right lower leg, including lateral and medial anterior areas, with extensive necrotic tissue, copious drainage, and exposed necrotic adipose, and a left buttock Stage III pressure ulcer. A wound NP note described extensive ulcers covering approximately 60% of the right leg with large areas of necrotic tissue and recommended IV antibiotics and hospital transfer for surgical debridement, while continuing Santyl and calcium alginate. The care plans required weekly skin checks, measurement and documentation of wound size and status, monitoring for signs of infection, and notifying the physician and resident/representative of changes. The DON confirmed that wounds were to be evaluated at least weekly, that only limited wound evaluations were present in the e-chart, that the wound care nurse should have been documenting weekly follow-up, and that the discharge summary listed multiple open vascular wounds on both lower extremities and a buttock wound, without addressing the gaps in wound care and assessment documentation identified in the TARs and wound records. The facility’s own policies on prevention of skin impairment and change in resident condition required comprehensive skin assessments on admission, ongoing inspection during care, evaluation and documentation of changes in skin condition, and timely notification of the physician and resident representative of changes in condition. For both residents, the documentation and interviews showed that these processes were not followed: for the first resident, there was no documented comprehensive assessment, vital signs, SBAR, or representative notification in response to a significant change in respiratory status prior to death; for the second resident, there were repeated lapses in performing and documenting ordered daily wound treatments and weekly wound evaluations for extensive vascular and pressure wounds, despite care plan directives to monitor, measure, and document wound status and to notify the physician of changes.

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 complete appropriate post-fall assessments, including timely vital signs and neurological checks, for a resident who experienced two falls on the same day. The resident had multiple significant diagnoses, including dementia, pancreatic cancer, atrial fibrillation, history of falls, hypotension, and other comorbidities, and required supervision or touching assistance for toileting and bathing per the most recent MDS. The resident was care planned as being at risk for falls related to forgetfulness, history of falls, unsteady gait/poor balance, and multiple medications. Despite this identified fall risk, the facility did not ensure that post-fall assessments were fully and accurately completed and documented. For the first fall on 12/31, the facility’s internal form showed the fall occurred at approximately 10:45 a.m., but the SBAR documented at 12:00 p.m. did not specify the time of the fall. The vital signs recorded on the SBAR for this morning fall were taken at 9:14 a.m., 10:07 a.m., and 12:08 p.m., which the DON confirmed were obtained before the fall occurred. The DON verified there were no vital signs or neurological checks documented at the actual time of the fall, and no neuro check documentation was provided for this first fall. The DON also confirmed that, although the resident herself was notified, the family should have been notified and there was no indication that this occurred for the morning fall. The resident later reported having found and taken a pink pill (Benadryl) from the floor, and the DON stated staff looked at the resident’s floor but did not find anything and could not recall if other rooms were checked. For the second fall that evening, staff documentation and interviews showed that the resident was found on the floor with a small amount of blood and a raised open area on the back of the head. Staff B, LPN, documented returning from lunch and being informed by staff that the resident was on the floor, finding her lying on the floor with a head wound, cleansing the area with normal saline, and applying a bandage. The resident was able to move extremities on command and complained of slight ankle pain and chronic shoulder pain. An SBAR for this evening fall documented vital signs taken after the fall and indicated that the primary care clinician was notified and that staff were awaiting a call back; however, the DON verified there was no documentation that the provider ever called back or that any follow-up discussion occurred, despite the resident having hit her head. Neurological checks were documented as starting at 10:10 p.m. on 12/31 and continuing until 01/03 on the day shift, but there was no neuro check documentation tied to the first fall at approximately 10:45 a.m. Staff interviews were inconsistent about the timing and sequence of the falls, and the DON confirmed that the expectation was to see neurological checks after the first fall and clear documentation of provider communication, which were not present. The facility’s own policies required timely physician notification and documentation for accidents or incidents involving residents and for significant changes in condition, as well as individualized fall management and documentation for residents who experience falls. The policy on change in condition required the nurse to notify the attending physician when there was an accident or incident involving the resident and to record information related to changes in the resident’s condition in the medical record. The falls policy required that residents who experience a fall have appropriate documentation completed. In this case, the surveyors found that for one resident with a known fall risk and complex medical history, the facility failed to obtain and document vital signs and neurological checks at the time of the first fall, failed to clearly document the time of the fall on the SBAR, and failed to document follow-up communication with the medical provider after the second fall in which the resident hit her head, resulting in incomplete post-fall assessment and monitoring.

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 required notification of a change in condition to a resident’s representative and to adequately follow up with the primary provider after falls. Resident #3, who had multiple diagnoses including dementia, pancreatic cancer, atrial fibrillation, history of falls, and hypotension, was cognitively intact per a recent MDS with a BIMS score of 13 and required supervision or touching assistance for toileting and bathing. The resident was care planned as being at risk for falls due to forgetfulness, history of falls, unsteady gait/poor balance, and multiple medications. On 12/31/25, the resident experienced a fall in the late morning. Documentation in the SBAR and progress notes showed that vital signs were taken, but the SBAR did not include the date and time of the vital signs, and the neurological evaluation section was marked as not clinically applicable. The SBAR indicated that the primary care clinician was notified and that there were no new orders, and that the resident herself was notified, but there was no documentation that the resident’s family or representative was notified of this fall, despite facility policy requiring such notification when a resident is involved in an accident or incident. The DON later verified that the family should have been notified of this first fall and that neurological checks were expected after this fall. Later that same day, the resident had a second, unwitnessed fall in the evening. A progress note documented that staff found the resident on the floor with a small amount of blood on the back of her head and a small raised open area that was cleansed and bandaged. The resident was able to move extremities and complained of slight ankle pain. The LPN documented that a message was left for the NP on call and for the resident’s husband, and an SBAR for this second fall showed vital signs and indicated that the primary care clinician was notified and that staff were awaiting a call back. The DON confirmed there was no documentation that the medical provider returned the call or that any follow-up occurred after the notification, even though the resident had hit her head. The DON also confirmed that the exact time of the second fall was not documented in the progress note, and that the facility’s policy requires documentation of changes in condition and timely notification of the physician and resident representative after accidents or incidents.

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

Surveyors identified a deficiency related to the facility’s failure to maintain a safe, clean, and comfortable environment when multiple resident room privacy curtains were observed to be visibly soiled or stained. In one room, the privacy curtain had multiple brown stains smeared along its length, and in another room, the curtain had a large brown smear. Staff interviews revealed inconsistent understanding and execution of responsibilities for identifying, changing, and ordering replacement privacy curtains. The Housekeeping Manager stated that stained curtains are supposed to be addressed and swapped out right away, that CNAs or housekeeping staff notify him of dirty curtains, and that he attempts to check all curtains weekly. However, he acknowledged that he does not keep a formal log of curtain changes and instead notes needed changes on a notepad or scrap paper, and he stated that the majority of curtains are stained rather than dirty. Further interviews showed confusion and lack of formal tracking regarding who is responsible for ordering replacement privacy curtains. The Nursing Home Administrator initially stated housekeeping is responsible for putting in orders for new curtains, while the Director of Operations, District Manager, and Housekeeping Manager later stated that central supply is responsible for ordering curtains after being advised of the needed quantity. Central supply staff, however, reported that it is not their responsibility to make privacy curtain orders and that calls are made to a regional company, housekeeping, or maintenance instead. A CNA reported that privacy curtains are sometimes not changed right away despite requests. The DON stated that housekeeping is expected to be notified immediately when curtains appear dirty so they can be switched out right away, acknowledged that curtains are not expected to be or appear dirty after viewing photo evidence, and noted there is no way to determine when a curtain is stained versus soiled. The facility’s Environmental – Cleaning policy requires a clean, safe, orderly, comfortable, and attractive environment, including maintaining walls and ceilings free from dirt or other matter and providing fresh, clean, odor-free linens as needed. Photographic evidence of the stained curtains was obtained.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to effectively implement its Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, and Injury of Unknown Origin (ANEMMI) policy and procedure in response to complaints and an allegation of verbal abuse involving two residents. One resident, who was cognitively intact with a BIMS score of 15 and had multiple medical conditions including necrotizing fasciitis, type 2 diabetes, chronic combined systolic and diastolic heart failure, difficulty in walking, muscle weakness, and colostomy status, filed two grievances on the same day. His care plan documented a colostomy related to a large buttock wound with interventions for ostomy care daily and PRN, and extensive assistance with ADLs and bed mobility. Despite these documented needs, the resident reported that when his colostomy bag broke open, leaving feces on his stomach, his call light went unanswered for approximately three hours during the 3 p.m. to 11 p.m. shift, and that staff repeatedly told him they would get to it but did not promptly provide care. The same resident stated that the colostomy appliance was coming away from the skin with feces on it and that he had to wait for a nurse, who he believed was occupied with three admissions that night. He reported that the colostomy bag broke around 9 p.m. and was not addressed until about 11 p.m., and that the colostomy was supposed to be changed as needed. He indicated that he filed a grievance about the delayed response and that “that is as far as it went,” stating that no one came and talked to him about that grievance. He also filed another grievance related to his POA attempting to call the nursing desk multiple times and being hung up on; he reported that the nursing home administrator did speak with him and his POA about the phone complaint, but there is no indication in the report that the facility treated the colostomy-related grievance as a potential neglect concern or investigated it under the ANEMMI policy. A second resident reported an allegation of verbal abuse by a CNA during incontinence care. During this episode, the staff member was heard to say three times, “I do not give a damn,” and, when the resident requested a replacement gown, the staff member was heard to say “no.” The resident confirmed she was not provided a replacement gown during the care. The facility’s SNF Risk Management Tracking Tool documented an entry for this resident as an allegation of verbal abuse on the date of the incident. The facility’s ANEMMI policy defined abuse to include deprivation of goods or services necessary to maintain physical, mental, and psychosocial well-being, and neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required immediate reporting and thorough investigation of all allegations. The survey findings indicated that the allegation of verbal abuse was verified, yet there was no update to this resident’s care plan, and the overall findings concluded that the facility failed to effectively implement its ANEMMI policy and procedure for both 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 investigate and report within required timeframes an allegation of neglect related to untimely care and services for one cognitively intact resident. The resident had multiple diagnoses including necrotizing fasciitis, type 2 diabetes mellitus, chronic combined systolic and diastolic heart failure, difficulty in walking, muscle weakness, and colostomy status. The resident’s care plan documented a colostomy with daily and PRN ostomy care and extensive assistance needs for ADLs and bed mobility. The facility’s ANEMMI policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress, and required reporting of suspected events to state agencies within specified timeframes. On the date in question, the resident filed two grievances. The first grievance, received and dated with the same incident date, documented that the resident “waited too long for call light to be answered” and was investigated and resolved by the ADON the following day. The second grievance, also received and dated with the same incident date, documented a concern about customer service and was likewise marked as investigated and resolved the next day. However, the grievance documentation did not include a resident interview or resident statement for either grievance, and there was no indication that the allegation was treated as a potential neglect incident requiring ANEMMI investigation and external reporting. During interview, the resident reported that his colostomy bag broke during the 3p–11p shift, around 9 p.m., resulting in feces on his stomach and concerns about his wound, and that it took approximately three hours for staff to respond to his call light and complete the colostomy care around 11 p.m. He stated staff repeatedly told him they would get to it, and that he filed the grievance because of the delay and his concern about the integrity of his wound. He also reported that no one came and talked to him about the grievance related to the call light and colostomy issue, although the administrator did speak with him and his POA about the separate phone call complaint. The DON, who was the Abuse Coordinator, stated she viewed the grievance as a customer service issue, did not know how long the resident had waited, confirmed no resident interview was attached to the grievance investigation, and acknowledged that a three-hour wait for a call light response would be a problem. The DON later stated they were going to file a neglect report for this event, indicating it had not been reported within the required 24-hour timeframe.

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 update and implement comprehensive care plans to address ongoing nail and hygiene care needs for two residents. Facility policy requires that comprehensive care plans be reviewed and revised by the interdisciplinary team after each MDS assessment and that services in the care plan be provided by qualified staff. For one resident with COPD, Parkinson’s disease, ataxia, and tremors, surveyors observed orange and brown buildup under the nails. The resident’s quarterly MDS showed severe cognitive impairment with no documented rejection of care, and the care plan identified an ADL self-care deficit related to Parkinson’s disease, indicating the resident should be encouraged and assisted with all ADLs, including personal hygiene, with limited to extensive assistance. Progress notes contained no documentation of refusal of ADLs, including nail care, and shower sheets for multiple dates showed no nail care documented or refused, with one instance where nail care was initially marked as completed, then crossed out and changed to refused. For the second resident, who had Type 2 diabetes, COPD, and hypertensive heart disease, surveyors observed brown and dark-colored buildup under the nails on two occasions. The resident’s quarterly MDS indicated they were unable to complete the BIMS interview and showed no documented rejection of care. The care plan documented an ADL self-care deficit and the need for encouragement and assistance with all ADLs, including personal hygiene, with dependent assistance from one or two staff. Progress notes showed no documentation of refusal of nail care, and shower sheets for multiple dates showed no nail care documented or refused. Staff interviews revealed that shower sheets are supposed to be completed for all hygienic care and refusals, that nail care should be provided on non-shower days if needed, and that both residents’ care plans should have been updated to reflect the need for frequent nail care. The DON confirmed the expectation that hygienic care be provided even on non-shower days and acknowledged that the residents’ nails were not acceptable and that their care plans should have been updated to reflect frequent nail care needs.

Penalty

No penalty information released

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

Summary

The facility failed to provide adequate ADL nail care for two residents who required assistance. For one resident with COPD, Parkinson’s disease, ataxia, and tremors, surveyors observed orange and brown buildup under the nails. The resident’s MDS showed severe cognitive impairment with no documented rejection of care, and the care plan identified an ADL self-care deficit related to Parkinson’s disease, indicating the resident should be encouraged and assisted with all ADLs, including personal hygiene, and may need limited to extensive assistance by one or two staff. Review of progress notes showed no documentation of refusal of ADLs, including nail care. Shower sheets indicated scheduled showers on Wednesdays and Saturdays, with multiple dates where nail care was neither documented as provided nor refused. On one date, nail care was initially marked as completed, then crossed out and changed to refused by a CNA. In interview, the CNA stated that when the resident refuses nail care, they contact the family to help convince the resident, and that nail care would be provided on non-shower days if needed, with shower sheets completed for each attempt. For the second resident, who had Type 2 diabetes, COPD, and hypertensive heart disease, surveyors observed brown and dark-colored buildup under the nails on two separate days. The MDS indicated the resident was unable to complete the BIMS interview and showed no rejection-of-care behaviors. The care plan documented an ADL self-care deficit and the need for encouragement and assistance with all ADLs, including personal hygiene, with dependent assistance by one or two staff. Progress notes contained no documentation of refusal of nail care. Shower sheets showed scheduled showers on Wednesdays and Saturdays, with dates where nail care was not documented as provided or refused. An LPN stated that shower sheets are to be completed for any hygienic care and refusals for each attempt and that this resident usually does not refuse care. The unit manager and DON acknowledged that both residents’ care plans should have been updated to reflect frequent nail care needs, and the DON stated that hygienic care is expected even on non-shower days and that the second resident’s nails were not acceptable and should have been addressed, consistent with the facility’s ADL Care and Services policy that includes nail care.

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

Multiple deficiencies were identified regarding the facility's failure to provide a safe, clean, comfortable, and homelike environment for residents. Several residents reported malfunctioning overhead lights, with one resident stating their light flickered on and off and another's did not work at all. Staff confirmed these issues but did not immediately resolve them. Another resident received a replacement bed due to a malfunction, but the new bed's head mechanism was also nonfunctional, requiring the resident to restart the request process. In another case, a resident's overhead bed light required aggressive pulling to operate, which the resident was unable to do independently. Environmental observations revealed significant maintenance and sanitation issues in both resident and common areas. The activities room had a ceiling tile with visible mold-like growth, loose baseboards, and water accumulation in a garbage can. The area outside the activities room showed bio growth and peeling paint, with missing ceiling texture and further mold-like substances. The pantry room's refrigerator and freezer were operating at unsafe temperatures, resulting in thawed and lukewarm food items. The pantry also had a large collection of dark bio growth under the sink, a partially hanging ceiling tile, and an exterior wall vent with debris and an opening to the outside. Flooring in multiple areas was loose and could be lifted easily, posing a tripping hazard, as noted by a resident using a walker. Additional deficiencies included a resident room with a non-functioning air conditioning unit, resulting in a noticeably warmer environment and a hygrometer reading of 80°F. The AC filter was covered in black bio growth, and a missing bathroom ceiling tile exposed pipes. These issues were confirmed by facility leadership during a walkthrough. The facility's own policy requires maintaining a clean, safe, and orderly environment, but observations and interviews demonstrated that these standards were not met in several areas, affecting both resident rooms and shared spaces.

Plan Of Correction

What corrective actions (s) will be accomplished for those residents found to have been affected by the deficient practice: 1. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews and room audits completed. 2. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 3. By 7/12/2025, Resident #7 bed replaced with head of bed working properly. 4. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 5. By 7/12/2025, the loose baseboard along the perimeter of the activities room was replaced. 6. By 7/12/2025, the bio-growth substance outside of the sliding glass door to the left of the activities room exiting to the courtyard was cleaned. 7. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling tile was repaired and repainted. 8. By 7/12/2025, the refrigerator in the nourishment room on the east hallway was removed, discarded, and replaced. The cupboard under the sink of the east pantry was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall was cleaned. 9. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room. The missing ceiling tile in the bathroom was replaced. The flooring in resident #12 room was replaced. 10. By 7/12/2025, the loose flooring was replaced/repaired in the east 200 hallway. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident room, and common area audits will be conducted to ensure equipment is safe, sanitary, comfortable, and operational. The audit will include resident room HVAC, refrigerator and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired and/or replaced as appropriate. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on reporting safe, sanitary, comfortable, and operational equipment via TELS. 2. Newly hired staff will be educated on reporting safe equipment, maintenance, and environmental concerns via TELS. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational weekly for 4 weeks then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met and sustained.

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 functioning Quality Assurance and Performance Improvement (QAPI) program, as evidenced by ongoing deficiencies in the timely repair and maintenance of essential equipment and the failure to provide a safe, sanitary, and comfortable environment for residents. Multiple observations revealed that several resident rooms had malfunctioning overhead lights, with one resident reporting a flickering light and another stating their light did not work at all. In another instance, a resident received a replacement bed that was also not functioning properly, specifically the head adjustment feature. Staff confirmed these issues during interviews and observations. Environmental concerns were also documented throughout the facility. The activities room had a ceiling tile with visible mold and water damage, loose baseboards, and bio growth both inside and outside the room. Water accumulation was observed in a garbage can placed under the damaged ceiling. The pantry room in the east hallway had a refrigerator and freezer with temperatures outside the normal range, resulting in thawed and lukewarm food items. The inside of the pantry cabinet showed significant mold growth, and a ceiling tile was partially hanging down. Additionally, a wall fan vent had an opening to the outside, allowing debris and leaves to enter. Flooring in several areas was loose and could be lifted easily, posing a tripping hazard, and a bathroom had a missing ceiling tile with exposed pipes. Air conditioning issues were persistent, with one unit (A/C #11) reported as non-functional since the previous October. Residents reported discomfort due to non-working A/C units, with one resident's room measured at 80 degrees Fahrenheit and the A/C filter covered in black bio growth. Staff interviews confirmed that the maintenance issue had been ongoing and that the facility lacked a policy for A/C maintenance and repairs. The administrative team was unaware of some of these issues until they were pointed out during the survey. These findings demonstrate a lack of effective systems for identifying, tracking, and correcting quality deficiencies, as required by the facility's QAPI program.

Plan Of Correction

This Plan of Correction constitutes this facility's written allegation of compliance for deficiencies cited. However, submission of this Plan of Correction is not an admission that the deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. F867 What corrective actions(s) will be accomplished for those residents found to have been affected by the deficient practice: 1. Quality Assurance Performance Improvement Plan meeting was held 6/13/2025 and 6/18/2025 to review F908. 2. By 7/12/2025, Roof top Air Conditioning Unit (#11) repaired by 7/12. 3. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews completed and rooms audited. 4. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 5. By 7/12/2025, Resident #7 bed replaced, with head of bed working properly. 6. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 7. By 7/12/2025, the loose baseboard along the perimeter of the activities room replaced. 8. By 7/12/2025, the green bio-growth substance outside of the sliding glass door to the left of the activities room exiting the courtyard was cleaned. 9. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling file was repaired and repainted. 10. By 7/12/2025, the refrigerator in the nourishment room on east hallway was removed, discarded, and replaced. The cupboard under the sink of the east pantry room was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall with the collection of debris was cleaned. 11. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room, and the missing ceiling tile in the bathroom was replaced. 12. By 7/12/2025, the flooring in room 215 was replaced. 13. By 7/12/2025, the loose flooring was replaced in the east 200 hallway. 14. By 7/12/2025, common areas, to include food storage pantry areas, were audited to ensure equipment is safe, sanitary, comfortable, and operational. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident rooms, and common areas will be audited to ensure equipment is safe, sanitary, comfortable, and operational. The audit includes roof top AC units, resident room HVAC, refrigerators and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired or replaced as/or designee educated staff on the Quality Assurance Performance Improvement process. Additional corrective actions include: - Resident #7 bed replaced, with head of bed working properly. - The ceiling tile in the activities room on the south hallway replaced. - The loose baseboard along the perimeter of the activities room replaced. - The green bio-growth substance outside of the sliding glass door to the left of the activities room exiting the courtyard was cleaned. - The ceiling outside of the activities room adjacent to the ceiling file was repaired and repainted. - The refrigerator in the nourishment room on east hallway was removed, discarded, and replaced. The cupboard under the sink of the east pantry room was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall with the collection of debris was cleaned. - The air conditioning was replaced in Resident #12 and #13 shared room, and the missing ceiling tile in the bathroom was replaced. - The flooring in room 215 was replaced. - The loose flooring was replaced in the east 200 hallway. - Common areas, including food storage pantry areas, were audited to ensure equipment is safe, sanitary, comfortable, and operational. How you will ensure the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on the Quality Assurance Performance Improvement (QAPI) process. 2. By 7/12/2025, the Administrator and/or designee will educate staff on reporting of safe, sanitary, comfortable, and operational equipment concerns via TELS. 3. Newly hired staff will be educated on QAPI and reporting equipment, maintenance, and environmental concerns via TELS. How the corrective action will be monitored to ensure the practice will not recur: The Administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The maintenance director and/or designee will audit the roof top AC units weekly for 4 weeks and then monthly for 3 months. The findings of the audits will be reported to the Quality Assurance Performance Improvement committee monthly until the committee determines substantial compliance is maintained.

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 develop and implement policies and procedures to ensure the reporting of a reasonable suspicion of a crime, as required by federal and state regulations, for one resident out of four sampled. The deficiency centers on an incident involving a resident who reported feeling sexually harassed and abused by a male Occupational Therapist Assistant (OTA) after he entered her room while she was undressed. The resident stated that she told the OTA to leave, which he did, and subsequently refused therapy with him. She reported the incident to a female supervisor and the DON, expressing that she did not want the OTA in her room anymore and described her feelings of harassment and abuse. Interviews with facility staff revealed inconsistencies in the communication and handling of the resident's allegation. The Director of Rehabilitation stated that the resident reported the incident to her, and she subsequently interviewed the OTA and relayed the information to the DON, who is the facility's abuse coordinator. However, the DON denied receiving any report of sexual harassment or abuse from the Director of Rehabilitation, stating that the only concern brought to her attention was the resident's preference for a therapy schedule and not wanting certain therapists. The DON confirmed that if an allegation of abuse or sexual harassment had been reported, she would have suspended the staff member, reported the allegation, and initiated an investigation, none of which occurred. A review of the facility's state agency reportable log showed no evidence that a report was filed with state agencies or that an investigation was conducted regarding the resident's allegation. The facility's policy requires staff to report any allegations of abuse, neglect, exploitation, or mistreatment immediately to the appropriate personnel and to state agencies within the required timeframe. Despite these policies, the incident involving the resident and the OTA was not reported or investigated as required, resulting in noncompliance with federal and state regulations.

Plan Of Correction

N917 Resident #3 abuse allegation was reported, an investigation conducted, and investigative findings confirm unsubstantiated for sexual abuse. Resident #3 discharged home as planned and no longer resides in the facility. The facility DOR and Staff C no longer are employed at the facility. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Like resident interviews conducted with no reported concerns regarding sexual abuse or care concerns. Process of reporting abuse, neglect, and exploitation reviewed with residents at Resident council by 7/12/2025. Staff interviews and education conducted to ensure no reported allegations of abuse, neglect, or exploitation. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. The administrator educated the DON on reporting requirements of abuse, neglect, and exploitation allegations with competencies. 2. The administrator and/or designee educated staff on reporting requirements to the facility abuse coordinator of allegations of abuse, neglect, and exploitation with staff competencies. 3. Newly hired staff will be educated on reporting requirements to the facility abuse coordinator of abuse, neglect, and exploitation allegations and the facility abuse coordinator. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents on each unit. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The administrator and/or designee will conduct random 10 staff interviews for competencies on reporting allegations of abuse, neglect, and exploitation. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met. This plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to ensure the immediate reporting and investigation of an allegation of sexual harassment made by a resident. The resident, who was cognitively intact with a BIMS score of 13, reported that a male occupational therapy assistant entered her room while she was undressed, despite her telling him to leave. She described feeling sexually harassed and abused by the incident and communicated her concerns to a female supervisor and the DON, stating she did not want the staff member in her room anymore. Despite the resident's clear report of feeling sexually harassed, there was no evidence in the facility's state agency reportable log that a report was filed or that an investigation was conducted regarding the allegation. Interviews revealed conflicting accounts between the Director of Rehabilitation and the DON regarding whether the allegation was communicated and acted upon. The Director of Rehabilitation stated she reported the incident to the DON, while the DON denied receiving any report of sexual harassment and stated that, had she been informed, she would have suspended the staff member and initiated an investigation. The facility's policy required staff to report any allegations of abuse, neglect, exploitation, or mistreatment immediately to the risk manager, direct supervisor, or abuse coordinator, and to report such allegations to state agencies within the required federal timeframes. However, in this case, the required procedures were not followed, resulting in the failure to report and investigate the resident's allegation of sexual harassment as mandated by federal regulations.

Plan Of Correction

Resident #3 abuse allegation was reported, an investigation conducted and investigative findings confirm unsubstantiated for sexual abuse. Resident #3 discharged home as planned and no longer resides in the facility. The facility DOR and Staff C no longer are employed at the facility. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Like resident interviews conducted with no reported concerns regarding sexual abuse or care concerns. Process of reporting abuse, neglect and exploitation reviewed with residents at Resident Council by 7/12/2025. Staff interviews and education conducted to ensure no reported allegations of abuse, neglect, or exploitation. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. The administrator educated the DON on reporting requirements of abuse, neglect and exploitation allegations with competencies. 2. The administrator and/or designee educated staff on reporting requirements to the facility abuse coordinator of allegations of abuse, neglect, and exploitation with staff competencies. 3. Newly hired staff will be educated on reporting requirements to the facility abuse coordinator of abuse, neglect, and exploitation allegations and the facility abuse coordinator. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents on each unit. This audit will be completed weekly for 4 weeks then monthly for 3 months. The administrator and/or designee will conduct random 10 staff interviews for competencies on reporting allegations of abuse, neglect and exploitation. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met. This plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law.

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 thoroughly investigate an allegation of resident-to-resident abuse involving two residents. The incident occurred when one resident, who had a history of behavioral disturbances including aggression and agitation, struck another resident on the back of the head with a PVC pipe while on the smoking patio. Staff were present and intervened immediately, placing the aggressor on one-to-one supervision, but later reduced this to 15-minute checks due to increased agitation. The resident who was struck was assessed and sent to the emergency department for evaluation, where a CT scan was negative for acute injury, and he returned to the facility the same day. Despite multiple staff and resident interviews confirming that the aggressor made contact with the other resident's head using the PVC pipe, the Director of Nursing (DON) reported the incident as an "attempted" contact rather than a substantiated case of abuse. The DON based this decision on the absence of documented injuries and negative CT scan results, despite witness statements and the victim's own report of pain. The facility's documentation lacked a timely skin assessment and did not include adequate documentation of pain status or physician notification at the time of the incident. The facility's policy requires thorough investigation of abuse allegations, including interviews, observations, and documentation of injuries. However, the investigation did not fully comply with these requirements, as evidenced by incomplete documentation and the failure to substantiate the abuse despite corroborating evidence. The deficiency was identified due to the lack of a comprehensive investigation and failure to recognize and report the incident as substantiated abuse.

Plan Of Correction

F610 What corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #14 discharged and no longer resides in the facility. Resident #15 was sent to the hospital for further evaluation and returned with no new orders, CT was negative and the resident is back to baseline. Resident #15 was interviewed and has no concerns regarding care. Resident #15 head to toe skin assessed and pain assessed, with no skin alterations and no complaints of pain. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Like resident interviews conducted with no reported concerns of abuse, neglect, or exploitation or care concerns. Process of reporting abuse, neglect, and exploitation reviewed with residents at Resident Council by 7/12/2025. Staff interviews conducted to ensure no reported allegations of abuse, neglect or exploitation. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. The administrator educated the DON on reporting requirements of abuse, neglect, or exploitation allegations with competencies. 2. The administrator and/or designee educated Staff on reporting requirements to the facility abuse coordinator of allegations of abuse, neglect, and exploitation allegations with staff competencies. 3. Newly hired staff will be educated on reporting requirements to the facility abuse coordinator of abuse, neglect, and exploitation allegations and the facility abuse coordinator. 4. The Director of Nursing and/or designee educated licensed nurses on resident change in condition to include physician notification of the change in condition, completion of skin and pain assessments to be included for abuse allegation investigation events. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator and/or designee will conduct an interview of 5 residents on each unit. This audit will be completed weekly for 4 weeks, then monthly for 3 months. This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is submitted to meet requirements established by state and federal law. F0610

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 pest control program, as evidenced by multiple direct observations and resident and staff interviews confirming the presence of live and dead roaches throughout resident rooms and common areas. Surveyors observed live roaches in resident rooms, on windowsills, walls, dressers, and inside dresser drawers. Accumulations of dead roaches and roach body parts were found in areas such as the pantry and overhead light fixtures. Residents consistently reported seeing roaches frequently in their rooms and stated that they had not witnessed pest control treatments being performed in their rooms. Staff interviews corroborated the residents' accounts, with several CNAs, housekeeping staff, and nursing staff reporting regular sightings of both live and dead roaches in various parts of the facility. Staff described killing roaches themselves and cleaning up the remains, and some reported documenting pest concerns in the pest control log. However, inconsistencies were noted in the use of the pest control log, with the contracted pest control serviceman stating that the log was not always utilized appropriately and that reports of pest activity varied from week to week. The pest control serviceman indicated that he visited the facility weekly, reviewed pest logs, and provided both verbal and written reports to the maintenance assistant. However, there was confusion regarding the receipt and review of these reports, as the maintenance assistant did not receive emailed reports and the newly hired Nursing Home Administrator was unaware of certain facility issues, such as holes in the building exterior that could allow pest entry. The pest control serviceman also noted that some ultraviolet pest control lights were not functioning and had not been repaired for several months. The facility's own pest control policy required maintenance services to assist in pest control when necessary, but observations and interviews indicated ongoing and widespread pest issues.

Plan Of Correction

This plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law. What corrective action will be accomplished for those residents found to have been affected by the deficient practice: 1. Resident #4 provided pest control. Housekeeping cleaned Resident #4's windowsill, walls, and dressers. The growth of dark brown/black dusty-like debris behind Resident #4's dresser was cleaned. Resident #4 was interviewed and room observed with no pest control concerns. 2. Resident #7 provided pest control. Resident #7 was interviewed and room observed with no pest control concerns. 3. Resident #3 provided pest control. Housekeeping cleaned Resident #3's floor and under her dresser. Resident #3 was interviewed and room observed with no pest control concerns. 4. Resident #11 provided pest control. Resident #11 was interviewed and room observed with no pest control concerns. 5. Resident #8 provided pest control. Housekeeping cleaned Resident #8's dresser drawer. Resident #8 was interviewed and room observed with no pest control concerns. 6. Housekeeping cleaned the pantry room in the north hallway. Both sides of the refrigerator were cleaned as well as the floor. 7. Shared room for Resident #12 and #13 was provided pest control. Housekeeping cleaned the room and bathrooms. Resident #13's overbed fight fixture was replaced. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: 1. An audit of resident rooms was completed, with no observations of pest concerns. 2. Resident interviews were completed to ensure prompt response for any pest control items reported. 3. An audit of the exterior of the facility was completed to ensure holes identified are repaired to minimize points of entry by 7/12/2025. 4. The facility's lawn service provider cleaned the foliage and trees on the exterior of the facility to minimize points of entry. 5. Two filters, one located on the east nurse's station and one located in the kitchen, were replaced with new bulbs, and filters continue to be cleaned and changed out monthly and as needed. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. Staff educated by the administrator/designee on pest control process and use of pest control log of any observed pest control concerns. 2. Housekeeping staff educated on cleaning of resident rooms and other common areas and the use of the pest control log if any observation is made. 3. Residents educated during resident council meetings regarding proper storage of food in the room to minimize pest control concerns and to report any observations to staff. 4. Maintenance staff educated on walking rounds of the exterior of the facility to identify any holes, points of entry, and foliage to minimize pest control concerns. 5. The pest control serviceman was educated by the administrator to provide written reports of each service to the administrator and maintenance staff. 6. The administrator and/or designee will review the pest control service reports to identify any issues or trends and follow up with the pest control company as needed. 7. Pest control service increased from once/week to twice/week and as needed. How the corrective action will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents and audit 5 rooms on each unit and common areas to ensure the facility maintains an effective pest control program. This audit will be completed weekly for 4 weeks, then monthly for 3 months. The designee will audit the pest control log for trends. The audit of the pest control log will be completed weekly for 4 weeks, then monthly for 3 months. Identified concerns or trends will be communicated with the pest control company for follow-up as needed. The findings of the audits will be reported to the Quality Assurance Performance Improvement Committee monthly until substantial compliance and sustainability are met. The maintenance director and/or designee will audit the pest control log for trends. The audit of the pest control log will be completed weekly for 4 weeks then monthly for 3 months. Identified concerns or trends will be communicated with the pest control service company for follow-up as needed. The findings of the audits will be reported to the Quality Assurance Performance Improvement committee monthly until the committee determines substantial compliance is maintained. F0925

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 timely repair and maintenance of essential equipment, specifically one of its rooftop air conditioning (A/C) units, identified as unit #11. According to staff interviews and record review, the A/C unit had a bent fan blade and had not been functioning properly since October 2024. Despite the ongoing issue, the problem was not addressed or escalated appropriately, and the Nursing Home Administrator (NHA) was unaware of the malfunction until it was brought up during the survey. Staff members, including a maintenance assistant and a maintenance director from another facility, confirmed the prolonged nature of the problem. Observations during the survey included a staff member fanning herself in the affected hallway, indicating discomfort due to inadequate cooling. Additionally, the facility did not have a written policy regarding the maintenance and repair of A/C units, as required by regulation. The lack of a maintenance policy and the failure to address the malfunctioning A/C unit in a timely manner contributed to the deficiency. The survey also noted that the facility could not confirm payment or completion of repairs for previously identified A/C issues, and that the problem with unit #11 had not been included in prior repair requests. The deficiency was cited as a Class I violation, and the facility was found to be out of compliance with relevant state and federal regulations.

Plan Of Correction

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The AC unit (#11) in the south hallway/activities room area repaired by 7/12/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of the roof top AC units in the facility was completed. Roof top AC units identified with concerns will be repaired and/or replaced by 7/12/2025. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, Staff educated by the Administrator and/or designee on essential equipment, safe operating condition and identified concerns to be reported via TELS. 2. Newly hired staff will be educated on essential equipment, safe operating condition and identified concerns to be reported via TELS. How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator and/or designee will conduct a random audit of the roof top AC units to ensure essential equipment is in safe operating condition weekly for 4 weeks, then monthly x 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance is sustained.

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 timely repair of essential equipment, specifically one of the rooftop air conditioning (A/C) units, identified as unit #11, out of a total of 19 units. According to staff interviews and observations, the A/C unit #11 had a bent fan blade and had not been functioning properly since October 2024. The maintenance assistant was aware of the ongoing issue, but the Nursing Home Administrator (NHA) stated she was unaware of the problem until it was brought to her attention during the survey. During the survey, staff were observed attempting to find cooler areas in the building, indicating discomfort due to the malfunctioning A/C. The facility did not have a policy in place for the maintenance and repair of A/C units. Maintenance staff confirmed that the issue with A/C unit #11 had persisted for several months without resolution. The NHA could not confirm whether payment had been made to the A/C company for previous repair requests, and only a new quote for repairs was available at the time of the survey. The lack of timely repair and absence of a maintenance policy contributed to the deficiency cited by surveyors.

Plan Of Correction

F908: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The AC unit (#11) in the south hallway/activities room area repaired by 7/12/2025. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit of the roof top AC units in the facility was completed. Roof top AC units identified with concerns will be repaired and/or replaced by 7/12/2025. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, Staff educated by the Administrator and/or designee on essential equipment, safe operating condition and identified concerns to be reported via TELS. 2. Newly hired staff will be educated on essential equipment, safe operating condition and identified concerns to be reported via TELS. How the corrective action (s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Administrator and/or designee will conduct a random audit of the roof top AC units to ensure essential equipment is in safe operating condition weekly for 4 weeks, then monthly x 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance is sustained.

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

Multiple deficiencies were identified in the facility's physical environment, impacting both resident rooms and common areas. Observations revealed that several residents had non-functional or malfunctioning overhead lights, with some lights flickering or not working at all. In one case, a resident received a replacement bed that was also not fully operational, as the head of the bed would not adjust. Additionally, air conditioning issues were noted, with one resident's AC unit not providing airflow and the filter covered in heavy black bio growth, resulting in a room temperature of 80 degrees Fahrenheit. Another room had a missing bathroom ceiling tile with exposed pipes. Common areas, including the activities room and pantry, exhibited significant maintenance and sanitation concerns. The activities room had a ceiling tile with visible water damage and bio growth, loose baseboards, and bio growth outside the sliding glass door. The pantry refrigerator and freezer were found to be operating at temperatures above safe ranges, with perishable items such as milk and ice cream thawed and not properly chilled. The pantry also had a large collection of dark bio growth under the sink, a partially hanging ceiling tile, and an exterior wall vent with an opening to the outside environment. Throughout the facility, loose flooring was observed in hallways and resident rooms, with some areas easily lifted by foot and posing a tripping hazard. Residents and staff confirmed these issues during interviews and walkthroughs. Facility leadership, including the NHA and DON, were made aware of these deficiencies during the survey and acknowledged the findings.

Plan Of Correction

What corrective actions (s) will be accomplished for those residents found to have been affected by the deficient practice: 1. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews and room audits completed. 2. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 3. By 7/12/2025, Resident #7 bed replaced with head of bed working properly. 4. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 5. By 7/12/2025, the loose baseboard along the perimeter of the activities room was replaced. 6. By 7/12/2025, the bio-growth substance outside of the sliding glass door to the left of the activities room exiting to the courtyard was cleaned. 7. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling tile was repaired and repainted. 8. By 7/12/2025, the refrigerator in the nourishment room on the east hallway was removed, discarded and replaced. The cupboard under the sink of the east pantry was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall was cleaned. 9. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room. The missing ceiling tile in the bathroom was replaced. The flooring in Resident #12 room was replaced. 10. By 7/12/2025, the loose flooring was replaced/repaired in the east 200 hallway. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident room and common area audits will be conducted to ensure equipment is safe, sanitary, comfortable, and operational. The audit will include resident room HVAC, refrigerator and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired and/or replaced as appropriate. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on reporting safe, sanitary, comfortable, and operational equipment via TELS. 2. Newly hired staff will be educated on reporting safe equipment, maintenance, and environmental concerns via TELS. How the corrective actions will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational weekly for 4 weeks then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met and sustained.

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

Multiple deficiencies were identified regarding the facility's failure to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Several residents reported malfunctioning overhead lights in their rooms, with one resident stating the light flickered and another indicating their light did not work at all. Staff confirmed these issues during observations. Additionally, a resident who received a replacement bed reported that the new bed's head would not go up or down, and another resident's overhead bed light required aggressive pulling to operate, which the resident was unable to do independently. Environmental concerns were also observed in common areas and food storage locations. The activities room had a ceiling tile with visible gray/black and brown discoloration, loose baseboards, and green and black bio growth near the sliding glass door and adjacent wall. Water was found collected in a garbage can under the affected area. In the east hallway pantry, the refrigerator and freezer were found to be operating at temperatures above safe ranges, with milk being lukewarm and frozen items thawed. The area under the pantry sink contained dark brown/black bio growth, and a ceiling tile above the door was partially hanging down. A wall fan had an opening to the outside environment, with leaves and debris present. Additional deficiencies included loose flooring in the east hallway and room 215, which could be lifted easily and posed a tripping hazard, as noted by a resident using a walker. In a three-resident room, one resident's air conditioning unit was not functioning, resulting in a room temperature of 80 degrees Fahrenheit, and the AC filter was covered in heavy black bio growth. The bathroom for these residents had a missing ceiling tile with exposed pipes. Facility staff and administration confirmed these findings during a tour and acknowledged the areas of concern.

Plan Of Correction

F921: What corrective actions (s) will be accomplished for those residents found to have been affected by the deficient practice: 1. By 7/12/2025, Residents #5, #6, #7, #11, #12, and #13 interviews and room audits completed. 2. By 7/12/2025, Residents #5, #6, and #11 overbed light repaired. 3. By 7/12/2025, Resident #7 bed replaced with head of bed working property. 4. By 7/12/2025, the ceiling tile in the activities room on the south hallway replaced. 5. By 7/12/2025, the loose baseboard along the perimeter of the activities room was replaced. 6. By 7/12/2025, the bio-growth substance outside of the sliding glass door to the left of the activities room exiting to the courtyard was cleaned. 7. By 7/12/2025, the ceiling outside of the activities room adjacent to the ceiling tile was repaired and repainted. 8. By 7/12/2025, the refrigerator in the nourishment room on the east hallway was removed, discarded and replaced. The cupboard under the sink of the east pantry was cleaned. The ceiling tile above the door was replaced. The exhaust fan in the wall was cleaned. 9. By 7/12/2025, the air conditioning was replaced in Resident #12 and #13 shared room. The missing ceiling tile in the bathroom was replaced. The flooring in Resident #12 room was replaced. 10. By 7/12/2025, the loose flooring was replaced/repaired in the east 200 hallway. How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By 7/12/2025, resident interviews, resident room and common area audits will be conducted to ensure equipment is safe, sanitary, comfortable, and operational. The audit will include resident room HVAC, refrigerator and cupboards in pantry rooms, ceiling tiles, flooring, beds for proper function, resident room overbed lights, and fans in the pantry rooms. Maintenance equipment and/or environmental items identified on the audit will be repaired and/or replaced as appropriate. What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: 1. By 7/12/2025, the Administrator and/or designee will educate staff on reporting safe, sanitary, comfortable, and operational equipment via TELS. 2. Newly hired staff will be educated on reporting safe equipment, maintenance, and environmental concerns via TELS. How the corrective actions will be monitored to ensure the practice will not recur, e.g., what quality assurance program will be put in place: The administrator and/or designee will conduct an interview of 5 residents and audit 5 resident rooms on each unit to ensure equipment is safe, sanitary, comfortable, and operational weekly for 4 weeks then monthly for 3 months. The findings of the audits will be reported to the QAPI committee monthly until the committee determines substantial compliance has been met and sustained.

Penalty

Fine: $18,070

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 functioning Quality Assurance Performance Improvement (QAPI) program, resulting in repeated deficiencies related to the timely repair and maintenance of essential equipment and the provision of a safe, sanitary, and comfortable environment for residents. Multiple observations revealed that several resident rooms had malfunctioning overhead lights, with one resident reporting a flickering light and another stating their light did not work at all. In another instance, a resident received a replacement bed that was also not functioning properly. Additionally, the activities room and pantry areas were found to have significant environmental issues, including water damage, bio growth (mold), loose baseboards, and exposed pipes. The pantry refrigerator and freezer were not maintaining safe temperatures, resulting in thawed food items and lukewarm milk, and the area under the pantry sink was contaminated with dark bio growth. Ceiling tiles were missing or damaged in several locations, and loose flooring was observed throughout the facility, creating potential tripping hazards. Several residents reported issues with their air conditioning (A/C) units, with one resident stating their A/C did not work and another moving their bed to receive better airflow. Observations confirmed that some A/C units were non-functional, had filters with heavy black bio growth, and that room temperatures were uncomfortably high. Staff interviews revealed that the issue with at least one A/C unit had been ongoing for several months, but the facility administration was unaware of the problem until the survey. The maintenance assistant confirmed the long-standing nature of the A/C issue, and the facility did not have a policy in place for A/C maintenance and repairs. During facility tours, the Nursing Home Administrator (NHA), Director of Nursing (DON), and other staff acknowledged the environmental and equipment deficiencies only after they were pointed out by surveyors. The QAPI committee and program were found to be ineffective in identifying, tracking, and correcting these deficiencies, as evidenced by the recurrence of issues previously cited and the lack of awareness among leadership regarding ongoing problems. The facility's policies on general cleaning and maintenance were not being followed, resulting in unsanitary and unsafe conditions in both resident and common areas.

Penalty

Fine: $18,070

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 timely repair of essential equipment, specifically two rooftop air-conditioning (A/C) units out of a total of nineteen. The Maintenance Director reported that A/C unit #5, located over the dining room, had been out of order since January and that if the dining room temperature exceeded 81 degrees, residents were moved back to their rooms. Additionally, A/C unit #19, located over the North Wing nurse's station, began having issues at the end of July and went out of service by early August. The Maintenance Director also mentioned that A/C unit #1, over the therapy gym, had been out of service since October, with a portable A/C unit placed in the therapy room as a temporary measure. The Maintenance Director indicated that obtaining repairs was difficult due to outstanding payments owed to A/C companies, and while quotes for repairs were available for units #1 and #19, no quote or evidence of repair was provided for unit #5. During the survey, documentation was provided for proposals to replace A/C units #1 and #19, but not for unit #5. An LPN confirmed that the dining room would become warm, prompting residents to return to their rooms. The lack of timely repair and absence of evidence for addressing the malfunctioning A/C unit in the dining room contributed to the deficiency cited by surveyors.

Penalty

Fine: $18,070

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

Summary

The facility failed to maintain the South Wing pantry and its associated eye wash station in a safe and sanitary condition. During a facility tour, a strong musty odor was detected near the pantry, and upon entry, multiple areas of water damage were observed, including brown and black discoloration, mildew, and crusted material around the sink. Staff interviews confirmed the pantry had been unusable for approximately eight months due to the odor and suspected mold, with staff and residents avoiding the area. The refrigerator and snacks were relocated to a nearby activity room, which was then locked and inaccessible to residents, limiting their use of the space. The Maintenance Director reported a leaking pipe in the pantry wall, which was shut off two months prior, but repairs had not been completed. The eye wash station in the pantry, the only one on the South Wing, remained accessible but was located in an unsanitary environment. The DON acknowledged the importance of maintaining a clean environment for the eye wash station. The Nursing Home Administrator was unaware of the pantry's condition. Observations also noted dislodged wall covering, exposed wall innards, and water damage under a window A/C unit, as well as an ice maker that required replacement.