Longwood Health And 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 facility failed to provide a resident’s court-appointed plenary guardian with timely access to the resident’s personal and medical records within 24 hours of a written request, excluding weekends and holidays. The resident, who had chronic kidney disease, major depressive disorder, and dementia, was cognitively impaired with a BIMS score of 6/15 and had become a ward of the state with a guardian appointed by the county court. The guardian completed an Authorization for Use and Disclosure of Protected Health Information form requesting medical and billing records from the date of admission to the present, in electronic format. The Medical Records Director stated that the process for receiving records typically took two to three days and that corporate legal determined release of records. He recalled the guardian requesting medical and financial records and said she was given all the information she needed at the time, but also stated that financial records could not be provided because the Business Office Manager was not on the premises and that the guardian refused physical copies at that time. Despite the written authorization, the Social Services Director and Business Office Manager reported they were unaware of any request from the guardian and stated they had never met her nor received emails or calls requesting records. The Business Office Manager indicated that some earlier financial records were likely with the previous company that had operated the facility. The guardian reported she had requested medical and financial records, had been told she needed to make a written request, and later came to the facility to make a formal request but still had not received any records, despite multiple follow-up calls and being told by the Medical Records Director that the facility was still working on her request. The Nursing Home Administrator and Director of Nursing acknowledged that residents have a right to access their medical records at any time or as soon as possible, and the NHA stated that waiting almost a month for records was not acceptable, even considering that some records related to previous ownership. The facility’s policy stated that residents are to be allowed access to personal and medical records in a manner that acknowledges and respects resident rights, which was not followed 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

Surveyors identified a deficiency in medication administration when a resident’s physician-ordered 9:00 AM medications were found unattended at the bedside several hours later. At 12:27 PM, a medication cup containing four pills (a yellow tablet, a pink tablet, a white tablet, and a pink and gray capsule) and a six-ounce clear plastic cup with clear liquid and a spoon were observed on the resident’s bedside table next to the lunch tray. The resident, who was alert to person, place, and time, stated these were his 9:00 AM medications and that the clear liquid was his MiraLAX, both of which he reported had been left at the bedside by the nurse. Review of the resident’s physician orders showed scheduled 9:00 AM doses of Aspirin 81 mg, Flomax 0.4 mg, Losartan 25 mg, MiraLAX 17 g, and Oxybutynin 10 mg. The assigned LPN stated she did not know where the medications at the bedside came from and said they were not present when she administered the 9:00 AM medications, although she acknowledged leaving the resident’s 9:00 AM liquid stool softener (MiraLAX) at the bedside in a clear plastic cup. The facility’s MAR documented that the resident’s 9:00 AM medications had been given by the LPN at 9:00 AM, which conflicted with the surveyor’s observation of the medications still present in the cup at 12:27 PM. The DON later confirmed, after speaking with the physician and verifying the medications, that the four pills and the clear liquid were indeed the resident’s scheduled 9:00 AM medications that remained on the bedside table three and a half hours after the scheduled administration time. Facility policy on Medication Administration required that medications be administered by licensed staff as ordered and that staff observe resident consumption of medication and report and document refusals, which did not occur 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 and implement an infection prevention and control program when it did not place a resident diagnosed with influenza B and sore throat on droplet precautions in a timely manner. Resident #29, who had diagnoses including myasthenia gravis, sequelae of cerebral infarction, osteoarthritis, and fibromyalgia, had intact cognition and reported that she had been diagnosed with flu and strep throat after seeing an outside PCP. Her After Visit Summary documented influenza type B and sore throat with orders for oseltamivir, amoxicillin, and fluticasone, but the room was not identified for isolation and no PPE was observed outside or inside the room. The physician’s orders did not include droplet precautions until six days after the influenza diagnosis. The facility also failed to follow infection control practices related to hand hygiene and PPE use. A sitter was observed leaving a resident room wearing gloves, speaking in the hallway, and then re-entering the room with the same gloves still on. The sitter acknowledged she should have removed the gloves and sanitized her hands before exiting the room but did not do so. A CNA was also observed leaving another resident room holding a soiled bag while still wearing gloves, entering the soiled utility room, and later removing the gloves only after exiting. The CNA stated she usually kept her gloves on until after discarding the bag and acknowledged she knew gloves should be removed before leaving the room, but said she was uncomfortable handling the soiled bag with bare hands. The facility further failed to follow transmission-based precautions and enhanced barrier precautions for a resident receiving IV antibiotics for a urinary tract infection. Resident #81 had diagnoses including dementia and end stage renal disease, and laboratory results showed an elevated WBC count and a urine culture positive for Klebsiella pneumoniae. The resident had an order for ertapenem IV, but the medication was not administered on multiple days, with documentation stating it was waiting on pharmacy delivery or waiting on a midline IV. The IP and DON confirmed there was no documentation that the physician was notified about missed doses. During observation, the IP entered resident #81’s room without a gown while the room displayed a sign for enhanced barrier precautions, and he acknowledged he should have worn a gown. The IP also stated he was responsible for monitoring antibiotic use but had not performed antibiotic audits during the prior month, and the facility’s antibiotic stewardship program required monitoring of antibiotic use and random audits of prescriptions.

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 QAPI program by not identifying and addressing repeated deficiencies and by not ensuring complete monitoring documentation for corrective action plans. During interview, the NHA stated the QAPI program included non-compliance assessments, review of identified problems during monthly and Ad Hoc meetings, and a four-step process involving problem identification, root cause investigation, correction plan development, and tracking of progress and trends for one year. However, when the surveyor reviewed the QAPI binder and PIPs with the NHA and DON, documentation of monitoring for previously identified deficiencies was incomplete or missing. In February 2025, the facility identified Dietary Department concerns and held an Ad Hoc QAPI meeting where a PIP was developed to correct the issue, but the NHA and DON were unable to locate the monitoring documentation and audits. The NHA also stated the Certified Dietary Manager had kept the PIP records separate. During the recertification and complaint survey from 9/29/25 to 10/03/25, deficient practice was again identified for F0584, F0842, and F0880. The facility's written QAPI standards stated that all QAPI goals and action plans were to be stored in the QAPI binder.

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 conduct a medication self-administration assessment for a resident who was cognitively intact and had diagnoses including cerebral infarction, end stage renal disease, type 2 diabetes mellitus with diabetic neuropathy, and major depressive disorder. The resident’s MDS quarterly assessment showed a BIMS score of 15 out of 15, with no behaviors and no rejection of care, but the electronic medical record contained no physician’s order for self-administration of medications and no self-administration assessment. During observation, a medication cup containing pills was found on the resident’s bedside table after the LPN had administered scheduled 9:00 AM medications at 10:15 AM. The resident stated the nurse left the cup there because he usually takes a while to swallow the pills. The LPN confirmed he had administered the medications and that the resident was not allowed to self-administer, but he also acknowledged he saw the resident lift the cup to his mouth and then became distracted by the roommate, leaving the medications unattended. The UM and DON were informed, and the UM stated it was unacceptable for the LPN to leave the medications with the resident; the DON stated there were no residents in the facility assessed for self-administration of medications.

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 the necessary maintenance services to ensure a safe, clean, comfortable, and homelike environment in 3 of 32 rooms in the B wing, including rooms 13, 14, and 17. Broken window blinds were observed in room 13 on 9/29/25 and in room 17 on 9/30/25. Resident 19, who was in room 14, stated on 9/30/25 that the wall clock in his room had been without a battery for five days and that he had informed staff, but it had not been fixed. He stated on 10/01/25 that the clock was still not working. On 10/02/25, the blinds in rooms 13 and 17 were still broken, and the wall clock in room 14 remained nonfunctional. The Maintenance Director stated he was responsible for maintenance of the building, including residents’ rooms, and that he performed routine inspections and repaired items as needed. He said staff entered work orders into the electronic TELS system, which he or his assistant checked multiple times daily, but the facility did not maintain records of room inspections. During observation with the Maintenance Director, he acknowledged the broken blinds and nonworking clock. He later reviewed the TELS report for the affected rooms and confirmed the issues had not been previously identified. A housekeeper stated she verbally reported findings from cleaning residents’ rooms to maintenance and acknowledged the broken blinds, noting she had not reported them to the Maintenance Director because she had not noticed them earlier. The facility policy stated it would provide a safe, clean, comfortable, and homelike environment and that furniture in disrepair should be reported promptly to Maintenance.

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 appropriate care and services according to professional standards for monitoring and management of an IV therapy site for one resident. The resident was admitted after a fall and had diagnoses including fractures of the sacrum, left pubis, and right ilium, along with essential tremor, cognitive communication deficit, Parkinson's with dyskinesia, and dementia. He was treated for a UTI with IV Ertapenem, and records showed a 22-gauge peripheral IV was inserted into the left forearm and later a midline was placed in the left arm. When observed, the resident had both IV access devices in place, including an undated peripheral IV and a midline dressing dated the prior day, and he could not recall why he needed the IVs. The physician orders did not include orders to monitor the peripheral IV or midline site, flush either line with normal saline, or change the dressings. The record also showed no order for insertion of the peripheral IV, and no orders for monitoring, flushing, or dressing changes for the midline. Nursing staff and the DON confirmed that these orders were absent. The DON stated nurses were expected to add those orders whenever a resident had an IV site, but she could not explain why those orders were not obtained. The facility policy stated IV dressings would be changed every 72 hours unless otherwise ordered and that staff were to check IV sites every four hours or as needed for signs and symptoms of infection or inflammation. The facility also failed to provide appropriate care and services according to professional standards for medication administration for another resident. That resident was cognitively intact, had impaired vision, and had an order for Lubricating Plus Eye Drops to be instilled in both eyes every 12 hours for dry eyes. The resident stated she had not received her eye drops as ordered. Later, an RN administered generic eye lubricant from a box that did not have the resident's name or date on it, and the RN confirmed it was not the prescribed medication. The RN acknowledged she did not verify the medication before administration, and the UM and DON confirmed the resident received the wrong eye drops. The facility policy on medication administration stated nurses were to review the MAR to identify the medication to be administered.

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 a trauma-informed care plan based on a resident’s past experiences and preferences to help mitigate triggers that could cause re-traumatization. Resident #29 was admitted with diagnoses including myasthenia gravis, sequelae of cerebral infarction, osteoarthritis, and fibromyalgia, and her admission MDS showed a BIMS score of 15 out of 15, indicating intact cognition. Her record also showed a Social Services trauma-informed care evaluation that identified affirmative responses to questions about unwanted sexual contact, believing her life was in danger or she might be seriously injured, and being seriously injured, with self identified as a trigger for potential re-traumatization. On 9/06/25, a male resident entered resident #29’s room and sat in a chair by her bed. Resident #29 reported that staff were not watching the male resident, that a CNA had left him sitting in her room and walked away, and that he then moved toward her, pushed her bedside table aside, and sat at the edge of her bed while cursing. She stated she screamed and yelled, felt terrified and defenseless, and said the event triggered memories of a prior attempted murder. She also reported that staff laughed and told her it was okay, and she remained upset because she did not feel safe. The record showed the incident was documented on a grievance form and that psychotherapy notes later described her being triggered by another resident entering her room and her history of multiple traumatic experiences, including almost being killed by ex-partners. The Social Services Director stated she had completed the psychosocial evaluation and referred the resident for psychological services and counseling, but acknowledged she should have developed a trauma-informed care plan and that the 9/06/25 incident was another opportunity to update the care plan to address trauma as a focus area. The facility policy stated that trauma-informed care should identify trauma history and triggers and include individualized care plan interventions to minimize triggers and re-traumatization.

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 pharmacy recommendations were implemented in a timely manner for one resident reviewed for unnecessary medication regimen review. The resident had diagnoses including type 2 DM, hemiplegia and hemiparesis following a cerebral infarction, atrial fibrillation, and heart failure. A pharmacist review identified multiple diabetes medications that could cause hypoglycemia, including Glimepiride, Metformin, Humulin 70/30, Trulicity, and Humalog sliding scale, and recommended adding a hold parameter to the Humulin 70/30 order because of the additive effects of multiple diabetes medications. A handwritten DON note reflected a telephone order to hold the insulin for BG below 150, and the physician signed the order, but the active physician orders did not include that parameter until later. The resident’s MAR showed Humulin 70/30 was administered three times daily, and 28 doses were given despite the hold order for BG levels under 150. On those days, the resident’s BG ranged from 87 to 148. A separate pharmacist recommendation for PRN Hydrocodone-acetaminophen and Morphine orders called for adding a pain scale to the PRN instructions, but the physician orders did not include the recommended pain scale. The DON confirmed the pharmacy recommendations and the Humulin 70/30 physician order were not followed and stated she updated the orders only after reviewing them and realizing the recommended parameters had not been entered.

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 the medical record contained documentation of an incident involving a resident and a male resident, along with follow-up assessments. Resident #29 was admitted and readmitted to the facility with diagnoses including myasthenia gravis, sequelae of cerebral infarction, osteoarthritis, and fibromyalgia. Her MDS admission assessment showed a BIMS score of 15 out of 15, indicating intact cognition. She reported that a male resident entered her room, pushed her bedside table aside, and sat on the edge of her bed while she screamed and was frightened. She stated staff later removed the male resident, and she also reported that her BP was taken afterward and was 162/90, which she said had never been that high before. The medical record did not contain documentation of the incident on the day it occurred or the BP reading she reported. A psychotherapy note later documented that she had a recent experience when another resident entered her room and that staff intervention and hydroxyzine were needed to calm her. Staff interviews confirmed the incident occurred, that resident #29 was upset and fearful because of prior trauma, that a head-to-toe assessment was offered but refused, and that no note was entered in her medical record about the event or assessment. The facility policy required accurate, complete, and timely documentation of residents' assessments, observations, and services in the medical record.

Penalty

Inspection fine: $16,801

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

Summary

The facility failed to honor a resident's advance directive, specifically a Do Not Resuscitate Order (DNRO), resulting in the resident receiving unwanted cardiopulmonary resuscitation (CPR). The incident involved a male resident with severe cognitive impairment and multiple health issues, including dementia and chronic kidney disease. Despite the resident's wife signing a DNRO form, the facility did not update the electronic medical record (EMR) to reflect the change in code status from Full Code to DNR. On the night of the incident, the resident was found unresponsive in his wheelchair. A Licensed Practical Nurse (LPN) initiated CPR without verifying the resident's code status in the EMR or the Code Status Binder. Emergency Medical Services (EMS) continued CPR upon arrival and transported the resident to the hospital, where he was intubated and later passed away after life support was withdrawn at the wife's request. The failure to update the EMR and verify the code status led to the administration of life-saving measures against the resident's explicit wishes. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) was responsible for updating the EMR but failed to do so due to being busy with other tasks. The Director of Nursing (DON) and other staff members were aware of the DNRO but did not ensure the EMR was updated. The incident highlighted a breakdown in communication and procedure adherence, resulting in the resident's advance directive not being honored.

Removal Plan

• A medical record audit was completed for current residents to ensure DNR forms were present in the electronic medical record for residents with DNR orders.
• Current licensed nurses were educated on resident's rights regarding treatment and Advanced Directives by the Director of Nursing/delegate.
• 40 out of 41 total licensed nurses received education; 98% of nurses: 10 out of 41 nurses completed the education, 24% of nurses, an additional 29 of 41 nurses completed their education, 71% of nurses. An additional 1 of 41 nurses completed the education, 2%. 1 remaining licensed nurse to receive education upon return from leave and prior to working next shift.
• New hire nurses at the facility will receive the above education during orientation and prior to working an assignment.
• Current licensed nurses participated in mock code drills: 18 out of 41 total Licensed Nurses participated in mock code drills; 44% of nurses: 11 out of 41 nurses participated in mock code drills, 27% of nurses. 7 out of 41 nurses participated in mock code drills, 17%. 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift.
• New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment.
• Residents and/or responsible parties for current residents residing in facility were interviewed by Social Services/Delegate to validate current physician orders for code status reflect resident and/or responsible party's current wishes for code status. Code status updated, if applicable based on interviews conducted.
• Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting completed with Medical Director, Administrator, and additional Interdisciplinary team (IDT) members on the adherence to CPR policy and policy and procedure for Resident Rights Regarding Treatment and Advance Directives and a review of the root cause analysis was completed.
• As part of the ongoing Quality Assurance Assessment (QAA) process, an ad hoc QAPI was conducted that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on the Advance Directives process, code process and results of audits. No discrepancies or concerns were noted related to Advanced Directive code status standards and guidelines.

Penalty

Inspection fine: $16,801

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

Licensed nurses at the facility failed to adhere to the policy and procedure for Cardiopulmonary Resuscitation (CPR) by not verifying the resuscitation or code status of a resident in an emergency situation. The incident involved a resident who was found unresponsive in his wheelchair at the nurse's station. Without verifying the resident's code status in the medical record, a licensed nurse initiated CPR. This action was contrary to the resident's documented wishes and a physician's order for Do Not Resuscitate (DNR). The resident, an elderly male with severe cognitive impairment and multiple medical conditions, had a documented DNR order signed by his wife and attending physician. Despite this, the electronic medical record (EMR) contained a conflicting physician order indicating Full Code status. The discrepancy arose because the Assistant Director of Nursing (ADON) failed to update the EMR with the correct DNR status after a care plan meeting where the resident's wife signed the DNR order. Consequently, when the resident was found unresponsive, the staff relied on the outdated EMR information, leading to the initiation of unwanted resuscitation efforts. The failure to verify the resident's code status before initiating CPR resulted in the resident undergoing aggressive resuscitation efforts, which were against his and his family's wishes. The incident highlighted a breakdown in communication and procedure adherence among the nursing staff, as multiple staff members assumed the code status had been verified by others. This oversight placed the resident at risk for unwanted medical intervention and prolonged suffering, ultimately leading to his transfer to the hospital where he was intubated against his wife's wishes.

Removal Plan

• Current licensed nurses were educated on facility's CPR policy and on procedure for performing a code to include confirmation of resident code status prior to initiating CPR. Post test and code procedure competencies completed to validate comprehension.
• 39 of 41 total licensed nurses received education; 95% of nurses: 10 out of 41 nurses completed the education, 24% of nurses, an additional 29 of 41 nurses completed their education, 71% of nurses.
• 2 remaining licensed nurse to receive education upon return from leave and prior to working next shift.
• New hire nurses at the facility will receive the above education during orientation and prior to working an assignment.
• Current licensed nurses participated in Mock Code Drills: 18 of 41 total licensed nurses participated in mock code drills; 44% of nurses 11 out of 41 nurses participated in mock code drills, 27% of nurses, 7 out of 41 nurses participated in mock code drills, 17%.
• 23 remaining licensed nurses to participate in mock code drills upon return from leave and prior to working next shift.
• New hire nurses at the facility will participate in a mock code drill during orientation and prior to working an assignment.
• Ad Hoc QAPI completed with Medical Director, Administrator, Director of Nursing and additional IDT members on the adherence to CPR policy and checking the residents code status prior to initiating CPR.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that licensed nurses had the necessary skills and competencies to provide care and services according to the plans of care for all residents. During the Recertification survey, it was found that an admission nurse did not identify and document a resident's IV site, and none of the assigned nurses assessed the site or questioned the lack of physician orders. Additionally, another resident's IV dressing was not changed according to physician orders. The Director of Nursing (DON) confirmed that the nurses did not follow the facility's protocols. Furthermore, a nurse left medication unattended on top of the medication cart and did not follow proper infection control practices, such as disposing of a used sharp, performing hand hygiene, and disinfecting a blood glucose meter. The Assistant Director of Nursing (ADON) acknowledged that the nurse had only a brief orientation without competency checks and minimal knowledge of the policies and procedures reviewed with her. The B Wing Unit Manager (UM) confirmed that all nurses assigned to a resident failed to acquire an ordered eye ointment, and 13 nurses inaccurately documented the administration of the medication, which was never in the facility. Additionally, another resident did not receive a prescribed skin ointment for several days because the nurses did not contact the pharmacy for timely delivery. The ADON confirmed that nurses were to administer all medications as ordered by the physician and document administration at the time it occurred. Infection control concerns were also identified during wound care observation, where a nurse did not change her gloves or perform hand hygiene throughout the procedure. The ADON acknowledged that several nurses administered multiple doses of a blood pressure medication outside of the physician-ordered parameter, indicating a lack of careful reading or comprehension of the order. The DON acknowledged that direct care nurses and nursing management failed to identify a resident's declining ability to feed himself and initiate a therapy referral in a timely manner. Concerns related to personal hygiene tasks, including nail care and shaving, were also noted. The ADON, who was also the Staff Development Coordinator, confirmed that the facility did not conduct an annual skills fair or review competencies at regular intervals to ensure all nurses possessed or maintained the necessary skills. The Corporate Director of Education acknowledged that the nursing competency for glucose meter disinfection was incorrect and that the company planned to move towards standardized competencies with a requirement for all nurses to perform return demonstrations. The DON confirmed that there was no evidence of utilizing the Competency Based Orientation packet or preceptor checklists to verify the competencies of newly hired and current staff nurses.

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 care plan meetings were attended by residents and/or their representatives, and the required members of the interdisciplinary team (IDT) for two residents. Resident #8, a male with multiple diagnoses including Multiple Sclerosis and depression, was admitted in December 2022. Despite his cognitive intactness and expressed preference for family involvement, neither he nor his mother were invited to or attended most care plan meetings. The facility's records showed that out of five scheduled meetings, only one was attended by his mother, and none were attended by a Certified Nursing Assistant (CNA). Additionally, there was no documentation indicating that the resident received invitations or that the meetings were rescheduled when necessary. Resident #24, a female with diagnoses including diffuse large cell lymphoma and stroke, also experienced similar issues. She did not recall receiving invitations to care plan meetings, and her medical record lacked documentation of an Admission care plan meeting. A quarterly meeting was attended by the resident and only two IDT members, missing other essential team members. The facility's MDS Coordinator confirmed that care plan meetings were behind schedule and not always attended by the required IDT members. The Director of Nursing acknowledged that the expectation was for residents and/or their representatives and all required IDT members to participate in care plan meetings. The facility's policy indicated that care plans should be developed and reviewed by an IDT, incorporating the resident's preferences. However, the facility failed to adhere to this policy, resulting in inadequate involvement of residents and their representatives in care planning processes.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely and appropriate treatment and services to maintain and/or improve the ability to perform activities of daily living (ADLs) related to eating for a resident. The resident, a male with multiple diagnoses including Multiple Sclerosis and muscle weakness, was admitted to the facility and required partial to moderate assistance for eating. Despite having a care plan in place to monitor and refer for therapy if a decline in ADLs was noted, the resident did not receive the necessary therapy services or adaptive utensils to aid in self-feeding. The resident's mother had raised concerns during a care plan meeting, but no follow-up actions were taken by the facility to address these concerns, and the resident did not receive the recommended therapy or adaptive spoon. The facility's policy required referrals to therapy services for residents needing assistance with feeding, but this was not adhered to in the resident's case. The Director of Rehabilitation confirmed that no therapy referral was received after the care plan meeting, and the Director of Nursing acknowledged that the facility should have helped the resident continue feeding himself. The facility's failure to provide the necessary therapy services and adaptive equipment resulted in a deficiency in maintaining the resident's ability to perform ADLs related to eating.

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 activities of daily living (ADLs) care for dependent residents, specifically related to shaving and nail care. Resident #83, a cognitively intact male with a history of stroke and muscle weakness, had dirty and excessively long fingernails. Despite being dependent on staff for personal hygiene, his nails had not been trimmed or cleaned for two to three months. The Assistant Director of Nursing (ADON) confirmed the resident's nails were dirty and too long, and the resident expressed a desire for nail care that had not been provided. Weekly skin evaluations did not document the condition of his fingernails, and there was only one recorded refusal of a bath in the past 30 days. Resident #77, a male with moderate cognitive impairment and end-stage heart failure, had long, unkempt facial hair and dirty, jagged fingernails. Despite his need for substantial assistance with personal hygiene, he had not been shaved or had his nails trimmed. The resident expressed a desire to be shaved and have a haircut, but these needs were not met. His assigned nurse and CNA acknowledged the resident's poor hygiene but did not take action to address it. The Unit Manager confirmed the resident's ADL care was inadequate and stated that baths and nail care should be provided at least twice weekly. Resident #73, a cognitively intact male with a history of traumatic brain injury and seizures, had excessive facial hair and had not been shaved for approximately three months since transferring to a different unit. The resident expressed a preference for a neatly trimmed goatee and moustache but had not received the necessary grooming. The Unit Manager and Director of Nursing (DON) confirmed that nurses and CNAs were responsible for ensuring residents' personal hygiene and that refusals of care should be documented and reported. The facility's policy required staff to provide ADL care, including bathing and grooming, for residents unable to perform these activities themselves.

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 proper care and services for intravenous (IV) catheters according to standards of practice for two residents. Resident #90 had a peripherally inserted central line catheter (PICC) with a semi-permeable dressing dated 3/31/24. Despite a physician's order to observe the catheter site every shift and change the dressing weekly, the dressing had not been changed for 8 days. The Assistant Director of Nursing stated that PICC dressings were changed on Wednesdays, and since the resident was readmitted on a Friday, the dressing was not due to be changed until the following Wednesday. This practice did not align with the Infusion Nurses Society's guidelines, which specify that transparent semipermeable dressings should be changed every 5-7 days. Additionally, there was an incorrect physician order identifying the type of IV as a Midline instead of a PICC, which could have contributed to the oversight in care. Resident #108 had a Midline IV catheter with a dressing dated 3/22/24. The dressing had not been changed in 17 days, although it should have been changed every 7 days per nursing standards of practice. The assigned LPN confirmed the lack of orders for dressing changes or flushes for the Midline IV since the resident's readmission. The B-wing Unit Manager and the Director of Nursing both acknowledged that the dressing should have been changed weekly. The facility's policy also indicated that PICC and Midline dressings should be changed weekly or more frequently if soiled, but there were no standing orders to address these types of IVs, requiring nurses to contact the physician for specific orders.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely acquisition and proper administration of physician-ordered medication for three residents. Resident #77, who had a physician order for Midodrine HCl to be held if systolic blood pressure (SBP) was greater than 120 mm/Hg, received the medication multiple times despite having SBP readings above the specified limit. This error was confirmed by the Assistant Director of Nursing (ADON), who acknowledged the risk of administering the medication under these conditions. Resident #73 had a physician order for Artificial Tears Ointment to be administered at bedtime for eye irritation. However, the medication was never acquired, and nurses substituted it with a different eye drop without a physician's order. The resident continued to experience symptoms, and the B Wing Unit Manager (UM) confirmed that the facility did not stock the prescribed ointment and that the nurses should have contacted the pharmacy and the physician when the medication was not available. Resident #98 had a physician order for Clindamycin Phosphate 1% gel to be applied three times daily for a rash. The medication was not available over the weekend, and the resident missed several doses. The B Wing UM and other nursing staff confirmed the medication was not reordered in time, and the small tube initially provided was insufficient to cover the treatment period. The Evening Shift Nursing Supervisor noted that the medication was almost empty and not available over the weekend, leading to missed doses documented inaccurately by the nursing 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 ensure the medical record accurately reflected the administration of a prescribed eye ointment over a 34-day period for a resident. The resident, a male with a history of traumatic subdural hemorrhage, seizures, and carpal tunnel syndrome, was prescribed Artificial Tears Ointment to be administered at bedtime for eye irritation. Despite the Medication Administration Record (MAR) being initialed by 13 nurses over this period, the resident reported not receiving the medication and continued to experience persistent, itchy, and watery eyes. Upon investigation, it was discovered that the order for the eye ointment was never filled by the pharmacy, and there was no evidence that Central Supply had ordered it. This discrepancy indicated that multiple nurses documented the administration of a medication that was never actually provided to the resident. The Unit Manager (UM) and the Director of Nursing (DON) confirmed the findings, acknowledging the significant issue of false documentation. The facility's policy on medical record documentation emphasized the importance of accurate representation of the resident's experiences and explicitly stated that false information should not be documented. The failure to administer the prescribed medication and the subsequent false documentation by the nursing staff led to the deficiency identified in the report.

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 perform proper hand hygiene and change gloves during wound care for a resident with an infected wound on the left foot. The wound nurse did not change gloves or perform hand hygiene between removing the dirty dressing and cleaning the wound, which is against the facility's policy and CDC guidelines. The Assistant Director of Nursing (ADON) expressed concern when informed of this break in infection control practices. Additionally, a registered nurse (RN) failed to disinfect a glucometer according to the manufacturer's instructions and facility policy. The RN used the glucometer for multiple residents without cleaning it between uses and disposed of a used lancet improperly by rolling it inside her gloves and placing it in the trash instead of a designated sharps container. The RN also did not perform hand hygiene after removing gloves or before preparing medications. The facility's policies for hand hygiene, glucometer disinfection, and medication administration were not followed, leading to potential cross-contamination and infection risks. The ADON confirmed the expectations for proper infection control practices, including the use of hand sanitizer or washing hands with soap and water after removing gloves and before medication administration.

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 replace a broken bed in a timely manner, compromising the comfort and safety of a resident. The resident, who had multiple medical conditions including diffuse large cell lymphoma and stroke, reported that the remote control for her bed stopped working over the weekend, forcing her to sleep in an upright position. Despite the resident's discomfort and the efforts of CNAs to assist her, the bed was not replaced until Monday morning. The Maintenance Director confirmed that no staff contacted him over the weekend, and the Director of Nursing acknowledged that the situation was mishandled, as functional beds were available in the facility. Additionally, the facility failed to maintain cleanliness and proper storage of resident care items in a shared bathroom. Observations revealed that multiple unlabeled and dirty items, including bath basins, a bed pan, and a urinal, were improperly stored in the bathroom. The Evening Shift LPN Nursing Supervisor and the Director of Nursing both confirmed that these items should have been labeled and stored in plastic bags to prevent infection and maintain a clean environment. The facility's policy on maintaining a safe and homelike environment was not followed, leading to concerns about infection control and environmental cleanliness. The facility's policy and procedure for a safe and homelike environment, which includes ensuring sanitary conditions and prompt maintenance, were not adhered to. Staff failed to report the broken bed to maintenance over the weekend and did not properly store or label resident care items in the shared bathroom. These deficiencies highlight lapses in both maintenance and infection control protocols, directly impacting the residents' comfort and safety.

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 report an alleged violation of neglect for a resident who was cognitively intact and required one-to-one supervision due to multiple falls. On the night in question, the resident was found walking alone in the hallway with a bloody nose, having fallen because the assigned sitter left before being relieved. The sitter, a CNA, had informed the shift supervisor that she wanted to leave early, but was instructed to stay until the end of her shift. Despite this, the CNA left the resident unattended, leading to the fall and minor injury. The shift supervisor reported the incident to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) the following morning via a messaging service. However, the DON did not receive an audible notification and was unaware of the situation until three days later. The facility's policy requires that allegations or suspicions of neglect be reported immediately and within 24 hours, but this protocol was not followed in this case. The resident's medical record and care plan indicated a high risk for falls, necessitating constant supervision. Despite this, the CNA left her post, and the supervisor did not ensure immediate coverage. The DON acknowledged that the CNA's actions could be considered neglect and that the incident should have been reported promptly. The facility's failure to adhere to its own policies and procedures resulted in a delay in reporting the neglect, which was only addressed after the DON became aware of the situation days later.

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 appropriate supervision to prevent a fall with minor injury for a resident who was at high risk for falls. The resident, who had diagnoses including schizoaffective disorder, anxiety disorder, muscle weakness, lack of coordination, and repeated falls, was supposed to have one-to-one supervision every shift. Despite this, the resident experienced an unwitnessed fall with minor injury when the assigned Certified Nursing Assistant (CNA) left her post before being relieved by another staff member. The CNA had informed the 3 PM to 11 PM Supervisor that she wanted to leave early, but the supervisor instructed her to stay until the end of her shift. The CNA left anyway, resulting in the resident being unsupervised and subsequently falling and injuring her nose. The Director of Nursing (DON) confirmed that the resident was supposed to be under constant supervision due to her impulsive behavior and poor safety awareness. The incident log and medical records revealed that the resident had a history of falls, including a witnessed fall on 2/11/24, a witnessed fall on 3/09/24, and the unwitnessed fall on 4/05/24. The facility's policy on accidents and supervision, revised on 10/18/22, stated that supervision is an intervention to mitigate accident risk and should be based on the individual resident's assessed needs. The DON acknowledged that the one-to-one sitter should not have left the resident unsupervised, as the expectation was for the sitter to remain with the resident until properly relieved by another staff member. This failure to adhere to the supervision policy directly led to the resident's fall and minor injury.

Penalty

No penalty information released

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

Summary

The facility failed to administer medications as ordered by the physician for one resident, resulting in a medication error rate of 6%. Specifically, a registered nurse (RN) omitted the scheduled 9:00 AM doses of Fluticasone Propionate nasal spray and Spiriva Respimat inhaler for a resident with a history of encephalopathy, pulmonary embolism, COPD, and COVID-19. The resident, who had moderate cognitive impairment, questioned the RN about the missing medications, but the RN incorrectly assured him that all medications had been administered. During a medication reconciliation, it was confirmed that the RN did not administer the inhaler and nasal spray as required. The B Wing Unit Manager later discussed the issue with the RN, who acknowledged the omission but claimed to have returned to administer the medications later that morning. The Assistant Director of Nursing expressed confusion over why the RN did not administer all scheduled medications at the bedside, as per the facility's policy and procedure for medication administration, which mandates that medications be administered as ordered by the physician and in accordance with professional standards of practice.

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 keep medication under direct observation when not secured in a locked compartment, as observed on one of the two medication carts on the B Wing. On 4/08/24 at 1:59 PM, an RN left her medication cart unattended at the nurses' station and entered a resident's room to perform a blood glucose check. Upon returning at 2:04 PM, a medication cup containing a Gabapentin pill was found on top of the cart, partially covered by a towel. The RN admitted to pulling the medication earlier in the shift but did not administer it because the resident was not in her room. Instead of securing the pill in the cart's drawer, she left it on top of the cart, unattended for about 10 to 15 minutes. The Assistant Director of Nursing confirmed that it was unacceptable for the RN to leave a pill in a cup on top of an unattended medication cart. The facility's policy, revised on 5/04/22, mandates that all drugs be stored in locked compartments and that medications must be under the direct observation of the person administering them or locked in the medication storage area/cart. The RN's actions were in direct violation of this policy, leaving the medication accessible to anyone in the vicinity of the nurses' station.

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 meals that met the dietary requirements and preferences of a resident, leading to a deficiency. The resident, a male with Multiple Sclerosis and mild protein-calorie malnutrition, required a regular diet with finger foods. Despite this, he frequently received inappropriate food items such as oatmeal, rice, and corn, which he could not easily pick up with his fingers. Additionally, the resident repeatedly received chicken for both lunch and dinner, which he disliked, and the staff did not assist him in opening containers or setting up his meals, further complicating his ability to eat independently. The resident's care plan included providing and serving the diet as ordered, monitoring meal intake, and having the Registered Dietitian (RD) evaluate and make recommendations as needed. However, the facility did not adhere to these interventions. The resident's mother confirmed that although finger foods were noted on every meal slip, the resident often received inappropriate items. The Certified Dietary Manager (CDM) acknowledged the errors and confirmed that the food provided did not reflect the menu options on the meal slip. Further observations revealed that the resident continued to receive meals that did not meet his preferences or dietary requirements. The CDM admitted that the meal tracking software incorrectly categorized certain foods as finger foods and was unaware that the resident was not consuming the House Shakes provided as supplements. The facility's policy on Resident Food Preferences was not effectively implemented, leading to the resident's nutritional needs not being met adequately.

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 services furnished to a resident by an outside agency were properly arranged. Specifically, the facility did not have a contract or written agreement with the dialysis center to provide hemodialysis services for a resident who depended on dialysis. This deficiency was identified during a review of the care provided to a resident with multiple diagnoses, including chronic kidney disease stage 4 and dependence on dialysis. The resident was observed to have a clean and dry dialysis fistula site and reported attending dialysis sessions regularly. Despite the regular communication between the dialysis center and the facility, and the completion of nursing assessments upon the resident's return from dialysis, the facility was unable to provide documentation of a formal arrangement or contract with the dialysis center. The Director of Nursing confirmed that no such agreement existed, highlighting a lapse in ensuring that necessary services were formally arranged and documented for the resident's 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

The facility failed to post required nurse staffing information daily and did not retain the postings for a minimum of 18 months. On 4/08/24, the nurse staffing information posted in the lobby was dated 4/04/24, indicating it was not updated over the weekend. The Staffing Coordinator, responsible for creating and posting the nurse staffing form, confirmed she did not work over the weekend and the Weekend Nursing Supervisor was supposed to update the information. Additionally, the Staffing Coordinator could not provide nurse staffing forms for January 2023, as she only assumed her role in October 2023 and was informed of the 18-month retention requirement shortly after. The facility's policy, revised on 11/28/22, mandates daily posting and 18-month retention of nurse staffing information, which was not adhered to in this instance.