Vivo Healthcare Fort Pierce

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 failure to provide a safe, clean, comfortable, and homelike environment in multiple resident rooms, including both occupied and unoccupied rooms. A grievance from the spouse of Resident #2, who had been admitted and later discharged, documented that the floor in the resident’s room was not clean. When Resident #2’s room was observed after a reported deep cleaning, both beds had dated papers indicating recent cleaning, yet one mattress remained stained, the privacy curtain was dirty, trash was present in the trash can, crumpled paper towels were on the floor under the privacy curtain, a previous resident’s personal items were still in a labeled bag in the closet, and the floor and wood molding were stained near the closet and bathroom. Another grievance from a family member of Resident #3 reported that housekeeping failed to clean up a spill and that the floor had not been sufficiently cleaned. During observation of this room, the floor appeared clean, but wallpaper was peeling behind both beds. Additional room observations revealed discolored floors and walls with drywall damage in one room, and discolored and missing flooring with dirty wall areas in another. In a further room, despite signs indicating both beds had been cleaned and clean sheets were present, surveyors observed an adaptive reacher, a pad from a wheelchair leg rest, and a folded red plastic bag on the countertop, trash in both bedroom and bathroom trashcans, a hole in the wall under the A/C unit, a dirty privacy curtain, and a blue mat with ripped areas behind the bedside table. Record review showed that Resident #1, admitted with a diagnosis including acute respiratory failure and later discharged, had a family member who reported the room appeared unclean on admission. The family member stated that the previous resident’s clothing and paperwork were left in the closet, there was a mold-like substance around an electrical outlet and in the A/C unit, and hair was present on the bedding. Observation of this room later showed an electrical outlet with drywall open around the outlet cover and dark blackish stains on the wood molding around the A/C unit. In interviews, the Housekeeping Manager described the deep-cleaning process and confirmed that a signed paper on the bed signifies the whole room is deep cleaned and ready for a new resident, but agreed that Resident #2’s room still had a dirty privacy curtain, trash, mattress residue, and stained floors and moldings despite being marked as cleaned. The Maintenance Director stated he only checks rooms when he has the opportunity and focuses on call lights, bathrooms, televisions, and A/C units, and he did not routinely identify mold in A/C units, while the Nursing Home Administrator acknowledged difficulty accessing rooms for repairs and agreed with the survey findings.

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 their automatic fire sprinkler system (AFSS) in accordance with NFPA 101 standards. During a record review conducted with the Maintenance Director, it was found that the facility did not provide the 5-year internal inspection report of the backflow device, which is a requirement under NFPA 25. No previous inspection report was available for review. This deficiency was acknowledged by both the Executive Director and the Maintenance Director during an interview and was further discussed during the exit conference.

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 housekeeping and maintenance in two resident hallways, affecting multiple residents. Observations revealed several environmental and housekeeping concerns, including a broken window air conditioner in a resident's room that had not been addressed since admission, stained and odorous privacy curtains, and visibly dirty floors with debris and darkened stains. Additionally, a resident's over-the-bed table had rust, and the recliner's headrest was worn off, making it difficult to clean. Another resident's room had a large area of unpainted plaster on the wall, which had been left unaddressed since a repair in late 2024. Interviews with the Housekeeping and Maintenance Directors revealed a lack of effective communication and follow-up on maintenance and housekeeping issues, with the Maintenance Director being the sole person responsible for repairs and life safety, leading to delays in addressing reported issues. Further observations in the common area and hallways showed that many ceiling vents were dirty or had a rust-like substance, and there were areas of bubbling and peeling paint on the walls. The Maintenance Director acknowledged these findings during an interview. The report highlights a systemic issue in the facility's housekeeping and maintenance processes, with inadequate documentation and follow-up on identified problems, contributing to an environment that does not meet the residents' right to a safe, clean, and comfortable living space.

Plan Of Correction

F-584 Safe/Clean/Homelike Environment 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Ceiling vents have been corrected. Ceiling vents on 100, 200, 300 and 400 Halls, and in the central common area have been removed, sanded & repainted to an acceptable condition, and then replaced in their proper slots. This was completed on All areas of bubbling and peeling paint were repaired and repainted in Hall 300 and Hall 400, as of Resident # 42 privacy curtains were replaced with new clean curtains on 3/, and privacy curtains will be examined daily and changed daily, or as needed. Resident # 42 baseboard behind bed was replaced with new, as of Resident # 42 A new bed was provided to this resident as of Resident # 42 Floor was sanitized and cleaned on , and this room is inspected daily and will be cleaned daily or as needed. Resident # 23 A new overbed table was provided for this resident, as of Resident # 23 The recliner was removed from this resident's room, as of Resident # 66 The wall behind the bed was repaired to an acceptable condition as of Resident # 244 A new Air Conditioner has been installed in this room, on Resident #42: room where this resident resides has been added to the 'target list' of rooms that are inspected every day. (2) How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Maintenance & Housekeeping Department Heads will incorporate a weekly resident room inspection at the beginning of the week. These inspections will be documented and discussed upon completion to identify areas of concern. Findings will be addressed and corrected depending on the severity & impact on the residents. Inspections for the room inhabited by resident #42 will be daily. The resident uses the privacy curtains to wipe himself when using the bathroom. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur? Maintenance & Housekeeping staff have been made aware of the additional weekly inspections. All other staff members have been re-educated regarding reporting maintenance & housekeeping issues in the maintenance logbooks posted at the nurse's stations. All staff members have also been instructed to verbalize their requests, when possible, in addition to noting them in the maintenance logs. All staff members have been educated on the escalation process should they feel an environmental issue has not been addressed. Daily inspections of the 'target rooms' list will continue ongoing. Facility staff were educated by the Executive Director/Designee on ensuring a safe, clean, homelike environment, and how to report concerns for maintenance and environmental services. (4) 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 Maintenance & Housekeeping Departments will conduct a weekly efficiency & quality review of the additional maintenance and housekeeping inspections & reporting process x 4 weeks, and then every 2 weeks x 2 months then PRN as indicated. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months, or until the committee determines substantial compliance. The Administrator/Designee will conduct a quality review of resident rooms, kitchen, to ensure the facility is providing a safe, clean and comfortable homelike environment 3 times weekly x 4, then weekly x 4 weeks, then monthly x 1 month and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months or until 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 maintain a clean and sanitary kitchen environment, as observed during a survey. Several issues were noted, including peeling paint and rust-like surfaces on tables in the food preparation area, pitchers with leftover sticker debris, and a plastic serving cart with scratches and stains. The floor around cooking appliances was soiled with debris and a black liquid-like substance, and the plate warmer had visible dried brown substance or corrosion. Additionally, the dispensing hose and nozzle for the juice bin were found lying directly on the floor, and a plastic bin with syrup containers was sticky. The oven handle was greasy with dried debris and carbon build-up, and the walk-in refrigerator had brownish-black debris around the frame. Clean utensils were stored in a dirty plastic bin on a utility cart with dirty items, and water was pooling on the floor near the ovens and steamer. The facility also failed to ensure that food items were not past their use-by or expired dates. In the dry storage area, several expired items were identified, including large cans of chicken and dumplings, chili, a case of jelly, a can of beef stew, a can of chili con carne, a jar of peanut butter, and cases of butterscotch pudding, pinto beans, carrots, and peanut butter. Additionally, four packages of walnuts had unreadable hand-written dates and lacked use-by dates. The Certified Dietary Manager was unable to provide use-by dates by the lot number for these items. These deficiencies could potentially affect 72 of the 75 residents who consume an oral diet at the facility.

Plan Of Correction

F812 Food Procurement, Store/Prepare/Serve- Sanitary 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Table in food preparation area with peeling paint on and shelf has been sanded and painted on. B. Table in food preparation area with rust-like surfaces have been sanded and painted on. C. Dissolvable stickers are being used for dating the pitchers and thoroughly cleaned when removed. D. Plastic serving cart with scratches and staining has been discarded. E. Staff have been educated to thoroughly clean floor at the end of each meal. F. Plate warmer has been thoroughly cleaned, sanitized, and added to the weekly cleaning schedule. G. The juice machine has been replaced, and the hoses are secured. H. Condiment bins are being cleaned and sanitized after each use prior to restocking. I. Oven is being wiped down after each use and thoroughly cleaned weekly. J. Refrigerator gaskets are being wiped down daily. K. Separate areas designated for clean and dirty items to avoid cross-contamination. L. Water pooled along the wall was cleaned on the spot. Steamer has been serviced with new gasket in place to prevent leaks. M. Chicken and dumplings discarded 2/10/2025. N. Canned chili discarded 2/10/2025. O. Case of jelly discarded 2/10/2025. P. Case of beef stew discarded 2/10/2025. Q. Can of chili con carne discarded 2/10/2025. R. Jar of Skippy peanut butter discarded 2/10/2025. S. Case of butterscotch pudding, case of pinto beans, case of carrots, and case of peanut butter all labeled with "Use by" dates. T. Four packages of walnuts discarded on 2/10/2025. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; CDM completed a sanitation audit of the kitchen on 2/17/2025 to include but not limited to the doors, door seals, floors, juice machine, dish racks, can opener, kitchenware, food storage, sanitation solution, and equipment function. No negative findings. CDM completed a food storage audit on 2/17/2025 to ensure all food items are dated, labeled and packaged properly to prevent contamination and growth of organisms. No negative findings. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; LNHA initiated ongoing education with CDM and dietary staff on the components of this regulation with emphasis of following proper sanitation, kitchen/nourishment room cleaning schedules, safe food handling to prevent the outbreak of foodborne illness, proper food storage including labeling and dating food items. LNKA initiated ongoing education with CDM and dietary staff on proper notification to the maintenance staff when issues or concerns are identified. (4) 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; CDM/Designee to conduct a sanitation audit of the kitchen 5 days weekly x 2 weeks, 2 days weekly x 2 weeks and then weekly x 2 months or until substantial compliance is met ensuring the kitchen is meeting the sanitation requirements as per federal guidelines. CDM/Designee to conduct a food storage audit 5 days weekly x 2 weeks, 2 days weekly x 2 weeks and then weekly x 2 months or until substantial compliance is met to ensure all food items are dated, labeled and packaged properly to prevent contamination and growth of organisms. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months, or until the committee determines substantial compliance.

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 safe, clean, and homelike environment as required by regulations. Observations revealed several deficiencies in housekeeping and maintenance across multiple resident hallways and common areas. In particular, a resident reported a broken window air conditioner that had not been addressed since their admission, and another resident's room had stained privacy curtains and an unpleasant odor. Additionally, the over-the-bed table for another resident was rusted, and a recliner was worn and uncleanable. A resident also noted a longstanding plaster issue on their wall. The Housekeeping Director acknowledged the issues but indicated that the deep cleaning schedule did not include the affected rooms, and the Maintenance Director admitted to being the sole maintenance person, which delayed repairs. Further observations in the common areas and hallways revealed dirty and rust-like substances on ceiling vents, as well as bubbling and peeling paint on walls. The Maintenance Director confirmed these findings but noted that the maintenance book lacked entries for the current year, indicating a lack of documented maintenance activities. The report highlights the facility's failure to ensure timely housekeeping and maintenance, affecting the living conditions of several residents.

Plan Of Correction

N-110 Safe/Clean/Homelike Environment 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Ceiling vents have been corrected. Ceiling vents on 100, 200, 300 and 400 Halis, and in the central common area have been removed, sanded & repainted to an acceptable condition, and then replaced in their proper slots. This was completed on. All areas of bubbling and peeling paint were repaired and repainted in Hall 300 and Hall 400, as of. Resident # 42 privacy curtains were replaced with new clean curtains on 3/, and privacy curtains will be examined daily and changed daily, or as needed. Resident # 42 baseboard behind bed was replaced with new, as of. Resident # 42 A new bed was provided to this resident as of. Resident # 42 Floor was sanitized and cleaned on, and this room is inspected daily and will be cleaned daily or as needed. Resident # 23 A new overbed table was provided for this resident, as of. Resident # 23 The recliner was removed from this resident's room, as of. Resident # 66 The wall behind the bed was repaired to an acceptable condition as of. Resident # 244 A new Air Conditioner has been installed in this room, on. Resident #42: room where this resident resides has been added to the 'target list' of rooms that are inspected every day. (2) How will you identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Maintenance & Housekeeping Department Heads will incorporate a weekly resident room inspection at the beginning of the week. These inspections will be documented and discussed upon completion to identify areas of concern. Findings will be addressed and corrected depending on the severity & impact on the residents. Inspections for the room inhabited by resident #42 will be daily. The resident uses the privacy curtains to wipe himself when using the bathroom. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Maintenance & Housekeeping staff have been made aware of the additional weekly inspections. All other staff members have been re-educated regarding reporting maintenance & housekeeping issues in the maintenance logbooks posted at the nurse's stations. All staff members have also been instructed to verbalize their requests, when possible, in addition to noting them in the maintenance logs. All staff members have been educated on the escalation process should they feel an environmental issue has not been addressed. Daily inspections of the 'target rooms' list will continue ongoing. Facility staff were educated by the Executive Director/Designee on ensuring a safe, clean, homelike environment, and how to report concerns for maintenance and environmental services. (4) 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 Maintenance & Housekeeping Departments will conduct a weekly efficiency & quality review of the additional maintenance and housekeeping inspections & reporting process x 4 weeks, and then every 2 weeks x 2 months then PRN as indicated. The findings of these quality reviews are to be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months, or until the committee determines substantial compliance. The Administrator/Designee will conduct a quality review of resident rooms, kitchen, to ensure facility is providing safe, clean and comfortable homelike environment 3 times weekly x 4, then weekly x 4 weeks, then monthly x 1 month and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months or until 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 ensure that the call bell was within reach for a resident who was capable of using it and required assistance. The resident, who had a history of a stroke affecting his left side and needed maximum to total assistance for activities of daily living, was observed in two separate instances where the call bell was not accessible. During an interview and observation, the call bell was found looped over the lowest part of the mobility bar with the button on the floor, making it unreachable for the resident. In another observation, the resident was sitting in an adaptive chair with the call bell placed on the bed and out of reach. Despite the resident's request for the call bell, the CNA did not immediately place it within reach, delaying the resident's ability to call for help.

Plan Of Correction

F558 Reasonable accommodation of needs Resident #42 call bell out of reach Corrective actions What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #42 call light was placed within reach during survey. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. DON/designee conducted an initial audit of all residents' call lights conducted to identify any other affected residents affected by deficient practice on 2/13/25. There were no other affected residents. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur. Weekly audits of all rooms will be conducted by DON or designee to ensure compliance with appropriate call bell placement X 4 weeks, then bi-weekly x 2 weeks then monthly X 1 then PRN. Results will be reviewed for quality by DON or designee. Guardian angels will round in their assigned times weekly x 4 weeks, then bi-weekly x 2 weeks then with their scheduled routine room rounds for appropriate call bell placement. All staff will be reeducated to ensure the call bells are secured within easy reach of residents after provision of care and services before leaving residents' rooms. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. DON will present the results of quality review in QAPI for oversight and revision if needed. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state 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 provide timely fingernail care for two residents, leading to deficiencies in their activities of daily living (ADLs) care. Resident #6, who has severe cognitive impairment and requires substantial assistance for personal hygiene, was observed with excessively long fingernails containing a red-brown substance. Despite the care plan instructions to check, trim, and clean nails on bath days and as necessary, the resident's nails were not adequately maintained. Observations revealed the resident using her long nails to scratch an open area on her face, resulting in bleeding. Interviews with staff indicated confusion about responsibility for nail care, with some staff believing it was the responsibility of the activities department rather than the CNAs. Resident #61, also with severe cognitive impairment and needing moderate assistance with personal hygiene, was observed with long fingernails containing debris. The resident expressed dissatisfaction with the nail length and stated it had been several weeks since they were last trimmed. Despite the care plan's instructions for regular nail maintenance, the resident's nails remained long and uncleaned until several days after the initial observation. This deficiency highlights a lack of adherence to the facility's nail care policy, resulting in inadequate personal hygiene care for the residents.

Plan Of Correction

F677 Tag ADL Care: Nail grooming not performed for two residents #6 and #61. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #6, nails were cut and cleaned during survey. Resident #61, nails were cut and cleaned during survey. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? An audit of all residents' nails was conducted to identify other residents who may be affected by deficient practice. Any exceptions found were addressed at the time of the audit. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur? Nursing staff educated re residents' nail grooming and cleanliness during daily ADL care by: Weekly audits x 4 weeks will be conducted, then bi-weekly x 2, then monthly x 1 to identify any deviation from the compliance plan by: Guardian angels will do weekly checks of assigned residents' nails during their routine rounding for need of grooming and report need to Unit Managers for care by: How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? The plan will be submitted to the QAPI process for monitoring and review x 3 months or until substantial compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state 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 ensure wound dressing changes were completed per physician orders for a resident with severe cognitive impairment. The resident was admitted to the facility with orders for daily wound care on the right heel and leg, as well as instructions to offload the right heel while in bed. However, observations revealed that the resident's right heel was directly on the mattress without offloading, and the dressings on the right leg had not been changed as ordered. The dressings bore the same date and initials for two consecutive days, indicating that the dressing change had not been performed. The Unit Manager confirmed that the dressing had not been changed as documented in the Treatment Administration Record (TAR), which falsely indicated that the dressing change had been completed. When the dressing was eventually changed, it was found to have a moderate amount of drainage and was malodorous, suggesting that the wound care was not being managed appropriately. This failure to follow physician orders and accurately document care led to a deficiency in the facility's wound care management for the resident.

Plan Of Correction

F684- Quality of Care: care was not completed as ordered; care was documented as done. What corrective action(s) will be implemented for those residents found to have been affected by the deficient practice? The physician was informed by the Unit manager of the order for care not being executed, on /24 for resident #61, a new order for PRN obtained and care performed on. The resident's was evaluated by care on and showed no adverse outcome from missed care. How will you identify other residents who have the potential to be affected by the same deficient practice and what corrective action will be taken? DON and Unit managers completed an audit of all similar residents to identify any other residents affected by the deficient practice on. The audit revealed that no other residents were affected by the deficient practice. What measures will be implemented or what systemic changes will you make to ensure that the deficient practice does not recur? All licensed nurses will be reeducated on care policy and procedures and on following physicians' orders by. All licensed nurses will be reeducated on nursing documentation of provision of care in residents' medical records only after the care is completed by. Weekly quality review of care provision and documentation will be conducted by DON/designee of 5 residents with x 4 weeks then bi-weekly x 2 then monthly x 1 by. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? Results of quality review by DON/designee will be introduced in the QAPI process for monitoring and review for 3 months or until substantial compliance with care policy. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and for executed solely because it is required by the provisions of federal and state 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 effectively manage and communicate the pain management needs of a resident with severe cognitive impairment and chronic pain conditions. The resident, who had a history of stroke, neuropathy, back pain, and left shoulder pain, was observed experiencing significant pain and cramps in the left leg. Despite the care plan's instructions to evaluate the effectiveness of pain interventions and monitor non-verbal signs of pain, there was inconsistency in documenting the resident's pain location and no medication order for cramps or muscle spasms. The resident frequently complained of left leg cramps, which were not adequately addressed by the nursing staff. During an observation, the resident experienced a painful cramp in the left leg, which was not effectively managed by the CNA, who only provided verbal instructions and repositioning. The RN was unaware of the resident's pain being described as a cramp until the surveyor's intervention. The lack of communication and appropriate treatment for the resident's pain led to the deficiency, as the facility did not ensure the resident's pain was effectively managed according to the care plan and physician's orders.

Plan Of Correction

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? The physician was notified of the resident's complaint of spasms and an order obtained for relaxant on Resident. The resident was referred to Management practitioner and evaluated on and an as needed order for was obtained. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken? An audit of all residents was done to verify they have active orders for assessment. Nursing staff will be reeducated to report all symptoms to primary physicians and Management provider when identified. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur? Residents will have assessment by licensed nurse every shift to identify incidence of for timely intervention. CNAs will be reeducated to immediately report any complaints by residents of discomfort to the floor nurse and immediately by. How will the corrective action(s) be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place? A weekly quality review will be conducted by DON or designee weekly x 4, then bi-weekly x 2, then monthly x 1. Quality reviews will be entered by DON in QAPI for monitoring x 3 months or until substantial compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state 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 ensure adequate monitoring of side effects and behaviors for a resident receiving psychotropic medications. The policy titled 'Use of Psychotropic Medication' requires that residents are not given psychotropic drugs unless necessary to treat a specific condition, and the medication's effects must be documented. Resident #16, who was admitted with diagnoses including Non-Alzheimer's Dementia and a psychotic disorder, was prescribed Seroquel to address psychosis. The physician orders required behavior and side effect monitoring using a specific coding system. However, the February 2025 Medication Administration Record (MAR) showed that behavior monitoring was recorded with check marks instead of the mandated codes, failing to document the resident's response to the medication accurately. An interview with the Director of Nursing (DON) revealed that the behavior monitoring should have included coding entries as directed, and the use of check marks was not sufficient. The DON confirmed that the nurses should have recorded a zero if no behaviors were exhibited, rather than using check marks. This oversight in documentation did not comply with the facility's policy and the physician's orders, leading to a deficiency in monitoring the resident's response to the psychotropic medication.

Plan Of Correction

F757 Drug Regimen is Free from Unnecessary Drugs (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #16 had a new order for behavior monitoring was added to the resident's chart on and revised on, documentation scheduled for every shift. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. An audit was conducted of the medical records of all patients on medication to identify any without behavior monitoring on by DON/ designee. Any found without were corrected. Weekly audits will be conducted X 4 by DON or designee then monthly x 3 or until substantial compliance. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. Education provided to licensed nurses by DON by on the components of this regulation with emphasis on adequate monitoring associated medication use per physician's order requiring monitoring and the residents plan of care. (4) 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 DON /designee will conduct quality review of 5 residents' receiving medications weekly x 4 weeks for appropriate behavior monitoring as indicated, and then every 2 weeks 2, then monthly x1 then PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months or until substantial compliance is maintained. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state 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 adhere to appropriate infection prevention and control practices, specifically in the use of hand hygiene and personal protective equipment (PPE) during care for two residents. Resident #65, who had a history of atherosclerosis with gangrene, diabetes, and an unhealed Stage 3 pressure ulcer, was observed receiving incontinence care without the use of a gown by Staff A, a CNA. Staff A did not change gloves or perform hand hygiene during the care process, despite the presence of feces, and there was no Enhanced Barrier Precautions (EBP) signage or PPE available in the resident's room. Resident #61, who required daily wound care for open areas on the right heel and leg, also did not have EBP signage or PPE set up at the room. During a dressing change, Staff E, a Unit Manager, did not wear a protective gown. The facility's Director of Nursing (DON) admitted to misunderstanding the guidelines for EBP, which led to the removal of EBP signs from residents' rooms and a lack of proper precautions during care. The deficiencies were identified through observations and interviews, revealing a lack of compliance with the facility's own policy on EBP. The DON acknowledged the oversight and misunderstanding of the EBP guidelines, which contributed to the improper infection control practices observed during the care of Residents #65 and #61.

Plan Of Correction

F880- Tag Control What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident# 65 was observed for sign or symptoms of none discovered. DON was educated by Corporate Chief Clinical Director on Enhanced Barrier Precautions (EBP) during survey and an action plan presented to survey team. CNA who demonstrated deficient washing and gloving practice received a 1:1 in-service on by DON. All staff educated on EBP and the need for wearing gloves and gowns while providing care by. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. A review of all residents was done to identify those who meet criteria for EBP. Signage was posted on the doors of all residents with EBP status and supplies placed in containers in hallway or on residents' doors on. Goal of 95-100% of all staff are reeducated by on handwashing and glove donning/doffing and changing is compliant with control procedures for. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. The ongoing EBP in-service will occur weekly for new employees. Bins with PPE have been placed in hallways for easy access by staff effective. How the corrective action(s) will be monitored to ensure the deficient practice will not recur. What quality assurance program will be put into place. The DON/designee will conduct quality review observations of ADL care for 5 residents dependent on ADL care weekly x 4 weeks, bi-weekly for every 2 weeks x 2 months then PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 3 months or until substantial compliance is achieved. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state 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 effectively manage and communicate the health care needs of Resident #42, who was experiencing severe cramps and spasms. Despite the resident's repeated complaints and visible discomfort, the staff did not evaluate the effectiveness of interventions or provide appropriate treatment. The care plan required staff to monitor and report symptoms, but there was inconsistency in documentation and a lack of medication orders for cramps or spasms. Observations showed the resident experiencing significant discomfort, yet the staff did not take timely action until surveyor intervention prompted a medication order. Additionally, the facility did not ensure timely and adequate nail care for Residents #6 and #61. Both residents had excessively long nails with debris underneath, which were not addressed according to the care plans. The staff responsible for nail care were unclear about their duties, leading to inconsistent and inadequate care. Resident #6 was observed scratching an open area on her cheek, and Resident #61 expressed dissatisfaction with the length of his nails, indicating a lack of routine maintenance. Furthermore, the facility failed to follow physician orders for Resident #61's wound care. The resident's right heel was not offloaded as instructed, and the dressings were not changed daily as required. Observations revealed that the dressings had not been updated, and the Treatment Administration Record inaccurately documented that care had been provided. This oversight resulted in the resident having a malodorous dressing with drainage, indicating a failure to adhere to treatment protocols.

Plan Of Correction

#1 Tag Management What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. The physician was notified of the resident's complaint of spasms and an order obtained for relaxant on. Resident was referred to Management practitioner and evaluated on and an as needed order for was obtained. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. An audit of all residents was done to verify they have active orders for, assessment on. Nursing staff will be reeducated to report all symptoms to primary physicians and Management provider when identified by. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur. Residents will have assessment by licensed nurse every shift to identify incidence of for timely intervention by CNAs reeducated to immediately report any complaints by residents of or discomfort to the floor nurse and immediately by. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Weekly quality review will be conducted by DON or designee weekly x 4, then bi-weekly x 2 then monthly x 1. Quality reviews will be entered by DON in QAPI for monitoring x 3 months or until substantial compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. #2 and #3 Tag ADL Care: Nail grooming not performed for two residents #6 and #61 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #6, nails were cut and cleaned during survey. Resident #61, nails were cut and cleaned during survey. How will you identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken. An audit of all residents' nails was conducted on to identify other residents who may be affected by deficient practice. Any exceptions found were addressed at time of audit. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur. Nursing staff educated re residents' nail grooming and cleanliness during daily ADL care by. Weekly audits x 4 weeks will be conducted, then, bi-weekly x 2, then monthly x 1 to identify any deviation from the compliance plan by. Guardian angels will do weekly checks of assigned residents' nails during their routine rounding for need of grooming and report need to Unit Managers for care by. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. The plan will be submitted to the QAPI process for monitoring and review x 3 months or until substantial compliance. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. #4: Quality of Care: care was not completed as ordered; care was documented as done. What corrective action(s) will be implemented for those residents found to have been affected by the deficient practice. The physician was informed by the Unit manager of the order for care not being executed, on /24 for resident #61, a new order for PRN obtained and care performed on. The resident's was evaluated by care on and showed no adverse outcome from missed. How will you identify other residents who have the potential to be affected by the same deficient practice and what corrective action will be taken. DON and Unit managers completed an audit of all similar residents to identify any other residents affected by the deficient practice on. The audit revealed that no other residents were affected by the deficient practice. What measures will be implemented or what systemic changes will you make to ensure that the deficient practice does not recur. All licensed nurses will be reeducated on care policy and procedures and on following physicians' orders by. All licensed nurses will be reeducated on nursing documentation of provision of care in residents' medical records only after the care is completed by. Weekly quality review of care provision and documentation will be conducted by DON/designee of 5 residents with x 4 weeks then bi-weekly x 2 then monthly x 1 by. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into place. Results of quality review by DON/designee will be introduced in the QAPI process for monitoring and review for 3 months or until substantial compliance with care policy. Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and for executed solely because it is required by the provisions of federal and state law.