West Delray Nursing & Rehab 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 appropriately respond to and resolve grievances for one resident, as required by its own grievance policy. The policy states that grievances may be voiced verbally to staff and must be documented on the facility grievance report. However, a review of the grievance records for May did not show any documentation of complaints or concerns from the resident's son, despite his statements that he reported multiple issues to both the former and new Administrators. These issues included concerns about medications, falls, a non-functioning bed and TV, and resident rights. The son reported that he did not receive any updates or progress regarding his complaints, and was particularly concerned about medications not being administered until the night before the resident's discharge. The resident involved had multiple diagnoses, including pulmonary hypertension, muscle wasting and atrophy, type 2 diabetes mellitus with peripheral angiopathy, atrial fibrillation, hypothyroidism, and chronic kidney disease. The resident was assessed as having intact mental cognition. Staff interviews revealed that grievances are typically assigned and resolved within a few days, and that maintenance issues are usually addressed promptly. However, the staff member responsible for social services was unable to explain why the resident's grievances were not documented in the report, stating that there were no reported grievances from the resident, despite the son's statements to the contrary.

Penalty

No penalty information released

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

Summary

A newly admitted resident with multiple complex diagnoses, including pulmonary hypertension, muscle wasting, diabetes mellitus with peripheral angiopathy, atrial fibrillation, chronic kidney disease, osteoporosis, and hypothyroidism, did not receive physician-ordered medications for immediate care upon admission. The resident was assessed as having intact mental cognition and was admitted with weakness and a recent fall. The Advanced Registered Nurse Practitioner recommended continuation of current medications and fall risk precautions, and the pharmacist reviewed the medication regimen and made recommendations. However, there were no documented physician orders for several recommended medications, including gabapentin, carvedilol, calcitriol, allopurinol, and sodium bicarbonate, at the time of admission. Nursing progress notes indicated that medications were ordered by telephone on the day of admission, but these orders were not reflected in the resident's medical record or Medication Administration Record (MAR) until the tenth day of the resident's stay. During this period, there was a lack of documentation specifying which medications were unavailable or what new orders were implemented. The resident did not receive the recommended medications until the night before a resident-initiated discharge, despite facility staff stating that medications should be started as soon as possible after admission. Facility leadership was unable to provide an explanation for the delay in 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 ensure that physician orders were followed, resulting in a medication error rate of 32%, which is significantly higher than the acceptable threshold of 5%. During observations, interviews, and record reviews, ten medication errors were identified out of 31 opportunities, affecting four residents. The facility's policy on drug administration requires medications to be administered within one hour before or after their prescribed time, but this was not adhered to, leading to the high error rate. The errors were documented during a medication pass observation signed by the Consultant Pharmacist for a Licensed Practical Nurse (LPN).

Plan Of Correction

(1) Actions taken to correct the deficient practice: Resident #2 was evaluated on by the Unit Manager. There have been no ill effects noted from the medication errors. The physician and family were notified. The resident remains at the facility and is stable. Resident #3 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #5 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a medication error rate below 5%, with an observed error rate of 32%. During medication administration observations, 10 errors were identified out of 31 opportunities, affecting multiple residents. The errors included improper timing of medication administration, with medications being given outside the one-hour window before or after the prescribed time. Staff members, including LPNs, were observed administering medications late, and some staff reported being overwhelmed with additional responsibilities such as skin care, answering call lights, and communicating with families and doctors. Specific instances included a resident receiving a chewable tablet separated from other medications due to its form, and another resident's medication being delayed due to low vital signs. Staff interviews revealed that management was aware of the delays, and some staff had attended medication administration in-services. Despite these efforts, the issue persisted, with staff struggling to manage their time effectively, leading to significant delays in medication administration.

Plan Of Correction

(1) Actions taken to correct the deficient practice: Resident #2 was evaluated on by the Unit Manager. There have been no ill effects noted from the medication errors. The physician and family were notified. The resident remains at the facility and is stable. Resident #3 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #5 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Resident #6 was evaluated on by the Unit Manager for any side effects due to medication timing and administration errors and none observed. The physician and resident family were notified. The resident remains at the facility and is stable. Staff A received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff B received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff C received re-education on by ADON on administering medications as per physician orders and notification to supervisor and/or physician if medications may be administered outside of scheduled time frame. Staff E received re-education on monitoring the timeliness of medication administration and facility process to follow specific to timeliness of medication.

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's Quality Assurance and Performance Improvement (QAPI) Program failed to effectively address and correct identified quality deficiencies related to medication errors. During a revisit survey, surveyors observed 10 medication errors out of 31 opportunities, affecting four residents. This repeated deficient practice was previously cited during a recertification survey, indicating ongoing issues with medication administration. The Director of Nursing (DON) was informed of the medication administration errors, which were documented under F759, Free of Medication Errors. Despite the facility's plan of correction, which included re-education of licensed nursing staff on the medication administration process, the errors persisted. The facility's QAPI program did not ensure that the medication error rate was maintained below the acceptable threshold of 5%. The facility's survey history and plan of correction records were reviewed, revealing that the Licensed Practical Nurses (LPNs) involved had undergone orientation and medication pass observations. However, these measures were insufficient in preventing the recurrence of medication errors, highlighting a lack of effective implementation and monitoring within the QAPI program.

Plan Of Correction

(1) What corrective actions will be taken for those residents found to have been affected by the deficient practice: AD Hoc QAPI Meeting was held on with the Administrator, Medical Director, Director of Nursing and interdisciplinary team members. The meeting agenda included the components of Regulations: F759 Free of Medication Error rates 5% or more and F867 QAPI and the areas of concerns communicated on survey exit by the Agency for Health Care Administration. (2) How you will identify other residents having the potential to be affected by the same practice and what corrective actions will be taken: The Regional Vice President of Operations re-educated the Administrator on regarding the components of this regulation with emphasis on ensuring quality assurance monitoring of facility processes related Medication Administration. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: QAPI meeting was conducted on and by the Administrator. Participation included interdisciplinary team members as well as the Medical Director. Meeting agenda included the components of Regulations: F-759 Free of Medication Error Rates 5 Percent or more F-867 QAPI. Education was provided by the Administrator to QAPI team members on related to the elements of the Quality Assurance and Process Improvement program and to ensuring quality assurance monitoring of facility processes related to Medication Administration. (4) How the corrective actions will be monitored to ensure the practice will not recur: The facility Administrator/designee will conduct a quality review of QAPI to ensure quality assurance monitoring of medication administration to ensure ordered medications are being administered in a timely manner and as prescribed by the physician weekly x 4 weeks, and then every 2 weeks x 2 months then PRN as indicated. The findings of this quality monitoring will be reported to the QAPI monthly. Quality Monitoring schedule will be modified based on findings with quarterly monitoring by the Regional Director of Clinical Services / designee.

Penalty

Inspection fine: $9,126

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

Summary

The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating their needs and preferences. Resident #8, who was admitted with diagnoses including dizziness and heart disease, had a fall resulting in knee injuries. Despite an updated care plan intervention to keep the call light within reach, it was observed out of reach behind her bed during an interview. Resident #8 confirmed her inability to reach the call light, which was crucial for her to call for assistance due to her fall risk. Similarly, Resident #71, admitted with repeated falls and dementia, was observed with the call light out of reach on two separate occasions. Despite her severe cognitive impairment, she acknowledged the presence of the call light but was unable to reach it. Staff B, a Certified Nursing Assistant, confirmed the importance of keeping the call light accessible and responding promptly, especially for residents at risk of falls. The failure to ensure call lights were within reach for these residents highlights a deficiency in the facility's adherence to its policy and the residents' care plans.

Penalty

Inspection fine: $9,126

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 update the Advanced Directives status for a resident, leading to a deficiency. The resident, who was admitted with conditions including Multiple Sclerosis and Major Depressive Disorder, had a documented Do Not Resuscitate (DNR) order signed by both the physician and the resident. However, this DNR status was not reflected in the physician orders or the resident's Electronic Health Record (EHR) profile in Point Click Care (PCC). The care plan indicated the resident's desire for their Advanced Directives to be honored, but it did not specify the chosen code status. Additionally, there were inconsistencies in the documentation, with some notes indicating a Full Code status despite the resident's DNR order. Interviews with staff revealed a lack of clarity and consistency in the process of documenting and updating Advanced Directives. A Registered Nurse stated that if a DNR order was present, it should be uploaded to the PCC, but this was not done for the resident in question. The Social Worker mentioned that Advanced Directives should be initiated immediately upon admission and included in both the paper chart and EHR, with a physician's order in place within a week. However, this process was not followed, leading to the deficiency. The staff's understanding of the procedures for documenting Advanced Directives was inconsistent, contributing to the oversight.

Penalty

Inspection fine: $9,126

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 a resident's unwitnessed fall with an injury of unknown source, which is a violation of their policy and state law. The resident, who had a history of repeated falls and cognitive impairment, was found on the floor with significant injuries, including a large laceration on the forehead and skin tears on both legs. Despite the severity of the injuries and the resident's inability to explain the cause of the fall, the incident was not reported to the state agency as required. The Director of Nursing (DON) and the Administrator did not recognize the incident as reportable, assuming the fall was due to the resident's behavior of attempting to ambulate without assistance. The facility's investigation into the fall was incomplete, lacking documentation of corrective actions, follow-up, and a comprehensive fall risk assessment. Additionally, there was no evidence of neurologic checks or a fall log to track the resident's falls, which are essential components of the facility's policy. Interviews with staff revealed a lack of awareness and understanding of reporting requirements for falls with injuries of unknown sources. The Administrator believed that only incidents involving abuse or neglect needed to be reported, while the DON was unable to provide a complete investigation or corrective actions. This oversight highlights a significant deficiency in the facility's adherence to reporting protocols and the management of resident safety.

Penalty

Inspection fine: $9,126

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 Resident #2 received treatment and care in accordance with physician orders for skin conditions. The resident, who was admitted with multiple diagnoses including Parkinson's Disease and cognitive impairment, had specific physician orders for wound care on her knees. These orders included cleansing and dressing changes on specified days. However, the facility's records and observations revealed that these orders were not consistently followed, as evidenced by undated and outdated dressings on the resident's knees. The March 2025 Treatment Administration Record (TAR) for Resident #2 lacked documentation of weekly skin checks and did not show evidence of dressing changes as per the physician's orders. Observations on multiple days showed that the dressings on the resident's knees were not changed according to the schedule, and there was no documentation of the resident refusing care. Interviews with the resident and staff confirmed the inconsistencies in care, with the resident expressing pain and difficulty in movement following a fall, and staff acknowledging the resident's confusion and occasional refusal of care. Further interviews with the Wound Care Nurse and Unit Manager confirmed that the dressing changes were not performed as ordered, and there was a lack of communication and documentation regarding the resident's care. The Wound Care Nurse admitted to performing a dressing change on a day not scheduled by the physician's orders, and the Unit Manager acknowledged the discrepancies in the TAR and the lack of progress notes regarding the resident's refusal of care. These failures in following physician orders and documenting care contributed to the deficiency identified by the surveyors.

Penalty

Inspection fine: $9,126

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 supervision and assistance to prevent accidents for a resident with a history of falls and cognitive impairment. The resident, who was admitted with diagnoses including a history of traumatic fracture, Parkinson's Disease, and repeated falls, did not have a Fall Risk Assessment completed upon admission. Despite the facility's policy requiring such assessments within 24 hours of admission, this critical step was overlooked, leaving the resident without a tailored fall prevention plan. The resident experienced an unwitnessed fall resulting in significant injuries, including a laceration to the forehead and skin tears on both knees. The incident was not properly documented or investigated, as evidenced by the lack of a completed fall investigation report and missing documentation of neurologic checks after the resident returned from the hospital. The facility's Director of Nursing (DON) was unable to provide a comprehensive investigation or corrective actions, and there was no evidence of a fall log or follow-up as per the facility's policy. Interviews with staff revealed that the resident was often confused and attempted to ambulate without assistance, yet there was no effective intervention in place to address these behaviors. The resident's care plan was not updated in a timely manner, and the facility failed to report the fall with injury to the state, as required for such incidents. The lack of documentation and follow-up highlights a significant deficiency in the facility's fall prevention and response protocols.

Penalty

Inspection fine: $9,126

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 catheter care for Resident #96, who was observed with a urinary drainage bag hanging on the side of the bed without an anchoring device to secure the indwelling catheter. The resident, who has a history of neurogenic bladder and other medical conditions, was found to have an unsecured catheter, which was not in compliance with the facility's policy for catheter care. The resident had previously experienced a urinary tract infection, highlighting the importance of proper catheter management. During an observation of catheter care provided by Staff K, a CNA, several deficiencies were noted. The CNA did not perform hand hygiene after removing gloves and before putting on a new pair, which is against the facility's hand hygiene policy. Additionally, the CNA failed to provide privacy for the resident during the procedure, as the privacy curtain was not pulled, and the window blinds were not closed. The CNA also did not wear a gown, which is required under the facility's enhanced barrier precautions policy for high-contact resident care activities. The CNA's technique for cleaning the catheter was incorrect, as she wiped the catheter tubing from the drainage bag toward the resident's penis, rather than from the least contaminated to the most contaminated area. Furthermore, the catheter tubing was placed under the resident's leg without an anchor, which is not in accordance with the care plan's intervention to secure the catheter with a securement device. The Director of Nursing acknowledged these deficiencies during a side-by-side observation, confirming the improper placement and lack of anchoring for the Foley catheter.

Penalty

Inspection fine: $9,126

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

Summary

The facility failed to address significant weight loss in a timely manner for two residents, leading to deficiencies in nutritional care. Resident #14 experienced a 7.10% weight loss from January 7 to February 5, 2025, which was not addressed until February 13, 2025, when a nutritional note recommended adding Ensure and enhanced foods. However, documentation showed that the Ensure supplement was only recorded as given and accepted on 10 days out of the period from February 13 to March 8, 2025, without any percentage intake documented. Interviews with staff revealed that the documentation system only allowed for a yes or no response, and there was no option to record the percentage of supplement consumed. Resident #69 also experienced a significant weight loss of 18% from October 5 to December 5, 2024. A follow-up nutrition note on December 9, 2024, indicated a 17.2% weight loss trend, and Ensure was added twice a day for oral support. Despite this intervention, documentation from February 13 to March 8, 2025, showed that the Ensure supplement was only recorded as given and accepted on 23 out of 30 days, again without any percentage intake documented. Observations noted that Resident #69 was missing items from his breakfast tray, which were later provided by staff. Interviews with the Registered Dietitian and CNAs highlighted issues with the documentation process, as the system did not allow for detailed recording of supplement intake. The Registered Dietitian acknowledged that the response to significant weight loss should have been more prompt, and the CNAs confirmed that they could only document whether the supplement was taken, not the amount consumed. The facility's failure to adequately monitor and document nutritional intake contributed to the deficiencies identified by the surveyors.

Penalty

Inspection fine: $9,126

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 attending physician visits were performed in a timely manner for a resident with severe cognitive impairment. According to the facility's policy, residents should be seen by their physician at least monthly for the first 90 days following admission and at least once every 60 days thereafter. However, a review of the medical records for the resident revealed that there was no documentation from the attending physician, Staff H, indicating that he had performed a visit from December 6, 2024, to March 9, 2025. During an interview, Staff H stated that he sees residents initially every 30 days for the first 90 days and then alternates with the Nurse Practitioner (NP) every 60 days. He mentioned that the NP authors all notes and documents their collaboration on the plan of care, but he does not author any notes himself. The Director of Nursing acknowledged the lack of documentation indicating that the resident had been seen by the attending physician, confirming the deficiency in adhering to the facility's policy on physician visits.

Penalty

Inspection fine: $9,126

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 minimum required nursing staff daily for 3 out of 28 days reviewed. According to the facility's policy, the minimum daily average hours for nursing staff should be 1.0 or greater, and for Certified Nursing Assistants (CNAs), it should be 2.0 or greater. However, the facility's Nurse Staffing Calculations from February 9, 2025, to March 8, 2025, showed that on February 15, 2025, the CNA daily average was 1.99, and on March 1, 2025, it was 1.97. Additionally, the nursing daily average was 0.98 hours on March 1, 2025, and 0.93 hours on March 8, 2025, both below the required minimum. Interviews with the Staffing Coordinator and the Director of Nursing confirmed that the staffing levels were below the required minimum during this period, particularly on weekends.

Penalty

Inspection fine: $9,126

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 complete and timely nurse staffing information for four consecutive days, as required by federal and state guidelines. Observations on multiple days revealed that the CMS Staff Postings at the nursing stations on both Unit 1 and Unit 2 only listed hours worked, without specifying the number of nursing staff or the name of the facility. This incomplete information was consistently observed on postings dated 02/28/25, 03/09/25, 03/11/25, and 03/12/25. Interviews with facility staff revealed a lack of clarity and consistency in the posting process. The Human Resources Director, who temporarily took over the posting duties, was unaware of the specific requirements and timing for posting the information. The regular Staffing Coordinator, who usually handles the postings, stated that she does not include the number of staff members on the postings, as this information is available on the assignment board at each nursing station. This practice led to the omission of required details on the CMS Staff Postings, contributing to the deficiency.

Penalty

Inspection fine: $9,126

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 residents receiving PRN psychotropic medications were limited to 14 days or had documented rationale for extending the order beyond 14 days. This deficiency was identified for three residents. Resident #11 was admitted with anxiety and depression and was prescribed Alprazolam for 30 days without documentation justifying the extension beyond 14 days. Interviews with the Consultant Pharmacist and the Director of Nursing confirmed the lack of compliance with the 14-day limit. Resident #35, diagnosed with Generalized Anxiety Disorder, had a PRN order for Lorazepam without any documented rationale for extending the order beyond 14 days. The Director of Nursing acknowledged the absence of documentation to justify the extended use of the medication. The care plan for Resident #35 included interventions for mood changes but did not address the extended use of Lorazepam. Resident #15, with diagnoses of Generalized Anxiety Disorder and Major Depressive Disorder, had a PRN order for Alprazolam for 30 days. The Medication Administration Records for January, February, and March 2025 showed frequent administration of the medication, but there was no documentation of when the medication started or an end date. The Consultant Pharmacist and the Director of Nursing confirmed the lack of rationale for extending the PRN order beyond 14 days, indicating non-compliance with the facility's policy.

Penalty

Inspection fine: $9,126

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

Summary

The facility failed to maintain a medication error rate below 5%, with an observed rate of 13.33%. This deficiency was identified during medication administration observations involving two residents. Resident #85, who has Parkinson's Disease and moderate cognitive impairment, was administered medications significantly later than the prescribed time. The medications, including Carbidopa-Levodopa, Gabapentin, and Midodrine, were scheduled for 9:00 AM but were given at 12:00 PM. Additionally, the medications were improperly crushed and mixed with juice, contrary to administration guidelines. Interviews with staff revealed a lack of understanding regarding which medications should not be crushed, contributing to the error. Resident #11, diagnosed with Type 2 Diabetes Mellitus and moderate cognitive impairment, also experienced a medication administration error. The resident's Metformin was scheduled for 9:00 AM but was administered 1 hour and 50 minutes late. Interviews with staff indicated a misunderstanding of the facility's policy, which allows for a one-hour window before and after the scheduled time for medication administration. These errors highlight a failure in adhering to the facility's medication administration policies and procedures.

Penalty

Inspection fine: $9,126

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 supervision and storage of medications for two residents, as well as secure medication carts. Resident #16, who has severe cognitive impairment and multiple diagnoses including dementia and depression, was observed with over-the-counter (OTC) medications such as Voltaren gel, saline nasal gel, and Refresh Tear eye drops left unattended on her bedside table and in her nightstand drawer. There was no physician order or care plan for self-administration of these medications, and staff confirmed that these items should not have been in the resident's room. Resident #307, who has no cognitive impairment but requires assistance with activities of daily living, was found with a tube of Voltaren gel on her bed. The resident stated she applied the gel before therapy, and the nurse was aware, but there was no physician order or care plan for self-administration. Staff removed the medications upon discovery and acknowledged the lack of proper authorization for the resident to have these medications at her bedside. Additionally, the facility failed to secure medication and treatment carts. An unlocked and unattended treatment cart was observed at the nursing station, and staff admitted it had not been used yet that day. Similarly, a medication cart was left unlocked and unattended by a nurse who had just arrived at the facility. A wound care cart containing prescription medications was also found unlocked and unattended, with the responsible nurse acknowledging she left it that way in a hurry.

Penalty

Inspection fine: $9,126

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 professional standards for food service safety during multiple visits to the main kitchen. During the initial tour, several issues were identified, including a garbage bin with food debris and no lid in the food production area, and multiple sanitation buckets with no detectable sanitizing solution. Additionally, a square container with unidentified food and a jar of expired milk were found in the reach-in refrigerator, which was operating at an unsafe temperature of 58 degrees Fahrenheit. The walk-in refrigerator contained undated containers of Salisbury Steak and sandwiches past their use-by dates. The dishwasher machine was not functioning properly, with the wash cycle temperature below the required minimum. Personal water bottles were found in the food production area, and a cooking pot was noted with a dark sticky material. Egg salad plates were stored at unsafe temperatures, and the dietary aide confirmed they were prepared earlier that day. During a second visit, further deficiencies were observed, including an opened and unlabeled plastic bag of unidentified food in the walk-in freezer. These observations indicate a pattern of non-compliance with food safety standards, including improper food storage, inadequate sanitation practices, and equipment maintenance issues. The facility's failure to maintain proper food safety protocols poses a risk to the health and safety of its residents.

Penalty

Inspection fine: $9,126

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 accurate clinical records for two residents, leading to deficiencies in care. For Resident #2, who was admitted with conditions including Parkinson's Disease and a history of falls, the facility did not accurately document wound care for a skin tear on the left knee. Despite physician orders for regular dressing changes, observations revealed that the dressing was not changed as documented in the Treatment Administration Record (TAR). The dressing was dated incorrectly, and there was no evidence that the resident refused treatment on several occasions, indicating a lack of accurate documentation and adherence to care protocols. For Resident #97, who was admitted with severe cognitive impairment and a history of traumatic subdural hemorrhage, the facility's records inaccurately listed a Nurse Practitioner as a Physician in the Medical Practitioner Notes. This misrepresentation occurred multiple times over several months, and there was no documentation of visits by the attending physician. The Director of Nursing acknowledged these inaccuracies, highlighting a failure in maintaining accurate and truthful medical records for the resident.

Penalty

Inspection fine: $9,126

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 CDC guidelines for Standard Precautions during the care of Resident #25. Staff Q, a Certified Nursing Assistant, was observed using the same set of gloves for multiple tasks, including opening the resident's door, handling trash, moving a meal table, and assisting with personal care, without changing gloves or performing hand hygiene. This action was contrary to the CDC's hand hygiene and PPE guidelines, which require changing gloves and washing hands between different tasks to prevent cross-contamination. In another instance, the facility did not properly disinfect vital signs equipment used for Residents #31 and #72. Staff O, a Registered Nurse, was observed using a blood pressure cuff and an oxygen saturation clip on Resident #31 without disinfecting them after prior use on Resident #72. Additionally, the equipment was returned to the storage basket without being cleaned, and there was no disinfectant available on the rolling vital signs machine. This failure to disinfect equipment between uses is a breach of CDC guidelines for the safe handling of potentially contaminated equipment. Resident #31, who had multiple health issues including Acute Respiratory Failure and a Multi Drug Resistant Klebsiella Urinary Tract Infection, was at risk due to the lack of proper equipment disinfection. Similarly, Resident #72, who was waiting for medication and had not yet had their blood pressure taken, was exposed to potential infection risks due to the improper handling of the blood pressure cuff. These observations highlight the facility's failure to maintain proper infection control practices, as confirmed by Staff R, an RN, who stated that staff were trained to perform hand hygiene and disinfect equipment, but these practices were not consistently followed.