Westminster Towers

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 physician orders and implement the comprehensive care plan for a resident with a history of atrial fibrillation, hypertension, type 2 diabetes, and stroke. The resident was prescribed Hydralazine 100 mg three times a day for hypertension, with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 65. Despite these orders, the medication was administered outside of the prescribed parameters multiple times in February and March 2025, as documented in the Medication Administration Record (MAR). The Licensed Practical Nurse (LPN) involved admitted to administering the medication even when the heart rate was below the specified threshold, citing a lack of awareness of the updated order parameters. The Director of Nursing (DON) acknowledged that the nurses were not correctly following the physician's orders for the resident's medication. The facility's policies on Medication Regimen Review and Medication Administration, which emphasize the importance of adhering to physician orders and professional standards, were not followed. The failure to act upon the pharmacist's recommendations and ensure that the nursing staff was aware of and adhered to the current medication parameters contributed to the deficiency.

Plan Of Correction

Resident #43 was assessed by the physician upon notification of the medication concern. The medication was discontinued, and a new order written for a different medication. An audit of current residents with medications with parameters for administration was completed by the DON and/or designee to ensure medications were administered within the parameters. The physician was notified of any discrepancies. The licensed staff were in-serviced by the DON and/or designee on medication administration guidelines to follow the physician orders, including medication parameters. Weekly audits will be completed by the DON and/or designee for a minimum of three months or until significant compliance has been met to ensure licensed nurses are following the physician orders, including medication parameters. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain 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 ensure proper self-administration of medication for two residents. Resident #57, who was cognitively intact with a BIMS score of 13/15, was found with Neosporin ointment on his nightstand, which he used for a rash on his thigh. However, there were no physician orders for this medication, and the resident's assessment indicated he was not to self-administer medications. The primary RN acknowledged the presence of the ointment and explained that medications unknown to the nurse could cause interactions with other medicines. Similarly, Resident #83, also cognitively intact with a BIMS score of 13/15, was found using Voltaren cream for arthritis pain in her knees, which her daughter had brought for her. The cream was discovered in her nightstand drawer, and there were no physician orders for its use. The RN supervisor acknowledged the absence of orders and removed the cream for safekeeping. The DON confirmed that both residents were assessed as not being permitted to self-administer medications, as per facility policy, which requires an interdisciplinary team evaluation and physician orders for self-administration.

Plan Of Correction

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both federal and State laws. F554 Self Admin of meds Medications were immediately removed from rooms for residents #83 and resident #57. Self-administration of medication assessment was completed for resident #57 on Resident #57 was reviewed for the c/o to right side on Skin assessment completed on for resident #57 with no integrity issues. #83 was reassessed for Resident #83 MD was contacted, and new order was obtained cream to. Resident #83 for on discharged home on. An audit of the residents rooms completed by nursing management team did not reveal any additional on over the counter medications or treatments stored at the bedside. All resident self-administration of medications were reviewed to ensure accuracy of self-administration and found to be correct. Resident #57 and the family were educated regarding not having medication at bedside on and to notify the nurse if the resident needs a specific product, so staff is able to assess and to update the physician. Resident #83 discharged home. The licensed staff were in-serviced by the DON and/or designee regarding self-administration of medications, including families should not bring in any over the counter medications and they are required to report to the charge nurse any medications found at bedside. The education will be completed to staff on. Facility will provide education to residents and families via the Monthly Activities Newsletter regarding not to bring in any medications and to notify the nurse if you feel a specific medication is needed so the physician may be notified. This will notify all existing residents. A new process was put in place adding a notice to new admissions packet requesting outside medications not to be brought in and notifying the nurse if something specific is needed. Staff who complete Angel rounds were educated to focus on monitoring for medications at bedside during rounds and to report to the charge nurse any found. Staff also educated to ask the resident if they have any medication not obviously visible in the room. Angel rounds audits will be submitted to the NHA for review upon completion for any reports of medication at bedside. Random weekly audits of 5 resident rooms per floor will be conducted four times a week by the DON and/or designee to ensure any medications are not stored in the residents room without a physicians order. The room audits will be conducted for a minimum of 3 months or until significant compliance is met. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain 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 ensure a written summary of the baseline care plan was provided to two residents within the required timeframe. Resident #390, a male with diagnoses including right ankle osteomyelitis and asthma, was admitted to the facility and did not receive a written summary of his initial care plan. The Baseline Care Plan Assessment for this resident was completed and signed by staff, but there was no signature from the resident or his representative, and no documentation was found to confirm that a copy was provided to the resident. The Assistant Director of Nursing (ADON) acknowledged the oversight and could not confirm if the resident received the required documentation. Resident #546, admitted with diagnoses including aftercare following surgery on the digestive system, also did not receive a timely written summary of her baseline care plan. Although the resident was admitted on a Friday, the baseline care plan was not completed and signed until several days later, beyond the 48-hour requirement. The ADON admitted that the baseline care plan should have been completed and signed within the required timeframe to ensure the resident was informed of her care plan. The facility's policy mandates that a baseline care plan be developed and provided to the resident within 48 hours of admission, which was not adhered to in these cases.

Plan Of Correction

F655 Baseline Care Plan Resident #390 baseline care plan was completed and reviewed with the resident on Resident #546 baseline care plan was completed and reviewed with the resident on An audit of current residents records for the baseline care plans was completed by nursing management on Baseline care plans were completed as appropriate. The licensed staff will be in-serviced by the DON and/or designee regarding providing a written summary of the baseline care plan within the required time frame. Newly admitted resident baseline care plan will be reviewed and updated with 48-hour time frame. Nursing staff will review baseline care plan completion date with resident daily to ensure completion within 48-hours. Weekly audits of all new admissions will be completed by the DON and/or designee for three months then until significant compliance has been met to ensure the baseline care plan has been completed within the required time frame. The results of the audits will be reviewed and discussed at the monthly QAPE committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain 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 provide showers per resident preference and as scheduled for a resident who was dependent on staff for activities of daily living. The resident, who had intact cognition and required extensive assistance for personal hygiene, preferred showers three times a week. However, the facility did not adhere to this schedule, as evidenced by the resident's report of not receiving showers as scheduled and the facility's records showing missed showers on multiple occasions. The resident expressed that he was not asked if he wanted a shower on scheduled days and sometimes received a bed bath instead, which was not his preference. Interviews with staff revealed inconsistencies in the documentation and communication regarding the resident's care. Certified Nursing Assistants (CNAs) stated they informed nurses when the resident refused showers and provided bed baths instead, but there was no documentation of refusals in the resident's progress notes. The Registered Nurse and Unit Manager were unaware of any refusals, and the Director of Nursing expected refusals to be documented, which was not done. The facility's policy required showers to be provided as per request or schedule, but this was not consistently followed, leading to the deficiency.

Plan Of Correction

Resident #75 received a shower per his preference and receives showers as scheduled. If he refuses his scheduled shower, the CNAs will document the refusal and notify the nurse. Resident's care plan was updated to offer a bed bath if the resident declines a shower. An audit was completed to ensure showers were completed per the resident preference and as scheduled, with refusals documented. Any discrepancies were corrected as appropriate. The DON and/or designee will in-service the CNAs and licensed staff to provide showers per resident preference and as scheduled, including documentation of resident refusal and notification of the nurse. Staff will honor resident preferences for showers. Resident preferences will be care planned. Random weekly audits of five residents for each floor/unit will be completed by the DON/designee to provide showers per resident preference and as scheduled, including documentation of resident refusal. The audits will be completed weekly for a minimum of three months or until significant compliance has been met. The results of the audits will be forwarded to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain 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 coordinate necessary eye care for a resident with quadriplegia, slurred speech, polyneuropathy, and mild vascular dementia. The resident had a medical order for vision consults as needed, starting from June 2022, and was experiencing eye irritation, for which artificial tears were prescribed. Despite the resident's ongoing complaints of eye discomfort and the ineffectiveness of the artificial tears, the facility did not arrange for an eye specialist consultation. The resident's condition included watering eyes and reddened conjunctivas, and the resident reported significant pain in the right eye. The Assistant Director of Nursing had requested an eye specialist appointment for the resident in January 2025, but the Social Services Director did not follow through with the coordination of care. The in-house eye specialist was out of network for the resident's insurance, and the resident could not afford to pay out of pocket. Despite being aware of these issues, the Social Services Director did not seek alternative arrangements or request facility assistance to cover the cost, resulting in the resident not receiving the necessary specialist care.

Plan Of Correction

Resident #45 was seen by the optometrist on and new orders received. An audit was completed on by Social services of current residents and any additional resident referrals were followed up on. The facility has contacted an outside to ensure that the resident's new insurance was covered by an optometrist for any future needs completed by. On Social services was educated on the process for ensuring that all referrals are submitted on a timely basis by the Administrator. The Social service team has been educated on the importance of documenting each step of the referral and any roadblocks that they are trying to overcome. Social services will perform weekly audits of residents' referral orders to ensure are obtained and follow up on timely. Audits will continue weekly for a minimum of 3 months or until significant compliance has been met after. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain 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 ensure accurate and complete documentation for a 98-year-old male resident with multiple diagnoses, including dementia and impaired mobility. The resident was admitted to the facility and required assistance with transfers and toileting due to his cognitive and physical impairments. An incident occurred where the resident was found wandering without his walker and ended up in another resident's bathroom. Despite the family reporting this incident and increasing private sitter care to 24/7, there was no documentation of the incident in the resident's clinical records or the facility's incident log. Interviews with facility staff, including the Administrator and the Director of Nursing (DON), revealed that the incident was known but not documented. The Administrator acknowledged the incident and stated it was reported to the night shift nurse, but no record of this was found. The DON confirmed that no documentation could be identified regarding the incident or any subsequent assessments or monitoring of the resident's condition. The facility's policy requires timely and accurate documentation of residents' experiences, which was not adhered to in this case.

Plan Of Correction

Resident #55 was seen by the nurse practitioner on and and into no adverse effects of another resident room were noted. An audit was conducted with staff nursing on each shift to determine if any unusual occurrences or behaviors have occurred and verified if documentation has occurred. Licensed nurses were provided education by regarding documentation of resident experience to include any unusual occurrences or incidents that have occurred on the shift. If there is an unusual occurrence, staff should assess the patient and implement appropriate interventions if necessary. DON and/or designee will complete 4 random interviews with staff on each shift weekly for 3 months to determine if any unusual occurrences or behaviors have been observed, and then DON and/or designee will audit resident records to ensure this has been appropriately reflected in the resident record. The results of the audits will be submitted to the Administrator for review and discussed at the monthly QAPI committee meeting. The committee will direct improvement to the plan when necessary to achieve and maintain 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 deficiency involved a failure by licensed nurses to follow the facility's policy and procedure regarding the verification of a resident's code status in an emergency situation. A resident, who was receiving hospice care, was found unresponsive in her bed by RN A. Despite the resident's documented status as a Full Code, RN A did not verify this information and failed to initiate life-saving measures. Instead, RN A assumed the resident was a Do Not Resuscitate (DNR) due to her hospice care status and proceeded with postmortem care without calling Emergency Medical Services or a Code Blue. The resident's medical records clearly indicated her Full Code status, which had been confirmed in discussions with her husband and documented in her care plan and physician orders. However, RN A, along with RN C and RN Supervisor B, did not verify the resident's code status as per the facility's procedure. This oversight led to the resident not receiving the resuscitative measures she had requested, as her wishes were not honored due to the staff's failure to check her chart and confirm her code status. The incident placed all residents receiving hospice care at risk of not having their wishes honored, resulting in Immediate Jeopardy. The facility's policy required staff to provide basic life support in accordance with the resident's advance directives, but this was not followed. The deficiency was identified as having the potential for more than minimal harm, although it was not considered Immediate Jeopardy after the initial finding.

Plan Of Correction

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both federal and State laws. 1. Resident #1 expired on Nurse A and Nurse B were suspended immediately. 2. Residents who, in house in the past 3 months were reviewed to ensure all advanced directives were followed. This was completed by and no discrepancies were noted. All Code statuses were followed as ordered. Social services validated all current residents' code status and validated the status is correct according to their individual wishes on Nurse A is no longer employed at the facility and the results of the investigation were reported to the board of nursing. Education was provided to Nurse B prior to returning to work. 3. Facility completed code blue drills each shift 72 hours post incident and re-educated staff on our code blue policies. Completed by Staff received an electronic communication with immediate education on resident rights, advanced directives, and validating residents' code status in their chart prior to calling a code blue on. The nursing supervisors were re-educated by the ADON and/or designee regarding verifying code status on any resident found without vital signs or unresponsive prior to having contact with residents. Licensed nurses have been in-serviced by the ADON and/or designee that residents receiving hospice service does not equate to the resident being a full code and staff must check all residents' code status when they are found unresponsive. This was completed prior to having contact with residents. A new process was put into place where the Facility will add residents' full code status order to the MAR to be signed off every shift by the nurse if the patient is on hospice and is a full code to increase visibility to nursing staff. Written Code blue competency tests were administered to the licensed staff and CNAs and validated by the DON/Designee. Regularly scheduled staff completed by and PRN staff will complete testing prior to having contact with residents. Any new staff members will receive code blue education and competency testing during their orientation days before working the floor alone ongoing. Facility staff were re-educated by the ADON and/or designee of the advance directive processes; neglect and; resident's rights regarding treatment and advance directives; communication of code status; and physician notification of changes. Regularly scheduled staff completed by and PRN staff will complete education prior to having contact with residents. 4. Facility completed ad hoc QAPI on and continued with ad hoc QAPI for the following three weeks on and Code blue drills varying day/shift will continue weekly for one month, followed by three drills a month varying day/shift monthly thereafter to be completed by DON/designee. Random weekly checks will be completed by DON and/or designee for three months to ensure the nurses & CNAs are competent with checking the residents' code status when a resident is found unresponsive, regardless of status, i.e., Hospice, STR, etc. ADON and/or designee will complete weekly audits of current hospice residents to ensure there is a separate order being signed off stating the resident's full code status if appropriate. Audits will be completed weekly for one month, followed by monthly for two months. DON and/or Designee will audit any new hires to ensure a code blue competency test has been satisfactorily completed monthly x3 months. Incident was reviewed during QAPI meeting on and the committee agrees with this corrective action. Results of the previously mentioned audits including checking the code status, code blue drills, auditing of hospice resident orders, physician notification of change of condition for full code hospice residents, and new hire competencies will be submitted to the Administrator and brought to QAPI for review and evaluation monthly. Audits will continue for a minimum of 3 months or until significant compliance has been met as deemed by the QAPI committee.

Penalty

Inspection fine: $22,133

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 verifying code status in an emergency situation for a resident who was receiving hospice care. The resident, who had a history of severe cognitive impairment and was on hospice care, had a documented Full Code status, which was not honored when she was found unresponsive. The failure to verify the resident's code status led to the omission of life-saving measures, as the staff assumed she was a Do Not Resuscitate (DNR) due to her hospice status. On the evening of the incident, the resident was found unresponsive in her bed by RN A, who did not verify the resident's code status and failed to initiate cardiopulmonary resuscitation (CPR) as per the resident's wishes. RN A, along with RN C, provided postmortem care without calling a Code Blue or contacting emergency medical services. RN A later acknowledged that she was unaware of the resident's Full Code status and admitted that she did not check the resident's chart, which would have indicated the need for resuscitative measures. The RN Supervisor B, who was informed of the resident's passing, also assumed the resident was a DNR due to her hospice care and did not verify the code status. This assumption was incorrect, as the resident's husband had confirmed her desire to be a Full Code. The facility's failure to ensure staff followed procedures related to honoring an advance directive resulted in Immediate Jeopardy, as it placed all residents receiving hospice care at risk of not having their wishes honored.

Plan Of Correction

Preparation and execution of this plan of correction does not constitute admission or agreement of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by both federal and State laws. 1. Resident #1 expired on Nurse A and Nurse B were suspended immediately. 2. Residents who , in house in the past 3 months were reviewed to ensure all advanced directives were followed. This was completed by and no discrepancies were noted. All Code statuses were followed as ordered. Social services validated all current residents code status and validated the status is correct according to their individual wishes on Nurse A is no longer employed at the facility and the results of the investigation were reported to the board of nursing. Education was provided to Nurse B prior returning to work. 3. Facility completed code blue drills each shift 72 hours post incident and re-educated staff on our code blue policies. Completed by Staff received an electronic communication with immediate education on resident rights, advanced directives, and validating residents code status in their chart prior to calling a code blue on The nursing supervisors were re-educated by the ADON and/or designee by regarding verifying code status on any resident found without vital signs or unresponsive prior to having contact with residents. Licensed nurses have been in serviced by the ADON and/or designee by that residents receiving hospice service does not equate to the resident being a and staff must check all residents code status when they are found unresponsive. This was completed prior to having contact with residents. A new process was put into place where the Facility will add residents full code status order to the MAR to be signed off every shift by the nurse if the patient is on hospice and is a full code to increase visibility to nursing staff on. Written Code blue competency tests were administered to the licensed staff and CNAs and validated by the DON/Designee. Regularly scheduled staff completed by and PRN staff will complete testing prior to having contact with residents. Any new staff members will receive code blue education and competency testing during their orientation days before working the floor alone ongoing. Facility staff were re-educated by the ADON and/or designee of the advance directive processes; neglect and; resident's rights regarding treatment and advance directives; communication of code status; and physician notification of changes. Regularly scheduled staff completed by and PRN staff will complete education prior to having contact with residents. 4. Facility completed ad hoc QAPI on and continued with ad hoc QAPI for the following three weeks on and Code blue drills varying day/shift will continue weekly for one month, followed by three drills a month varying day/shift monthly thereafter to be completed by DON/designee. Random weekly checks will be completed by DON and/or designee for three months to ensure the nurses & CNAs are competent with checking the residents code status when a resident is found unresponsive, regardless of status, ie Hospice, STR, etc. ADON and/or designee will complete Weekly audits of current hospice residents to ensure there is a separate order being signed off stating the resident full code status if appropriate. Audits will be completed weekly for one month, followed by monthly for two months. DON and/or Designee will audit any new hires to ensure a code blue competency test has been satisfactorily completed monthly x3 months. Incident was reviewed during QAPI meeting on and committee agrees with this corrective action. Results of the previously mentioned audits including checking the code status, code blue drills, auditing of hospice resident orders, physician notification of change of condition for full code hospice residents and new hire competencies will be submitted to the Administrator and brought to QAPI for review and evaluation monthly. Audits will continue for a minimum of 3 months or until significant compliance has been met as deemed by the QAPI committee.

Removal Plan

• Administrator and DON initiated an investigation into discrepancies in resident #1's chart regarding her passing.
• The facility completed an in-house audit for code status of all residents.
• Licensed nurses were educated on the facility's policy and procedure for verifying code status prior to initiating or withholding lifesaving procedures including Code Blue drills to validate comprehension.
• Resident #1's husband was notified regarding discrepancies found and investigation.
• Law enforcement and elderly affairs were notified out of abundance of caution. An immediate report was filed with the state agency.
• A record review of resident #1 was completed by the DON.
• Social Service Director completed an audit of all current residents' code status.
• RN Supervisor B and RN A received personal training from the DON on checking residents' code status and starting Code Blue procedures. Both nurses were suspended pending investigation.
• Nursing Supervisors received individual education on checking code status when residents were unresponsive and initiating Code Blue procedures from the DON.
• A text was sent to all nursing staff containing education regarding if a resident was found unresponsive, it was the responsibility of the nurse to verify code status in the chart and initiate if Full Code.
• 64 of 81 total licensed nurses received education.
• 48 out of 81 nurses completed the education.
• An additional 10 of 81 nurses completed their education.
• An additional 6 of 81 nurses completed their education.
• Remaining licensed nurses would receive education prior to working next shift.
• New hire nurses at the facility would receive the above education during orientation and prior to working an assignment.
• Mock Code Blue drills were conducted to validate education received was retained.
• Starting weekly code blue drills to be conducted on varying shifts and days to include all shifts.
• Random weekly audits to be completed to ensure staff follow facility procedure for verifying residents' code status prior to initiating or withholding.
• New hire nurses at the facility to participate in a mock code drill during orientation and prior to working an assignment.
• Ad Hoc Quality Assurance and Performance Improvement (QAPI) held to review the recommendations made from the investigation. The QAPI committee reviewed education in progress and code blue drills.

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 in a timely manner for a resident with Alzheimer's disease, dementia, and other conditions. The resident, who had a moderate cognitive impairment and used a wander/elopement alarm daily, was admitted to the facility with a care plan for wandering and at risk for elopement. On the morning of August 7, 2024, the resident was found missing during rounds by the 7:00 AM - 3:00 PM nurse, prompting a facility search. The resident was eventually located at a nearby hospital after leaving the facility unsupervised. The facility's administrator, responsible for filing reports of allegations of abuse or neglect, confirmed that the immediate report of neglect was filed late, on August 8, 2024, around 3:00 PM. The administrator acknowledged the delay, stating he wanted to ensure the investigation was complete before submitting the report. According to the facility's policy and procedure for Abuse, Neglect, and Exploitation, alleged violations should be reported no later than 24 hours after the allegation if the event did not involve abuse and did not result in serious bodily 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 provide adequate supervision to prevent the elopement of a resident with Alzheimer's disease and dementia. The resident, who had a history of wandering and elopement, was equipped with a wander/elopement alarm. However, on the night of the incident, the resident managed to cut off the alarm and hide it in her dresser drawer. She then swapped her walker with another resident's walker, which did not have an alarm, and left the facility unsupervised. The staff on duty, including a registered nurse, a certified nursing assistant, and a dietary aide, did not adequately monitor the resident. The dietary aide allowed the resident to follow him into an elevator without realizing she was a resident, as no alarm sounded. The resident exited the facility through the employee entrance and walked to a nearby hospital, where she was admitted. The staff did not notice her absence until the next morning, despite the facility's policy requiring staff to check on residents at least every two hours. Interviews with staff revealed a lack of communication and assumption that the resident was in her room or on leave. The facility's investigation confirmed that the resident was seen on camera leaving the facility. The administrator acknowledged that alarms are not a substitute for supervision and that staff should have checked on the resident more frequently, especially given her risk for elopement.

Penalty

No penalty information released

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

Summary

The facility failed to ensure a physician's order was obtained for medications at the bedside for a resident who was reviewed for pressure ulcer care. The resident, a male with multiple diagnoses including cellulitis, diabetes type II, lymphedema, anxiety disorder, and stage III pressure ulcers, was observed with a tube of Ammonium lactate 12% cream and a tube of Santyl ointment on his tray table. The resident's Minimum Data Set (MDS) admission assessment indicated intact cognition and functional limitations in range of motion. However, there was no physician's order for self-administration or bedside storage of these medications. The Licensed Practical Nurse (LPN) confirmed the presence of the medications at the resident's bedside and acknowledged that they should not be left there without a physician's order. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that a physician's order was necessary for medications or treatments to be stored at the bedside. The facility's policy required an interdisciplinary team assessment and a care plan reflecting the resident's self-administration and storage arrangements, which were not in place for this resident.

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 wound care for pressure ulcers as per physician's orders for two residents. The first resident, a male with a history of malignant neoplasm of the tongue, gastrostomy, and pneumonia, had an unstageable pressure ulcer on his sacrum and stage IV pressure wound on his coccyx. The treatment plan included specific applications of Gentamicin, Santyl, and Dakin's solution, but the Treatment Administration Record (TAR) showed missing entries on several dates, indicating that wound care was not consistently provided as ordered. The Director of Nursing (DON) and the Wound Care Registered Nurse (RN) acknowledged these omissions during a review of the TAR. The second resident, an 86-year-old male with cellulitis, diabetes, lymphedema, anxiety disorder, and stage III pressure ulcers on his buttocks, also did not receive wound care as ordered. The resident's physician orders included specific wound care treatments for multiple wounds, but the TAR lacked documentation for wound care on certain dates. The Wound Care RN confirmed the absence of documentation for wound care on specific dates, and the DON stated that clinical records, including TARs, were reviewed for completeness during morning clinical meetings, acknowledging that there should not be any blank entries.

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 timely change of a Peripheral Inserted Central Catheter (PICC) line dressing for a resident, as per physician's orders and professional standards. The resident, a male with multiple diagnoses including cellulitis, diabetes, lymphedema, anxiety disorder, and stage III pressure ulcers, was admitted with a central line for intravenous access. The physician's order required the PICC line dressing to be changed every seven days on the evening shift. However, on observation, the dressing was found to be dated 5/04/24, indicating it had not been changed by the due date of 5/11/24. The Licensed Practical Nurse (LPN) and the Assistant Director of Nursing (ADON) both confirmed the discrepancy between the documented dressing change dates and the actual date on the dressing. The Medication Administration Record and Treatment Administration Record indicated that the dressing was changed on 5/03/24 and 5/10/24, but the physical evidence contradicted these records. The Director of Nursing (DON) acknowledged the issue, noting confusion due to two different orders in the system and confirmed that the dressing was not changed as required. The facility's policy mandates weekly dressing changes to minimize infection risk, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to ensure accurate medical records regarding the dressing of a Peripheral Inserted Central Catheter (PICC) line for a resident. The resident, a male with multiple diagnoses including cellulitis, diabetes type II, lymphedema, anxiety disorder, and stage III pressure ulcers, had a physician order to change the PICC line dressing every seven days. However, upon observation, the dressing was dated 5/04/24, indicating it had not been changed as per the order. The Medication Administration Record and Treatment Administration Record (TAR) showed signatures indicating the dressing was changed on 5/03/24 and 5/10/24, which was inconsistent with the actual date on the dressing. The RN Supervisor and the Assistant Director of Nursing confirmed the discrepancy between the documented dates and the actual date on the dressing. A Licensed Practical Nurse (LPN) admitted to signing off on the TAR without changing the dressing, mistakenly believing she was confirming the standing order. The facility's policy on documentation requires that each resident's medical record accurately reflect their experiences, and false information should not be documented. This incident highlights a failure to adhere to this policy, resulting in inaccurate medical records for the resident.