Bonterra Transitional Care & Rehabilitation

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy for the use of personal protective equipment (PPE) during high-contact care. The facility’s EBP policy, updated February 2025, requires gowns and gloves for residents with wounds and/or indwelling medical devices, including urinary catheters and ostomies, when staff perform high-contact activities such as bathing, dressing, toileting, hygiene, and catheter care. The policy also directs that gowns and gloves be made available near or outside the resident’s room and that EBP be implemented for residents with indwelling devices or wounds, even if they are not known to be infected or colonized with a multidrug-resistant organism. The resident involved had a suprapubic catheter, colostomy, sacral wound, and neurogenic bladder and bowel, and was care planned for EBP implementation during catheter and skin care. The resident was cognitively intact but dependent on staff for bathing, dressing, toileting, hygiene, bed mobility, and transfers, and used an indwelling catheter and ostomy. During an observation, a CNA provided suprapubic catheter care and a bed bath to this resident while only wearing gloves, despite EBP signage and a star posted on the door and PPE supplies available outside the room. The CNA did not don a gown and was unable to identify any additional actions needed before care until prompted about the EBP signage, at which point he acknowledged he should have worn a gown but forgot. In a subsequent interview, the IP nurse and DON confirmed that staff had been educated that gowns are required during high-contact care for residents with catheters, colostomies, and other devices, and that the posted signage and star were intended to alert staff to the need for enhanced PPE use.

Penalty

Inspection fine: $17,66016 days payment denial

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

Summary

A deficiency occurred when a resident with a history of dysphagia following cerebral infarction, oropharyngeal phase dysphagia, cerebrovascular disease, adult failure to thrive, and severe cognitive impairment was not provided care in accordance with their comprehensive care plan. The resident's care plan and physician orders specified a mechanically altered, pureed diet with thin liquids due to their swallowing difficulties and risk of choking. Despite these documented dietary restrictions, the resident was given a sandwich by a Certified Nursing Assistant (CNA), which was not consistent with the prescribed diet. The incident was observed when the resident, while sitting in a wheelchair at the nursing station, began choking on undigested food. Food was seen falling from the resident's mouth, and the resident was struggling to breathe. Immediate interventions, including the Heimlich maneuver and a mouth sweep, were attempted by an LPN but were unsuccessful. Cardiopulmonary resuscitation (CPR) was initiated, and emergency services were called. The resident eventually started breathing again and was transported to the hospital by EMS. Following the event, it was determined that the resident was admitted to a hospice facility after hospital discharge and subsequently expired. The facility's failure to implement the resident's care plan and provide the appropriate diet as ordered directly led to the choking incident and the resident's transfer to the hospital, hospice admission, and eventual death. The survey identified this as noncompliance with federal requirements for comprehensive care planning and quality of care.

Removal Plan

• The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed and staff in-service education was initiated. All policies were reviewed with 100% staff except those on Leave of Absence and Family Medical Leave Act.
• An Ad Hoc QAPI meeting was held with key facility leadership and staff to review the IJ Removal Plan. The Care Plan policy was reviewed with no changes. A Daily Diet Verification Audit was performed for 100% of current residents to ensure meal tray cards matched diet orders, Kardex, and care plans.
• No staff worked until they had completed the in-service education. Part-time, PRN, and contracted staff will be in-serviced and educated on the relevant policies before being allowed to work.
• All newly hired staff will be in-serviced on their first day of hire during orientation, annually, and quarterly. Individuals will not work until they have received this in-service/training. All residents' care plans were reviewed and updated to reflect appropriate diet orders.
• The facility implemented interventions to minimize environmental risks and hazards, including Daily Diet Verification Audit, Snack Distribution Audit, and Meal Tray Observation Audit for 100% of current residents. Education was provided to all staff regarding relevant policies and reporting procedures.
• New interventions will be monitored by the DON for effectiveness using audit tools. If a problem is identified, it will be addressed by the Food Service Director, Administrator, DON, and Medical Director, with possible Ad Hoc QAPI meetings and corrective action if necessary.

Penalty

Inspection fine: $17,66016 days payment denial

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

Summary

A deficiency occurred when a resident with severe cognitive impairment and a history of dysphagia, oropharyngeal phase, was not provided with the prescribed pureed diet. The resident was admitted with multiple diagnoses, including dysphagia following cerebral infarction, cerebrovascular disease, adult failure to thrive, and required supervision or assistance with eating. Physician orders and the care plan specified a no added salt (NAS), pureed/dysphagia puree texture, and thin liquids consistency diet. Despite these orders, the resident was given a sandwich by a Certified Nursing Assistant (CNA), as confirmed by camera footage and staff interviews. The facility's policies required careful reading of tray cards to ensure correct food textures were served, and the risks and benefits of specialized diets were to be communicated by the physician and dietician. On the day of the incident, the resident was observed pointing to a snack tray, after which the CNA handed him a sandwich. Shortly after, the resident was found choking on undigested food at the nurse's station, with food falling from his mouth and difficulty breathing. Staff attempted the Heimlich maneuver and a mouth sweep, but initial efforts were unsuccessful. Emergency services were called, and CPR was performed until the resident was transported to the emergency room. Subsequent investigation substantiated the allegation of neglect, and the CNA involved was terminated. The resident was later transferred to a hospice facility, where he expired. The facility's failure to follow prescribed diet orders and care plan interventions directly led to the resident receiving an inappropriate food item, resulting in a choking incident and subsequent death.

Removal Plan

• Review and update the facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy; initiate staff in-service education on these policies.
• Hold an AdHoc QAPI meeting with key facility leadership to review the IJ Removal Plan and Care Plan policy.
• Perform a Diet Verification Audit for 100% of current residents to ensure meal tray cards match diet orders, Kardex, and care plans.
• Provide in-service education to all staff, including administrative, nursing, dietary, housekeeping, maintenance, and activities staff, on relevant policies.
• Require that no staff work until they have completed the in-service education; ensure all part-time, PRN, and contracted staff are educated before working.
• Implement a process for all newly hired staff to be in-serviced during orientation, with annual and quarterly retraining.
• Review and update all residents' diet orders and care plans to ensure accuracy.
• Implement environmental interventions including Diet Verification Audit, Snack Distribution Audit, and Meal Tray Observation Audit for all residents.
• Educate all staff on reporting unmatched meal trays and diet orders to the Food Service Director and Director of Nursing.
• Report all audit findings to the QAPI Committee and conduct an Ad Hoc QAPI meeting.
• Monitor new interventions for effectiveness using audit tools; address identified problems with the Food Service Director, Administrator, DON, and Medical Director.
• Establish a process for meetings with all relevant parties if a policy violation occurs, with escalation to Ad Hoc QAPI meeting and corrective action if needed.
• Validate completion of all corrective actions and removal of Immediate Jeopardy status.

Penalty

Inspection fine: $17,66016 days payment denial

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 implement and follow the care plan for a resident who was ordered to receive a mechanically altered diet. Despite the resident's dietary restrictions, a Certified Nursing Assistant (CNA) provided the resident with a sandwich, which was not consistent with the prescribed pureed snack. This action was observed by the Administrator through facility camera footage. As a result of receiving the inappropriate food item, the resident was sent to the local emergency room and subsequently transferred to a hospice facility, where the resident expired. The incident was recognized as a failure to comply with federal regulatory requirements related to quality of care and comprehensive care planning for residents with altered diets. The Administrator and Director of Nursing were aware of the incident and acknowledged that the resident's care plan was not followed. The facility's noncompliance was determined to have caused or had the likelihood to cause serious injury, harm, impairment, or death to residents, leading to the identification of Immediate Jeopardy for multiple federal regulations.

Removal Plan

• An Ad Hoc Quality Performance Improvement (QAPI) meeting was held with the Administrator, Social Services Director (SSD), the DON, Corporate Operations Consultant (COC), and Food Service Director (FSD) to identify the root cause of failure to follow R165's care plan. The facility's Modified Texture of Food Policy, Care Plan Policy, and Resident Food Preferences Policy were reviewed; no changes were made.
• The Administrator's job description was reviewed with the Administrator, FSD, SSD, and DON by the COC. No revisions were made.
• The COC in-serviced the Administrator, DON, FSD, and SSD on how to implement a process on how to verify diet orders before distributing resident meal trays, how to track and trend to determine a root cause analysis, and communication among departments on reviewing and updating resident care plans timely. The facility's QAPI policy was reviewed specifically regarding how to determine root cause analysis (RCA).
• The COC reviewed and approved the facility's audit forms and Plan of Correction (PoC) for any further areas of concern. Name of Audits- Daily Diet Verification Audit and Snack Distribution Audit. Residents' diets and care plans were discussed with the Administrator, DON, and FSD. Interventions were put into place, such as removing accessible snacks from the nurse stations; snacks were placed inside the pantry and available upon request. A snack diet reference sheet was initiated and placed inside the pantry.
• The Corporate Nurse Consultant (CNC) and DON audited the resident's diet orders and meal tray cards. The audits are named Daily Diet Verification Audit and Snack Distribution Audit. The Administrator, DON, and FSD will discuss all diet order changes in the morning and the clinical meeting to ensure all care plans are updated and accurate. Documentation will be monitored through the Abuse Performance Improvement Plan (PIP) and reported during QAPI by the DON and Administrator. The SSA reviewed and compared Diet Master from the Dietary Department and the Facility's Diet Type Report for all residents in the facility; no discrepancies were found.
• The COC met with the Administrator and DON to review the process of providing direct oversight of the following correct processes in the building as it relates to following care plans for resident diet orders. There is ongoing educational training for all members of the facility through the company's online courses. The Administrator was also in-service on how to conduct a QAPI meeting and how to identify and complete an RCA by the COC. The SSA reviewed in-service education related to the QAPI meeting and RCA with no concerns.
• The corrective actions were completed, and the facility alleges that the immediate jeopardy was removed. All corrective actions were completed. The facility's IJ was determined to be Past Noncompliance, removed.

Penalty

Inspection fine: $17,66016 days payment denial

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

Summary

A deficiency occurred when the facility failed to provide safe and appropriate pain management for a resident following a recent surgical amputation. The resident, who had a history of bilateral lower extremity amputations, diabetes, and other complications, was admitted with orders for pain management and wound care. The care plan included monitoring and documenting pain, as well as interventions for wound management. Despite these plans, the facility did not ensure the resident attended a scheduled post-operative appointment for staple removal due to a failure to arrange transportation. As a result of the missed appointment, the resident experienced ongoing pain and discomfort, with staples remaining in the surgical site. The wound care nurse attempted to remove the staples at the facility after obtaining a verbal order from the vascular clinic, but was unable to remove the last six staples due to the resident's pain. Observations revealed that these remaining staples became embedded in the skin, with crust build-up, and the resident reported persistent pain and concern about possible infection. Staff interviews confirmed that the resident frequently expressed pain related to the embedded staples. The medical director was not initially aware that the resident had missed the post-op appointment or that the staples remained in place, and pain assessments were not effectively communicated to the physician. The facility's policy required ongoing pain recognition and management, but the failure to provide transportation and ensure timely removal of surgical staples resulted in actual harm to the resident, as evidenced by embedded staples and unmanaged pain.

Penalty

Inspection fine: $17,66016 days payment denial

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 arrange transportation for a resident to attend a post-operative medical appointment, resulting in the resident missing a scheduled staple removal following an amputation surgery. The resident, who had a history of major orthopedic surgery, bilateral lower extremity impairment, and pain management needs, was admitted with multiple complex diagnoses including diabetes, atherosclerosis, and surgical site complications. Documentation showed that the resident's appointment was rescheduled without notifying the family, and ultimately canceled due to transportation not being arranged by the facility. The family was not informed of the changes, and the resident reported that transportation was never scheduled. Interviews with staff and review of records revealed that the unit clerk responsible for transportation coordination was aware of the appointment but did not ensure transportation was arranged. The resident experienced pain and reported tightness around the surgical staples, which became embedded due to the missed appointment. The facility did not provide requested documentation of appointment and transportation forms, and the Director of Nursing confirmed that a log should be maintained to track appointments and transportation, which was not effectively done in this case.

Penalty

Inspection fine: $17,66016 days payment denial

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 establish and maintain an effective Antibiotic Stewardship program as required by its own policy. Observations and record reviews revealed missing laboratory orders, unresolved dates for antibiotics, lack of documentation on the duration of antibiotic therapy, and inadequate monitoring of residents with infections, particularly those admitted or transferred from hospitals. The Infection Control Book did not contain necessary information to determine true infections, and there was no consistent follow-up on laboratory results or tracking of clinical signs and symptoms related to infections. Interviews with the Infection Preventionist (IP) Nurse confirmed that she did not routinely perform lab follow-up or document resolved dates for antibiotics, and that infections among newly admitted residents were not being tracked or monitored. The Director of Nursing (DON) acknowledged that the IP Nurse was expected to submit weekly listings and follow the facility's policy, and confirmed that missing information could increase the risk of infections not being treated appropriately. The Administrator stated that the DON oversees the Infection Control Program and expected the IP Nurse to adhere to facility policy.

Penalty

Inspection fine: $17,66016 days payment denial

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 observed that handrails in both the East Wing and another named wing were repeatedly blocked by dressers, making them inaccessible to residents. These obstructions were noted on multiple occasions over several days, with varying numbers of dressers placed between or beside rooms, directly impeding access to the handrails. Interviews with the Maintenance Director revealed that the obstructions were due to ongoing construction and remodeling of closets, with new wardrobes being delivered and temporarily stored in the hallways. Both the DON and the Administrator confirmed that the handrails were blocked and acknowledged that this interfered with residents' ability to use them for mobility support. Additionally, a deficiency was identified regarding the facility's failure to adequately assess a resident for self-administration of medication. One resident was observed with multiple medications, including triamcinolone acetonide ointment, nystop powder, and milk of magnesia, stored on his nightstand over several days. The resident reported receiving the medications from the hospital and using them regularly for skin issues. However, a review of the electronic medical record showed no physician orders for these medications and no assessment for the resident's ability to self-administer them. The facility's policies require that residents be assessed by the interdisciplinary team and have a physician's order before being allowed to self-administer medications. The DON confirmed that no such assessment or order was present for the resident in question and that staff are expected to monitor for and report medications found in residents' rooms. The lack of assessment and oversight resulted in the resident having access to and using medications without proper authorization or evaluation.

Penalty

Inspection fine: $17,66016 days payment denial

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

Staff failed to properly lock and secure three of four medication carts, as required by facility policy and professional standards. Observations revealed that medication carts on the East Wing and [NAME] Wing were left unlocked and unattended while residents were present in the vicinity. In one instance, an LPN left a medication cart unlocked outside the nurse station while she sat behind the station working on a computer, confirming that the cart contained various medications, including psychotropics, diuretics, and narcotics. Another medication cart was left unlocked for 10-15 minutes by a CMA, who was away from the cart and working at the nurse station. Additional observations showed that medication carts were left unlocked and unattended by other staff, including an LPN who left the cart while attempting to access a computer and another LPN who left the cart unlocked while in a resident's room. Interviews with staff and supervisors confirmed awareness of the policy requiring medication carts to be locked at all times when unattended. Staff acknowledged recent in-service training on medication cart security and recognized the potential for residents, staff, or family members to access unsecured medications. Supervisory staff reiterated the expectation that medication carts remain locked when not in direct view of staff, regardless of the duration of absence. Despite this, multiple instances of non-compliance with the policy were observed and confirmed by staff.

Penalty

Inspection fine: $17,66016 days payment denial

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 use a formal recipe when preparing pureed food for residents requiring a pureed diet. During an observation, a food service staff member was seen preparing pureed carrots without referencing a recipe, instead relying on her own experience to determine the amount of carrots and broth to use. The staff member adjusted serving sizes and ingredient amounts without measurement, and added broth by sight rather than by a measured amount. When questioned, she acknowledged that she should be measuring the broth and using a recipe, but did not do so during the observed preparation. The recipe she later produced did not match the number of servings or ingredients used in the preparation. The Dietary Kitchen Manager confirmed that no recipe was followed and that the recipe provided was outdated and not in use, as the facility had changed its menu system and no longer used thickeners. The DKM also acknowledged that not following a recipe could result in incorrect food consistency, which may cause harm to residents. The Administrator stated that kitchen staff are expected to follow recipes to ensure the correct consistency when preparing pureed foods. This deficiency had the potential to affect six residents on a pureed diet.

Penalty

Inspection fine: $17,66016 days payment denial

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 multiple deficiencies in the facility's food storage and handling practices. During observations with the Dietary Manager (DM), several opened food items in the pantry, such as vinegar, peanut butter, quick oats, and creamy wheat, were found without expiration dates. In the cooler, bags of cut cabbage, carrots, spinach, and hot dogs were either not labeled with expiration dates or not labeled at all, with the spinach also noted as wilted. In the freezer, a bag of green peas was not properly sealed. These findings were inconsistent with the facility's policies, which require all food items to be labeled, dated, and properly stored to prevent cross-contamination. Additionally, the ice machine was found to contain debris during an observation and interview with the DM, who stated that the machine is typically cleaned monthly. The Maintenance Director confirmed responsibility for cleaning the ice machine and acknowledged the presence of debris after being shown a photo. Interviews with the DM and Administrator confirmed that staff are expected to label and date food items and that the Maintenance Director is responsible for cleaning the ice machine according to the established schedule. These lapses in following established policies had the potential to affect all residents receiving food orally.

Penalty

Inspection fine: $17,66016 days payment denial

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 proper surveillance and monitoring for infections and communicable diseases for all 114 residents. Review of the Infection Prevention and Control Program policy revealed requirements for ongoing monitoring, documentation, and reporting of infections, but the facility's Infection Control Book was missing infection criteria sheets, accurate data collection, color-coded infection tracking on facility maps, and surveillance records for two months. The Infection Preventionist (IP) Nurse confirmed these deficiencies, acknowledging missing documentation and incomplete monitoring and tracking. The DON and Administrator both stated that the IP Nurse was expected to follow policy and complete the infection control process without missing items, and confirmed that the lack of information could increase the risk of infections not being treated accordingly. Additional observations included improper handling of residents' personal clothing and laundry. A resident's personal clothing was found stored on a unit linen cart, which the Assistant DON confirmed was inappropriate. Furthermore, a Laundry Aide was observed transporting an uncovered laundry cart with clean clothing exposed in the hallways, contrary to infection control practices. The IP Nurse confirmed that clean clothing should be covered during transport and that the housekeeping department was expected to comply with infection control protocols.

Penalty

Inspection fine: $17,66016 days payment denial

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 an effective behavioral health training program consistent with its facility assessment and person-centered care requirements. The deficiency was identified through observations, staff and resident interviews, record reviews, and a review of the facility's policy on education and training requirements. The policy stated that training should be based on the needs identified in the facility resource assessment, but evidence showed that staff did not receive adequate training on behavioral health topics relevant to the resident population, including schizophrenia, mental disorders, and PTSD. Three residents with significant behavioral health needs were reviewed. One resident had diagnoses including cerebrovascular disease and schizoaffective disorder/bipolar type, with care plans addressing screaming and verbal outbursts. Another resident had schizophrenia and exhibited verbal aggression, accusations, and suicidal behavior, with care plans and physician orders reflecting these issues. A third resident had mood disorder, PTSD, and cognitive decline, with care plans noting delusions, negative self-feelings, and resistance to care. The facility assessment confirmed that mental disorders, schizophrenia, and PTSD were common diagnoses among residents. Despite these needs, training records revealed only one in-service on managing crisis behaviors and one on behavior management in the past year, with little or no content specific to schizophrenia, mental disorders, or PTSD. Orientation materials for CNAs and other non-nursing staff did not include behavioral health topics. Interviews with CNAs, LPNs, RNs, agency staff, housekeeping, dietary, activities, and other staff consistently revealed a lack of training on behavioral health, schizophrenia, mental disorders, and PTSD. Agency staff and volunteers also did not receive documented behavioral health training. The staff development coordinator and social services director confirmed that training on these topics was infrequent or outdated, and that agency staff were expected to self-educate using binders that lacked relevant materials.

Penalty

Inspection fine: $17,66016 days payment denial

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

Staff failed to maintain a resident's dignity and privacy during the provision of personal care. The facility's policy requires that all residents be treated with dignity and respect, and that privacy be maintained by closing the door and pulling the privacy curtain during care. A cognitively intact resident with hemiplegia and significant dependence on staff for activities of daily living, including toileting and bathing, was observed receiving peri-care and assistance with changing while the door to her room was left open. Staff interviews confirmed that the door should have been closed during these activities, and both CNAs involved acknowledged the expectation to maintain privacy by closing the door and pulling the curtain, especially since the resident has a roommate who could enter at any time. The resident herself reported that staff left the door open while providing a bed bath. The Director of Nursing also confirmed that the facility's expectation is for the door to be closed and the privacy curtain pulled during personal care. These actions and inactions resulted in a failure to provide care in a manner that maintained or enhanced the resident's dignity, as required by facility policy and resident rights regulations.

Penalty

Inspection fine: $17,66016 days payment denial

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 homelike environment in one resident room located on the East Wing. Facility policy required that walls, blinds, and window curtains be cleaned when visibly soiled, and that staff spot clean walls daily. During observations, brown stains were noted on the wall to the left of the entrance in the identified room. A resident in the room reported that the stains were feces thrown by his roommate and that they had been present for some time. Subsequent observations confirmed that the stains remained on the wall over multiple days. Interviews with housekeeping staff revealed that the assigned aide did not notice or clean the stains, despite her responsibilities including cleaning walls and edges of rooms. The Housekeeping Director confirmed that staff are expected to clean any spots found on the walls. The Administrator also stated that her expectation is for resident walls to be maintained in a clean and sanitary condition. The failure to address the visibly soiled wall resulted in the room not being maintained in accordance with facility policy and resident rights.

Penalty

Inspection fine: $17,66016 days payment denial

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 protect a resident from misappropriation of prescribed narcotics, specifically oxycodone, as required by its Abuse Prevention and Drug Diversion policies. The resident, who was cognitively intact and had significant medical needs including recent amputations and pain management requirements, was prescribed 15 tablets of oxycodone to be administered as needed. Documentation revealed inconsistencies in the administration and accounting of the medication, with only a few doses recorded as given and the remainder unaccounted for. The controlled drug sheet for the medication was missing, and the facility was unable to provide a clear record of the medication's administration or disposition. Interviews with staff and review of records indicated that the required procedures for handling, documenting, and reconciling controlled substances were not followed. Several LPNs provided conflicting or incomplete statements regarding the administration of the medication, and some staff were asked to write statements after the fact, sometimes without clear recollection or supporting documentation. The DON confirmed the absence of the controlled drug sheet and was unable to account for the remaining medication. The pharmacy also reported discrepancies in the order and delivery of the medication. The resident and her family expressed concerns about the missing medication, with the family stating that all 15 pills were gone within three days and doubting that the resident had received all doses. The resident herself recalled taking only three pills and was not informed about the dosing schedule or when the medication would run out. The facility's failure to maintain accurate records, secure the medication, and follow established protocols resulted in the misappropriation of the resident's prescribed narcotics.

Penalty

Inspection fine: $17,66016 days payment denial

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 suspected misappropriation of prescription narcotics for one resident to the State Survey Agency (SSA) as required by policy and regulation. The resident, who was cognitively intact and had a history of major orthopedic surgery and pain management needs, was admitted with a hospital discharge order for oxycodone. Documentation showed discrepancies between the number of oxycodone tablets received and administered, with the resident and her family reporting that all 15 pills were gone within three days, despite the resident recalling only taking three pills. The facility was unable to produce the controlled drug sheet for the medication, and the DON confirmed the medication was not in her possession or in the locked box. Interviews with staff, the DON, and the Medical Director revealed a lack of clear documentation and communication regarding the administration and disposition of the narcotic medication. The DON and Administrator both acknowledged that misappropriation of property related to narcotics is a reportable offense, yet the incident was not reported to the SSA. The facility's own policies required investigation and reporting of such incidents, but these procedures were not followed in this case.

Penalty

Inspection fine: $17,66016 days payment denial

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 obtain a Level II PASARR screening for two residents with mental disorders or intellectual disabilities, as required by its own policy and federal regulations. For one resident, the electronic medical record showed diagnoses including schizoaffective disorder, bipolar type, and a care plan addressing cognitive impairment and behavioral symptoms such as screaming and cursing. This resident was dependent on staff for all ADLs and was prescribed psychotropic medications. Despite these indicators, there was no evidence of a completed Level II PASARR screening prior to or after admission. For the second resident, the record indicated diagnoses of mood disorder due to a physiological condition with mixed features and PTSD, with care plans addressing negative feelings, cognitive decline, and problematic behaviors such as yelling and resistance to care. The social worker and DON both confirmed that a Level II PASARR screening had not been completed for this resident, with the social worker stating she was unaware that PTSD qualified for such screening. Interviews with staff revealed a lack of understanding regarding which diagnoses require a Level II PASARR, and the facility's process did not ensure compliance with its policy or regulatory requirements.

Penalty

Inspection fine: $17,66016 days payment denial

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

Staff failed to provide adequate nail care for a resident who was dependent on staff for personal hygiene due to moderate cognitive impairment and medical conditions including a recent heart attack and metabolic encephalopathy. The facility's policy required staff to supervise and assist with ADLs, including cleaning and trimming nails as needed. The resident's care plan noted a preference for refusing some ADL care, but the resident specifically stated he did not refuse nail care and had requested staff assistance to cut his fingernails. Despite this, observations on multiple occasions revealed the resident's fingernails were long, curled, and had a dark substance underneath. Interviews with staff confirmed awareness of the resident's long nails and the presence of debris, with one CNA stating that nail care should be performed every two weeks and acknowledging the resident's nails had not been properly maintained. The DON stated the resident was care planned for refusals but also confirmed that ADLs, including nail care, should be attempted daily if the resident allows. The failure to provide necessary nail care occurred despite the resident's requests and lack of refusal, resulting in the deficiency.

Penalty

Inspection fine: $17,66016 days payment denial

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

Staff failed to administer oxygen therapy according to physician orders for two residents receiving oxygen therapy. One resident with chronic obstructive pulmonary disease, atelectasis, and respiratory failure with hypoxia was ordered to receive oxygen at 3 liters per nasal cannula continuously. However, observations showed the oxygen concentrator was set at 4.5 liters and later at 5 liters, exceeding the prescribed rate. The resident was cognitively intact and had a care plan specifying continuous oxygen as ordered by the physician. Another resident with pulmonary embolism and emphysema, who had severe cognitive impairment, was ordered to receive oxygen at 3 liters per mask or cannula continuously. Observations revealed the oxygen concentrator was set at 5 liters, higher than the ordered rate. Multiple staff interviews confirmed that nursing staff are responsible for checking physician orders and ensuring the oxygen concentrator is set to the correct rate, but this was not done for these residents.

Penalty

Inspection fine: $17,66016 days payment denial

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 necessary dental services for one resident who was identified as having a loose tooth and experiencing significant oral pain. According to the facility's Dental Services Policy, routine and emergency dental services should be available based on resident assessments and care plans, with annual and as-needed dental assessments. The resident in question was admitted with hemiplegia and hemiparesis, had moderate cognitive impairment, and required assistance with oral hygiene. The care plan and physician's orders indicated the need for dental evaluation and treatment as indicated. Despite these documented needs, the resident's oral assessments repeatedly noted a loose tooth, but the section indicating whether a referral to a dentist was needed was left blank. The resident reported daily to nursing staff about severe tooth pain and the need for extraction, but no referral was made. Multiple interviews with staff confirmed that the process for dental referrals was not followed: the nurse did not complete the referral section of the assessment, and the Social Services Director was not notified of the need for a dental consult. The resident continued to experience pain and had not seen a dentist since admission. Staff interviews revealed a lack of awareness and communication regarding the resident's dental needs. CNAs reported oral concerns to nurses, but the nurses did not act on the information by initiating a referral. The Social Services Director and unit manager confirmed that the resident qualified for Medicaid dental benefits and should have been referred to the in-house dental program, but this did not occur. The Director of Nursing and Administrator acknowledged that the failure to make a timely dental referral could result in negative outcomes, and confirmed that the required process for dental referrals was not followed for this resident.

Penalty

Inspection fine: $17,66016 days payment denial

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

Summary

A deficiency occurred when a resident with severe cognitive impairment and a history of falls was not provided with a functional and accessible call system in their room. During an observation, a registered nurse repeatedly instructed the resident not to use the call device, stating that the resident was pressing it frequently for a snack. The nurse was observed leaving the room after making these statements. The call system cord was later found extracted from the wall, rendering it nonfunctional. Interviews with the resident's roommates confirmed that the nurse had told the resident to stop pressing the call light. The nurse acknowledged that staff are not supposed to keep the call device away from the resident but explained her actions by stating the resident had already received a snack. The resident's medical record indicated severe cognitive impairment, dependence on staff for activities of daily living, and a care plan that encouraged the use of the call bell for assistance. Facility policy required that call lights be answered promptly and remain accessible to residents. The Director of Nursing confirmed that all call lights should remain in place and that staff should not instruct residents not to use the call device. The failure to ensure the call system was accessible and functional for this resident constituted a deficiency.