Glenwood Health Center By Harborview

Penalty

2 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 deficiency involves the facility’s failure to implement and maintain fall-prevention interventions for a resident with known cognitive impairment and prior fall history, as required by its Fall Prevention Program policy. The policy directed that after any fall, the facility must assess the resident, complete a post-fall assessment and incident report, notify the physician and family, review and update the care plan as indicated, and document all assessments and actions. Following a fall on 9/19/2025 in which the resident leaned forward, fell while being taken to the dining room, and hit their head, the incident report documented that the resident sustained a forehead bruise, vital signs were taken, and family was notified. The documented intervention after this fall was that staff were to ensure the resident was fully back in their wheelchair with feet on the footrests and clothing/shoes adjusted before transport began. The resident, who had Alzheimer’s disease, moderate cognitive impairment, short- and long-term memory problems, and used a wheelchair, had a documented history of a fall with major injury since the prior MDS assessment and a diagnosis of nontraumatic intracranial hemorrhage. On 10/28/2025, a post-fall record and exception report indicated that the resident slid out of their wheelchair to the floor and hit their head while being transported from the cafeteria to their room after lunch, resulting in a laceration, swelling, bruising, and a hematoma above the right eye. The resident was sent to the hospital, where records showed a laceration of the head, nontraumatic intracranial hemorrhage, and nontraumatic subarachnoid hemorrhage, with CT imaging revealing a trace subarachnoid hemorrhage and documentation that the resident was critically ill and required ICU-level monitoring. Staff interviews revealed that on the day of the 10/28/2025 fall, the CNA pushing the resident from the dining room stated the resident’s legs were straight out about five inches off the floor and that there were no footrests on the wheelchair at the time of transport. This CNA stated she noticed there were no footrests only after the fall, and that footrests should have been present. Another CNA, who had gotten the resident up and taken them to the dining room earlier, stated she thought the footrests were on the wheelchair when she transported the resident to the dining room, but acknowledged that sometimes the wheelchair had footrests and sometimes it did not, and that footrests should have been on before transport. The LPN who responded to the fall stated she had told the CNA to make sure the footrests were on before taking the resident to the dining room and suggested that someone may have removed them in the dining room so the resident’s legs could fit under the table, but confirmed they should have been put back on before transporting the resident. The DON and Administrator both stated that all interventions, including footrests, should have been in place before transporting the resident, indicating that the required fall-prevention intervention of using footrests during wheelchair transport was not consistently implemented at the time of the fall.

Penalty

2 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 deficiency involves the facility’s failure to thoroughly investigate and accurately document multiple abuse allegations, contrary to its Abuse, Neglect and Exploitation policy requiring immediate investigation and complete documentation. For one incident, two cognitively intact or moderately impaired residents were involved in a resident-to-resident altercation in which one resident allegedly spat on the other and the other allegedly struck back. The Director of Nursing documented hearing a commotion and observing spit on a resident’s shirt at a specific time, but the Facility Incident Report Form omitted the time of the incident, and the exception reports for each resident listed conflicting times. The investigative summary sent to the state survey agency did not include the time of the incident or when the Administrator, who served as Abuse Coordinator, was notified. In a second incident, a non-verbal resident with a history of stroke, TBI, major depressive disorder, and anxiety allegedly pointed to their genitalia and then to a Certified Medication Assistant, prompting an abuse allegation. The Facility Incident Report Form categorized the event as “Other” and noted that an investigation was initiated, but it did not document the time of the incident. The facility’s investigation documents for this event also did not indicate when the Administrator/Abuse Administrator was notified of the allegation, omitting key timing information required for a complete investigation. In a third incident, a resident with severe cognitive impairment and diagnoses including major depressive disorder, anxiety, dementia, and schizoaffective disorder allegedly was slapped by another severely cognitively impaired resident. The Facility Incident Report Form documented the date but not the time of the incident, and the investigation documents did not show when the Abuse Coordinator was informed. In a fourth incident, a cognitively intact resident reported that a CNA was rough with them. The Facility Incident Report Form again omitted the time of the incident, and an Exception Report showed the Administrator reviewing the incident on a date that conflicted with the alleged occurrence date. The investigation documents did not include when the Administrator was notified. Both the DON and the Administrator later stated their expectation that investigations include the exact date and time of the incident and the time the Abuse Coordinator was notified, which was not met in these cases.

Penalty

2 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 deficiency involves the facility’s failure to report allegations of abuse and injuries of unknown origin to the state survey agency within the required two-hour timeframe, as required by facility policy and regulatory expectations. The facility’s Abuse, Neglect and Exploitation policy states that all alleged violations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than two hours after the allegation is made. Despite this, the facility did not meet the two-hour reporting requirement for two separate incidents involving two residents. In the first incident, a resident with a history of stroke, traumatic brain injury, major depressive disorder, and anxiety disorder, and documented short- and long-term memory problems, allegedly indicated possible sexual abuse. The non-verbal resident pointed to their genital area and then to a certified medication aide. The incident occurred at approximately 7:00 p.m., and staff including a receptionist, an LPN, and a unit manager became involved in assessing the allegation. The administrator, who served as the abuse coordinator, participated by phone during the resident interview. However, the state survey agency did not receive the facility’s initial report until after 10:18 p.m., more than three hours after the incident occurred and beyond the two-hour reporting requirement. Staff interviews confirmed their understanding that allegations of abuse, including sexual abuse, must be reported to the state within two hours of the facility becoming aware of the allegation. In the second incident, a resident with type 2 diabetes mellitus, chronic kidney disease, dementia, blindness, and significant ADL self-care deficits was found to have a subdural hematoma while at the hospital. The resident’s family member reported to the facility that the hospital physician indicated the subdural hematoma could have been caused by a fall or a strike to the head, constituting an injury of unknown origin. The family reported this information to the facility on one day, but the administrator did not report the allegation to the state survey agency until the following day. The administrator acknowledged that the allegation should have been reported within two hours of the facility being made aware of it, and both the DON and administrator stated their expectation that injuries of unknown origin be reported to the state within two hours, which did not occur in this case.

Penalty

2 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 deficiency involves the facility’s failure to provide appropriate nail care as part of activities of daily living (ADLs) for one resident, contrary to its own policies on Nail Care and ADLs. The Nail Care policy required routine cleaning and inspection of nails during ongoing ADL care, with nails kept smooth to avoid skin injury and specific provisions for residents with diabetes. The ADL policy required that residents unable to carry out ADLs receive necessary services for grooming and personal hygiene, based on their assessment and care plan. The resident’s care plan directed staff to provide nail care as needed. The resident involved had a history of hemiplegia and hemiparesis following cerebrovascular disease, cerebellar stroke syndrome, type 2 diabetes mellitus, and major depressive disorder, and had severe cognitive impairment with a BIMS score of 3. The MDS indicated the resident required partial to moderate staff assistance with personal hygiene. On observation, the resident was seen in a wheelchair with fingernails on both hands extending approximately one-half inch past the fingertips, with yellow tint and brown matter under the nails on the left hand, and a black middle fingernail and white discoloration on the fifth fingernail of the right hand. The resident stated staff never asked to cut their nails and that they wanted staff to cut them. Progress notes from a ten-day period showed no documentation that the resident refused nail care. A CNA who provided a bed bath reported not cleaning or trimming the resident’s nails, and another CNA who checked off nail care on a shower sheet stated that this meant only cleaning the nails and that he did not notice if they needed cutting. An LPN stated neither the resident nor CNAs informed her that nail trimming was needed and that she did not notice the need herself. The unit manager, upon observing the nails, described them as thick, overgrown, and discolored and stated staff should have taken care of them. The DON and Administrator both stated expectations that CNAs clean nails during bathing and that staff provide nail care when giving showers, when requested, or as needed, which had not occurred for this resident as required by policy and the care plan.

Penalty

No penalty information released

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

Summary

Surveyors observed multiple sanitation and pest control deficiencies in the facility's kitchen. Flies were seen on and around food preparation areas, including on a carton at the food prep station, a box of potato pearls, and hovering over cooked food such as dinner rolls and meatloaf. The back door to the kitchen was found propped open with a rock, and the fly zapper near the door was unplugged until staff plugged it back in during the observation. Additionally, a mold-like substance was noted on a drop-in ceiling tile, which the Dietary Manager attributed to condensation from the air conditioning. Three vents directly over food preparation areas were found to have a build-up of dirt and debris. Interviews with staff revealed a lack of clarity regarding responsibility for cleaning the vents, with the Maintenance Director stating he had not been in the kitchen recently and was unsure who was responsible for vent maintenance. The Maintenance Director also stated that the substance on the ceiling tile looked like mold but had not been tested. The Administrator provided a kitchen vent cleaning schedule, but it lacked any indication of the date or year of cleaning. These failures in maintaining a sanitary environment and preventing pest contamination had the potential to affect all residents consuming food prepared in the kitchen.

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 deficiency was identified regarding the facility's failure to protect residents from all forms of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report notes that residents were not adequately safeguarded against these types of mistreatment, but does not provide specific details about the actions, inactions, or events that led to the deficiency, nor does it mention any particular residents or incidents.

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 an effective discharge planning process for one resident who required ongoing wound care services. The resident, who was cognitively intact and had multiple diagnoses including heart failure, acute respiratory failure, type 2 diabetes, and acute hematogenous osteomyelitis, was discharged without confirmation that home health or skilled nursing wound care services were arranged. Documentation showed that the resident was initially planned to be discharged home with home health, skilled nursing wound care, and therapy services, but later records indicated a discharge to a homeless shelter with instructions that an outside provider would handle wound care. However, there was no evidence that these services were actually set up prior to discharge. Further review revealed that the resident's insurance coverage was inactive, and attempts to verify or utilize Medicaid benefits were unsuccessful. The social worker allowed the resident to keep facility equipment but did not update the discharge order or assessment to reflect the lack of skilled nursing services for wound care. The discharge assessment also lacked documentation of education on wound care or contact information for follow-up care. Staff interviews confirmed that the discharge paperwork was not updated to reflect the resident's actual discharge situation and that the resident was not provided with adequate information or resources for wound care after leaving the facility.

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 accurate and complete medical records for one resident. A review of the resident's electronic medical record showed documentation indicating the resident had a physician's order for oxygen therapy via nasal cannula at 2 liters per minute, and that the resident was educated on the importance of complying with these oxygen orders. The medical record also included notes stating the resident was non-compliant with oxygen therapy and had received education about it. However, a review of the resident's physician orders revealed there was no order for oxygen therapy at any time. Interviews with the Director of Nursing confirmed that the resident never had a physician's order for oxygen. The documentation in the medical record was therefore false and did not meet the facility's policy requirements for accuracy, relevance, and completeness. The resident involved had multiple complex medical diagnoses, including type II diabetes, acute kidney failure, congestive heart failure, and other chronic conditions, and was noted to be moderately cognitively impaired at the time of the incident.

Penalty

Fine: $19,7455 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 develop and implement comprehensive person-centered care plans for several residents, particularly concerning their smoking habits. Observations and record reviews revealed that six residents were not provided with adequate care plans addressing their smoking needs, which included necessary supervision and safety measures. For instance, one resident with moderate cognitive impairment was observed smoking without a required smoking apron, despite having a history of unsafe smoking practices. Another resident, who was not initially identified as a tobacco user, was found smoking unsupervised, highlighting discrepancies in smoking assessments and care plans. Additionally, the facility did not develop a care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident's care plan lacked focus areas or interventions addressing the PTSD diagnosis, despite the resident experiencing agitation and depression. This oversight indicates a failure to address the resident's mental health needs comprehensively, as required by the facility's policy on comprehensive care plans. The surveyors identified these deficiencies as creating potential risks for the safety and well-being of the residents. The facility's noncompliance with care planning requirements was determined to have the likelihood of causing serious harm or injury to residents, leading to the declaration of an Immediate Jeopardy situation. The facility's failure to monitor smoking practices adequately, maintain accurate smoking assessments, and ensure supervision during smoking activities contributed to this critical finding.

Removal Plan

• The facility failed to develop a comprehensive person-centered care plan for residents R25, R145, R111, R19, R71, R118, R266 and R365. The Regional Nurse Consultant and Director of Nursing reviewed and revised each of their smoking care plans to ensure that they are person centered and comprehensive.
• The Regional Director of Operations in-serviced the Director of Nursing, Assistant Director of Nursing, Minimum Data Set nurses and Regional Nurse Consultant on the smoking policy, ensuring that smoking care plans are followed and completed timely, and importance of accurate smoking assessments. The Administrator will be in-serviced by the Regional Director of Operations.
• Regional Director of Operations in-serviced the MDS nurses on reviewing for complete and accurate comprehensive person-centered smoking care plans for all residents who smoke.
• The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking policy, all residents on Dementia Unit will be required to wear smoking aprons, smoking times, and on the smoking monitors will be present at all smoke breaks.
• Registered Nurses, Licensed Practical Nurses, Certified Nurse assistants, and Certified Medication Aides have been in-serviced on importance of following care plans. There is currently 94% in-serviced completion.
• The Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Regional operations, and/or Regional Nurse began in-servicing all staff on the smoking monitors will be present at all smoke breaks.
• All new licensed staff will be in-serviced on these items above during the orientation process by the Assistant Director of Nursing and/or Director of Clinical Education.
• AD Hoc Quality Assurance Performance Improvement (QAPI) meeting was completed for policy review and root cause analysis was determined staffing education was needed. Attendance to the meeting was Regional Director of Operations, Director of Nursing, Regional Nurse, President of Quality, business office manager, dietary manager, dietary assistant manager, medical supply clerk, transportation coordinator, Director of Rehab, Social Worker, and Unit Managers. The Medical Director was notified by phone.
• Corrective actions will be completed.
• Care Plan and Smoking Assessment Review: R25 - Unsafe smoker, Care plan revised, Smoking assessment was completed - requires supervision. R145 - is a safe smoker however was observed lighting cigarettes for other residents. R145 is a safe smoker - R111- is an unsafe smoker - requires supervision and an apron. R19 - is an unsafe smoker - needs supervision and an apron. R71- is an unsafe smoker. Resident solicits to residents, staff, and/or visitors when cigarettes are not available. Resident has a history of being non-compliant with smoking policy - requires supervision and an apron. R118 - is unsafe smoker - requires apron, cigarette holder, someone to light and extinguish and supervision. R266- Resident is a safe smoker - no supervision, R365- is a safe smoker; however, sometimes non-compliant with the smoking policy. History of lighting other resident's cigarettes - independent smoker.
• In-service education was conducted by Regional Director of Operations and Training and Development Coordinator, Licensed Practical Nurse Unit Manager. In-service included ensuring the residents have their smoking aprons, smoking times, and direct supervision over all smokers safe and unsafe.
• In-service education was conducted by Regional Director of Operations and LPN Unit Manager. In-service education was relating to the smoking policy, abiding by smoking times and ensuring all smokers are care planned. Once a person who wants to smoke is identified a smoking assessment is completed.
• Director of Nursing received in-service from her Regional Director of Operations. She was educated on the new smoking times, smoking policy and creating safe smoking habits for residents. Smoking assessments must be done quarterly and as needed (PRN) and all care plans must be updated to ensure they are in alignment with the assessment. Unsafe smokers will not have their equipment on them, instead they will be locked in a lock box.
• Assistant Director of Nursing received in-service education relating to all the smokers in the building. Smokers cannot smoke anytime they like and are not allowed to hold their own smoking material. In-service education consisted of smoker's policy, timely assessments and care plans. Each resident must be supervised every 2 hours, and a smoking list kept at each nursing section.
• Minimum Data Set nurse received in-service education from the Regional Director of Operations. Topics covered included updating care plans, the smoking policy and smoking assessments for all residents that smoke.
• LPN received in-service on smoking. Training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. Unit Manager gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station.
• Scheduling Manager received smoking in-service training. Everyone on Magnolia Hall is considered unsafe. Apron should be on, they are not to have cigarettes or lighters on person. Smoking box is kept at the nursing station. Nursing keeps the list of the smokers, also list in the smoke box upstairs. Fire blankets are kept in the boxes in both locations up and down stairs. Smoking assessment must be done by the nurses, clinical manager or MDS personnel. Once the assessment is completed it is put in the care plan.
• CNA received smoking in-service. In-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. Nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision.
• In-service training for the removal plan determined all numbers are accurate.
• LPN received in-service on smoking. Training pertained to the residents, fire extinguisher, aprons, and smoking hours. In addition to care plan for safe smokers and unsafe smokers. Unit Manager gave the staff the updated list of smokers with safe and unsafe identified residents. The smoker list is posted in the CNA book and the Nurse book behind the nurse's station.
• CNA received in-service pertaining to smoking. In-service referred to the up-to-date policy, safe smokers, and unsafe smokers. Safe smokers do not have to have an apron on versus the unsafe smokers don't have to have an apron. Nurses are the ones who do the smoking assessment. The updated list is found at the nurse station. Unit upstairs smokes every two hours and downstairs on Magnolia start at 10:00 am - 6:00 pm.
• CNA received smoking in-service. In-service training pertained to the safety of the residents, the nurses conducting the smoking assessments. Nurses are the monitors and the CNA are making sure they keep their smoking aprons on and providing supervision.
• LPN received the in-service training for smoking. Training pertained to safe and unsafe smoker, the smoking aprons, light the cigarettes and monitor them. If the resident is deemed safe still monitor. Nurses can do the assessment for smoking. All Magnolia residents are monitored at all times during smoking times. Keep the cigarettes locked in the smoke box which is located in the Activities office. If any new staff, the staff can show them the list that is posted at the nurse's station.
• New onboarding employees will review the smoking policy as part of their orientation process. During this onboarding process the smoking components are: There is a new Smoking Schedule, and all staff should direct residents to the times. Smoking Assessment will be conducted as soon as the resident is identified as a smoker with care plan. All unsafe smokers should have a care plan, assessment, supervised residents will have on a smoking apron at all times. All residents on Magnolia are required to wear a smoking apron. Smoking Monitors should be present at all schedule smoking break times. Importance of following smoking care plans and accurately completing smoking assessment in a timely manner. Ensure smoking aprons are on correctly, residents are not allowed to light other resident cigarettes. Residents not on the smoking list are not allowed to smoke until the Charge Nurse, Administrator, or Director of Nursing have been notified and Smoking Assessment is completed.
• Record Review of the AD HOC QAPI Meeting confirmed the root cause was determined and that education to staff and residents on the smoking policy and expectations was needed, and a set smoking schedule established.
• Record Review revealed the removal plan binder with printed sheets in large bold print of the smoking schedule for the designated smoking area in courtyard and downstairs courtyard outside of Magnolia. Smoking schedule starts at 6:00 am - 6:30 am and repeating availability every 2 hours for 24 hours a day for a total of twelve (12) smoke breaks. The Downstairs Courtyard outside of Dementia Unit smoking schedule is 10:00 am - 10:30 am, 12:00 pm - 12:30 pm, 2:00 pm - 2:30 pm, 4:00 pm - 4:30 pm, and final break for the night at 6:00 pm - 6:30 pm for a total of five (5) smoking breaks.
• Record review of the AD HOC QAPI Meeting Log revealed Medical Director was notified over the phone. Record review of the AD HOC QAPI Meeting Log for F835 confirmed all stated staff was present at the AD HOC QAPI Meeting.

Penalty

Fine: $19,7455 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 enforce its smoking policy and Banned Item List, leading to Immediate Jeopardy for eight residents. These residents were observed smoking unsupervised, with some keeping smoking materials in their possession despite requiring supervision. For instance, one resident with moderate cognitive impairment was seen smoking with burn holes in her clothing, indicating unsafe smoking practices. Another resident, who was not listed as a tobacco user, was found with an unlit cigar, which he claimed to dry puff as part of his effort to quit smoking. Additionally, the facility did not ensure that three residents were prevented from keeping hazardous materials in their rooms. This oversight posed potential risks to the safety and well-being of the residents, staff, and visitors. The facility also failed to maintain safe water temperatures, with 18 rooms across five units having water temperatures exceeding 120 degrees Fahrenheit, which could lead to scalding injuries. Furthermore, a portable oxygen cylinder was not properly secured in one resident's room, creating a potential hazard. The facility's noncompliance with safety protocols and supervision requirements led to a determination of Immediate Jeopardy, as these deficiencies had the likelihood to cause serious injury, harm, impairment, or death to residents.

Removal Plan

• The facility will ensure that all residents are assessed for smoking safety.
• Residents requiring supervision while smoking will be directly supervised by staff, family members, or volunteers.
• Smoking materials for residents requiring supervision will be maintained by nursing staff and not kept in resident rooms.
• The facility will enforce the smoking policy and Banned Item List, ensuring no residents have unauthorized smoking materials.
• Staff will be trained on the facility's smoking policy and procedures, including the use of smoking aprons and supervision requirements.
• The facility will conduct regular audits to ensure compliance with smoking policies and procedures.
• Resident care plans will be updated to reflect current smoking assessments and safety measures.
• The facility will ensure that water temperatures in resident rooms are maintained below 120 degrees Fahrenheit.
• Portable oxygen cylinders will be properly secured in resident rooms.

Penalty

Fine: $19,7455 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 administration failed to enforce its smoking policy, leading to several deficiencies in the management of resident smoking practices. Observations revealed that residents were allowed to keep smoking materials on their person and smoke unsupervised, contrary to the facility's policy that required supervision and restricted possession of smoking items. This lack of enforcement was evident as residents were seen smoking outside without staff supervision, and one resident was observed smoking inside the building, which is strictly prohibited. The facility also failed to maintain accurate smoking assessments and implement person-centered care plans for residents who smoke. Specific residents were identified as lacking proper assessments and care plans, which are crucial for ensuring their safety and adherence to smoking policies. The absence of these assessments and care plans meant that staff were not adequately informed about which residents required supervision or additional safety measures, such as smoking aprons. Interviews with staff and management highlighted a lack of knowledge and competency in assessing residents' smoking habits and implementing care plans. The Director of Nursing and other staff members acknowledged that smoking assessments were not consistently completed, and there was confusion about which residents were considered safe or unsafe smokers. This oversight contributed to the facility's inability to provide a safe environment for residents who smoke, as required by their own policies and regulatory standards.

Removal Plan

• The facility failed to address residents smoking unsupervised. Smoking times were instituted for all residents who smoke, with supervised smoke breaks assigned.
• A smoking assessment was completed on all residents, identifying those who choose to smoke and those needing smoking aprons.
• Residents observed lighting other residents' cigarettes were educated to only light their own cigarettes.
• Residents observed smoking inside the building had their smoking materials confiscated and were reassessed as unsafe smokers.
• A list of residents requiring smoking aprons was compiled and made available at each nursing station.
• Smoking care plans for identified residents were reviewed and revised to ensure they are person-centered and comprehensive.
• All smoking care plans were reviewed and revised to ensure they are person-centered and comprehensive.
• Smoking assessments were conducted on all residents to identify those who choose to smoke, reassess unsafe smokers, and identify those needing smoking aprons.
• A master list of unsafe smokers, safe smokers, and those requiring smoking aprons was compiled and made available at each nursing station.
• Staff were in-serviced on the smoking policy, ensuring smoking care plans are followed and completing timely and accurate smoking assessments.
• All staff were educated on the smoking policy, including the use of smoking aprons and the designated smoking areas.
• Residents on the Dementia Unit are required to wear smoking aprons and adhere to set smoking times.
• Daily assignment of smoking monitors was implemented, with expectations on ensuring smoking aprons are donned correctly and residents do not assist others in lighting cigarettes.
• Job descriptions of the Director of Nursing and Administrator were reviewed, and they were educated on their responsibilities and job duties.
• An Ad Hoc QAPI meeting was completed for policy review and root cause analysis, determining that education on the smoking policy and a set smoking schedule were needed.
• Corrective actions were completed, and the facility's written IJ Removal Plan was validated by the State Survey Agency.

Penalty

Fine: $19,7455 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 adhere to its own policies regarding food safety and storage, leading to multiple deficiencies. Observations revealed that food items were not properly labeled or dated, with several items found expired or without any indication of when they should be used by. This included unwrapped cheese, unlabeled liquids, and expired dry goods such as biscuit and gravy mixes. Additionally, there were issues with the storage of food in the refrigerator and freezer, where items were found uncovered and without proper labeling. The facility also failed to maintain sanitary conditions in the kitchen, as evidenced by the presence of a dirty dish container in a sink used for food preparation, rust and debris in the three-compartment sink, and a can opener with a red/brown buildup. The ice machine was found with dust-covered ventilation openings and black flake material inside, compromising the cleanliness of the ice. Furthermore, the hood vent was not cleaned by the scheduled service date, and lighter fluid was stored near plastic and paper, posing a potential safety hazard. Interviews with staff revealed a lack of accountability and adherence to food safety protocols. The Lead Dietary Aide and other staff members acknowledged that the dietary department was short-staffed and that there was a lack of proper training and supervision. The Assistant Dietary Manager admitted that expired and unlabeled items were overlooked and that the last in-service training on food storage, labeling, and dating had not been effective. The facility was in the process of hiring new staff and management, which contributed to the nonchalant attitude towards food safety practices.

Penalty

Fine: $19,7455 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 safe, clean, and comfortable environment for residents across multiple wings, including the Georgia, Dogwood, Magnolia, and [NAME] Wings. Observations revealed numerous deficiencies such as dirty bathrooms with rust-colored substances, non-functional light switches, and noisy, dusty exhaust vents. Packaged terminal air conditioner (PTAC) units were found with filters covered in debris, and there were instances of broken windows and dead insects in resident rooms. Additionally, a resident on the Dogwood Wing reported infrequent cleaning of their room, which was corroborated by the presence of trash and a strong odor. The facility's laundry room was also found to be in disarray, with a rancid odor, leaking pipes, and dirty laundry overflowing from the chute onto the floor. Observations noted trash and lint atop the dryers, and a dusty fan in the clean laundry room. The laundry equipment was not fully operational, with only two out of four dryers working, and one missing a door. Exposed pipes with lint and debris were also noted, contributing to the unsanitary conditions. Interviews with maintenance and housekeeping staff revealed discrepancies in the cleaning schedule for PTAC air filters, which were being cleaned every three months instead of the manufacturer's recommended monthly schedule. The facility's maintenance director acknowledged the need for more frequent cleaning. Additionally, the laundry room's issues were attributed to power problems rather than equipment failure, although the maintenance director confirmed the need for service intervention to address the broken dryers.

Penalty

Fine: $19,7455 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 ensure that nursing staff provided adequate supervision and oversight for residents during the third shift, as evidenced by staff members engaging in inappropriate activities such as sleeping and watching videos. Observations on the dementia care unit, Magnolia Hall, revealed that a Certified Nurse Assistant (CNA) was found sleeping at the nurse's station, while two other CNAs were watching a movie on a laptop in the resident dining room with their backs turned away from the resident rooms. Additionally, a Licensed Practical Nurse (LPN) was observed nodding off at the nurse's station, and the Infection Preventionist was seen scrolling on her phone. Interviews with the Director of Nursing (DON) and other facility leaders confirmed that these actions were unacceptable and not in line with the facility's policy on sufficient and competent nursing. The DON acknowledged that there was no night supervisor, and the LPNs on each hall were designated as Charge Nurses for the overnight shifts. The DON also stated that the incident was not reported to her, and she expected staff to be accountable for their actions. The Regional Director of Operations noted that no residents were harmed during the observed period, and believed there should not be a federal regulation violation.

Penalty

Fine: $19,7455 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 an effective infection prevention and control program, as evidenced by multiple observations and interviews. Staff did not consistently perform hand hygiene during critical tasks such as tracheostomy care, medication administration, and handling of clean linens. Hand sanitizer dispensers were not maintained, with several being non-functional, and personal care items were improperly stored, leading to potential cross-contamination. Additionally, reusable equipment like blood pressure machines was not cleaned and disinfected between uses, and resident bathrooms were not cleaned appropriately. The facility's infection surveillance data lacked comprehensive documentation, with missing details on symptoms, testing, and antibiotic usage. The Director of Nursing (DON) was temporarily handling the Infection Preventionist duties, which may have contributed to the oversight. Observations revealed that staff did not adhere to hand hygiene protocols, and shared equipment was not disinfected between resident uses. Interviews with staff confirmed these lapses, and the DON acknowledged the need for continuous hand hygiene education. Further deficiencies were noted in the handling of linens and cleaning practices. The laundry chute was overflowing with dirty linens, and housekeeping staff did not follow proper protocols for transporting cleaning tools, such as toilet brushes. The facility's policies on routine cleaning and disinfection were not consistently followed, as evidenced by the improper handling of cleaning equipment and the lack of necessary supplies. These deficiencies highlight significant gaps in the facility's infection prevention and control measures.

Penalty

Fine: $19,7455 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 the dignity of a resident, identified as R94, by displaying clinical information related to her swallowing difficulties openly in her room. This information was visible to visitors, which is against the facility's policy on promoting and maintaining resident dignity. The policy emphasizes protecting resident rights and maintaining privacy. R94, who was cognitively intact, was admitted with diagnoses including cirrhosis of the liver, acute pancreatitis, and oropharyngeal dysphagia. Her care plan required a mechanically altered diet, and she was known to be noncompliant with dietary recommendations. Despite this, a sign indicating her need for thickened liquids was posted above her bed without her knowledge or consent. Interviews with staff revealed that the sign was likely placed at the request of the resident's family, although this was not confirmed. The LPN mentioned that all staff were aware of the resident's dietary needs, and the speech therapist acknowledged that the resident was noncompliant with her diet and that her son had been educated about her dietary requirements. However, the therapist admitted that the sign was not part of the care plan and that he did not seek the family's permission to post it. The Director of Nurses also indicated that such signs were typically placed at the family's request, although she was unsure if this was consistent with the facility's policy.

Penalty

Fine: $19,7455 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 assess and determine the ability of a resident, identified as R83, to safely self-administer medications before allowing the resident to exercise this right. The facility's policy on Resident Self-Administration of Medication requires an interdisciplinary team to assess each resident's capability to self-administer medications, considering factors such as cognitive status, physical capacity, and understanding of medication instructions. However, there was no evidence that R83 was assessed for self-administration, nor was there a care plan reflecting this capability. During an observation, several medications, including Latanoprost Ophthalmic Solution, vapor inhalers, and over-the-counter items like VapoRub and Tylenol Precise Pain-Relieving Cream, were found at R83's bedside. The clinical record showed no physician orders for these medications to be at the bedside for self-administration. Interviews with facility staff, including the Director of Operations and the Director of Nursing, confirmed that these medications should not have been in the resident's possession without proper assessment and physician orders, as they could potentially cause adverse reactions with other prescribed medications.

Penalty

Fine: $19,7455 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 offer scheduled baths to one of the sampled residents, R266, which potentially affected the resident's comfort, body image, and increased the risk for infections. The facility's policy on Resident Rights emphasizes the importance of self-determination and the need to treat residents with kindness, respect, and dignity. R266, who was admitted with diagnoses including wasting disease, HIV, protein-calorie malnutrition, and sepsis due to E. coli, was cognitively intact and expressed a preference for choosing between different types of baths. Despite this, the facility's records showed only one shower sheet marked with bed baths and no documentation of refusals since the resident's admission. Interviews with R266 revealed dissatisfaction with the care received, stating that only two baths had been provided since admission and expressing a dislike for the night shift bath schedule. Staff interviews indicated that all showers and refusals should be documented, but there was no further documentation of baths for R266. The Unit Manager stated that bath schedules could be adjusted upon request, but was unaware of any such requests. The Director of Nursing acknowledged that residents should be accommodated if their bath schedule was not acceptable.

Penalty

Fine: $19,7455 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 adequate language assistance services to a resident with limited English proficiency, identified as R182. The facility's policy on Language Assistance Service mandates that individuals with limited English proficiency should have access to language assistance services to ensure meaningful communication regarding their medical conditions and treatment. However, observations and interviews revealed that R182, who speaks Spanish and little to no English, was not provided with the necessary resources to understand communications about his healthcare regimen. The care plan for R182 indicated a need for non-verbal cueing, communication devices, and Spanish-speaking staff, but these interventions were not effectively implemented. During observations, R182 was seen attempting to communicate with staff and his roommate using gestures and pointing, indicating a communication barrier. Staff members were observed trying to communicate with R182 without using any translation services or devices. Interviews with R182, facilitated by a Spanish-speaking surveyor, revealed his frustration with the communication barrier and his lack of understanding regarding his care plan and treatment. He expressed that the admission paperwork was presented in English, which he did not understand, and he relied on the facility to manage his care appropriately. Further interviews with staff, including the Unit Manager, LPN, CNA, Social Worker, and Admission Director, highlighted a lack of awareness and resources for language assistance. The Unit Manager admitted that the dementia care unit did not have a posted language line, and the communication binder was missing. The LPN and CNA were unaware of how to access a language line, and the Social Worker was unfamiliar with R182's communication barriers. The Admission Director confirmed that the admission process was conducted in English and acknowledged the need for a language line in R182's care plan. The Director of Nursing and Regional Nursing Consultant confirmed that staff should use communication assistance when necessary, but this was not consistently practiced.

Penalty

Fine: $19,7455 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 an injury of unknown origin to the State Survey Agency (SSA) within the required timeframe for a resident who was reviewed for abuse and neglect. The resident, who was admitted with diagnoses including lobular pneumonia, pressure ulcer, hypertension, chronic respiratory failure, and traumatic brain dysfunction, was totally dependent on staff for all care. The incident involved a hip fracture that was identified after the resident was transferred to a hospital due to shortness of breath. The resident's spouse informed the facility of the fracture, which was diagnosed during the hospital admission. The facility's policy requires immediate reporting of such incidents, but the report to the SSA was delayed until two days after the spouse's notification. The facility's investigation into the incident was incomplete at the time of reporting, as the date and time of the incident were marked as 'to be determined.' The Regional Nurse Consultant and Regional Director of Operations confirmed the delay in reporting and attributed it to the late receipt of hospital records confirming the fracture. This delay in reporting has the potential to affect the resident's quality of life and could lead to future unreported injuries.

Penalty

Fine: $19,7455 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 ensure the accuracy of Minimum Data Set (MDS) assessments for a resident, identified as R118, regarding their smoking habits. R118 was admitted with multiple diagnoses, including paraplegia and hypertension, and their quarterly MDS assessment indicated no cognitive impairment. However, the section for Current Tobacco Use was left unmarked. Despite the facility's smoking assessments indicating that R118 did not use tobacco products, the resident admitted to occasionally smoking once or twice every two to three months. This discrepancy was confirmed during an interview with the MDS Regional Coordinator, who acknowledged that residents who occasionally smoke should be care planned and assessed accordingly. Further investigation revealed that R118 was not listed on the facility's Smoking List, and their care plan lacked any mention of smoking. During an observation, R118 was seen smoking a cigarette in the facility's designated smoking area, with staff present. Interviews with the Director of Nursing and the Regional Nurse Consultant indicated that the nursing staff was responsible for completing smoking assessments. Despite a request, the facility did not provide a policy on resident assessment, highlighting a gap in the documentation and assessment process.

Penalty

Fine: $19,7455 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 proper medication management and storage protocols, as evidenced by several observations and staff interviews. On the West Wing, an LPN did not wash her hands before administering medication and failed to maintain the correct narcotic count for Lyrica, a schedule V controlled substance. The LPN retrieved a capsule from the medication punch card, leaving six capsules, while the narcotic sign-out sheet indicated seven should remain. The discrepancy was due to an extra capsule that should have been wasted with the night shift nurse, which was not done. On Dogwood Hall, an RN left a medication punch card with gabapentin capsules unattended on top of the medication cart, and an expired Humulin Kwik Pen was found in the cart, which should have been discarded. Further observations revealed that a medication cart on Dogwood Hall was left unlocked during a night shift, with syringes and tube feeding formula accessible on top. The LPN responsible for the cart confirmed it should not have been left unlocked. Interviews with the DON confirmed that all medications for waste must be destroyed and witnessed by two licensed nurses, and that medication carts should not be left unlocked and unattended. These actions and inactions led to deficiencies in medication management and storage, compromising the facility's compliance with health regulations.

Penalty

Fine: $19,7455 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 prepare food in a manner that conserves nutritive value, flavor, and appearance, as evidenced by the experience of a resident, R91. R91, who has been at the facility for five years and has intact cognition, reported being served a burnt grilled cheese sandwich and hard pizza with burnt crust. Despite her complaint, the kitchen staff refused to replace the burnt sandwich. Photographic evidence provided by R91 corroborated her claims, showing the poor quality of the meals served. Interviews with various staff members, including the Lead Dietary Aide, Assistant Dietary Manager, and Regional Director of Operations, confirmed the deficiency. The Lead Dietary Aide acknowledged that the burnt sandwich should not have been served. The Assistant Dietary Manager confirmed that the meal was prepared by the evening shift and deemed it unacceptable. The Regional Director of Operations, although personally liking burnt food, agreed that the food should be replaced if a resident does not like it. These admissions highlight a failure in the facility's adherence to its own Food Preparation Guideline policy, which mandates that food be prepared to preserve or enhance a resident's nutrition and hydration status.

Penalty

Fine: $19,7455 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 ensure that resident call lights were within reach for residents to call for staff assistance in seven out of 22 rooms on the memory care unit, Magnolia. Observations conducted over several days revealed that call lights were often found lying on the floor, behind beds, or positioned on the vacant side of the room, making them inaccessible to residents. Specific instances included call lights being on the floor in rooms with residents, under beds, or on the vacant side of the room, which were confirmed by the Assistant Administrator, Maintenance Director, and Regional Maintenance Director. Interviews with staff, including a Certified Nursing Assistant (CNA) and a Unit Manager (UM), confirmed that call devices should be placed beside residents or on their beds at all times. The Regional Nurse Consultant (RNC) acknowledged that while residents might occasionally knock call devices onto the floor, staff are responsible for ensuring they are promptly repositioned to be accessible. The facility's policy on answering call lights, revised in September 2022, emphasizes the importance of ensuring call lights are plugged in, functioning, and accessible to residents at all times.