Riverview Health & Rehab Ctr

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 residents were free from accident hazards and that fall assessments were completed after falls for three residents reviewed. The facility policy titled Falls-Clinical Protocol stated staff would evaluate and document falls that occur in the facility and document risk factors for falling in the resident’s record. Review of records and staff interviews showed that fall risk assessments were not completed after documented falls for residents R109 and R55, despite facility staff stating that fall risk assessments are to be completed upon admission and anytime a resident has a fall. R109’s record showed a BIMS score of 10, indicating moderate cognitive impairment, with diagnoses including encephalopathy, syncope, non-Alzheimer’s dementia, and muscle weakness. The care plan identified R109 as at risk for falls related to confusion, psychotropic medication use, incontinence, hypotension, and muscle weakness. R109 had a fall on 02/27/2026, was evaluated by the on-call provider on 03/01/2026 for head and shoulder pain, and was later sent to the hospital and returned to the facility. The last fall assessment in the record was dated 12/19/2025, and the DON confirmed no fall assessment was completed for the 02/27/2026 fall. R55’s record showed diagnoses including periprosthetic fracture around the left hip prosthesis, multiple right rib fractures, acute respiratory failure with hypoxia, unspecified dementia with behavioral disturbance, and falls. The Five Day MDS showed a BIMS score of 4, indicating severe cognitive impairment. The resident had falls on 1/25/2026, 1/27/2026, 2/4/2026, 3/7/2026, and 3/15/2026, and no fall risk assessments were completed after any of those falls. In addition, R148’s room and the facility Medication Storage Room each had a free-standing oxygen cylinder tank positioned upright on the floor and not in a holder. R148’s room door was open, allowing access to the tank, and staff confirmed the tank was free-standing. An LPN stated oxygen tanks should be stored in a holder or in a designated labeled closet.

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 drugs and biologicals were stored in locked compartments and labeled in accordance with accepted professional principles. During observation, a wound care cart on Evergreen Hall was left unlocked with the keys in the lock while no staff member was near it, and a medication cart was also observed left unlocked in the hallway during medication administration, including times when the nurse could not see the cart from inside a resident room. Staff interviews confirmed that both carts were unsecured while in use and that the carts should have been locked with the keys kept by the nurse. The facility also had multiple expired or improperly dated medications and biologicals in medication carts, medication rooms, and central supply. Observations and interviews identified expired wound care products, expired oral and topical medications, expired suppositories, expired ear drops, expired nicotine patches, expired medical food, and expired central supply items. In addition, an insulin pen, an insulin lispro vial, and a methotrexate vial were found without open dates or expiration dates, and staff confirmed they did not know when they had been opened. Staff acknowledged that expired items should have been removed from carts and that nurses were responsible for checking medication storage for expired products. Interviews with nursing leadership and staff confirmed that nurses, unit managers, and central supply were responsible for keeping medication carts and rooms clean, locked, and free of expired medications. The DON stated that nurses were responsible for dating and labeling medications and confirmed that insulin and methotrexate should have open dates and expiration dates. The report documents that these storage and labeling failures were observed directly by surveyors and confirmed by staff during the survey.

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 implement its infection prevention and control program, specifically related to enhanced barrier precautions and hand hygiene for residents receiving IV therapy, wound care, and colostomy care. Facility policy on Enhanced Barrier Precautions required the use of gown and gloves for high-contact resident care activities such as device care (including central lines) and wound care. Policy on Handwashing/Hand Hygiene required hand hygiene before touching a resident, before aseptic tasks, after contact with blood or body fluids, after touching a resident or their environment, before moving from a soiled to a clean body site, and immediately after glove removal. Surveyors observed an LPN preparing and administering IV therapy to a resident with a PICC line without wearing a gown, despite the resident being on enhanced barrier precautions as indicated in the electronic medical record and by signage on the door. The LPN acknowledged awareness of the precautions and admitted she should have worn a gown. In another observation, a wound care LPN prepared a tray of wound care supplies while wearing gloves, then removed gauze, ABD pads, and a super-absorbent dressing from their packaging with ungloved hands. She then entered the resident’s room wearing a gown and gloves, packed the wounds, and did not change gloves or perform hand hygiene before applying the outer dressings. She later confirmed she had not worn gloves while preparing supplies and had not washed her hands or changed gloves after packing the wound. Additional deficiencies were identified during colostomy care for another resident under enhanced barrier precautions. An LPN confirmed he did not wear a gown while providing colostomy care, despite knowing the resident was on enhanced barrier precautions and acknowledging he should have worn a gown, mask, and gloves. He also admitted he did not change gloves or wash his hands after cleaning the colostomy site with soap and water and before cutting out the colostomy bag. A CNA involved in colostomy-related care confirmed she was not wearing a gown, could not recall the resident’s precautions, and acknowledged she should have worn a gown and gloves. She reported using wipes to clean the skin and wafer after removing the bag, stated she ran out of soap, and admitted she should not have used wipes to clean the area. Interviews with supervisory staff, including a unit manager, an LPN, and the DON, confirmed that residents with PICC lines, wounds, feeding tubes, catheters, and colostomies are under enhanced barrier precautions and that staff are required by facility policy to wear appropriate PPE and perform hand hygiene when transitioning from dirty to clean tasks.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that two sampled residents, R155 and R113, did not have unauthorized, unsecured medications at the bedside and failed to complete assessments to determine whether either resident was capable of self-administering medications. R155 had diagnoses including acute kidney failure, hypertension, and sepsis, was cognitively intact with a BIMS score of 15, and was dependent to requiring partial or moderate assistance with ADLs and nonambulatory. Review of the EHR showed no order for the prescription and no completed self-administration assessment. Observations on 03/15/2026 and 03/16/2026 found nystatin cream on the bedside stand in public view, and R155 stated she was self-administering the cream without staff assistance and had had it since admission. An LPN confirmed the medication was in the room and that R155 had not been assessed for independent self-administration. R113 had diagnoses including non-traumatic acute dural hemorrhage, unspecified dementia, and chronic lymphocytic leukemia of B-cell type in remission. The resident’s quarterly MDS documented a BIMS score of 10, indicating moderate cognition and periods of cognitive impairment, and the EHR also lacked a completed self-administration assessment and an order for the prescription. Observations on 03/15/2026 and 03/16/2026 found eye drops on the bedside stand and a bottle of peroxide and wound spray on a dresser drawer stand next to the television, all visible to anyone entering the room. R113 reported self-administering the eye drops without staff assistance and having them for months. An LPN confirmed the eye drops were in the room and that R113 had not been assessed to self-administer medications independently, and the DON stated she was unaware of the medications in the residents’ possession.

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 develop or implement a comprehensive person-centered care plan for two sampled residents, R56 and R6. The facility policy stated that the interdisciplinary team is responsible for developing care plans with measurable objectives and timetables to meet each resident’s physical, psychosocial, and functional needs. For R56, the quarterly MDS dated 12/30/2025 showed a BIMS score of 00, severe cognitive impairment, diagnoses including cerebral infarction without residual deficits, dysphagia, and muscle weakness, and that the resident received oxygen while a resident. The care plan dated 12/25/2025 did not address oxygen therapy, even though the physician order dated 8/20/2025 directed continuous oxygen at 2 LPM via NC every shift for comfort. Survey observations on 03/15/2026, 03/16/2026, and 03/17/2026 found the oxygen concentrator set between 3.5 and 4 LPM, and an LPN confirmed the setting was above the ordered 2 LPM. The RN/RAI Director and DON confirmed that oxygen therapy was not addressed in the care plan. For R6, the quarterly MDS dated 01/14/2026 showed a BIMS score of 12, moderate cognitive impairment, diagnoses including obstructive sleep apnea and cerebral infarction without residual deficits, and that the resident received a non-invasive mechanical ventilator while a resident. The physician order dated 09/5/2025 directed CPAP to be removed in the morning. Survey observations on 03/15/2026, 03/16/2026, and 03/17/2026 found the CPAP mask not bagged, not cleaned, and stored on top of toothpaste, cleaning products, and in a basket. An LPN stated the mask should have been bagged and cleaned and that night shift should have bagged and cleaned it, and the RN/RAI Director confirmed the care plan intervention was to clean the mask daily.

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

Professional standards of quality were not followed for a resident with a right upper arm PICC line who was receiving intravenous antibiotics. The facility policy titled Central Venous and Midline Catheter Flushing stated that the CVAD catheter should be aspirated for blood return to confirm patency before administration of medications and solutions. The resident had physician orders for ertapenem sodium 1 gram IV every 24 hours and daptomycin 700 mg IV every 24 hours, along with an order to flush the PICC line with 10 cc normal saline before and after each medication administration three times a day. During observation of medication administration, an LPN cleaned the PICC lumen, connected a 10 mL syringe of normal saline, flushed the line with 8 mL, and did not aspirate for blood return before connecting the ertapenem infusion. In interview, the LPN confirmed she did not aspirate for blood return and stated she should have done so, explaining she did not flush to the end of the syringe because there was air in it and she forgot to remove the air. The DON later stated that the nurse should verify the antibiotic order, prepare supplies, identify the patient, prime the antibiotic line, clean the PICC hub, flush, and check for blood return, and that checking for blood return verifies PICC patency.

Penalty

No penalty information released

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

Summary

The facility failed to provide colostomy care consistent with professional standards of practice for a resident with a colostomy, cerebral infarction without residual deficits, and muscle weakness. The resident’s quarterly MDS showed a BIMS score of 15, indicating little to no cognitive impairment, and the care plan identified the resident as at risk for complications related to the colostomy with an intervention to perform colostomy care as ordered. During observation, a CNA used bed wipes to clean the skin around the stoma and, after running out of soap, continued cleaning the area with bed wipes again; blood was observed on the wipes. A LPN was also observed using alcohol wipes to remove the colostomy wafer, then cleaning the area with soap and water, sealing the bag to the wafer, applying a no-sting barrier, and applying powder to the skin before attaching the bag. Staff interviews confirmed that bed wipes should not be used to clean the site and that alcohol wipes should not be used to remove the wafer; the DON stated that CNAs should clean and empty the colostomy bag daily and remove the bag to clean the area with soap and water.

Penalty

No penalty information released

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

Summary

The facility failed to provide oxygen at the physician-ordered rate for one resident with severe cognitive impairment. The resident had diagnoses including cerebral infarction without residual deficits, dysphagia, and muscle weakness, and the MDS documented that the resident received oxygen while in the facility. The MAR showed an order for continuous oxygen at 2 LPM via nasal cannula every shift for comfort, but observations on multiple occasions showed the oxygen concentrator set between 3.5 and 4 LPM. An LPN confirmed the higher flow rate and stated she checked the oxygen level after medication pass. The UM and DON stated nurses were expected to check the oxygen flow rate at the beginning of each shift and during the shift, and to adjust it to match the physician's order. The facility also failed to ensure that another resident's CPAP mask was properly cleaned and stored. That resident had obstructive sleep apnea and cerebral infarction without residual deficits, and the care plan directed staff to clean the CPAP mask daily. The MAR showed an order for CPAP to be removed in the morning. Observations showed the CPAP mask lying unbagged on top of a toothpaste box in a basket of fruit, then on top of bottles of cleaning products, and later still uncleaned and lying on top of bottles in a basket. An LPN confirmed the mask was not clean and should have been bagged, and the DON confirmed the mask was not cleaned or stored correctly.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a call light was within reach for one of 32 sampled residents, R121. The facility policy titled Call System, Resident stated that residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Review of R121’s Quarterly MDS dated 03/03/2026 showed a BIMS score of 11, indicating moderate cognitive impairment, and diagnoses including vascular dementia, traumatic brain injury, repeated falls, and normal pressure hydrocephalus. The assessment also showed that R121 was dependent for activities of daily living. During observations on 03/15/2026 and 03/16/2026, R121 was found in bed lying on her right side, and the call light was observed in the overhead light rather than within the resident’s reach. During interview, R121 stated that she did not have a call light and that she did not call for help. The Unit Manager, LPN II, stated that residents should have access to a call light clipped to the bedside within reach, and that residents who could not push the button had access to a push pad. The DON stated that all residents should have a call light near them and that residents unable to press the call light would use a touch button.

Penalty

Inspection fine: $92,7945 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 residents from various forms of abuse, including verbal, sexual, and physical abuse. Specifically, three residents were not safeguarded from sexual abuse by another resident, while one resident was subjected to physical and verbal abuse by a CNA. The incidents involved inappropriate and non-consensual physical contact, such as kissing, and aggressive behavior towards residents who were unable to consent or defend themselves. The facility's staff, including the DON and LPNs, were aware of these incidents but failed to take appropriate and timely action to prevent further abuse. Reports of abuse were not adequately investigated, and there was a lack of follow-up on reported incidents. In some cases, staff members were instructed to downplay or ignore the incidents, and there was no evidence of immediate intervention to protect the residents involved. The facility's policies on abuse prevention and reporting were not effectively implemented, leading to a failure to maintain a safe environment for residents. Staff members did not receive adequate training on abuse prevention, and there was no evidence of in-service training following the incidents. The lack of proper oversight and response to abuse allegations contributed to the continuation of abusive behavior within the facility.

Removal Plan

• The facility failed to maintain an environment free from abuse by R64 affecting R60, R125, and R30 and one physical abuse incident affecting R30.
• Resident #64 is currently residing at the facility. Resident placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
• The resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents.
• The facility has reassessed this resident for potential clinical needs per primary care physician.
• CBC, CMP, UA with C&S, PSA, TSH, RPR, and viral load have been ordered.
• The resident's care plan has been reviewed and revised.
• The facility contacted psych services requesting an onsite evaluation, however services have been refused by residents.
• Social Services reviewed status with IDT for appropriate placement.
• LTC Ombudsman has been notified.
• Law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30.
• Resident R64 has discharged from facility.
• Resident #R125 is currently residing at the facility. The resident is responsible for self, has a BIMS of 15, and is capable of verbally expressing herself and reporting to staff.
• Resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
• The care plan has been reviewed and updated.
• A psych follow-up visit was provided.
• Resident #60 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises.
• Resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified.
• The care plan has been reviewed and updated.
• The resident's representative and primary care physician were notified by facility of the reported incidents.
• The facility has referred R60 for psych services for assessment and support.
• Resident #30 is currently residing at the facility. Resident's BIM is unable to be determined, but resident can make known nonverbal indicators of discomfort or distress through noises.
• Resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
• The care plan has been reviewed and updated.
• The resident's representative and primary care physician were notified by facility of the reported incidents.
• The facility has referred R30 for psych services for assessment and support.
• The facility met and assessed with R60, R125 and R30's roommates for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
• The facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
• Upon the report from the State surveyor, CNA AA has been suspended pending further investigation.
• The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
• The administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting.
• The facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures.
• 132 of 150 (88%) of facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• The remaining 18 team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
• 5 of 5 (100%) agency staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
• A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
• The facility administration reviewed all audits related to residents vulnerable for potential abuse for identification of safety concerns.
• All corrective actions were completed.
• All immediacy of the IJ was removed.

Penalty

Inspection fine: $92,7945 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 provide protective oversight to ensure the highest practicable physical and psychosocial well-being of its residents. Specifically, the administration did not take appropriate action on allegations of employee-to-resident physical and verbal abuse involving a resident, and failed to protect three residents from sexual abuse by another resident. The administration's inaction included not adhering to facility policies on the prevention, reporting, and investigation of abuse allegations. The facility's Director of Nursing (DON), who is also the Abuse Coordinator, was aware of an incident involving two residents on a specific date but did not conduct a thorough investigation. The DON assumed that the staff member who reported the incident would notify the family and authorities, which did not happen. Additionally, the facility failed to investigate and report another incident of physical abuse by a Certified Nursing Assistant (CNA) towards a resident, where the CNA threw a mechanical lift pad at the resident, causing it to land on her face. The facility was unable to provide documentation of thorough investigations, follow-up interviews with staff, or additional resident interviews related to the incidents. The Administrator was aware of the incidents but assumed that the DON had reported them. The lack of follow-up and adherence to job responsibilities contributed to the failure in protecting residents from abuse, as the staff did not perform their duties as expected, leading to potential harm to residents.

Removal Plan

• The facility failed to provide oversight and supervision to ensure residents R30, R60, and R125 were protected from abuse by R64 and abuse by CNA AA to R30.
• CNA AA has been suspended pending further investigation.
• Resident R64 placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
• Resident R64 has discharged from facility.
• The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
• The facility had completed meeting/assessing with all residents who were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
• The facility administration reviewed all audits related to residents' vulnerable for potential abuse for identification of safety concerns. No safety concerns were identified.
• The facility administration contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting.
• Education was provided to Administration from external consultant on job description.
• The facility administration notified President of Governing Board of Directors.
• The facility administration reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures. 132 of 150 of facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• 5 of 5 (100%) agency staff (4 LPN and 1 CNA) have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• 16 of 22 (78%) contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining 6 PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments of their next scheduled workday.
• A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
• A Performance Improvement Plan (PIP) was initiated related to abuse prevention and abuse reporting. ADHOC meeting held.

Penalty

Inspection fine: $92,7945 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 allegations of verbal, sexual, and physical abuse to the State Survey Agency (SSA) as required by federal and state law. Specifically, two residents were sexually abused by another resident, and another resident was verbally and physically abused by a Certified Nursing Assistant (CNA). The facility's policy mandates that all alleged violations involving abuse must be reported immediately to the administrator and to the appropriate authorities, but this was not done in these cases. The Director of Nursing (DON), who is the facility's Abuse Coordinator, was informed of a kissing incident between two residents but failed to ensure the incident was reported to the appropriate entity. The DON admitted to not following up on the required 5-day report due to being busy and not knowing how to complete it. Additionally, there was no evidence that the staff to resident abuse by the CNA was reported to the SSA or law enforcement. The facility's Administrator was aware of the incident but did not contact law enforcement. The facility's failure to report these incidents in a timely manner and to the appropriate authorities constitutes a serious deficiency in compliance with abuse reporting requirements, potentially putting residents at risk of harm.

Removal Plan

• The facility failed to notify family and resident representatives of R30, R125, and R60 of alleged incidents of abuse. The facility failed to report incidents of abuse to law enforcement. The facility failed to report the results of the investigations for R30, R60 and R125 to the Administrator and State Survey agency of alleged incidents of abuse.
• Resident placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
• The resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents.
• The facility has reassessed this resident for potential clinical needs per primary care physician. CBC, CMP, UA with C&S, PSA, TSH, RPR, and viral load have been ordered.
• The resident's care plan has been reviewed and revised.
• The facility contacted psychiatric services requesting an onsite evaluation, however services have been refused by resident.
• Social Services reviewed current status with IDT for appropriate placement.
• LTC Ombudsman has been notified.
• Law enforcement was notified of the reported abuse incidents affecting R60, R125, and R30.
• Resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
• The care plan has been reviewed and updated.
• A psych follow up visit was provided.
• Law enforcement was notified of the reported abuse incident.
• Resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified.
• The care plan has been reviewed and updated.
• The resident's representative and primary care physician were notified by facility of the reported incidents.
• The facility has referred R60 for psych services for assessment and support.
• Law enforcement was notified of the reported abuse incident.
• Resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
• The care plan has been reviewed and updated.
• The resident's representative and primary care physician were notified by facility of the reported incidents.
• The facility has referred R30 for psych services for assessment and support.
• Law enforcement was notified of the reported abuse incident.
• The facility met and assessed with R60, R125 and R30's roommates for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
• The facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns identified.
• Upon the report from the State surveyor, CNA AA has been suspended pending further investigation.
• The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
• The facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures.
• The administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting.
• 132 of 150 facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
• 5 of 5 agency staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• 16 of 22 contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
• A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.

Penalty

Inspection fine: $92,7945 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 allegations of abuse were thoroughly investigated for two residents. Specifically, the facility did not investigate allegations of resident-to-resident sexual abuse involving one resident and another resident, as well as an allegation of employee-to-resident abuse involving a CNA and a resident. The facility's policy required that all reports of abuse be promptly and thoroughly investigated, but this was not adhered to in these cases. The investigation into the incident between the two residents was incomplete, with only a copied and pasted email statement, an undated written statement from the unit manager, and two undated written statements from a staff member who did not witness the incident. There were no resident statements, no evidence that the incidents were reported to law enforcement, and no evidence that the residents were assessed for physical or psychological harm. Similarly, the employee personnel file for the CNA involved in the other incident contained a handwritten note from an LPN who witnessed the abuse, but there was no evidence of reporting these allegations to the SSA or law enforcement. Interviews with the DON and the Administrator revealed a lack of follow-up on the incidents. The DON admitted to not completing the required 5-day follow-up due to being busy and not knowing how to proceed. The Administrator was aware of the incidents but assumed the DON had reported them. This lack of communication and follow-through resulted in the facility's noncompliance with requirements of participation, which had the likelihood to cause serious harm to residents.

Removal Plan

• The facility failed to thoroughly investigate incidents of abuse.
• Resident placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
• The resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents.
• The facility has reassessed this resident for potential clinical needs per primary care physician.
• CBC, CMP, UA with C&S, PSA, TSH, RPR, and viral load have been ordered.
• The resident's care plan has been reviewed and revised.
• The facility contacted psych services requesting an onsite evaluation, however services have been refused by resident.
• Social Services reviewed current status with IDT for appropriate placement.
• LTC Ombudsman has been notified.
• Law enforcement was notified of the reported abuse incident to R30, R60, and R125.
• Resident R64 has discharged from facility.
• Resident #R125 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
• The care plan has been reviewed and updated.
• A psych follow up visit was provided.
• Law enforcement was notified of the reported abuse incident.
• Resident #R60 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incident identified.
• The care plan has been reviewed and updated.
• The resident's representative and primary care physician were notified by facility of the reported incidents.
• The facility has referred R60 for psych services for assessment and support.
• Law enforcement was notified of the reported abuse incident.
• Resident #R30 has been reassessed for safety and potential physical/psychosocial outcomes based upon the incidents identified.
• The care plan has been reviewed and updated.
• The resident's representative and primary care physician were notified by facility of the reported incidents.
• The facility has referred R30 for psych services for assessment and support.
• The facility has met and assessed with R60, R125 and R30's roommates as well as residents who are deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
• The facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
• Upon the report from the State surveyor, CNA AA has been suspended pending further investigation.
• The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
• The facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting policies and procedures.
• The administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on abuse prevention and reporting.
• 132 of 150 facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• The remaining team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
• 5 of 5 agency staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• 16 of 22 contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• The remaining PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
• A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
• All corrective actions were completed.
• All immediacy of the IJ was removed.

Penalty

Inspection fine: $92,7945 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 behavioral health services to a resident, identified as R64, who exhibited repeated verbal abuse and hypersexuality behaviors towards other residents. The resident was admitted with diagnoses including stroke and hemiplegia affecting the left side. Despite having a Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment, the resident's behavior progress notes documented incidents of yelling, berating, and inappropriate physical contact with other residents. On multiple occasions, R64 was reported to have entered female residents' rooms uninvited, yelled, cursed, and even grabbed a resident's arm while she was sleeping. The Social Services Director had spoken to R64 about these behaviors, but the resident justified his actions by claiming he was trying to be helpful or that the residents had invited him in. The facility's Director of Nursing (DON) was notified of these incidents, but there was no evidence that psychiatric services were sought for R64 until after the survey began. Interviews with the facility's Administrator and DON revealed that they acknowledged their failure to address the situation adequately. They admitted to attempting to send R64 for psychiatric services, which the resident refused. The lack of timely intervention and failure to seek psychiatric services for R64 before the survey indicated a significant oversight in providing necessary behavioral health care and services, leading to the deficiency being identified as Immediate Jeopardy.

Removal Plan

• The facility failed to complete a comprehensive assessment to provide the necessary behavioral health care and services to R64 based upon incidents identified.
• Resident placed on 1:1 supervision upon report from State surveyor of other alleged incidents.
• The resident's primary care physician, representative and the facility Medical Director have been notified of the reported incidents.
• The facility has reassessed this resident for potential clinical needs per primary care physician.
• CBC, CMP, UA with C&S, PSA, TSH, RPR, viral load, and head CT without contrast have been ordered.
• The resident's care plan has been reviewed and revised.
• The facility contacted psych services requesting an onsite evaluation, however services have been refused by resident.
• The facility administration and social services have reviewed the need for potential alternative placement for R64. This has been reviewed with R64 and the Ombudsman. The facility will continue to seek out options for R64 placement.
• Resident R64 has been accepted and agreed to go to another SNF. Discharge date pending per other SNF.
• LTC Ombudsman has been notified. LTC Ombudsman updated.
• Law enforcement was notified of R64's reported abuse incidents and behaviors.
• Resident R64 has discharged from facility.
• The facility met with all residents that were deemed vulnerable for potential abuse for identification of safety concerns related to the reported incidents. No safety concerns were identified.
• The facility notified the Medical Director who has been involved in the removal of the Immediate Jeopardy.
• The administrator contacted an external consultant(s) to assist with policy review, education development and leadership training on comprehensive assessment related to behavioral health care and services to attain or maintain the highest practical well-being for residents.
• The facility administrator reviewed and made any necessary changes to the abuse prevention and abuse reporting and comprehensive assessment related to behavioral health care and services policies and procedures.
• 132 of 150 facility team members have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining team members will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
• 5 of 5 agency staff have been educated on abuse prevention, abuse reporting and comprehensive assessments.
• 16 of 22 contracted therapy staff have been educated on abuse prevention, abuse reporting and comprehensive assessments. The remaining PRN contracted therapy staff will be educated on abuse prevention, abuse reporting and comprehensive assessments their next scheduled workday.
• A review and update of the facility orientation program and agency orientation program has been completed with respect to abuse prevention and abuse reporting requirements.
• A review and update of the facility orientation program and agency orientation program for licensed nursing and therapy staff has been completed with respect to comprehensive assessment processes related to residents behaviors and corresponding interventions for behavioral health care and services requirements.
• The facility administration reviewed all audits related to residents' vulnerable for potential abuse for identification of safety concerns. No safety concerns were identified.
• The facility has reviewed records of residents who display behaviors and corresponding documentation and assessment completion per policy.

Penalty

Inspection fine: $92,7945 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 required Registered Nurse (RN) coverage of at least eight consecutive hours per day, seven days per week, as mandated by their policy and federal regulations. This deficiency was identified through a review of the facility's Payroll-Based Journal (PBJ) records for the period from July 1, 2024, to September 30, 2024. The records revealed that on seven specific dates, there was no RN coverage for the required duration, which had the potential to affect all 161 residents residing in the facility. The facility's policy, revised in September 2022, clearly states that an RN must provide services for at least eight consecutive hours every 24 hours, seven days a week. During an interview with the Administrator on February 5, 2025, it was confirmed that there was an understanding of the PBJ data showing no RN hours on the specified dates. The Administrator acknowledged the expectation of having RN coverage and admitted to the absence of RN staff on those days, without providing an explanation for the deficiency. Despite the current presence of an RN providing patient care, the lack of coverage on the identified dates was verified, highlighting a significant lapse in meeting staffing requirements.

Penalty

Inspection fine: $92,7945 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 Infection Prevention and Control Manual Dietary Department policy, resulting in deficiencies in food storage and staff hygiene practices. During an observation, it was noted that dietary aides were not wearing proper hair restraints, such as hairnets and beard guards, while in the food preparation area. Additionally, a walk-in cooler inspection revealed several metal containers with food items, including puree eggs, ground pork sausage, puree corn beef, chopped turkey sausage, and chopped ham, that were not labeled with expiration dates. The Dietary Manager acknowledged these oversights, attributing the lack of labeling to human error and confirming the absence of hair restraints and beard guards among staff. This deficiency had the potential to affect 52 of the 61 residents receiving an oral diet.

Penalty

Inspection fine: $92,7945 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 two residents, R303 and R136, did not have unauthorized and unsecured medicated treatment products at their bedside, which could potentially allow unauthorized access to these medications by residents and visitors. For R303, the facility did not have a physician's order for self-administration of medication, nor was a Self-Administration Assessment Form completed to determine the resident's capability to self-administer medication. Despite this, nystatin hydrocortisone topical was observed on R303's bedside table. Interviews with staff, including a CNA, LPN, and the Director of Nursing, confirmed that the medication should not have been at the bedside without an order for self-administration. Similarly, for R136, there was no physician's order for self-administration of medication, and a Self-Administration Assessment Form had not been completed. However, Benadryl and Desitin cream were observed on R136's bedside table. Staff interviews confirmed that these medications should not have been at the bedside without the appropriate orders. Both residents' medical records and assessments indicated that the facility did not follow its policy regarding self-administration of medication, leading to the deficiency.

Penalty

Inspection fine: $92,7945 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 appropriate hygiene care for a resident, identified as R357, who was admitted with a diagnosis of cellulitis of the buttocks. Upon review, it was found that R357 was not scheduled for shower preferences upon admission, and there was no documentation of a shower or bed bath being offered since the resident's admission. Interviews revealed that the resident had not been offered a shower or bed bath since the previous Tuesday, the day of admission. Further investigation through interviews with facility staff, including an LPN and the Director of Nursing (DON), highlighted a lack of adherence to the facility's policy on Activities of Daily Living. The LPN could not locate shower sheets for R357, and the resident was not on the shower log. The DON stated that it is the responsibility of the unit manager to ensure that a shower or bed bath is offered and preferences are documented upon admission. A CNA also confirmed that the resident was not provided a bed bath, attributing the lack of care to either the service not being offered or the resident refusing, although no refusal was documented.