Arcadia Care On The Hill

Penalty

Inspection fine: $73,800

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 coordinate and provide ordered wound care, IV antibiotics, and timely surgical scheduling for a resident with a complex left foot diabetic wound and MRSA bacteremia. The resident had multiple diagnoses including infective myositis of the left foot, abscess of the tendon sheath, osteomyelitis, MRSA infection, non‑pressure chronic foot ulcer with muscle involvement, neuropathy, COPD, type 2 DM with foot ulcer, prior right great toe amputation, weight loss, hypertension, and anemia. The resident was cognitively intact per MDS and required supervision or touching assistance for most ADLs. Care plan entries noted chronic wounds/infection, risk for skin impairments related to diabetes and impaired mobility, and that the resident had a history of removing dressings and unplugging the wound vac without notifying staff. Wound notes documented progressive worsening of the left plantar foot wound from 2/10/2026 through 4/7/2026, with increasing size, presence of exudate, and visible bone. The facility did not consistently follow physician orders for wound care and IV antibiotic therapy after the resident’s hospitalization for left foot MRSA infection. Hospital discharge instructions included Daptomycin 500 mg IV every 24 hours until 4/17/2026 with weekly labs, and wound care orders from the podiatrist specified saline wet‑to‑dry dressing changes twice daily. The March MAR showed that an order to cleanse the left foot, leave the Restrada graft in place, and apply wet‑to‑dry dressings and ABD wrap when the wound vac was not available was not documented as completed from 3/13/2026 to 3/31/2026. The April MAR showed missed doses of Daptomycin on 4/8/2026, 4/9/2026, and 4/12/2026, and administration times that did not follow the every‑24‑hour order on five days. The April MAR also showed missed Hibiclens pre‑surgical dose, missed PICC/midline assessments on specified dates, and missed faxing of lab results on multiple days. The DON and ADON acknowledged that if care or medications were not documented on the MAR, they were not done, and the Medical Director stated he expected all physician orders to be followed and no doses to be missed. The facility also failed to effectively coordinate and prioritize scheduling of the resident’s needed foot surgery despite repeated contacts from the podiatrist and his clinic. The podiatrist documented on 3/31/2026 that the left foot wound was worsening, with exposed bone and need for repeat debridement and left first ray amputation, and stated he faxed orders to the facility and called multiple times without return calls. He reported calling the facility over six times, leaving messages that the resident needed surgery STAT due to exposed bone and osteomyelitis, and that no one called him back until the ADON eventually responded in April. The podiatry clinic RN reported attempts to contact the facility on multiple consecutive days to schedule surgery after insurance approval, with successful contact only after about a week. The CNA/receptionist and an LPN corroborated that the podiatrist had called repeatedly, was upset that the DON was not returning calls, and threatened to contact Public Health. Facility leadership, including the Administrator, DON, and ADON, stated they were initially unaware of issues or delays with scheduling the surgery, and staff reported that the facility had been without a wound nurse for about a month, during which time wound responsibilities were informally covered by an LPN while also working the floor. Ultimately, the resident underwent surgery and had more of the left foot amputated due to infection, with the podiatrist stating he believed more of the foot had to be removed because surgery was not scheduled earlier and that the facility had not coordinated care or returned calls in a timely manner. On physical observation shortly before surgery, the resident’s left foot showed a large plantar wound with visible bone and a red streak across the foot, with the area larger than a fifty‑cent piece. Staff interviews indicated that the wound had been present and problematic for at least a year, and that bone visibility was not noted that far back. Wound notes from late March and early April documented that the wound was advancing, increasing in size, with serosanguinous exudate and visible bone. The facility had no wound care policy, and the Administrator stated they expected physician orders to be followed. The Physician‑Family Notification policy required timely communication with the physician and family when there was a need to alter treatment significantly, and the Medication Administration policy required medications to be administered in accordance with physician orders and documented on the MAR. Despite these policies, the record review, interviews, and observations showed that the facility did not ensure consistent implementation of ordered wound care, IV antibiotic therapy, lab monitoring, PICC assessments, and timely coordination of surgical intervention for this resident’s worsening foot wound. The DON reported limited RN staffing for a census of 118 residents and stated that while they were doing the best they could, it was not enough at times. Staff also reported that the facility had been without a designated wound nurse for about a month, and that wound care duties were being informally covered by an LPN who was also assigned to floor duties. The podiatrist and his clinic staff described multiple unsuccessful attempts to reach facility leadership to arrange surgery, and internal staff accounts confirmed that calls were routed to the DON without response for a period of time. The combination of missed and improperly timed antibiotic doses, incomplete wound treatments, inconsistent lab faxing and PICC assessments, lack of a wound care policy, absence of a wound nurse for a period, and failure to respond promptly to the podiatrist’s repeated efforts to schedule surgery all contributed to a delay in surgical intervention for the resident’s left foot wound, culminating in a more extensive amputation due to the spread of infection.

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 resident safety by not keeping call lights within reach, not documenting fall risk assessments before and after falls, and not following fall-prevention interventions for residents identified as being at risk for falls. The report identifies three residents involved in these deficiencies: one resident with legal blindness, morbid obesity, moderate cognitive impairment, dependence for all ADLs and transfers, and a history of falls; a second resident with dementia, substantial/maximal assistance needs, and repeated falls; and a third resident with intact cognition who also had a history of falls and whose call light was not within reach. For the resident with legal blindness, the record showed a care plan identifying fall risk and interventions such as bolsters, non-skid socks, call light use, a body pillow, and non-skid strips beside the bed. During observations, the call light was clipped to itself and hanging down the wall, out of reach and not visible to the resident, and the resident stated staff sometimes took a while to respond when he yelled for help. The resident also stated no one had ever given him a body pillow. The record further showed no fall risk assessment dated after the resident’s earlier assessment and before later falls, and no updated care plan interventions after a fall in June 2025. The facility’s fall investigation and notes documented falls in the resident’s room, including one event where the resident was found on the floor and another where staff found him sliding out of bed and almost on the floor. For the resident with dementia, the care plan identified fall risk and included interventions such as keeping the call light within reach, appropriate footwear, moving the resident across from the nurse’s station, reminder signs, and side rails per order. The admission assessment documented fall risk, but there was no fall risk assessment documented. The resident experienced multiple falls, including one in the room and another in the bathroom, and staff documentation described the resident on the bathroom floor, attempting to use the restroom, with the urinary catheter pulled out. The record also showed no further fall risk assessments completed after each fall, despite the resident’s repeated incidents and dependence for transfers and toileting. For the resident with intact cognition, the care plan directed staff to keep the call light within reach and encourage its use, but observation showed the call light was not within reach when the resident was sitting in the wheelchair. The resident stated he had had several falls at the facility and knew to ask for help and use the call light. The medical chart did not document a fall risk assessment before the resident’s falls, and the report states that the facility expected nurses to complete a fall risk assessment upon admission, quarterly, and after any fall, while staff also acknowledged that call lights are sometimes unhooked or fall to the floor.

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 timely communication of urinalysis and urine culture results to a resident's urologist, which resulted in a significant delay in treatment for a urinary tract infection (UTI). The resident, who was nonverbal and had a complex medical history including hemiplegia, stroke, neurogenic bladder, and prostate cancer, had a physician's order for increased fluid intake and monitoring for UTI symptoms. However, there was no documentation that the order was followed or reflected in the care plan, and the urinalysis and urine culture results were not promptly sent to the urologist as required. The urologist did not receive the results until ten days after they were available, which led to a lack of timely antibiotic treatment and escalation of the resident's condition. The resident subsequently experienced a decline, including pain, discomfort, and ultimately required transfer to the emergency room, where he was diagnosed with a UTI and sepsis. He received IV hydration, antibiotics, and underwent invasive procedures such as a PICC line insertion and intubation. Documentation revealed that staff failed to reassess the resident for warning signs of sepsis after readmission and did not complete change in condition documentation, including current vital signs and assessments, on multiple occasions prior to the resident's deterioration. The lack of timely and thorough assessment and communication contributed to the resident's progression to septic shock and cardiac arrest, necessitating emergent CPR. A second resident was also identified as not having proper assessment or documentation during a change in condition, specifically lacking current vital signs and respiratory assessment prior to hospital transfer for pneumonia. Facility policies required prompt reporting of diagnostic results and thorough documentation during changes in condition, but these were not followed. Interviews with facility staff, including the DON and NP, confirmed expectations for timely communication and documentation, which were not met in these cases.

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 occurred when the facility failed to implement and document fall prevention interventions for a newly admitted resident with a documented history of multiple vertebral fractures and recent falls. Upon admission, the resident's hospital discharge plan and baseline care plan both indicated a significant risk for falls, including recent compression and burst fractures, low back pain, abnormal gait, muscle wasting, and lack of coordination. Despite these risk factors, no specific goals or interventions to prevent falls were documented in the resident's baseline care plan or admission assessment. Following admission, the resident experienced two unwitnessed falls within the facility. The first fall resulted in a skin tear to the left elbow, and the second fall led to a skin tear on the right elbow and post-fall lethargy, requiring transfer to the emergency department. The resident received IV fluids and narcotic pain medication at the hospital. Nursing notes and fall reports for both incidents did not document any interventions implemented to prevent future falls, nor were any changes made to the care plan after these events. Interviews with facility staff, including the Director of Nursing, confirmed that interventions should have been documented for residents with a history of falls. The facility's Fall Prevention Program requires individualized assessment and implementation of appropriate interventions at admission and after any fall, but these measures were not followed for this resident. The lack of documented interventions and failure to update the care plan after repeated falls constituted the deficiency.

Penalty

Inspection fine: $98,31362 days payment denial

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

Summary

A deficiency occurred when a registered nurse (RN) failed to demonstrate competency in responding to a resident experiencing severe hypoglycemia. The resident, who had a history of diabetes mellitus, end-stage renal disease, and other chronic conditions, was found lethargic with a blood glucose level of 49, which later dropped to 33. Instead of following the physician's order to administer Baqsimi (Glucagon) nasal spray for low blood sugar, the RN incorrectly assembled and administered an epinephrine auto-injector with a nasal spray cap, intended for Narcan, and delivered it nasally to the resident. The RN did not verify the medication before administration and was unfamiliar with the emergency medications in the facility's E-Kit. The incident was witnessed by another nurse, who assisted in retrieving the emergency kit and observed the incorrect assembly and administration of the medication. The RN initially misrepresented the events but later admitted to not checking the medications and being unfamiliar with their use. Documentation and interviews confirmed that the resident did not receive the ordered Glucagon, and the error was only discovered after emergency medical services arrived and found the epinephrine pen with the nasal spray cap in the resident's bed. The resident was unresponsive when EMS arrived and required intravenous glucose administration to stabilize blood sugar levels. The physician and medical director were not initially informed of the medication error, only of the hypoglycemic episode and hospital transfer. The facility's investigation and staff interviews revealed a lack of competency in medication administration and failure to follow professional standards and physician orders, resulting in a significant medication error affecting the resident's care.

Removal Plan

• All nurses were educated on the use of Emergency Medications by DON.
• Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
• DON, LPN, and RN, ADON reviewed the incident.
• 100% Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyperglycemia by DON and RN, ADON.
• Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
• NP was notified of the change in condition and MD notified of the resident being hypoglycemia and being sent to ER.
• V6 and V27 educated on ensuring right medication and dose prior to medication administration by DON.
• The monthly refresher will begin at our all-staff meeting.
• All nursing staff educated on the 5R's of medication administration by DON.
• V6 and V27 were educated and completed competent in medication administration on Narcan, Epinephrine, and Baqsiumi.
• 100% of nursing staff was educated on medication administration.
• DON or Designees will audit medication administration 2 times a week for 3 months.
• DON or Designee will audit 3 residents 2 times weekly to ensure blood sugar are within normal limit per MD orders for 3 months.
• DON or designee will perform an audit to ensure all emergency was handled correctly. This will be ongoing for 3 months and reviewed in our QA meeting.
• The emergency kits and the cart will be audit weekly to ensure educational material is in place. This will be ongoing for 3 months and review in our QA meeting. This will be monitored by ADON or designee.
• ADHOC QA completed with IDT regarding Policy and procedure.
• QA to review policy and procedure as part of Quality Assurance Process.
• This will be ongoing for 3 months.

Penalty

Inspection fine: $98,31362 days payment denial

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

Summary

A significant medication error occurred when a registered nurse (RN) failed to administer the correct medication to a resident experiencing a hypoglycemic crisis. The resident, who had a history of diabetes mellitus, end-stage renal disease, and other chronic conditions, was found to have a critically low blood glucose level. Despite having a physician's order for Baqsimi (Glucagon) nasal powder to be administered in such situations, the RN did not provide the prescribed medication. Instead, the RN mistakenly assembled and administered an epinephrine auto-injector with a nasal spray cap, believing it to be Glucagon, and delivered it nasally to the resident. This error was compounded by the involvement of another nurse who assisted in retrieving the emergency kit and handing the incorrect medications to the RN. The resident did not receive the ordered Glucagon, and his blood sugar continued to drop, necessitating emergency medical intervention and subsequent transfer to the hospital, where he was admitted to the intensive care unit. Interviews and documentation revealed that the RN was unfamiliar with the emergency medications and did not verify the medication before administration. The incident was further complicated by initial inaccurate reporting by the RN regarding the medications given. The facility's medication administration policy and the standard nursing practice of verifying the five rights of medication administration were not followed, resulting in the resident not receiving the appropriate treatment for hypoglycemia.

Removal Plan

• All nurses were educated on the use of Emergency Medications by DON.
• Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
• Nursing staff has been educated on the signs and symptoms of hypoglycemia and hyperglycemia by DON and ADON.
• Any nurses that are not available in person have been contacted via phone. If not reachable, will be educated prior to taking shift by DON or designee.
• NP was notified of the change in condition and MD notified of the resident being hypoglycemic and being sent to ER.
• V6 and V27 educated on ensuring right medication and dose prior to medication administration by DON.
• All nursing staff educated on the 5R's of medication administration by DON.
• V6 and V27 were educated and completed competency in medication administration on Narcan, Epinephrine, and Baqsimi.
• Nursing staff was educated on medication administration.
• DON or Designees will audit medication administration 2 times a week for 3 months.
• DON or Designee will audit 3 residents 2 times weekly to ensure blood sugars are within normal limit per MD orders for 3 months.
• The emergency kits and the cart will be audited weekly to ensure educational material is in place. This will be ongoing for 3 months and reviewed in our QA meeting. This will be monitored by ADON or designee.
• ADHOC QA completed with IDT regarding Policy and procedure.
• QA to review policy and procedure as part of Quality Assurance Process.
• This will be ongoing for 3 months.

Penalty

Inspection fine: $98,31362 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

Drugs and biologicals were not stored in accordance with accepted professional principles when medication carts were left unlocked in hallways and unattended. On one observation, a medication cart on the end of the 200-hall was sitting in the hallway unlocked with no staff member nearby; a CNA stated the nurse had gone to central supply and would return soon. The RN later stated the cart was broken, that staff were waiting for pharmacy to fix it, and that they were unable to lock it. The drawers on the right side were locked and could not be opened, so staff said they had to obtain medications from stock or emergency supply if needed. Additional observations found medication carts on the 4th floor and 3rd floor also sitting in the hall unlocked with no staff around. The DON stated nurses were expected to keep medication carts locked at all times when walking away from them. The facility also failed to dispose of an expired Tuberculin vial. In the 300-hall medication room refrigerator, surveyors found an opened multidose bottle of Tuberculin protein derivative Diluted/Aplisol 5TU/0.1 milliliters, 5ML/50 test that had been opened earlier. Staff stated that the 4th floor did not keep tuberculin testing serum on that floor and obtained it from the 2nd or 3rd floor medication room. The 200-hall medication room did not have a bottle of tuberculosis testing serum in the refrigerator, and the DON stated the facility had a bottle of tuberculosis test in the 3rd floor medication room that had been used when none was available in the 200-hall medication room. The Administrator stated the bottle of Tuberculin should have been thrown away a long time ago. The facility’s medication storage policy required medications and biologicals to be securely stored in locked cabinets, carts, or medication rooms and required opened medications with shortened expiration dates to be dated and handled according to manufacturer or supplier guidelines.

Penalty

Inspection fine: $98,31362 days payment denial

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

Summary

The facility failed to use hair nets while staff were in the kitchen, failed to provide paper towels at the handwashing sink, failed to label food items stored in the refrigerator, and failed to dispose of expired food items. During the initial kitchen tour on 9/7/25 at 8:50 AM, V18, Dietary Aide, and V19, Dietary Prep, were observed without hair nets and were seen getting hair nets and putting them on after the surveyor entered the kitchen. The handwashing sink did not have paper towels available for hand hygiene. In the refrigerator, a large piece of ham wrapped in plastic wrap was undated, a large pan of sliced tomatoes covered in plastic wrap was undated, and a pan of mixed vegetables covered in plastic wrap was undated. In the fourth-floor dry food storage room, three packages of hot dog buns were found expired on 9/4/25. V20, Cook, stated the items in the refrigerator should have been dated, especially since they were prepped and ready to eat, and said the delivery person usually rotates the bread when delivered. V21, Dietary Manager, stated dietary staff should wear hair nets while in the kitchen, label all opened and/or prepped food items placed in the refrigerator, and dispose of expired food items.

Penalty

Inspection fine: $98,31362 days payment denial

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

Summary

The facility failed to implement enhanced barrier precautions and failed to change gloves when soiled for residents reviewed for infection control. For one resident with physician orders for enhanced barrier precautions, a wound nurse and a CNA entered the room, and the CNA did not sanitize hands, don gloves, or wear a gown before entering. The CNA later sanitized hands and donned gloves at the bedside, but still did not wear a gown while assisting with repositioning during wound care. The enhanced barrier precautions sign in the room directed staff to clean hands before entering and when leaving and to wear gloves and a gown for high-contact resident care activities, including wound care. For another resident admitted with diagnoses including a groin abscess, infection following a procedure/surgical site, an open wound to the right lower leg, and type 2 diabetes mellitus, an LPN performed wound care and used the same gloves after cleaning the wound to obtain a sterile Q-tip and apply Medihoney and a dressing. The same LPN later assessed another open area after the resident reported oozing, donned PPE again, cleansed the wound, and again used the same gloves to apply Medihoney and a dressing without changing gloves between the soiled cleaning task and the application of treatment. The resident’s record showed the wound dressing on the right medial calf had not been changed the prior day. For a third resident with cerebral palsy, paraplegia, and malnutrition, two CNAs provided peri-care and catheter care while enhanced barrier precaution PPE was available at the door. During care, one CNA wiped the resident’s buttocks and anal area, changed gloves, then wiped the area again and later used the same soiled gloves to operate the bed remote, raise the bed, continue drying and positioning the resident, place a clean brief, adjust the resident in bed, and cover the resident with a sheet. Additional observations showed an LPN did not wear a gown while giving a G-tube water flush to a resident with enhanced barrier precautions for a Foley catheter, G-tube, and wounds, and a wound nurse did not wear a gown while changing dressings on another resident with enhanced barrier precautions for wounds.

Penalty

Inspection fine: $98,31362 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 identify and treat a resident’s wounds for 1 of 6 residents reviewed for wound care. The resident was admitted with multiple diagnoses including furuncle and abscess of the groin, infection following a procedure/surgical site, an open wound to the right lower leg, type 2 DM, CKD, ASHD, CHF, and HTN. The care plan and physician orders documented ongoing skin integrity concerns, including wounds to the right lateral calf, right medial calf, scrotum, right heel, and right toes, with orders for cleansing, medi-honey, bordered gauze, skin prep, and weekly skin assessment. The record showed a gap in skin monitoring and wound documentation. The resident’s skin condition report documented a new scrotal skin concern in 2024, but there was no other skin condition report until 9/9/25. The monthly charting for 8/22/25 did not document anything for the resident’s skin conditions, and the 7/22/25 monthly charting stated no new changes to skin integrity were noted. On 9/7/25, the resident stated the dressing had not been changed in a while and that it was supposed to be changed every day. The dressing on the right leg was old, heavily soiled, and had xeroform packing stuck to the open sites. On 9/8/25, the resident was observed with a new dressing dated 9/7/25. On 9/9/25, an LPN was told wound care was needed and stated she was not aware of the dressing to the right leg. The DON reviewed the orders and stated she did not see any wound care or dressing change orders for the right lower extremity. The LPN removed the old dressing, measured the right medial calf wound at 14.2 cm by 2 cm by 0 cm, and later identified a small open area on the right lateral calf measuring 1.1 cm by 0.3 cm by 0 cm after the resident mentioned it had been oozing for about a week. The wound nurse stated she had not been made aware of the right calf wounds and the DON stated she expected nurses and/or CNAs to report new wounds or skin conditions to the wound nurse to obtain physician orders.

Penalty

Inspection fine: $98,31362 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 prevent and assess a pressure ulcer for one resident with multiple sclerosis and traumatic brain injury who was moderately cognitively impaired and required partial to moderate assistance with dressing, toileting, bed mobility, and transfers. The resident was identified as at moderate risk for pressure ulcers on the Braden Observation. A nursing note documented consent for wound clinic services to begin, and the wound summary identified a facility-acquired coccyx pressure ulcer first noted on 7/16/25. However, the electronic medical record did not document a coccyx pressure ulcer assessment on 7/16/25 or 7/17/25, and the DON stated there was not an initial assessment of the coccyx pressure ulcer and that one should have been done when it was found. The wound summary showed the coccyx ulcer progressed from partial thickness with slough and scant serosanguineous drainage measuring 2.5 cm by 3 cm on 7/21/25 to unstageable with 30% slough and 70% necrotic soft tissue measuring 3.4 cm by 2 cm on 7/28/25. The July 2025 TAR documented daily treatment to cleanse the coccyx wound, apply calcium alginate, and cover with Mepilex starting 7/17/25. Later nursing documentation described slough, foul odor, brown wound bed, bright red peri-wound skin, and wound measurements of 3.7 cm by 2.6 cm by 1.9 cm. The resident stated his buttocks hurt and he did not know when he got the pressure ulcer. A wound culture was obtained, but the LPN/wound nurse stated the specimen was rejected by the laboratory because it was not collected on the lab's swab.

Penalty

Inspection fine: $98,31362 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 check for placement or residual of a gastrostomy tube for 1 of 2 residents reviewed for G-tubes. During observation, an LPN entered the resident’s room to give a 125 mL water flush, turned off the feeding pump, disconnected the tubing from the G-tube, and administered the water flush through the G-tube without checking for residual. The resident’s record documented a diagnosis of gastrostomy status and an order for enteral feeding every shift that included checking tube placement before feeding, flushing, and medications. When questioned, the LPN stated she had checked for residual, left the room, and then returned to give the water. The DON stated the residual should have been checked before giving the water flush. The facility policy for gastrostomy tube medication administration states to aspirate to visually verify stomach contents.

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 resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, lack of coordination, and reduced mobility was identified as being at risk for falls and dependent for toileting. The resident's care plan and fall risk assessment documented these risks and the need for staff assistance. On the date of the incident, the resident was being assisted with toileting by a CNA, who stepped out of the room to provide privacy while the resident was on the toilet, leaving the resident unattended. The resident's family was present in the room at the time. The resident subsequently fell off the toilet and was found lying on the bathroom floor by staff after being alerted by the family. The facility's Fall Prevention Program Policy states that residents requiring staff assistance should not be left alone after being assisted to bathe, shower, or toilet. Despite this policy, the CNA left the resident unattended, resulting in a fall. Interviews with facility staff confirmed that the CNA left the room and relied on the family to notify staff when the resident was finished, contrary to facility policy.

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 occurred when a cognitively intact resident, identified as an elopement risk, left the facility unsupervised, obtained alcohol, and was subsequently found by police and transported to the hospital. The resident was known to have a history of wandering and exit-seeking behaviors, as documented in multiple risk assessments and care plans. Despite these known risks, the resident was able to remove his wander guard device and exit the facility without staff knowledge. Staff interviews revealed that the resident was last seen in the building around 1 PM, and the facility did not become aware of his absence until contacted by police several hours later. The facility's policy required frequent monitoring and the use of electronic alert systems for residents at high risk of elopement. However, staff reported that rounds were made every two hours, and there was no formal policy on the frequency of these rounds. The resident's care plan included interventions such as a wander guard, door alarms, and structured routines, but these measures were not effective in preventing the resident from leaving. Staff also noted that the resident had previously removed his wander guard and had a pattern of wandering and exit-seeking, yet he was able to leave undetected. Documentation showed that the resident was alert and oriented at the time of the incident, and his medical records indicated a history of alcohol use and elopement risk. The facility's elopement policy focused primarily on cognitively impaired residents and did not clearly address procedures for cognitively intact individuals with elopement risk. The lack of effective supervision and monitoring allowed the resident to leave the facility, obtain alcohol, and require emergency medical evaluation.

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 notify the Power of Attorney (POA) of a change in condition for one resident who was being treated for pneumonia. The POA was not informed that the resident was placed on an antibiotic until the resident was being sent to the hospital. This lack of communication was confirmed by the POA and the facility's administrator, who acknowledged that the registered nurse did not notify the POA of the change in the resident's condition. The resident's medical records indicated a positive chest x-ray for pneumonia and a new order for Doxycycline, but there was no documentation of the POA being notified. The facility's policy requires that the resident's legal representative or family be informed of significant changes in the resident's health status. This policy was not followed, leading to the deficiency noted in the report.

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 properly store, label, and date raw poultry and other food items, as well as failed to properly sanitize dishware, cups, and silverware. During an inspection, a zip lock bag with thawed chicken was found on the top shelf of a refrigerator, with cups of juice underneath, and a sandwich dated from ten days prior. Another refrigerator contained undated fruit bowls and cups of a red, jelled substance. The dishwashing machine was found to be malfunctioning, with a chlorine test strip reading zero, indicating no sanitization was occurring. The machine was also leaking water, and its temperature gauge was broken. The dietary consultant, V15, acknowledged the issues with the food storage and the dishwashing machine, stating that the chlorine was not being dispensed properly. The administrator, V1, confirmed that the thawed chicken should have been dated and stored correctly. The facility's policies require all food to be labeled and dated, and for raw animal foods to be stored separately from ready-to-eat foods. The dishwashing machine should not be used if it is not functioning properly, and manual dishwashing procedures should be followed if necessary. However, the facility did not have a policy for manual dishwashing at the time of the inspection.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its water management policy, which is designed to prevent potential waterborne illnesses such as Legionella. The Maintenance Director, identified as V20, admitted to flushing the pipes in unoccupied rooms on the 1st and 4th floors only once a month without documenting the procedure. This is contrary to the facility's policy, which requires weekly verification and documentation of preventative maintenance activities, including flushing eyewash stations and ensuring water temperatures are within specified ranges. The Administrator, V1, acknowledged the ongoing construction on the 4th floor and the need for a log to document these procedures. Additionally, the facility did not follow its Enhanced Barrier Precautions (EBP) policy, which is intended to reduce the transmission of multidrug-resistant organisms. A resident, identified as R58, who has severe cognitive impairment and is dependent on staff for all activities of daily living, was not provided care in accordance with EBP. Two Certified Nursing Assistants (CNAs), V25 and V26, entered R58's room and performed peri-care without wearing the required personal protective equipment (PPE), despite a sign on the door indicating the need for EBP. The CNAs admitted to forgetting to wear gowns, and the Licensed Practical Nurse (LPN), V28, was unaware of the CNAs' actions. The facility's policy on Enhanced Barrier Precautions mandates the use of gloves and gowns during high-contact resident care activities, especially for residents with indwelling medical devices such as feeding tubes. The Administrator, V1, confirmed the expectation that all staff should wear appropriate PPE when entering a resident's room under EBP. The failure to comply with these infection control measures has the potential to affect all 109 residents residing in 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 accommodate the smoking needs of four residents, all of whom were cognitively intact and expressed dissatisfaction with the current smoking arrangements. Resident R14, who has a physical and psychological addiction to nicotine, was unable to smoke due to a broken wheelchair that limited his mobility, forcing him to stay in bed all day. This resident typically receives three smoke breaks a day, each lasting six minutes, which he feels is insufficient. The care plan for R14, initiated in 2020, acknowledges the potential for physical and psychosocial disturbances due to disruptions in his smoking routine. Other residents, R47, R61, and R97, also reported dissatisfaction with the smoking policy, which allows only one cigarette per break and limits the time to six minutes. These residents expressed feelings of being restricted and desired more time or additional cigarettes during their breaks. Observations confirmed that residents were given one cigarette and were taken back inside after six minutes, despite their requests for more. The facility's smoking schedule indicates designated times for smoking breaks, but the administrator acknowledged that residents are allowed more than one cigarette, although practical limitations and financial considerations were cited as reasons for the current policy.

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 timely and complete incontinent care for several residents, as observed during the survey. Resident R25, who has multiple diagnoses including Multiple Sclerosis and is frequently incontinent, reported waiting extended periods before being cleaned after incontinence episodes. Observations revealed that staff did not change gloves or perform hand hygiene between tasks, and contaminated clean water by using soiled gloves. This resulted in inadequate cleaning and potential risk of infection. Resident R58, who is severely cognitively impaired and always incontinent, also received inadequate care. Staff were observed using the same gloves throughout the cleaning process, contaminating clean water, and failing to thoroughly clean the peri area. This incomplete cleaning process was not in line with the facility's policies, which require thorough cleaning and drying of the resident's skin. Similar deficiencies were noted with residents R4 and R97. Staff failed to cleanse and dry all necessary areas during incontinent care, leaving soap suds on the skin and not addressing all soiled areas. These actions were contrary to the facility's policies, which emphasize the importance of thorough cleaning and drying to prevent skin breakdown and infection.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to its policy regarding tube feeding for a resident, identified as R58, who was admitted with multiple medical conditions including cerebral infarction with monoplegia, dysphagia, and gastrostomy. The care plan for R58 required specific interventions such as checking tube placement, maintaining the head of the bed (HOB) at a 45-degree angle during and after feeding, and proper labeling of feeding bottles. However, observations revealed that the tube feeding bottles were not consistently labeled with the resident's name, date, and time, and the feeding rate was incorrect on one occasion. During the survey, it was observed that an unlabeled bottle was used for R58's tube feeding, which was not in compliance with the facility's policy. The bottle was spiked and hung without proper labeling, and it was used for feeding despite the lack of identification. Additionally, the feeding rate on the unlabeled bottle was noted to be 65 ML/hour, which was not in accordance with the physician's order of 55 ML/hour. This discrepancy in labeling and feeding rate was not addressed by the staff, leading to a deficiency in the care provided to R58. Furthermore, during peri-care, the CNAs lowered R58's HOB without stopping the tube feeding, contrary to the facility's policy that required the feeding to be paused during such care. The CNAs were unaware of the need to inform the nursing staff to stop the feeding, and the LPN was not informed of the care being provided. This lack of communication and adherence to protocol contributed to the deficiency in the resident's care, as the tube feeding continued while the resident's position was altered, potentially compromising their safety.

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 administer medications according to the physician's orders for a resident diagnosed with intracerebral bleed, Alzheimer's, and atrial fibrillation. The resident was prescribed Seroquel 25mg, with instructions to take half a tablet every day and a full tablet at bedtime. However, the facility's records indicated that the resident was administered both a half tablet and a full tablet of Seroquel at bedtime, resulting in a total of 37.5mg being given instead of the prescribed 25mg. This medication error occurred over several days, from the 6th to the 10th of July, before being identified by the Assistant Director of Nursing during a review of consents. The error was acknowledged by both the Assistant Director of Nursing and the Director of Nursing, who confirmed that the resident received an incorrect dosage of Seroquel at bedtime, which was not in accordance with the doctor's orders. The facility's policy on medication administration requires adherence to doctor's orders, which was not followed in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to timely treat a urinary tract infection (UTI) for a resident (R3) who had an indwelling catheter due to obstructive uropathy. Despite the care plan indicating the need to monitor and report signs and symptoms of a UTI, the facility did not act promptly on the urinalysis results. R3's urinalysis, collected on 4/7/2024, indicated a UTI, but there was a delay in communication and follow-up with the urologist's office, resulting in a delay in antibiotic therapy and catheter change. This delay contributed to R3's condition worsening, leading to septic shock and admission to the intensive care unit (ICU). The urologist had ordered Bactrim, monthly catheter changes, and bladder irrigations, but these orders were not promptly executed by the facility staff. R3's medical history included a right femoral head fracture, obstructive uropathy, and chronic Foley catheter use. The urologist's progress note from 3/27/2024 indicated that R3's bladder was loaded with debris and the catheter tubing was very dirty, suggesting poor care at the facility. Despite the urologist's orders for better catheter care, the facility failed to follow through in a timely manner. The urinalysis results were not promptly communicated to the urologist, and there were multiple attempts by the urologist's office to contact the facility without success. This lack of timely communication and follow-up led to a significant delay in R3 receiving the necessary antibiotic treatment and catheter care. On 4/23/2024, R3 was admitted to the local hospital's emergency room with symptoms of septic shock, including suprapubic pain, weakness, decreased oral intake, and abnormal lab results. The hospital's emergency room notes documented that R3 had a history of UTIs and was found to have acute kidney injury, severe anemia, lactic acidosis, and sepsis secondary to a UTI. The delay in antibiotic therapy and improper catheter care at the facility were significant factors contributing to R3's deteriorating condition and subsequent hospitalization.

Penalty

Inspection fine: $47,515

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

Summary

The facility failed to provide the physician-ordered pain medication for a resident (R3) who was admitted with an infection and inflammatory reaction due to an internal left knee prosthesis. Despite having a physician's order for Oxycodone-Acetaminophen to be administered every four hours as needed for chronic pain, R3 did not receive the medication from 3/23/24 to 3/25/24. The resident reported severe pain during this period, rating it as a 30 on a 0-10 pain scale. The delay in medication was due to the prescription running out of refills and the subsequent order not being delivered until 3/26/24, despite being placed as a STAT order on 3/25/24. The resident's pain was not adequately managed with alternative medications, as he refused Tylenol offered by the nursing staff. Interviews with the nursing staff and the Director of Nurses revealed that the issue was identified on 3/25/24, but the pharmacy's cut-off time delayed the delivery of the new prescription until the following day. The staff noted that the resident often complained of pain but did not exhibit obvious signs of distress. The Director of Nurses acknowledged the lapse in medication management and the failure to ensure timely delivery of the pain medication. The facility was unable to locate the pharmacy policy at the time of the survey, indicating a potential gap in procedural adherence and documentation.