Central Nursing Home

Penalty

Inspection fine: $42,7002 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 one resident from abuse by a staff member during an incident at the front desk involving a planned supervised pass. The resident had diagnoses including aneurysm of other precerebral arteries, type 2 diabetes mellitus, and generalized anxiety disorder, and had a BIMS score of 15 indicating intact cognition. The resident had an active order allowing supervised passes. According to the resident, the Social Service Coordinator entered the area, said the resident was not leaving, attempted to unapprove the pass, and yelled at the resident, the resident’s sister, and other residents. The resident stated the staff member used profanity toward the resident and the resident’s sister. The receptionist stated the staff member came behind the reception desk, yelled at the resident, yelled at the resident’s sister, and caused the resident to cry. The receptionist called code gray during the incident, and part of the event was heard throughout the facility because the intercom was inadvertently turned on. The facility also failed to protect a resident from abuse by another resident during a verbal altercation involving a box cutter. One resident had diagnoses including urinary tract infection, intestinal obstruction, other neoplasms of uncertain behavior of lymphoid, and generalized anxiety disorder, with a BIMS score of 15. The other resident had diagnoses including COPD and schizophrenia, with a BIMS score of 14, and a care plan noting hallucinations, delusions, and disorganized thinking. Staff reported that the two residents were in line to smoke when an argument began, and one resident pulled out a knife or box cutter and threatened to kill the other resident. The police were called, and the box cutter was found in the resident’s pocket. The threatened resident reported feeling unsafe and later requested to leave the facility against medical advice. Record review showed the facility documented the incident as a verbal altercation with threats, with both residents separated and assessed with no injuries noted. Additional notes documented that the resident who possessed the box cutter was readmitted later and that a search of belongings found no prohibited items. The facility policy stated residents have the right to be free from abuse, including verbal, mental, sexual, or physical abuse, and that all possible incidents of abuse must be identified and investigated while protecting residents from further harm during investigations.

Penalty

Inspection fine: $42,7002 days payment denial

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

Summary

The facility failed to provide adequate and clean linen for residents. During observations on multiple floors, surveyors found linen carts with no washcloths or bath towels, and staff on the first, third, and fourth floors reported that linen supplies were not always fully stocked. A CNA on the fourth floor stated there was only one linen cart on that floor and that extra towels and linen were kept in a drawer at the nurses' station because the cart was not always fully stocked. On the third floor, a CNA stated there were no clean linen storage closets on either floor in the facility. Surveyors observed multiple drawers and linen carts containing towels that were ripped, torn, frayed, tattered, or heavily stained. On the fourth floor, surveyors found 9 towels in a drawer, including 4 ripped or torn towels with frayed and tattered edges, and the towels appeared to have been cut into smaller pieces to make more towels. On the third floor, surveyors observed 16 towels in a drawer, including 14 ripped or torn towels with frayed and tattered edges, along with 3 heavily stained towels that the CNA stated should not be in circulation for resident use and moved aside for housekeeping use. On the second floor, linen carts contained towels with ripped, torn, frayed, and tattered edges, and one cart had no towels at all. On the first floor, surveyors observed five linen carts, four of which had no towels and one that contained 3 towels with ripped, torn, frayed, and tattered edges. A RN stated the towels were probably cut to make more towels because the facility was low on towels. A laundry aide stated he had heard staff report a lack of towels and had noticed a lack of towels during washing and recirculating linen. In the basement linen storage room, surveyors found only 5 washcloths and 7 body towels, including 3 towels with ripped, torn, frayed, and tattered edges. The facility census documented 209 residents, and the Administrator stated linen was sometimes obtained from the corporate office warehouse, while the ADON stated the facility was constantly ordering towels.

Penalty

Inspection fine: $42,7002 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 a resident’s freedom of movement outside the facility when R5 was placed on restricted red pass privilege without a legitimate basis. R5 stated that the facility confused the situation and that a receptionist told them they were on red pass, which prevented them from going out for 48 hours. The Social Services Director stated that receptionists do not have authority to place residents on red pass, that there was no documentation supporting the restriction, and that an order is needed from the physician for red or green pass privilege. The Administrator stated the receptionist used an old pass list and that no one knew why R5 was placed on red pass. R5’s physician order summary showed an active order allowing unsupervised pass, and the MDS dated 5/1/2026 showed a BIMS score of 15, indicating intact cognition. The facility also failed to ensure Social Services met regularly with R4. R4’s diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, gait and mobility abnormalities, type 2 diabetes mellitus with hyperglycemia, history of TIA, and cerebral infarction without residual deficits. R4’s MDS documented a BIMS score of 12/15, indicating moderate cognitive impairment. The Social Services Director stated that social services are supposed to meet with residents at least once every three months to assess needs, but review of R4’s progress notes showed the last Social Services meeting with R4 and family was on 09/03/2025. The Social Services Director stated another meeting should have been conducted and that she had been too busy to meet with residents frequently. The facility further failed to ensure proper staff, resident, and representative communication by not ensuring all staff wore identification badges. During observations on multiple floors, several staff members including an RN, LPNs, CNAs, an activity aide, and a social worker were observed without name tags or ID badges. Some staff stated their badges were in a purse or locker, one said she lost hers the day before, and others stated they had never been issued an ID badge. The facility employee handbook stated that name badges are supplied by the facility and must be worn by all employees when on duty, and that all employees are required to have and wear their ID cards at all times while at work.

Penalty

Inspection fine: $42,7002 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 to the State Agency a suspicion of abuse involving one resident. The resident stated that while preparing to leave the building on a pass with a sister and nephew, the Social Service Coordinator came in, said they were not leaving, and began yelling at the resident, the resident’s sister, the receptionist, and other residents. The resident reported being told to shut up and described the interaction as unprofessional and abusive. The resident also stated the resident was on a red pass because of a late return from a prior pass, but could still go out with family, and identified the sister as the primary emergency contact. The receptionist stated that the incident occurred at the front desk when the resident was excited to go out, that the DON was called to verify the outing, and that the Social Service Coordinator came behind the reception desk, yelled at the resident, and yelled at the resident’s sister after she entered the building. The receptionist called code gray twice, and the second call inadvertently activated the intercom so part of the incident was heard throughout the facility. The Administrator stated the event was not reported because it was viewed as a conflict between the resident’s family member, the Social Service Coordinator, and the receptionist, and said the matter was still under investigation. The facility policy stated allegations must be investigated and reported within required federal timeframes.

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 an adequate supply of clean towels and linens in good condition for resident care, as evidenced by multiple observations, interviews, and record reviews. Residents reported having to purchase their own towels due to shortages, and staff confirmed that there were not enough towels and linens available to meet the needs of all residents. On several occasions, staff resorted to using sheets, pillowcases, or even diapers to clean residents when towels and washcloths were unavailable. The laundry staff acknowledged delivering significantly fewer towels than required, and described cutting up bath towels to create makeshift washcloths, which were observed to be tattered, frayed, and stained. Clean linens and blankets were also observed to have persistent stains, including feces, pus, and blood, which could not be removed despite laundering. Residents affected by this deficiency included individuals with significant care needs, such as those who were always incontinent of urine and bowel, required maximal assistance for hygiene, and had multiple comorbidities including morbid obesity, diabetes, contractures, and mobility limitations. These residents were dependent on staff for all aspects of personal care, including bathing, toileting, and hygiene. The lack of adequate linens and towels directly impacted their ability to maintain personal cleanliness and dignity, as they were sometimes unable to wash their faces or be properly cleaned after incontinence episodes. Staff interviews revealed that the shortage of towels and linens was a recurrent and well-known problem, with CNAs frequently having to search other units or purchase their own wipes to provide care. Laundry staff reported being unable to discard stained or damaged linens due to insufficient supply, and did not have access to new linens stored in a locked supply closet. Nursing and administrative staff were aware of the issue, with some indicating that they had provided instructions for reporting shortages, but the problem persisted due to lack of communication and inadequate replenishment of supplies.

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 prevent a resident-to-resident physical assault involving two residents, resulting in one resident sustaining a skin abrasion. One cognitively intact resident reported being struck on the left side of her face by another resident as she was leaving the dining room. She experienced bleeding from a small abrasion and sought assistance from staff, who provided first aid. The resident declined hospital treatment, reporting only a minor scratch and no ongoing pain. Staff observed a small scar on her face with no signs of infection during the survey. Interviews with staff revealed that the incident was reported promptly, and the involved resident was described as calm and non-provocative. The resident who committed the assault was a new admission with no prior signs of agitation or aggression. Staff and police were notified, and the resident responsible for the assault was sent for psychiatric evaluation. Documentation confirmed the physical altercation and the resulting injury, and the facility's abuse policy was referenced, which states that residents have the right to be free from abuse.

Penalty

No penalty information released

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

Summary

The facility failed to report an incident of resident-to-resident physical abuse to the State Agency as required. On the day of the incident, one resident was struck in the face by another resident while entering the dining room, resulting in a bleeding abrasion on the left side of the face. The injured resident, who was cognitively intact, reported the incident to staff, and the LPN on duty observed the injury and notified the Assistant Director of Nursing, the police, both residents' physicians, and family members. The resident who committed the act was sent to the hospital for psychiatric evaluation. Despite internal notifications and documentation of the incident, there was confusion among facility leadership regarding who was responsible for submitting the required report to the State Agency. The Administrator believed the DON was responsible, while the DON stated she was not able to submit the report due to being offsite and without computer access, and that the Administrator had agreed to handle it. Both parties referenced their usual practices for reporting but could not provide evidence that the report was submitted for this specific incident. Review of facility records and confirmation from the State Agency indicated that no report was received for the incident. The facility's own policy requires that all allegations of abuse involving injury be reported to the State Agency within two hours, with a final report submitted within five business days. For this incident, the initial and final reports provided by the facility were undated, untimed, and lacked any evidence of submission. The absence of confirmation documentation and the statements from both the Administrator and DON confirmed that the required reporting did not occur for this event.

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 follow its policy regarding the investigation and prevention of further abuse following allegations made by a resident. Specifically, a resident reported that a CNA was verbally abusive and that a Restorative Aide engaged in mental abuse. The resident could not recall the exact date or time of the incidents, and there were no witnesses. Upon being informed of the allegations, the Administrator acknowledged that there were no prior reports against the staff members in question but stated she would follow up. The facility's policy requires immediate suspension of any staff accused of abuse pending investigation to protect residents from potential harm. However, the Administrator did not suspend the accused staff, citing the need to maintain staffing levels during the holidays and the resident's absence from the facility. The Administrator conducted interviews with the accused staff and completed the investigation quickly, allowing the staff to continue working without suspension. The Director of Nursing confirmed that the facility's policy is to immediately suspend any staff accused of abuse, whether they are on duty or scheduled to work, until the investigation is complete. Documentation reviewed included the facility's abuse policy, investigation and reporting documents, and in-service attendance records. The failure to suspend the accused staff during the investigation was not in accordance with the facility's established policy and procedures.

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 as prescribed by physicians for two residents. One resident, with diagnoses including glaucoma, anxiety disorder, and major depressive disorder, did not receive all required doses of her prescribed eye drops (brimonidine tartrate) on two occasions, as confirmed by both her statements and a review of the Medication Administration Record (MAR). The MAR was not signed for these doses, and the nurse responsible could not provide an explanation for the missed documentation or administration. Another resident, with complex medical conditions including cellulitis, MRSA infection, and an open wound, did not receive his prescribed intravenous antibiotic (daptomycin) on three separate occasions. The MAR confirmed these missed doses, and the Assistant Director of Nursing acknowledged that the antibiotic should not have been missed to ensure proper treatment of the infection. The nurse practitioner indicated that insurance issues delayed approval for the medication, leading to a change in antibiotic therapy after several missed doses. Facility policy and job descriptions require medications to be administered as ordered and documented accordingly.

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's personal belongings were not treated with respect during the discharge process. When the resident was transferred to another facility, a family member arrived to collect the resident's items and found that all belongings had been placed together in a single bag on a dirty cart. The family member observed that chocolate syrup had leaked onto the resident's clothes, contaminating them. Staff interviews confirmed that food items, specifically a bottle of chocolate syrup, were packed together with clothing, resulting in the spillage. The staff involved were unclear about who specifically packed the belongings, but it was acknowledged that the facility's policy prohibits packing food with clothing and requires respectful handling of resident property. The Director of Nursing (DON) and an LPN both stated that the facility was not informed in advance that the family would be picking up the belongings, and the process for packing and storing items was not properly followed. The family member refused to accept the contaminated belongings and requested a refund, which led to further communication attempts with the facility's administration. The facility's policy, dated March 2025, specifies that resident belongings must be treated with respect, regardless of their perceived value, a standard that was not met 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 prevent both verbal and physical abuse involving staff and residents. In one incident, a former Licensed Social Worker (LSW) engaged in a verbal altercation with a resident in the dining room, during which both parties exchanged profanities. Multiple staff members and the resident involved confirmed that the staff member used inappropriate language and engaged in argumentative behavior, which was considered verbal abuse. The altercation was witnessed and reported by staff, and the resident expressed feeling abused by the staff member's actions. Additionally, the facility did not prevent physical abuse between residents in several instances. In one case, a resident was struck on the head by another resident without provocation, as observed by a CNA. In another incident, a resident was scratched on the face with a comb by another resident following an argument about a prosthetic sleeve, resulting in superficial injuries. The aggressor in this case had expressed unfounded fears about disease transmission, and the victim reported feeling unsafe due to the return of the aggressor to the facility. A further incident involved a resident slapping a cup out of another resident's hand, causing the cup to hit the resident in the lip during a verbal confrontation. The facility's abuse prevention policy states that residents have the right to be free from all forms of abuse, including physical and verbal abuse, and that protection must be provided from abuse by anyone, including staff and other residents. Despite this policy, the facility did not effectively prevent these incidents of abuse.

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 follow its fall clinical protocol for one resident who experienced an unwitnessed fall. According to staff interviews and record review, the resident was found sitting on the floor next to his bed early in the morning. Immediate assessment was performed, including checking vital signs, and the resident was assisted back to bed. The resident was severely cognitively impaired, with a history of cerebrovascular accident resulting in right hemiparesis, and was at high risk for falls as documented in his care plan. Despite the facility's protocol requiring assessment and documentation of all current medications, especially those associated with increased risk of bleeding, there was no evidence that the resident's use of antiplatelet medication was considered or communicated to the physician at the time of the fall. The primary physician later stated that, had he been informed of the resident's antiplatelet use and the unwitnessed nature of the fall, he would have ordered a CT scan due to the risk of internal bleeding, even though the resident's vital signs were stable. The protocol also required a thorough head-to-toe assessment and monitoring for signs of injury, which was not fully documented in the records reviewed. Staff interviews revealed inconsistent understanding and application of the fall protocol, particularly regarding the need to review medications and communicate relevant information to the physician. The facility's failure to follow its own clinical protocol for falls, including comprehensive assessment and communication, resulted in a deficiency related to providing appropriate treatment and care according to orders, resident preferences, and goals.

Penalty

No penalty information released

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

Summary

The facility failed to ensure the dignity of a resident during incontinence care. On January 15, 2025, a Certified Nursing Assistant (CNA) was observed providing care to a resident (R2) without the use of proper towels, instead using a bed/flat sheet to wipe the resident's bottom. The resident confirmed that the facility often runs out of towels, leading to the use of pillowcases and bed sheets for incontinence care. This practice was observed when the CNA had to leave the room to retrieve a linen cart, only to find no towels available, thus resorting to using a bed sheet. The facility's administrator acknowledged a previous concern regarding the availability of linen towels and mentioned that the issue might be due to staff mistakenly discarding them. The administrator stated that the lack of towels could lead to skin breakdown and affect the residents' dignity, as they have the right to an environment similar to their home. The resident involved, R2, is a cognitively intact individual with a BIMS score of 15/15 and has medical conditions including osteoarthritis, morbid obesity, and incontinence. The resident's care plan did not document the use of bed sheets for incontinence care, highlighting a gap in ensuring the resident's dignity and proper care.

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 nail trimming and care for a resident, identified as R1, who was part of a sample of three residents reviewed for activities of daily living (ADL) care. R1's admission record includes diagnoses such as moderate intellectual disabilities, acute kidney failure, major depressive disorder, hypertensive heart disease without failure, anxiety disorder, schizoaffective disorder, and scabies. Despite being cognitively intact with a BIMS score of 15, R1 required partial/moderate assistance for showering and supervision or touching assistance for personal hygiene. Observations on 9/30/24 revealed R1 struggling to open a milk carton due to long fingernails with debris underneath, indicating a lack of proper nail care. On 9/30/24, a registered nurse and a licensed practical nurse assisted R1 with drinking from the milk carton but did not address the long fingernails. R1 expressed a desire to have the nails trimmed, acknowledging that staff had previously offered to cut them. However, the nails remained untrimmed and unchanged by 10/1/24. A certified nursing assistant confirmed that R1 had requested nail trimming but noted that the clippers were kept with the nurse. The facility's wound care nurse and director of nursing acknowledged the importance of keeping R1's nails short to prevent skin tears, especially given R1's ongoing treatment for intrinsic eczema and tinea. The facility lacked a specific policy for grooming and nail care, relying instead on a general ADL policy. The policy stated that residents should receive routine daily care to promote hygiene and comfort, with ADL care provided throughout the day. Despite this, R1's care plan, which included interventions for skin integrity and self-care deficits, was not adequately followed, resulting in the observed deficiency in nail care. The facility's job descriptions for CNAs and RNs emphasized the importance of adhering to professional standards and providing comprehensive ADL care, which was not met 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 implement adequate fall prevention interventions and supervision for two high fall risk residents, R2 and R3. R2, who has multiple diagnoses including Parkinson's disease, Alzheimer's disease, and dementia, was identified as a high fall risk due to impaired cognitive skills and mobility issues. Despite this, R2 was left unsupervised at the nurse's station, leading to a fall incident. The staff, including CNAs and nurses, were inconsistent in their understanding and communication of R2's fall risk status, and R2 was observed wearing non-skid proof socks, contrary to the care plan's intervention for appropriate footwear. R3, also a high fall risk resident with a history of falling and multiple medical conditions, was found in a room with fall mats improperly placed away from the bed. R3's cognitive skills were severely impaired, and the resident was observed leaning over the bed without adequate supervision. The staff's responses indicated a lack of awareness of R3's fall risk status, and the fall prevention interventions were not consistently implemented, as evidenced by the improper placement of fall mats. The facility's policy required quarterly fall risk assessments and appropriate interventions for high-risk residents, but these were not consistently performed. R2's fall risk assessment was overdue, and there was a lack of communication among staff regarding the residents' fall risk status and necessary precautions. The facility's failure to adhere to its fall prevention program and ensure proper supervision and interventions contributed to the deficiencies observed in the care of R2 and R3.

Penalty

Inspection fine: $16,801

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 monitor and supervise a resident with a known risk of elopement, resulting in the resident leaving the facility without permission. The resident, who had a history of dementia, bipolar disorder, and PTSD, was cognitively impaired and required supervision to ensure safety. Despite these needs, the resident managed to exit the facility through a fire exit door, triggering an alarm that staff failed to respond to effectively. The resident was later found deceased in an abandoned building, highlighting the severe consequences of the facility's oversight. Interviews and observations revealed that the facility had inadequate security measures in place, such as malfunctioning alarms and easily accessible elevator codes, which residents could use to leave the building unsupervised. Staff members, including the receptionist and nursing staff, were aware of the resident's elopement risk but did not take appropriate actions to prevent the resident from leaving. The facility's elopement risk assessments and care plans were not effectively implemented, and there was a lack of documentation and communication regarding the resident's attempts to leave the facility. The facility's failure to maintain a secure environment and provide adequate supervision for residents at risk of elopement was further compounded by staff's inability to promptly locate the resident after the alarm was triggered. The facility's policies on missing residents and elopement risk were not adequately followed, leading to a tragic outcome. The lack of proper training and awareness among staff members contributed to the facility's inability to prevent the resident's elopement and subsequent death.

Removal Plan

• R1 is no longer at the facility.
• Resident head count of the whole facility was completed by the DON/clinical managers. There was no concern identified.
• Headcount is done during shift change as part of the nurse-to-nurse shift reporting and when the staff identifies that a resident is missing.
• Facility wide audit was done to identify residents that are high risk for elopement by the DON, unit manager, Administrator and Social Services.
• Any resident who is identified with wandering behavior/elopement risk will have care plans developed. This will be completed by the IDT.
• The elopement binders have been updated and all elopement binders in all floors. The elopement binder is updated when a new resident is added to the binder. A resident is added to the binder when the resident is identified with exit seeking-behavior/risk for elopement.
• The Maintenance Director or designee will check all exit doors. Initially done and daily.
• The DON or designee will provide education and competency test to the staff including agency staff. The education items include but not limited to: Code 99, Use of the elopement binders, Exit-seeking behaviors and interventions, Elopement risk and wandering and interventions, Policy on missing resident, Responding to alarms, Resident safety and supervision. The training was completed. Any staff who are not available, on vacation or leave of absence will have training completed at the start of their shift upon return to work.
• The DON or designee also reviewed the general orientation to ensure that the following items were included: Code 99, Use of the elopement binders, Exit-seeking behaviors and interventions, Elopement risk and wandering and interventions, Policy on missing resident, Responding to alarms, Resident safety and supervision.
• Ad-Hoc QAPI meeting was completed which were participated by the leadership team which includes the Director of Nursing, ADON, Social services Director, Assistant Administrator, Rehabilitation Manager, and the Activities Director. The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events.
• Elopement drill was completed by the Administrator. This will also be completed daily, for the seven days, and will be done at different shifts. After seven days, the elopement drills will be done weekly for three months, then monthly thereafter.
• All exit doors in the facility will also be checked by the Maintenance Director to ensure all doors were locked, secure and alarms are functioning. Staff will be stationed at each identified exit until the identified exits have a delayed egress installed. Service has been contacted and scheduled to install egress delays. Door checks will be completed daily, including weekends by the MOD manager or designee. The door checks will be completed by Maintenance Director, or designee. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed.
• Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD/charge nurse or designee will also conduct weekend clinical meetings to review new or worsening exit-seeking/wandering behaviors and ensure interventions are in place to prevent elopement.
• New admissions will be reviewed by the DON or designee for elopement risk and any resident identified as being at risk will be updated into the facility elopement books.
• The QAPI team will hold a weekly Ad-Hoc QAPI meeting to discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors. The QAPI team will determine if additional corrective actions are necessary based on concerns identified.
• Staff is stationed at each identified exit until the identified exits have a delayed egress installed.
• The identified exits are emergency exits and will have 15 second delayed egress installed.
• Service with outside vendor has been contacted and scheduled to install egress delays.
• All staff on the unit will respond to the codes. Follow up by the nurse-supervisor.
• Codes were changed to door. Residents do not have access to codes.

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 proper sanitation and food handling practices, which are essential to prevent foodborne illnesses among residents. During an observation, the head cook was seen pureeing a veal patty and subsequently instructed a kitchen aide to wash the blender pitcher and rubber spatula used in the process. The kitchen aide washed these items in a washer container, then moved them to a rinse container, and finally to a sanitizing compartment. However, the head cook used the blender pitcher and spatula to puree pasta while they were still wet with sanitizer, which could potentially contaminate the food. The kitchen aide acknowledged that the equipment should be completely dry before reuse to avoid contamination. The facility's policy on manual sanitizing in a three-compartment sink requires utensils and equipment to be sanitized by immersion in hot water or a chemical sanitizing solution, but it does not specify the need for drying before reuse.

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 proper infection prevention and control practices, as evidenced by several observations and interviews. A resident with a urinary catheter was found with the catheter bag lying flat on the floor, contrary to the facility's policy that requires the catheter to maintain a sterile, continuously closed drainage system. This oversight was noted by the Director of Nursing, who acknowledged that the urinary catheter bag should not be in contact with the floor to prevent contamination. The resident had a history of urinary tract infection and was receiving antibiotic therapy, highlighting the importance of adhering to infection control protocols. Additionally, the facility did not ensure that linens were handled in a sanitary manner. A housekeeping staff member was observed folding linens that touched the floor, which is against the facility's policy that requires linens to be folded on a table to prevent contamination. Furthermore, an air blower used in the clean linen room was found to be dusty and unclean, which could potentially compromise the cleanliness of the linens. The facility's infection prevention policies and procedures were outdated and lacked documentation of annual reviews, which is necessary to ensure they are in accordance with current national standards.

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 professional standards of medication administration documentation, affecting 19 residents. On the morning of the survey, a registered nurse (RN), identified as V15, completed a medication pass for the 9:00 AM scheduled medications but did not document the administration immediately as required. The surveyor observed that V15 took the medication administration record (MAR) away from the medication cart to sign off on the medications after the fact, which is against the facility's policy. The facility's policy mandates that medications must be documented immediately after administration to prevent errors. The Director of Nursing (DON), identified as V2, confirmed that if medication administration is not documented, it is considered not given, which could lead to medication errors. The review of the MAR for the first-floor medication cart #2 revealed that V15 did not sign for the medications administered to the 19 residents. The facility's policy, dated December 2022, clearly states that medication must be charted immediately following administration by the person administering the drugs, including the date, time, and dosage.

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 controlled substances were counted and documented at the beginning and end of each shift for two out of sixteen shifts, potentially affecting 45 residents on the fourth floor. On two occasions, the Shift Change Accountability Record for Controlled Substances was missing signatures, indicating that the required narcotic drug count was not performed or documented. Specifically, on August 6, 2024, a surveyor observed that the LPN responsible for the 4th floor medication cart did not sign the narcotic count sheet for the 7am-3pm shift. Additionally, on August 2, 2024, both the oncoming and off-going shifts for the same time period were missing signatures. The Director of Nursing (DON) stated that it is the facility's policy for off-going and oncoming nurses to count narcotics together to ensure an accurate count. If the oncoming nurse is late, the off-going nurse should count with another nurse or call the supervisor to perform the count. The facility's policy, dated April 11, 2023, requires that change of shift counts be conducted by authorized nursing personnel to reconcile drug availability. The failure to adhere to this policy raises concerns about the potential for drug diversion, which would necessitate an investigation.

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 medications were locked and secured while unattended and did not remove and discard expired house stock medication in three of six medication carts reviewed. On August 6, 2024, a surveyor observed a Licensed Practical Nurse (LPN) leaving a medication cart unlocked and unattended on the second floor. The LPN acknowledged that residents could potentially access the medications, leading to possible overdoses or medication errors if residents self-administered another resident's medication. Additionally, on August 7, 2024, a surveyor, accompanied by a Registered Nurse (RN), found an expired house stock medication, Vitamin B6, in a medication cart on the first floor. The Vitamin B6 had an expiration date of July 2024. The RN admitted that she does not check the medication cart for expired medications and confirmed that expired medications should not be stored in the cart and should have been discarded. The facility's policy mandates that medication carts be locked or attended by authorized personnel and that outdated drugs be immediately withdrawn from stock.

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 refer two residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. Resident R33, a [AGE] year-old individual, was diagnosed with paranoid schizophrenia, major depressive disorder, and unspecified schizophrenia. Despite having an initial Level I PASRR screening dated 03/04/2014, there was no documentation of a Level II PASRR screening. The facility administrator, V1, acknowledged that the system should trigger a referral for a Level II PASRR screening based on R33's diagnoses but was unsure why it was not completed. V1 also mentioned that all residents with mental health diagnoses, including those admitted long ago like R33, should have a Level II PASRR screening. Similarly, Resident R14, a [AGE] year-old male with diagnoses including schizoaffective disorder, schizophrenia, and major depressive disorder, was admitted to the facility without a Level II PASRR screening. R14 had an initial Level I PASRR screening dated 01/25/2000, but there was no documentation of a Level II screening. The facility's policy, dated 12/2023, outlines the expectation for the appointed screening agency to complete Level II screens for residents with severe mental illness or intellectual disability. However, V1 admitted that R14's name was not added to the PASRR Census Report for referral until the day of the survey, indicating a lapse in the facility's adherence to its 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 adequate toenail care for two residents, leading to overgrown and unkempt toenails. One resident was observed with toenails overgrown to approximately 1/2 inch past the tip of her great toes and 1/4 inch past the tip of her other toes. This resident expressed a desire to have her toenails cut, stating it had been more than two months since they were last trimmed. Her medical history includes type 2 diabetes mellitus, schizoaffective disorder, major depressive disorder, anxiety disorder, and mild cognitive impairment, with a BIMS score indicating she is cognitively intact. Her care plan included a referral to a podiatrist or foot care nurse for toenail care. Another resident was found with thick, curled, and overgrown toenails, with one toenail measuring approximately 1 inch in length and another with black discoloration. This resident also expressed a desire to have her toenails cut, stating it had been 6-7 months since they were last trimmed. Her medical history includes major depressive disorder, seizures, Parkinson's Disease, suicidal ideation, hypertensive heart disease, and schizophrenia, with a BIMS score indicating she is cognitively intact. Her care plan noted a risk for self-care deficit due to Parkinson's disease. The facility's policy states that toenail care is to be performed by a podiatrist, who visits weekly, but there was a failure in ensuring these residents were assessed and received the necessary care.

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 address behaviors that could endanger the health of a resident, identified as R92, who was observed chewing on a piece of his incontinence wear. R92, an individual with severe cognitive impairment and multiple medical diagnoses including unspecified dementia and major depressive disorder, was found by a surveyor to be chewing on a light blue and white item, which was later identified by a CNA as a piece of his incontinence wear. The CNA attempted to persuade R92 to remove the item by offering a chocolate bar, which R92 accepted, and subsequently spat out the inedible item. The CNA was unaware of R92's dietary restrictions and did not report the incident to the nurse immediately. The RN and RN Supervisor acknowledged that R92 should not be eating inedible items due to the risk of choking and gastrointestinal issues. They also noted that the CNA should not have given R92 a chocolate bar due to his dietary restrictions and risk of aspiration. The Director of Nursing confirmed that the CNA should have reported the behavior to the nurse, as R92 is on a mechanically altered diet with thickened liquids due to dysphagia. The facility's policy requires that any incident involving a resident be reported to the charge nurse as soon as practicable, which was not followed in this case.

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 determine, offer, and document the immunization status for two residents, R481 and R157, regarding influenza and pneumococcal vaccinations, as per their policy. Upon review, it was found that there were no records of any immunizations for these residents in the electronic record under the immunization tab. The Infection Preventionist/Registered Nurse, V7, acknowledged that the immunization details should have been recorded in the designated tab, especially since R157 had been admitted more than two months prior. Additionally, the facility's immunization policy, which was last revised in December 2013, was outdated and had not been reviewed or updated annually as required. These oversights have the potential to affect the residents by not minimizing the risk of acquiring, transmitting, or experiencing complications from influenza or pneumococcal pneumonia.

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 standard precautions and proper hand hygiene during incontinence care, as observed by a surveyor. A staff member, identified as V4, was seen performing incontinence care on two residents without washing hands or using appropriate cleansing materials. V4 did not bring necessary items such as a washbasin, soap, and water, and instead used a wet towel to clean the residents' perineal areas. This improper technique was observed during care for a resident with a heavily soiled incontinence brief, where V4 touched various surfaces with soiled gloves and failed to wash hands before donning new gloves. The residents involved had significant medical histories, including conditions like osteoarthritis, diabetes, heart failure, and incontinence. The facility's policies on perineal care and hand hygiene were not followed, as V4 did not perform hand hygiene before and after resident care, nor did they properly cleanse the perineal area. The Director of Nursing acknowledged the expectations for staff to follow these procedures to prevent infection and cross-contamination, especially when caring for multiple residents.

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 incontinence care for two residents, R1 and R2, who required assistance with toileting. R2, admitted with multiple diagnoses including hemiplegia and diabetes, was observed to have been left unchanged for approximately five hours, despite being always incontinent of bowel and bladder. The CNA assigned to R2 confirmed that she had not yet attended to R2, even though her shift began at 6:30 am, and the last recorded incontinence care was at 5:05 am. Upon inspection, R2's incontinence brief was found heavily soiled with urine. Similarly, R1, who also has a history of multiple medical conditions including osteoarthritis and heart failure, reported being left unchanged for several hours. R1 stated that she often urinates multiple times before being changed and sometimes waits 5-6 hours for care. During an observation, R1's incontinence brief was found soiled with both urine and feces. The CNA confirmed that R1 was last checked around 9 am, which was several hours before the observation. The facility's policy requires incontinence care to be provided at least every two hours, which was not adhered to 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

The facility failed to adhere to its call light protocol, resulting in several residents not having access to their call lights. Six residents were affected, with some reporting waiting times of over an hour for assistance. Residents expressed concerns about call lights being left out of reach, particularly when they were unable to move independently. One resident mentioned that this issue had persisted for over a month despite informing the administrator. Observations confirmed that call lights were often placed on the floor or nightstand, making them inaccessible to residents who required assistance. During the survey, a certified nurse assistant was observed using a cell phone while a resident's call light was on the floor, indicating a lack of attention to resident needs. The facility's policy requires call lights to be within reach at all times, but this was not consistently followed. The Director of Nursing acknowledged the importance of having call lights accessible to prevent potential harm. However, the facility did not conduct a call light assessment, and staff were not consistently ensuring that call lights were within reach during rounds.