Chalet Living & Rehab

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 food at a palatable and appetizing temperature during lunch tray line service. On 05/26/26, the chef took temperatures of multiple hot food items on the tray line, including pork chop at 161 degrees F, green beans at 172 degrees F, rice at 147 degrees F, mechanical soft pork chop at 145 degrees F, pureed pork chop at 141 degrees F, pureed rice at 145 degrees F, and pureed green beans at 131 degrees F. During tray line service, the chef pulled plates from a stack of ceramic and melamine plates that were not heated, and there was no heated pellet system in place. The surveyor tasted the pureed rice, pureed green beans, and pureed pork on the tray line and found them lukewarm, not hot, and not palatable. The Culinary Development Specialist stated the tray line holding temperatures should be at least 135 degrees F, with an aim of 150-155 degrees F, and that food below 150 degrees F should be reheated before being plated. The Food Service Director stated food should be between 145-160 degrees F when it reaches the resident and that if food is served below 135 degrees F in the kitchen, it could not reach 145 degrees F at the resident. The Consulting Registered Dietitian stated hot food should be held at least 165 degrees F and should not be below 135 degrees F at point of service. The facility’s policy stated food is to be palatable, attractive, and served at a safe and appetizing temperature. A test tray was prepared, sent to the unit, and then checked after meal distribution. The temperatures on the test tray were pork chop at 115 degrees F, green beans at 97 degrees F, and rice at 100 degrees F. The surveyor tasted the food and found it cold and bland. The Culinary Development Specialist also tasted the tray and stated the rice tasted cold, the green beans were not hot or warm, and the pork was not hot and tasted dry. Residents interviewed stated the food was always cold, that they had learned to eat cold food, that they sometimes bought delivery food or snacks because the kitchen food was cold, and that staff were often too busy to reheat meals. One resident stated the food was cold at lunch and another said the food was always cold and not appealing when served that way.

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 a resident’s comprehensive care plan for bed mobility and positioning. The resident was admitted with multiple diagnoses including COPD, type 2 diabetes mellitus, hypertension, hypothyroidism, obstructive sleep apnea, atherosclerotic heart disease, hyperlipidemia, GERD, gout, spinal stenosis, lumbago with sciatica, morbid obesity, bilateral knee osteoarthritis, and generalized anxiety disorder. The MDS dated 4/9/26 showed the resident’s cognition was intact. The resident’s fall risk evaluation dated 4/3/26 identified him as high risk for falls, and the physician order sheet dated 4/3/26 included an order to use 2 partial side rails for transfer and bed mobility. The side rail evaluation dated 4/3/26 stated that half-length rails were used as an enabler during bed mobility and repositioning, and the care plan dated 4/6/26 stated the resident may need to use two partial rails to enhance functional independence in positioning, turning, in-bed mobility movement, and getting up. On 4/7/26, the resident rolled over from the bed to the floor during the early morning shift change. The resident stated he did not have bed or side rails, so there was nothing to grab or hold onto when he turned on his side. A CNA stated there were no side or bed rails in place and that the resident rolled from the bed to the floor while turning on his side. The assigned LPN stated there were no side or bed rails and that rails help residents move from side to side so they do not fall from bed; she also stated the fall may have been prevented if rails had been in place. The fall nurse and DON both stated the resident rolled over from the bed to the floor and that he said he had no side rail to hold or grab onto. The DON stated the resident was high risk for falls and that the fall possibly could have been prevented if bed or side rails were provided.

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 checked for accuracy prior to administration to one resident who was assessed as cognitively intact and able to self-medicate. The resident’s record showed diagnoses including obstructive sleep apnea, morbid obesity, and vitamin D deficiency, and the care plan stated the resident was able to safely self-medicate with nursing monitoring and counseling as needed regarding proper medication administration. The resident stated that during second-shift medication passes, an RN provided the wrong dosage of vitamin D, giving 50,000 units instead of the prescribed 5,000 units, and also gave Tramadol even though the resident did not take that medication. The resident reported the capsules looked larger than usual and that the medications were not taken. The ADON stated the resident reported the RN entered the room and provided Tramadol and an incorrect vitamin D dosage, and the DON stated the RN became distracted while administering medications to another resident receiving Tramadol and mistakenly attempted to give the medications to this resident before correcting the error. The DON stated staff are expected to verify physician orders and follow the medication administration rights, including the right medication, right patient, right dosage, right frequency, right time, and right procedure.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow physician orders for catheter care every shift for two residents with indwelling Foley catheters, and the lack of a specific facility policy for catheter care. Both residents reported that no Foley catheter care had been performed on the day of the survey. Multiple nursing staff, including the assigned RNs and the wound nurse, stated that they did not perform catheter care on these residents on the days in question and believed that catheter care was the responsibility of another shift or another nurse. The wound nurse later confirmed that she did not perform Foley catheter care for these residents on the days in question, despite her initials being documented on the treatment administration records as if the care had been completed. The treatment administration records for both residents showed the wound nurse’s initials indicating that catheter care every shift had been completed on specific dates, even though she stated she had not done this care and had misunderstood the question as referring to catheter changes. The DON stated that Foley catheter care consists of ensuring the insertion area is clean and free of discharge and acknowledged that not performing Foley catheter care can increase the risk of infection. One resident with an indwelling catheter had developed an abscess on the penis near the catheter insertion site, with documentation of purulent discharge, malodorous seropurulent exudate, and treatment with antibiotics and topical Mupirocin. The DON also stated that the facility did not have a policy specifically addressing catheter 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 deficiency involves inaccurate documentation of Foley catheter care on treatment administration records (TARs) for two residents with physician orders for catheter care every shift. On 04/14/2026, both residents stated that no Foley catheter care had been performed that day. One resident, with a BIMS score of 11 indicating moderate cognitive intactness, and the other, with a BIMS score of 15 indicating cognitive intactness, each reported that staff had not provided catheter care. Nursing staff interviews revealed confusion and conflicting statements about responsibility for catheter care: the RN assigned to one resident stated that night shift nurses and wound care nurses perform the catheter care, and the RN supervisor for the other resident stated that he does not perform catheter care and only records output. The wound nurse stated that she does not perform Foley catheter care during wound care and that the nurse in charge of the resident is responsible for this task. Despite these statements that catheter care was not performed, review of the April 2026 TARs for both residents showed the wound nurse’s initials indicating that Foley catheter care orders were completed on 04/14/2026 and 04/15/2026. When the surveyor questioned this discrepancy, the wound nurse acknowledged that the initials were hers and admitted she had not performed Foley catheter care on those dates, explaining she had misunderstood and thought the question referred to changing the catheter. The DON stated that his expectation is that nurses follow through on physician orders for medications and treatments and document them accordingly. CMS Medicaid documentation guidance cited in the report emphasizes that complete, accurate, and timely documentation of services is necessary to meet patient needs and comply with federal and state laws.

Penalty

No penalty information released

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

Summary

Surveyors identified a deficiency in the facility’s infection prevention and control practices when a resident’s urostomy bag was observed resting on the floor. On 04/14/2026 at 11:30 AM, the resident, who was awake, alert, and cognitively intact with a BIMS score of 12, stated that she believed her bag was on the floor and did not know how it got there; the surveyor confirmed the bag was on the floor. When a registered nurse was brought into the room, the nurse observed the bag on the floor and acknowledged that it should not be on the floor because it can cause infections. Later that day, the Director of Nursing, who also serves as the infection preventionist, stated that a Foley bag should not be on the ground but instead hanging on the bed to prevent infection, and that a bag on the ground can lead to infection. The facility did not have a specific written policy or procedure for catheter care, despite Centers for Disease Control guidance stating that urine bags should be kept off the floor. These observations and interviews showed that the resident’s urostomy bag was not maintained off the floor as required for infection control, and that the facility lacked a specific catheter care policy to guide staff in proper catheter and drainage bag management.

Penalty

Inspection fine: $114,395

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 protect a cognitively impaired resident from sexual abuse by another resident with a known history of sexually inappropriate behavior and battery. The abused resident was admitted with diagnoses including bipolar disorder, autistic disorder, and drug-induced subacute dyskinesia, and had a BIMS score of 9, indicating moderately impaired cognition. Her care plan identified a difficult past related to severe mental illness and risk factors for being a recipient or perpetrator of mistreatment, with an expectation that she would remain safe and free of mistreatment. The alleged perpetrator had diagnoses including schizoaffective disorder bipolar type and generalized anxiety disorder, and a BIMS score of 15, indicating intact cognition. His care plan documented sexually oriented behavior, including making crude, sexually oriented, profane, or suggestive remarks, and directed staff to implement limit setting and intervene if he attempted inappropriate touching. On the day of the incident, the newly admitted resident reported that the male resident approached her, asked if she was new, and obtained her room number. Later that night, video surveillance showed him entering her bedroom and remaining there for approximately 30 minutes before she went to the nurse’s station and he exited the room. The resident stated that while she was lying in bed, he entered her room, initially stood and talked, then sat on her bed, rubbed her leg, and asked for sexual favors. She reported that she told him to stop and said no, but he continued to rub her leg, unzipped his pants, exposed himself, masturbated while rubbing her leg, and ejaculated on her bed. She stated she did not scream because she feared he would harm her, and after he finished, she ran to the nurse’s station and informed staff of what had occurred. During interview, she was visibly shaken and crying, reported being afraid it would happen again, and said she cried every time she entered her room. A roommate reported observing the male resident enter the room, go to the abused resident’s side of the room, and ask for sexual favors, then hearing “wet noise” and sexual sounds before telling him to leave; she stated he asked for a minute, later adjusted his pants, and left. Nursing staff documented that the resident came to the nurse’s station and reported that a male resident had entered her room and behaved inappropriately. An LPN assessed her and found her crying and in emotional distress; the resident told the LPN that the male resident exposed himself, pleasured himself while rubbing her leg, and ejaculated on her sheets, which the LPN removed and bagged. Social services staff and another resident reported that, prior to this incident, the male resident had been sexually inappropriate with another resident and had repeatedly asked another female resident for sexual favors, including offering marijuana in exchange, leading social services to instruct nursing staff to monitor him more closely and keep him in his room at night. The psychiatrist stated he was not informed by the facility that the male resident was making inappropriate sexual advances toward other residents, despite his known sexual preoccupation and comments about women. The facility’s own criminal history analysis for the male resident identified him as a moderate risk requiring closer supervision and more frequent observation than routine, with regular monitoring for behavioral changes and periodic assessment of supervision sufficiency, yet he was able to access and remain in another resident’s room at night, resulting in the sexual abuse. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, including forced observation of masturbation and coerced or extorted sexual activity, and stated that even if there is capacity to give consent, consent obtained through intimidation, coercion, or fear is considered sexual abuse. The policy also stated that sexual abuse includes non-consensual sexual relationships between residents or a consensual relationship involving a resident who lacks cognitive ability to consent. Social services staff stated that the facility uses BIMS scores to assess sexual appropriateness and that a sexual relationship is not consensual if residents’ BIMS scores are not on the same cognitive level, noting that the abused resident and the male resident were not on the same cognitive level. Despite the male resident’s documented sexually inappropriate behaviors, prior complaints from other residents, and a risk assessment recommending closer supervision, he was not effectively restricted from entering other residents’ rooms at night, and the psychiatrist was not made aware of his escalating sexual advances. These actions and inactions led to the incident in which the cognitively impaired resident experienced non-consensual sexual contact and exposure, constituting the cited abuse deficiency.

Removal Plan

• Resident R4 was discharged and is no longer a resident in the facility.
• Resident R1 was assessed for abuse risk identifying resident as high risk for abuse and an abuse care plan was initiated; R1 was reassessed for abuse risk and the care plan was reviewed.
• All current residents were reassessed for abuse risk using Screen for Abuse & Neglect UDA and each resident's abuse care plan was reviewed; Abuse UDA is completed on all new admissions within 72 hours of admission as well as quarterly, annually, and as needed by Social Services.
• A list was created of residents with a history of sexually inappropriate behaviors; the list is provided to the floors in a binder at the nursing station for identification/reference; the list will be updated as needed and reviewed at least weekly by Social Services; sources used include background check process, CHIRP, and Social Services assessment.
• Nursing staff including Social Services were in-serviced regarding the list of residents with sexually inappropriate behaviors to aid identification and ensure immediate reporting to the nurse supervisor and/or social service supervisor on call.
• Residents identified as exhibiting sexually inappropriate behaviors will be monitored every 2 hours by Nursing, Social Services and other designee with documentation on a monitoring tracker in the Residents Exhibiting Sexual Abuse Binder located at each nursing station.
• All newly hired nurses, CNAs, and Social Service workers will be in-serviced on the processes pertaining to the list of residents identified with sexually inappropriate behaviors prior to start date by the HR Director.
• All contracted workers will be in-serviced on abuse including reporting by the Administrator/designee.
• A protocol was created to provide various avenues to determine a resident's consent.
• All current residents were reassessed for cognitive ability to consent using the Brief Interview for Mental Status UDA by Social Services.
• An audit was completed to identify residents currently taking part in an intimate relationship; residents were identified and assessed by Social Services as able to consent based on BIMS score; their intimate relationship care plans were reviewed and updated.
• Residents identified as consenting to intimate relationships will be monitored weekly by Social Services to ensure continued consent; the list will be updated weekly and as necessary.
• Facility employees were in-serviced on the abuse policy with emphasis on sexual abuse.
• An additional all-in-house in-service was conducted on the abuse policy with emphasis on identifying and reporting inappropriate sexual behaviors.
• A QA audit tool was developed to monitor residents identified with sexually inappropriate behaviors to ensure identification and reporting is done immediately; to be completed 3 times per week for 12 weeks by Social Services/designee.
• A QA audit tool was developed to monitor residents identified as consenting to intimate relationships to ensure they continue to consent and are care planned; to be completed 3 times per week for 12 weeks by Social Services/designee.
• Results and trends from the QA audits will be discussed by the Assistant Administrator in the monthly QAPI meeting until resolution.
• The Medical Director was made aware of the abatement plan and agreed.

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 nursing staff each day to meet resident needs as outlined in its own facility assessment and staffing policy. The Scheduling Coordinator reported she creates schedules only for CNAs and that the DON schedules the nurses. She stated that for day and evening shifts the facility should have 5 CNAs on the 4th floor, 5 CNAs on the 3rd floor, and 4 CNAs on the 2nd floor, and 3 CNAs per floor on night shift, and that the facility does not use agency staff. She also stated she staffs according to a budget, was told she could staff 15 CNAs for morning and evening and 9 CNAs for night shift, and was unaware of the facility’s staffing budget details or minimum staffing requirements. The DON stated he is responsible for nurse staffing, does not use agency staff, and always ensures 2 nurses per floor per shift, staffing a total of 18 nurses per day and 37 CNAs per day, and reported he was not aware of low nurse staffing on weekends or responsible for PBJ submissions. Review of nursing staff time punch reports for nurses and CNAs from 07/01/2025 to 09/30/2025 for weekend shifts showed that on all 26 weekend days reviewed, the facility did not meet the stated minimum requirements of 18 nurses and 37 CNAs per day as described by the Scheduling Coordinator, DON, and facility assessment. A CMS PBJ report for the same fiscal quarter documented that the facility triggered for excessively low weekend staffing. The facility assessment documented staffing of two nurses per shift per floor, five CNAs on morning shift, five CNAs on evening shift, and three CNAs on night shift for each of the three floors, equating to approximately 39 CNAs per day, but elsewhere in the same assessment it documented staffing for only 13 CNAs per day, which contradicted both the other portion of the assessment and the statements from the Scheduling Coordinator and DON. The facility’s written staffing policy stated it would provide adequate staff to meet resident needs and specified 3.8 hours of nursing and personal care per day for residents needing skilled care and 2.5 hours per day for residents needing intermediate 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 deficiency involves failure to keep medications secured in locked compartments as required by facility policy and professional standards. On multiple occasions during a single morning medication pass, an LPN prepared medications for several identified residents and then walked away from the medication cart, leaving it unlocked and out of sight. At one point, the LPN also left prepared medication on top of the cart while the cart remained unlocked and unattended. These observations were made repeatedly over the course of the morning for different residents, indicating that the cart and medications were accessible when the nurse was not present. During an interview, the LPN acknowledged forgetting to lock the medication cart and stated they were not focused, further noting that whenever they walk away from the cart there should not be any medication on top of it because another resident or unlicensed person could take the medication or access the cart. The Assistant Director of Nursing confirmed that the medication cart should always remain locked when not in use and when the nurse is not present, and that failure to do so could allow another resident or unlicensed personnel to take medications that could potentially harm them. The facility’s written policies require controlled substances to be stored under double lock and all drug storage compartments, including carts, to be locked when not in use and not left unattended if open or otherwise available to others.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow prescribed portion sizes for both pureed and regular-consistency chicken as listed on the Diet Guide Sheets and required by facility policy. During observation of pureed food preparation, a cook stated she was preparing eight portions of pureed chicken, vegetables, and rice for lunch. She placed eight pieces of cooked chicken breast into a commercial blender with two cups of broth without weighing the chicken beforehand, and leftover pieces of cooked chicken remained in the container. When the surveyor later requested that one piece of the cooked chicken breast be weighed, it measured 2.5 oz, and the cook acknowledged she had not weighed the chicken prior to blending, despite the required portion being 3 oz. Further observation showed the cook transferring the pureed chicken to a metal container for reheating and then returning to prepare additional pureed chicken only after realizing the initial pieces were under the required weight. At the lunch tray line, the cook plated meals for residents on regular diets by placing one piece of chicken on each plate. The surveyor noted that the chicken pieces appeared small and requested that one chicken thigh be removed from a plate and weighed. The Food Service Director weighed the thigh at 2.4 oz including bone and skin, then reweighed the edible portion only, which measured 1.4 oz, below the required 3 oz edible portion documented on the Diet Guide Sheet. The Registered Dietitian confirmed that the Diet Guide Sheets should be followed so residents receive the correct items, consistencies, and portions to meet nutritional needs. She stated that for the lunch in question, regular diets should receive 3 oz of chicken and pureed diets should receive a #8 scoop (4 oz) of pureed chicken due to added liquid. She also confirmed that the 3 oz portion for regular diets refers to edible protein excluding bones and skin, and that a 1.4 oz edible portion was incorrect. Facility records showed five residents on pureed diets and 163 residents on regular diets for that meal. The facility’s menu policy requires menus to be planned in advance, meet residents’ nutritional needs, and be served as written, and the cook’s job profile requires following standardized recipes and nutritional guidelines, which were 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 deficiency involves the facility’s failure to timely report an allegation of abuse to the state survey agency within two hours of the initial allegation. The resident involved, R44, has multiple diagnoses including COPD with acute exacerbation, gait and mobility abnormalities, anxiety disorders, depressive episodes, psychoactive substance abuse, and hypertension, with a BIMS score of 12 indicating moderate cognitive impairment. R44’s care plan notes a history of suspected abuse/neglect and behavioral symptoms, including involvement in other residents’ care and difficulty with adjustment and mood. On the evening of 01/04/26, R44 wrote a letter to the Administrator/Executive Director describing an incident in which a CNA (V17) allegedly spoke hostilely to R44’s roommate, told R44 to “shut up,” blocked R44’s path, threatened to throw R44 out of the window, and bumped R44 as the CNA left the room. R44 reported feeling like a “nervous wreck” and physically shaking, and stated she went to the nurse’s station and then downstairs to report the incident and write the letter, which the receptionist placed in the administrator’s mailbox. On 01/06/26, during an interview, R44 again described the incident, stating that the CNA refused to immediately change the roommate, used profanity toward R44, blocked her from leaving the room, and threatened to throw her out the window, causing significant fear and shaking. R44 reported that she informed the nurse at the nurse station, then went downstairs, where the receptionist provided pen and paper for her to write a letter that was placed in the administrator’s mailbox. R44 also stated she told the Executive Director and the Social Worker about the incident. The Social Worker (V6) confirmed that R44 complained that a staff member was very abusive and that V6 reported this to the Executive Director. The receptionist (V7) confirmed that R44 came downstairs, complained that someone had threatened to push her out the window, and wrote a letter that V7 placed in the administrator’s mailbox; V7 acknowledged that this could be considered an allegation of abuse and that she did not follow protocol, treating it more as a complaint. The Executive Director (V2) stated that R44 interrupted him on 01/05/26 and gave a generalized account of a confrontation with a CNA who had dropped off food and was to care for the roommate. V2 checked the schedule and identified that the CNA was on duty, and acknowledged that R44 said the CNA threatened her. V2 reported that he considered the situation abuse and that he “probably should have reported it yesterday,” explaining that he initially thought R44 was having psychosis based on her care plan. The facility’s Abuse Report Initial Form, dated 01/06/26 at 12:10 PM, documents that the facility became aware of the incident at 10:30 AM on 01/06/26, lists the Administrator as the first staff aware, and characterizes the allegation as verbal/mental abuse by an unknown CNA. The facility’s Abuse and Neglect policy requires that all allegations of abuse be reported to the Administrator immediately and that all allegations be reported to the state agency immediately, not exceeding two hours after the initial allegation is received. Despite multiple notifications and the written letter on 01/04/26, the allegation was not reported to the state agency within the required two-hour timeframe, resulting in the cited deficiency.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to immediately initiate an investigation and report an allegation of abuse made by a resident. The resident, identified as R44, had diagnoses including COPD with acute exacerbation, gait and mobility abnormalities, anxiety disorders, depressive disorders, psychoactive substance abuse, and hypertension. R44’s BIMS score was 12, indicating moderate cognitive impairment, and the care plan documented a history of suspected abuse/neglect and behavioral symptoms, including involvement in other residents’ care. On a Sunday afternoon, R44 wrote a letter addressed to the Administrator or Executive Director stating that a CNA delivering food was hostile to the roommate, yelled at the roommate about being changed, told R44 to “shut up and mind my own business,” blocked R44’s path, threatened to throw R44 out the window, and bumped R44 while passing. R44 reported feeling like a “nervous wreck,” shaking, and expressed fear related to heart problems. R44 later reiterated the allegation in an interview, stating that two days earlier a CNA working the 3–11 p.m. shift, described as African American, came to deliver dinner trays and deferred changing the roommate for a couple of hours. When R44 questioned this, the CNA allegedly told R44 to get out of her face, used profanity, blocked R44 from leaving the room, and threatened to throw R44 out the window, causing significant fear and shaking. R44 reported going to the nurse’s station, speaking with the nurse and two other people there, then going downstairs to the receptionist, who provided pen and paper so R44 could write a letter that was placed in the administrator’s mailbox. R44 also stated that the Executive Director and Social Worker were informed. The receptionist confirmed that R44 complained that someone threatened to push her out the window, recognized that this could be considered abuse, and acknowledged not following protocol and “dropping the ball” by treating it as a complaint rather than an abuse allegation. The Executive Director stated that R44 interrupted him the day after the incident while he was busy, and he took time to speak with R44, who reported a confrontation with a CNA who had dropped off food and was supposed to care for the roommate. The Executive Director checked the schedule and identified the CNA, later identified as V17, and acknowledged that R44 said the CNA threatened her. He admitted he considered it abuse and that he “probably should have reported it yesterday,” explaining that he initially thought R44 was having psychosis based on the care plan. The Social Worker reported that R44 came to her office and complained that a staff member had talked to her in an incorrect way, and the Social Worker immediately informed the Executive Director. The facility’s reportable form documented that the facility became aware of the incident on a later date and initially listed the alleged perpetrator as unknown, despite the earlier letter and conversations. The facility’s abuse policy required immediate steps to protect residents, immediate notification to authorities not exceeding two hours after the initial allegation, and suspension of accused employees pending investigation. In this case, the allegation made to the receptionist and then to the Executive Director was not immediately reported or investigated, and the CNA continued to work on the unit until the Executive Director later identified and suspended the CNA after the Social Worker’s report. Additional interviews provided conflicting accounts of the incident but further highlighted the delay in response. The CNA, V17, stated that while passing trays she saw the call light on, dropped off the meal tray, and asked the roommate if she wanted to be changed, with the roommate requesting to eat first. According to V17, R44 then accused her of breaching a contract, was told to mind her own business, and began hitting V17’s leg with a walker and threatening to have her fired. V17 denied threatening to throw R44 out the window or doing anything to R44. Another CNA, V20, reported hearing R44 tell V17 at the elevator that she was going to report and fire V17, and that V17 responded she had not done anything. Despite these differing accounts, the key deficiency centers on the facility’s failure to treat R44’s initial report and written letter as an abuse allegation requiring immediate reporting and investigation, as required by the facility’s own abuse and neglect policy and federal guidelines. The facility’s own documentation shows that the reportable form listed the date and time the facility became aware of the incident as a later date and time, even though R44 had already reported the threat to the receptionist and had written a letter that was placed in the administrator’s mailbox earlier. The receptionist acknowledged not contacting the administrator as required when an allegation or witness of abuse occurs. The Executive Director acknowledged that he did not submit an initial reportable or start an investigation when he first spoke with R44 and that he should have reported the abuse allegation the previous day. As a result, the alleged perpetrator continued to work on the unit until the Executive Director later identified the CNA and suspended her pending investigation. This sequence of events demonstrates that the facility did not respond appropriately and immediately to the alleged violation of abuse, contrary to its written policy requiring immediate protection of residents, prompt notification to authorities, and timely initiation of 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 deficiency involves the facility’s failure to obtain a Level II PASARR evaluation for a resident who was later identified as having a serious mental disorder. The resident’s Level I PASARR, completed at the hospital prior to admission on 7/17/2024, documented that no Level II was required because there was no known or suspected severe mental illness, intellectual disability, or related condition, and no mental health medications at that time. The resident was admitted on 7/25/2024. Subsequently, the admission record reflected a diagnosis of schizoaffective disorder with an onset date of 1/17/2025. A psychiatrist’s progress note dated 8/08/2024 documented a diagnosis of schizoaffective disorder, depressed type, with a past psychiatric history of schizoaffective disorder and historical use of lithium, and included an order to add Seroquel 50 mg at night. Interviews and record review showed that, despite the new or previously unreported diagnosis of schizoaffective disorder and the initiation of antipsychotic medication, the facility did not request or obtain a Level II PASARR for this resident. The nurse consultant confirmed that the resident did not have the schizoaffective diagnosis at the time of admission based on hospital and referral paperwork and acknowledged that the facility did not resubmit for a Level II PASARR. The admissions director stated that the initial Level I PASARR was done at the hospital and acknowledged that if a new schizoaffective diagnosis was made or missed during the first assessment, a new PASARR should have been obtained. The facility’s own PASARR policy, adopted 7/16/2025, states that when a new psychiatric diagnosis under mental disability or intellectual disability is added by a physician, or when the facility suspects such a condition, the facility will notify the appropriate state-designated authority by requesting a PASARR screening via AssessmentPro, which was not done 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 deficiency involves the facility’s failure to ensure accurate PASARR Level I screenings and appropriate referrals for Level II evaluations for two residents with known serious mental illness diagnoses. One resident was admitted with documented diagnoses including bipolar disorder, current episode depressed, severe, with psychotic features, and post-traumatic stress disorder, yet the PASARR screening dated 06/09/2024 indicated the resident did not require a Level II PASARR due to no SMI/ID/RC. Another resident was admitted with diagnoses including schizoaffective disorder, bipolar type, other recurrent depressive disorders, and mild neurocognitive disorder due to a known physiological condition without behavioral disturbance. This second resident’s orders showed ongoing treatment with aripiprazole for psychosis, and the care plan documented a diagnosis and history of severe mental illness requiring psychotropic medication. Despite these documented mental health conditions and treatments, the second resident’s PASARR screening dated 02/13/2023 stated that the resident did not have a mental health condition requiring evaluation through the PASRR process, noted only depression as a DSM diagnosis, and concluded that no further PASARR evaluation was required. The Admissions Director, who had been responsible for completing PASARR screenings for 2.5 years, reported that he enters resident diagnoses and medications into the screening agency’s website and relies on the agency’s alerts to determine if a Level II PASARR is needed. He stated he was unsure who is responsible for ensuring PASARR information is accurate prior to admission and acknowledged that incorrect information entered into the Level I PASARR can result in inaccurate screening results. He further stated that one resident’s current PASARR screening was inaccurate and required a new screening due to the resident’s severe mental health diagnosis, demonstrating that the facility did not ensure accurate PASARR Level I screenings and appropriate referrals for Level II evaluations as required by its PASARR 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 deficiency involves the facility’s failure to follow its smoking protocol by allowing a resident to keep smoking materials in their room. During observation, the resident was first seen lying in bed and reported smoking cigars, stating that he did not keep a lighter in his room and that others lit his cigars for him, while he kept the cigars in his coat pocket. Shortly thereafter, the resident was observed going to his closet, removing his coat, and taking out a box filled with brown cigarettes/cigars, followed by an additional 8–10 brown cigarettes/cigars from the same coat pocket. Later, the social worker entered the resident’s room and found in the coat pocket a box of cigarettes/cigars, three additional unused cigarettes/cigars, and six used cigarettes/cigars of various lengths, and stated the resident should not have these items in his room for safety reasons. Staff interviews confirmed that the facility’s practice and policy require all smoking materials, including cigarettes/cigars and lighters, to be stored at the front desk and not kept on the nursing unit or in resident rooms. The activity aide, receptionist, and social worker each stated that residents are only allowed to have smoking materials on their person during supervised smoke breaks and must return all materials to the front desk afterward. The resident involved had multiple diagnoses including metabolic encephalopathy, bipolar disorder, unspecified dementia, cocaine abuse, schizophrenia, mild cognitive impairment of uncertain etiology, auditory hallucinations, tobacco use, alcohol use, and altered mental status. His MDS showed severely impaired cognition with a BIMS score of 3/15. His care plan identified him as a smoker who wished to smoke at the facility, with interventions including explaining the consequences of smoking and removal of all smoking materials except during supervised smoking. A smoking behavior agreement and smoking program evaluation documented that he was considered a safe smoker and could access smoking materials consistent with facility policy, yet the presence of multiple cigarettes/cigars in his room demonstrated that the facility did not ensure adherence to its own smoking protocol.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate records of usage and accountability for controlled substances on one of six medication carts for two residents. During a narcotic reconciliation count conducted at 10:21 AM, surveyors found that one resident’s Controlled Drug Administration Record Sheet documented seven tablets of lorazepam 2 mg available, while the corresponding blister card contained only six tablets. For a second resident, the Controlled Drug Administration Record Sheet documented twenty-nine tablets of clonazepam 1 mg, but the medication card contained twenty-eight tablets. These discrepancies showed that the documented counts on the controlled drug administration records did not match the actual number of tablets present in the blister cards. At 10:33 AM, the LPN responsible for the medication cart stated that they had administered the first resident’s medication around 7:45 or 8:00 AM and the second resident’s medication around 8:15 AM, and acknowledged that they were trying to hurry with the morning medication pass and believed they would sign out the narcotics after administration. At 11:10 AM, the Assistant Director of Nursing stated that after a nurse administers medication, they are required to immediately sign out that medication on the appropriate documents, and that controlled substances must be signed out on the controlled medication sheet for quick reference and accountability. Facility policy on controlled substances and medication pass, dated August 2020 and July 2025 respectively, requires controlled medications to be securely stored, counted at each change of custody, and documented immediately after administration, which did not occur in these instances.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide diet and liquid consistencies as ordered for a resident with dysphagia and COPD. During a lunch observation, the resident was seen eating mashed potatoes and cooked cabbage that contained various thicknesses of cabbage strands with thin liquid pooling around the edges, rather than the pureed seasoned cabbage specified on the meal ticket for his mechanical altered/ground diet. The meal ticket for that lunch listed a mechanical altered/ground diet with nectar thick liquids and specifically called for pureed seasoned cabbage, but the vegetable served was not pureed. At the same meal, the resident’s tray included a closed container of nectar thick apple juice and, next to the tray, a large bedside pitcher filled about one-third with ice and water. The resident drank the entire container of nectar thick juice at once and then coughed multiple times, and later took a sip from the bedside water pitcher and coughed again. The resident stated that he likes to drink water and that staff put ice in the pitcher and fill it with water. A CNA reported that she had filled the resident’s pitcher with ice and water that morning and confirmed that the water in the pitcher was not thickened. She also stated that CNAs were not allowed to thicken liquids and that only nurses could do so. A nurse confirmed that the resident was on nectar thick liquids due to swallowing problems and risk for aspiration and acknowledged that residents were not allowed to get ice themselves. The registered dietitian stated that kitchen staff should follow the meal ticket, that if the ticket specified pureed cabbage that is what should have been served, and that residents on nectar thick liquids should not have a bedside pitcher of ice and water because ice melts to a thin liquid. The speech language pathologist reported that the resident had been on a mechanical soft diet with nectar thick liquids due to COPD and swallowing discoordination, with prior recommendations for all liquids, including water, to be thickened to nectar consistency and no water pitcher within reach. At the time of the lunch observation, the physician’s order and care plan documented a mechanical soft diet with nectar thick liquids and aspiration precautions, and facility policies required that thickened liquids and therapeutic diets be provided as ordered.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to provide timely mail services and to protect the privacy of residents’ mail. During a resident council meeting, multiple residents reported that no mail is delivered to them on Saturdays and that they must wait until weekdays to receive their mail. Residents also reported that sometimes their mail is opened when they receive it. The facility census documented 194 residents residing in the facility. The Long Term Care Ombudsman Program Residents' Rights document states that the facility must deliver and send residents’ mail promptly and may not open mail without the resident’s permission. Interviews with staff confirmed that mail handling practices delayed delivery and involved multiple layers of processing by front office staff, the receptionist, and the activity department. The receptionist stated he works only Monday through Friday, places resident mail in a bin in the front office, and that front office staff come twice a week to sort and disperse mail. The Activity Director reported that three activity aides work weekdays and one works weekends, but the weekend aide does not distribute mail. He stated he was instructed by the front office to hold residents’ mail until Monday and that mail is distributed approximately three days during the week. He also stated that staff ask residents to open their mail in front of staff to check for contraband and that sometimes mail arrives to the activity department already opened, with front office staff providing explanations. These practices resulted in delayed delivery and compromised privacy of residents’ mail.

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 proper infection prevention and control by not quarantining a resident who tested positive for COVID-19 for the required 10-day period before cohorting with a non-positive resident. Specifically, a resident with a recent positive COVID-19 PCR test was moved into a room with another resident before completing the full isolation period as outlined by CDC guidelines. The resident's care plan and facility policy both indicated that a 10-day quarantine was necessary, with day 0 being the day of the positive test swab. Interviews with facility staff, including the Assistant Director of Nursing and the Infection Preventionist, confirmed that the expectation was to maintain isolation for 10 days from the date of the positive test. However, the resident was moved to share a room with another resident on the ninth day, prior to the completion of the required quarantine. The Assistant Administrator acknowledged a miscalculation in the isolation period, leading to the premature cohorting of the COVID-19 positive resident.

Penalty

Inspection fine: $248,675

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 supervise, monitor, and develop an effective plan to prevent residents with known histories of substance abuse from obtaining illicit drugs while in the facility. Three residents with documented opioid use histories experienced suspected overdoses while under the facility's care, despite not having community passes or leaving the facility. The facility did not have adequate care plans or interventions in place to address the risk of illicit drug use and distribution among these residents. One resident with a history of opioid abuse and moderate cognitive impairment was found unresponsive and required Narcan administration after a suspected heroin overdose. This resident later admitted to purchasing heroin from another resident within the facility. The care plan for this resident did not include specific interventions to prevent access to illicit substances, and there was a lapse in the continuation of prescribed Suboxone, which may have contributed to the resident's relapse. Another resident with a history of opioid abuse and mental health disorders experienced two suspected opioid overdoses, both requiring emergency intervention. This resident's care plan addressed general abuse and neglect factors but did not specifically address substance abuse or the risk of illicit drug use within the facility. A third resident, with a history of opioid dependence and intact cognitive function, was found with used syringes at the bedside after experiencing seizure activity and requiring hospital transfer and intubation. This resident reported that it was not difficult to obtain drugs within the facility and noted the lack of addiction support programs. The facility's failure to implement effective monitoring, individualized care planning, and substance abuse interventions for residents with known substance use histories directly resulted in multiple incidents of illicit drug use and suspected overdoses within the facility.

Removal Plan

• Administrator and Assistant Administrators were in-serviced and educated on doing a thorough investigation by the President of Operations and Nurse consultant.
• Administrator and Assistant Administrators reviewed and investigated the incidents thoroughly and concluded that the common factor was a resident with a history of distribution who was no longer in the facility.
• Leadership team interviewed each employee of the facility regarding awareness of any individuals, staff, or residents distributing illicit drugs within the facility.
• Leadership team interviewed all residents with a history of substance abuse regarding awareness of any individuals, staff, or residents distributing illicit substances within the facility.
• Background checks were pulled and reviewed for all residents with a history of substance abuse to identify any history of drug distribution; if found, the care plan would be amended to include this history. This process will be ongoing for new admissions.
• A form listing all residents with a history of substance abuse will be reviewed weekly by Social Services and Leadership to ensure compliance with substance abuse protocols. This list will be placed in each nursing station and updated weekly.
• The facility will conduct a QA Audit to ensure comprehensive and thorough investigation of any illicit drug distribution, promoting safety, accountability, and transparency. These audits will be conducted by the Administrator and Assistant Administrators when there is suspicion or allegation of illicit drug use or distribution.
• Package Security Procedure: All packages arriving by mail are checked in at the front desk, placed in a secured office, and delivered to residents by Activities staff, who will have the resident open the package in front of them. If unsafe, Security will secure the package.
• For packages delivered by individuals, the family member/other must open the package in front of Security for inspection before it is given to the resident.
• Security, Activities, and Front Office staff were in-serviced on identifying unauthorized items, including illicit substances, to prevent them from entering the facility.
• All residents were informed of the new package security process.
• The package security process will be posted at the Front Desk to inform visitors.
• The package security process will be reviewed at the emergency Resident Council Meeting and monthly for 3 months.
• All new admissions will be informed of the Package Security Procedure upon admission by Admissions Director/Designee.
• The facility will conduct a QA Audit 2x/weekly for 12 weeks to ensure new admissions are aware of the Package Security Procedure and that the process is being implemented.
• Independent/Community Out on Pass Protocol: A protocol was developed to prevent residents and visitors from bringing illegal substances into the facility after returning from out on pass.
• A sign will be placed in the Front Lobby notifying all residents and visitors not to bring illicit substances into the facility, with consequences stated.
• A statement will be printed on the resident out on pass log warning of consequences for bringing illicit substances into the facility.
• A destination section is added to the Resident Out on Pass Log for residents to declare their destination each time they go out on pass, with Security/Front Desk staff responsible for ensuring it is filled out.

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 policies for food storage and labeling, as well as maintaining proper sanitation temperatures in the dishwashing process. During an inspection, it was observed that several food items in the walk-in freezer and refrigerator were not labeled with preparation and expiration dates, including garlic toast, meatballs, tuna salad, cheese cubes, and raw chicken. Additionally, greens and carrot vegetables were found with expired dates. The Acting Dietary Supervisor acknowledged that dietary staff are required to label all foods before storage, but this was not done. Furthermore, two bags of white bread were found with delivery dates exceeding the facility's policy for discarding after 14 days. The facility also failed to ensure the dishwashing machine reached the required sanitation temperature. During a test cycle, the temperature test strip did not change color, indicating the machine did not reach the necessary 160 degrees Fahrenheit. A subsequent test with a thermometer confirmed the final rinse temperature was only 137.3 degrees Fahrenheit. The Acting Dietary Supervisor acknowledged the issue and stated that meals would be served on paper plates until repairs were made. The Maintenance Director later confirmed that the dishwasher was serviced, and recommendations were made to de-lime the machine more frequently to prevent future failures.

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 an effective pest control program, resulting in the presence of roaches in a resident's room. On December 8, 2024, a resident requested a surveyor to observe their bathroom, where one large cockroach was seen on the toilet seat and four small cockroaches were on the floor. The resident expressed dissatisfaction with the presence of roaches, indicating that this was not the first occurrence. The maintenance assistant confirmed the presence of roaches and mentioned that pest control services are utilized by the facility. The maintenance director acknowledged a recent increase in roach problems, attributing it to changing weather conditions and residents keeping food on the floors. The pest control company had visited the facility the previous Friday, and another visit was scheduled for the following Wednesday. The maintenance director noted that the resident's room was on the list for pest control services. The facility's pest control policy, dated August 16, 2024, states that there should be an effective pest control process in place.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident's call light was within reach, which is a critical aspect of accommodating the needs and preferences of residents. The deficiency was identified during an observation where a resident, who had a moderately impaired cognition with a BIMS score of 09, was unable to locate their call light. The resident's medical conditions included acute osteomyelitis, aftercare following surgery, cataracts, hypertensive retinopathy, hypertension, a benign neoplasm, peripheral vascular diseases, and a chronic ulcer. During the survey, the call light cord was found on the floor, out of the resident's reach, which the resident confirmed by stating they did not have a call light. A Certified Nursing Assistant (CNA) acknowledged that the call light string was misplaced and should have been attached to the resident's bedsheets to ensure accessibility. The CNA then corrected the situation by attaching the call light to the resident's bedsheets. The Director of Nursing confirmed that the call light should always be within the resident's reach, as per the facility's policy and the CNA's job description. The facility's policy explicitly states that call lights must be placed within reach of residents who can use them at all times, highlighting a lapse in adherence to established 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 adhere to physician's orders regarding the use of physical restraints for a resident identified as R25. The resident, who has a medical history including Alzheimer's, bipolar disorder, emphysema, anxiety, scoliosis, and motor and sensory neuropathy, was observed on multiple occasions with hand mittens on both hands, despite the physician's order specifying the use of a mitten on the right hand only. The resident's care plan, consent form, and restorative assessment all documented the use of a right-hand mitten only, indicating a clear deviation from the prescribed care. The deficiency was further highlighted during interviews with facility staff. A Restorative Aide (V33) admitted to placing mittens on both of the resident's hands, stating they were instructed to do so by the Restorative Director. However, the Restorative Director (V34) confirmed that the resident should only have a mitten on the right hand and denied instructing the aide to apply mittens to both hands. This miscommunication and failure to follow the physician's orders resulted in the inappropriate use of restraints on the resident.

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 proper use of low air loss mattresses for two residents, R44 and R66, who were at risk for pressure ulcers. Both residents were observed lying on low air loss mattresses with multiple layers of linens, including flat sheets, incontinent pads, and briefs, which is contrary to the intended use of these mattresses. The low air loss mattresses are designed to relieve pressure and prevent or treat pressure injuries, but the excessive layering of linens defeats this purpose. R44, with severe cognitive impairment and a Braden Scale Score of 14, was at moderate risk for skin alterations, while R66, also with severe cognitive impairment and a Braden Scale Score of 15, was at risk for pressure injury development. Interviews with facility staff, including a CNA, the Director of Nursing, and the Wound Nurse, confirmed that the low air loss mattresses should only have a flat sheet and either an incontinent pad or brief, not both. The facility's Wound Care Guidelines and the manufacturer's operation manual for the mattresses also support this practice. The failure to adhere to these guidelines and instructions led to the deficiency, as the improper layering of linens on the low air loss mattresses compromised their effectiveness in pressure relief and wound prevention.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that a resident, identified as R169, received the necessary equipment to maintain or improve their range of motion and mobility. R169, who has a diagnosis of Idiopathic Normal Pressure Hydrocephalus, Hypertension, Cognitive Communication Deficit, Bipolar Disorder, Hemiplegia, and Hemiparesis following a cerebral infarction affecting the right dominant side, was observed without a hand splint or carrot in their left hand, despite having an order for such a device. The resident, who is cognitively intact with a Brief Interview of Mental Status score of 15, reported that staff had never placed a rolled-up hand towel or carrot in their left hand to prevent further contracture. During the survey, a Restorative Aide (V20) was observed attempting to apply a hand brace to the resident's right hand, which was not contracted, and then to the left hand, causing the resident to grimace and moan in pain. The aide was then handed a carrot by another staff member (V19) and successfully placed it in the resident's left hand. The resident stated it was the first time a device had been placed in their left hand. The Restorative Director (V34) later confirmed that restorative aides are expected to apply residents' devices and are trained to do so, with a list available indicating which devices each resident should have. However, the Restorative Aide admitted to not remembering what device R169 used, indicating a lapse in the facility's protocol for ensuring residents receive appropriate care to maintain their range of motion.

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 contain oxygen equipment for a resident, specifically a nebulizer mask, which was observed uncontained in the resident's bed. The resident, who is cognitively intact with a BIMS score of 15, reported using the nebulizer mask daily for treatments and stated that there was no designated place to store it, leading to the mask being kept in bed. The resident has a medical history that includes atherosclerotic heart disease, chronic obstructive pulmonary disease, venous insufficiency, and hypertensive heart disease with heart failure. The Director of Nursing (DON) confirmed that the facility's policy requires oxygen equipment to be stored in a plastic bag when not in use to prevent infection. However, the Assistant Administrator admitted that there was no specific policy available to guide staff on storing nebulizer masks when not in use. The facility's existing documentation on oxygen storage emphasizes safe and proper storage but lacks specific instructions for nebulizer masks. The resident's physician's orders include regular nebulizer treatments, highlighting the need for proper storage of the equipment.

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 monitor and maintain the personal refrigerators of three residents, leading to potential health risks. For one resident, R113, the temperature log for their personal refrigerator was incomplete, with missing entries for several days. R113, who has intact cognition, reported that no staff checked the refrigerator temperature while they were out of the facility, and they were not provided with a new temperature log upon their return. This oversight left the resident's insulin pens and food items potentially exposed to improper storage conditions. Another resident, R145, had a personal refrigerator without a thermometer and no temperature log was observed. The refrigerator contained expired and improperly stored food items, and it was visibly unclean. Despite the resident's intact cognition and preference to clean the refrigerator themselves, the facility's housekeeping staff were responsible for monitoring and maintaining the cleanliness and temperature of the refrigerator, as stated by the Housekeeping Director and the Director of Nursing. For resident R135, the temperature log for their personal refrigerator was also incomplete, with missing entries. The resident, who is cognitively intact, stated that the staff documents the temperature whenever they check the refrigerator. However, the facility lacked a specific policy for documenting these checks, and the Assistant Administrator acknowledged the absence of such a policy. The facility's document titled 'Freezer Temperature Log for Non-24-Hour Operation' was presented as the log sheet for recording temperatures, but it was not consistently used, leading to gaps in monitoring.

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 an Enhanced Barrier Precaution (EBP) sign was posted for a resident on EBP, which is crucial for preventing the spread of multi-drug resistant organisms. This deficiency was identified during an observation on the fourth floor, which is designated as the dementia floor. A registered nurse confirmed that the resident, who has a gastric feeding tube, was on EBP, but no sign was posted by the resident's room. The absence of the sign was acknowledged by the Wound Care Coordinator, who then contacted the Infection Preventionist. The Director of Nursing and Infection Preventionist later posted the EBP sign, explaining that the facility's policy requires a PPE bin and an EBP sign to be posted by the resident's door to inform staff of the necessary personal protective equipment during high-contact care activities. The resident's care plan indicated the use of EBP due to the presence of a feeding tube, which poses a risk for the spread of infection. The facility's policy mandates the use of gowns and gloves during high-contact care activities for residents with indwelling medical devices, such as feeding tubes, to prevent the transmission of multi-drug resistant organisms.

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 post the current daily nursing staffing information, which has the potential to affect all 188 residents residing in the facility. On December 8, 2024, a surveyor observed that the daily staff posting displayed in a glass casing was dated December 6, 2024, indicating that it had not been updated for two days. Interviews with staff revealed a lack of clarity and responsibility regarding the updating of the daily staff posting, particularly on weekends. The weekend receptionist, V26, stated that they do not change the daily staff posting and believed it was the responsibility of the weekday receptionist. V26 was unaware of how often the posting should be updated. Further interviews with V27, the weekday receptionist, revealed that they update the daily staffing in the computer and change the posting in the glass casing manually from Monday through Friday. However, V27 was unsure who was responsible for posting the daily staffing on weekends. The Assistant Administrator, V3, acknowledged oversight in ensuring that the weekend receptionist was aware of the daily staff posting responsibilities. V3 admitted that V26 was not informed about the importance of the daily staff posting due to their previous evening shift role. The facility's document titled 'Facility Assessment' emphasizes the importance of having enough staff with appropriate competencies to care for residents' needs, highlighting the significance of accurate daily staff postings.

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 a garbage dumpster lid in a closed position due to the dumpster being overfilled with garbage, which forced the lid to remain open. This situation was observed on multiple occasions, with the first observation occurring during rounds with the Acting Dietary Supervisor, who acknowledged that the lid should be closed to prevent attracting rodents. The Assistant Administrator initially thought the lids were open due to high winds but was informed that the overflow of garbage was the cause. The facility's policy requires coordination between the Dining Services Director and the Director of Maintenance to ensure the area around the dumpster is free of rubbish, but this was not adhered to, leading to the deficiency.

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 all elevators were timely inspected and maintained according to city regulations, which has the potential to affect all residents, staff, and visitors using the elevators. Observations revealed that one of the elevators was out of order, and residents reported that elevator availability was a recurring issue. The facility's elevators were overdue for Category 1 Testing, which includes critical safety checks such as oil buffers, safeties, governors, and emergency operations. The facility had five violations noted in a city report, and all elevators failed reinspection. Interviews with maintenance staff revealed a lack of coordination and responsibility in scheduling necessary inspections and repairs. The Maintenance Assistant Director acknowledged that the facility's maintenance staff could not fix certain issues due to the need for a licensed professional. The Maintenance Director admitted that the testing for Category 1 was not scheduled, as it was the contractor's responsibility, and there was no fixed schedule for cleaning the elevators. The facility's elevators had been cited for issues such as non-functioning door restrictors since April 2023, and these problems remained unresolved. The facility provided a contract proposal from a contractor to install new mechanical door restrictors and test the elevators, but the proposal had not yet been accepted. The Maintenance Director explained that door restrictors are crucial for preventing elevator doors from opening when not in a proper position, and the restrictors were not functioning correctly. The facility's failure to address these issues in a timely manner resulted in ongoing elevator malfunctions and safety concerns, as evidenced by the report and interviews with staff and 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 follow its policy to ensure residents were free from abuse and mistreatment, as evidenced by the experiences of two residents, R2 and R3. R2, who has a diagnosis of traumatic brain injury and other conditions, reported an incident where a CNA deliberately threw spaghetti at him while feeding him, causing him distress. Despite R2's request to speak with the Nurse Supervisor, V10, about the incident, no follow-up occurred, and the LPN, V3, did not report the incident to higher authorities. R3 corroborated R2's account, stating that CNAs were mean to R2, throwing food at him and swearing. R3 also reported that the evening and night CNAs were unhelpful and rude, and he had to empty his roommate's urinals himself. Another resident, R4, mentioned witnessing CNAs yelling and swearing at residents. Despite these reports, the facility's administration, including the Administrator, V1, and the DON, V2, were unaware of these allegations until the surveyor's intervention. The facility's investigation into the incident concluded that there was no evidence of abuse, attributing the spaghetti incident to a possible accidental spill. However, the facility's abuse policy mandates reporting and investigating any suspected abuse, which was not adhered to in this case. The lack of communication and failure to report the incidents to the appropriate authorities contributed to the deficiency in protecting residents from abuse and mistreatment.

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 of reporting allegations of abuse to the administrator or the administrator's designee, as evidenced by the cases of two residents, R2 and R3. R2, who is cognitively intact with a BIMS score of 15, reported an incident where a CNA, identified as V9, allegedly threw spaghetti at him while feeding him, causing him distress. R2 attempted to report this incident to V3, an LPN, and requested to speak with the nurse supervisor, V10, but his concerns were not escalated as required by the facility's policy. R3, also cognitively intact, corroborated R2's account, stating that CNAs were mean to R2, threw food at him, and swore at him. V3, the LPN, admitted to witnessing a disagreement between R2 and V9 and acknowledged that R2 had complained about the spaghetti incident. However, V3 did not report the incident to the appropriate authorities, citing her inexperience and uncertainty about the situation being classified as abuse. The interim administrator, V11, and the administrator, V1, were unaware of the abuse allegations until informed by the surveyor, indicating a breakdown in communication and reporting within the facility. The facility's abuse policy mandates immediate reporting of all allegations or suspicions of abuse to the administrator or their designee, and to the state surveying agency within two hours. Despite this, the initial report to the state was only submitted after the surveyor's intervention. Interviews with the DON, V2, and the nurse supervisor, V10, revealed that they were not informed of the incidents involving R2 and V9, further highlighting the failure to follow established reporting protocols.

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 update a resident's care plan with fall prevention interventions after a fall incident. The resident, who is at high risk for falls and has a BIMS score indicating cognitive intactness, was observed ambulating with an unsteady gait and reported frequent falls without adequate intervention. Despite the resident's fall on 02/17/24, no fall interventions were documented or implemented in the care plan. The Falls Nurse admitted to forgetting to document and implement the necessary interventions after discussing them with the resident, who denied the fall and any injuries. The Director of Nursing confirmed that no fall interventions were put in place following the resident's fall on 02/17/24, and the Falls Nurse acknowledged the oversight. The facility's policy mandates that residents identified as high risk for falls should have interventions implemented and documented in their care plans. However, this procedure was not followed, leading to a deficiency in ensuring the resident's safety and preventing further falls.