Claridge Healthcare Center

Penalty

Inspection fine: $84,730

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 a safe environment and adequate supervision for a resident with a known history of elopement and severe cognitive impairment. The resident, who lived on a locked second-floor unit requiring a card key for elevator use, had previously eloped in September 2025 and was care planned and assessed as high risk for elopement, with dementia, impaired thought processes, poor short- and long-term memory, and severe cognitive impairment. The resident’s physician stated the resident was confused and required supervision when leaving the facility, and a psychiatrist note documented a history of auditory hallucinations. On the day of the incident, the resident was last seen at 11:30 AM. At 11:50 AM, a CNA went to the resident’s room to bring him to lunch and could not locate him. Nursing staff initiated a search of the facility, including outside areas, but were unable to find the resident. During this search, an RN checked the basement exit door and found that it did not alarm when opened. Multiple staff members, including the RN, CNA, and receptionist at the main desk facing the elevator and main exit, reported that they did not hear any door alarms around the time the resident went missing, and the receptionist did not see the resident exit via the elevator or main entrance. External reports and interviews confirmed that the resident had left the facility unsupervised. A sheriff’s report documented that the resident was reported missing and was later located offsite, and an employee at a nearby oil change shop reported that a confused man matching the resident’s description arrived there, was not appropriately dressed for the cold weather, and then wandered off, prompting a 911 call. Law enforcement later found the resident at a scrap metal recycling center approximately 1.6 miles from the facility, and a police officer stated the resident would have had to cross three busy, heavily traveled roads to reach that location. Hospital records showed the resident was evaluated in the emergency room for cold exposure. Subsequent testing of the basement exit door by maintenance confirmed that the door alarm did not activate when opened, and maintenance staff stated the alarm should have been activated and must have been turned off.

Removal Plan

• Revise and use the facility Elopement Risk Policy and Procedure to identify residents at risk for unsupervised exit; complete the Elopement Risk Assessment by Social Services upon admission, quarterly, and with change of condition.
• Complete R1 Social Service Unauthorized Departure/Elopement Risk Assessment and update R1 care plan.
• Have psychiatrist NP reassess R1 and increase olanzapine to twice daily.
• Move R1 to a room closer to the nursing station for closer monitoring.
• Place R1 on hourly safety checks.
• Review all residents at risk; revise the Elopement Book and update care plans by Social Services; monitor residents with elopement risk on an individualized basis based on risk assessment; provide continued staff training on elopement-risk residents; update the Elopement Risk Book with changes in residents’ appearance/condition and complete care plan changes at the time of book updates.
• Have 2nd-floor staff alternate desk coverage to monitor the elevator to prevent residents from entering; require staff to complete a sign-in/sign-out sheet to ensure 24/7 coverage indefinitely.
• Assign the floor nurse to check emergency exit doors for proper function by opening the door to confirm alarm sounds and resetting with key twice per shift; if alarms do not sound, notify Maintenance immediately.
• Have Maintenance test all exit doors to the outside daily to ensure doors are armed and alarms sound when opened.
• Begin in-services on the updated Elopement Risk Policy/Procedures and Elopement Risk Book for all departments, including the elevator monitoring plan and exit door procedures; complete all in-servicing.
• Implement daily random audits of elevator sign-in logs, unit emergency exit door checks, and outside exit door checks by the DON or designee; inform the Medical Director and involve them in QA; review progress at QA meetings to ensure corrections are achieved and permanent.

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 that a resident was treated with dignity and respect. During an interview, the resident, who was alert, pleasant, and a cancer survivor, reported that she becomes scared and anxious when someone yells or screams at her due to a history of abuse by her husband. She stated that when a registered nurse (V5) spoke to her, the nurse sounded like she was screaming and yelling, which triggered the resident’s anxiety. The resident also reported that when she learned her physician had been in the building, V5 told her that because she went to her mammogram appointment, she missed seeing her doctor. The resident said this comment did not sit well with her because, as a cancer survivor, she needed to attend her mammogram appointments. Additionally, when she complained to V5 about foot pain from bone spurs, V5 allegedly responded, "there's always something wrong with you," making the resident feel as though she did not matter. In a subsequent interview, V5 acknowledged that, even without being told the name, she knew the resident involved because the resident had previously said V5 screamed and yelled at her. V5 stated that this was her normal voice and questioned what she could do about it, and reported that she had told the resident to bring any issues to the DON. V5 confirmed telling the resident she did not see her doctor because she was out for a mammogram and stated she was aware the resident was a cancer survivor but did not know the resident was offended by the comment. V5 also stated that the resident had many complaints about staff and that she told the resident she was alert and could speak to the DON herself. The Assistant DON (V3) described V5 as having a high-pitched voice and a bubbly personality and stated that V5 might not realize how her voice came across to the resident, while affirming that all residents should be treated with respect. The facility’s undated Dignity policy states that the facility will promote care in a manner and environment that maintains or enhances each resident’s self-esteem and self-worth.

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 a resident received ordered follow-up care with an outpatient gastroenterologist. A hospital After Visit Summary dated 11/13/25 documented that the resident underwent an esophagogastroduodenoscopy (EGD) which revealed a cratered ulcer in the middle third of the esophagus, with severe ulceration and peeling appearance that led to deferral of scope and dilatation. The hospital instructions directed a repeat EGD with an interventional gastroenterologist in four weeks. Facility progress notes dated 11/26/25 showed that the return EGD appointment was scheduled for 12/10/25 at 9:45 AM. The resident later reported on 1/14/26 that she had been having issues with swallowing and felt something in her neck, and stated that her gastroenterologist had been trying to determine the cause. She said she was supposed to have the repeat EGD on 12/10/25, but the appointment was cancelled by the facility due to no escort being available to accompany her, which she stated delayed her treatment and caused her to wait more than a month for the repeat EGD. On the same day, a registered nurse confirmed that, due to no available escort, the appointment had to be cancelled and rescheduled to 1/15/26, more than a month after the original date. The nurse and the receptionist both stated that, per instruction from the DON, the facility could only schedule one medical appointment per day with an escort because of staffing limitations.

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 prevent an elopement from a locked unit, to maintain an accurate list of residents at risk for elopement, and to update a resident’s care plan after an elopement. A resident with diagnoses of schizophrenia, anxiety, and depression was admitted to the facility and had documented delusions, paranoia, irritability, and a stated desire to leave the nursing home. A hospital history and physical noted that the resident had previously tried to leave the nursing home to go to the store, and a social service note described the resident as ambulatory, aggressive with threats and gestures for several hours, and considered at high risk for leaving the facility unattended. An elopement risk evaluation dated 12/2/25 identified the resident as at risk for elopement, and the care plan documented the resident as an elopement risk/wanderer with interventions such as disguising exits and providing diversions. On the day of the elopement, staff interviews and documentation showed that the resident was brought from the locked second floor to the first floor for a smoke break by a CNA, along with another resident. When it was discovered that neither resident had cigarettes, the CNA returned both residents to the second floor and then continued caring for other residents. Shortly thereafter, the receptionist reported that the resident arrived alone at the reception area on the first floor and requested a cigarette. The receptionist paged second-floor staff to come get the resident, but the resident exited the building through the front door before staff arrived. Maintenance staff and an administrative assistant pursued the resident; maintenance staff caught up with the resident beyond the facility parking lot near a stop sign and continued walking with the resident until police arrived further away from the facility. The facility’s locked second floor required a fob to operate the elevator, and nursing staff and administration stated that residents on this unit should not be able to exit without staff assistance and that a staff member should be present at the nurse’s station at all times to monitor the elevator. Multiple staff, including the RN working on the second floor, the CNA, the LPN, and the assistant DON, stated they did not know how the resident got to the first floor unaccompanied. The psychiatric NP reported that she had been walking and talking with the resident near the elevator on the second floor and then used a nurse’s fob to access the elevator to go to another floor, leaving the resident in the common area near the elevator. At the time of survey, the facility’s elopement risk list, kept in a binder, had last been updated on 11/19/25 and did not include this resident despite the documented elopement risk; the LPN added the resident’s name during the survey. The resident’s care plan, printed on 1/5/26, showed elopement risk interventions initiated on 12/2/25, but no additional interventions were added after the elopement on 12/12/25, and staff confirmed that the care plan had not been updated following the incident.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including psychosis and malnutrition, was able to elope from a secured dementia unit. The resident, who was non-English speaking, confused, and required staff supervision for ambulation, was observed outside the facility and subsequently found walking in the road of a heavily traveled highway. The facility's elopement risk assessment for this resident was inconsistent with other documentation, incorrectly stating the resident was not physically able to leave the building and was not confused or disoriented. The incident was facilitated by a malfunctioning elevator security system, which had not been operational for several weeks. The elevator, which should have required a key card for access, was in a fail-safe mode that allowed anyone to use it without restriction. Staff and maintenance confirmed that the system had been reported as broken, and the security vendor had notified the facility that the system was beyond repair, but no action was taken until after the elopement event. Additionally, there was no staff monitoring the elevator or the front desk at the time of the incident, and the front door was unlocked early in the morning, further enabling the resident's exit. Multiple staff interviews revealed that the lack of supervision and the nonfunctional security system directly contributed to the resident's ability to leave the unit and the building unsupervised. The resident was not noticed missing until observed outside by a staff member, and the police were called only after an unsuccessful search by facility staff. The police report and staff statements confirmed that the resident was found walking in the wrong direction in traffic on a busy highway, approximately two miles from the facility, and that there had been previous issues with the security system not restricting access to the dementia unit.

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 protect a resident from physical abuse by another resident. An altercation occurred when a resident with Alzheimer's disease, cognitive impairment, and a language barrier entered another resident's room and did not leave when asked. The second resident, who also has dementia, responded by physically assaulting the first resident, resulting in a 1 cm laceration near the left eye, facial bruising, and a hospital visit for evaluation. Multiple staff members responded to the incident after hearing yelling and found the residents engaged in a physical struggle, with staff and maintenance intervening to separate them. Documentation and interviews confirmed that the assaulted resident frequently wandered into other residents' rooms due to confusion and required redirection, a risk noted in his care plan. Despite the known risk factors, including wandering behaviors and cognitive impairment, the facility did not prevent the resident from entering other rooms or ensure adequate supervision to avoid such altercations. Staff and other residents reported that the resident often entered rooms uninvited, and the incident escalated when he did not leave after being told to do so. The facility's abuse prevention policy requires the prevention of abuse and the establishment of a secure environment, but in this case, the measures in place were insufficient to prevent resident-to-resident physical 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

A deficiency occurred when the facility failed to protect a resident from misappropriation of personal property. The resident, who is alert, oriented, and hard of hearing, reported that $300 was missing from her wallet after taking a nap in her room. The wallet had been stored inside her walker, which she keeps with her at all times, even when leaving the room or going to the bathroom. The resident noticed the wallet was not secured and the envelope containing her money was gone upon waking. She immediately reported the missing money to a CNA, who then informed the nurse. A room search was conducted, but the money was not found, and the police were contacted to investigate. The resident was able to specify the denominations of the missing bills and confirmed that she had received cash from various sources, including withdrawals from her facility-managed account and a birthday gift. Staff interviews confirmed that the resident seldom leaves her room, always keeps her walker with her, and is hard of hearing, making it unlikely she would notice someone entering her room while she was asleep. The business office verified that the resident had access to the amount of cash reported missing. The facility's policy states that any missing money should be treated as theft unless there is clear evidence it was lost by other means. Despite these measures, the facility did not prevent the loss of the resident's money, and there were no cameras available to help identify a potential perpetrator.

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 immediate notification of the abuse coordinator following an allegation of misappropriation of a resident's property. A resident reported to a nursing assistant that $300 was missing from her wallet between 1 PM and 5 PM. The nursing assistant informed a registered nurse that evening, but the nurse did not notify the abuse coordinator or management immediately. Instead, the nurse left a message for the next shift to have social services see the resident the following day, despite being aware that immediate reporting was required for any abuse allegations, including theft or misappropriation. The Assistant Director of Nursing was not made aware of the missing money until the following day. Interviews confirmed that staff are required to report such allegations to the abuse coordinator or management immediately, and waiting until the next day is not acceptable. The facility's Abuse Prevention Program policy also states that any allegations of abuse or misappropriation should be reported to a supervisor, who must then immediately notify the administrator.

Penalty

Inspection fine: $16,57521 days payment denial

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

Summary

The facility failed to implement a system for monitoring and recording resident room temperatures during periods of hot weather, as observed in four out of five residents reviewed for comfortable room temperatures. Staff interviews revealed that temperature checks were only performed at nurse's stations and not in individual resident rooms, and there was no documentation of temperature monitoring. Maintenance staff and the heating and cooling representative acknowledged issues with the air conditioning system, including an obstructed condenser and insufficient cooling, with repairs pending. Despite the presence of a hot weather policy, it did not address the need for monitoring or recording temperatures during excessive heat. Residents and staff reported discomfort due to fluctuating and sometimes high temperatures, with some residents describing the environment as too hot and humid. Thermometer readings in various locations showed discrepancies, with some areas reaching nearly 79 degrees Fahrenheit and high humidity levels. Staff responded to complaints by using fans and adjusting drapes, but there was no systematic approach to ensure resident comfort or safety regarding room temperatures. The facility's policies did not specify procedures for temperature monitoring during hot weather, contributing 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 protect a resident (R1) from physical abuse by another resident (R2). R1, who has severe cognitive impairment due to dementia, was attacked by R2 in the dining room. R2, diagnosed with psychosis and major depressive disorder, exhibited aggressive behavior for the first time by kicking R1 to the ground and continuing to kick R1's torso multiple times. This incident was witnessed by staff and another resident, who intervened by shouting at R2 to stop. Despite the intervention, the facility's failure to prevent the incident resulted in a deficiency. R1 was assessed after the incident and showed no physical injuries or bruising, and could not recall the event. R2 had no prior history of aggression according to psychiatric notes and staff interviews. The facility's policy affirms the right of residents to be free from abuse, yet this incident indicates a lapse in maintaining a secure environment for 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 protect residents from physical abuse by another resident, resulting in multiple incidents involving five residents. Resident 1, a male with metabolic encephalopathy, hemiplegia, vascular dementia, and cerebral infarction, was involved in an altercation with Resident 2, who has dementia and Alzheimer's disease. Resident 1 attempted to move Resident 2 from a chair, leading to Resident 2 striking Resident 1 in the face, causing Resident 1 to fall and sustain a right hip fracture. This incident was witnessed by other residents, and Resident 1 required hospitalization and surgery for the hip fracture. Another incident involved Resident 3, who was struck in the face and arm by Resident 2 after asking him to move from her chair. Additionally, Resident 5 was found with a laceration above his left eye after being pushed by Resident 4, who stated that Resident 5 tried to enter his room. These incidents highlight the facility's failure to prevent resident-to-resident abuse, as documented in the facility's incident reports 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 notify law enforcement following incidents of physical altercations between residents, which resulted in injuries. In one incident, two residents with dementia and cognitive deficits were involved in an altercation where one resident struck the other in the face, causing the latter to fall and sustain a right hip fracture that required surgical intervention. Despite the severity of the injury, the police were not contacted as the families of the involved residents declined to do so. In another incident, a resident was found with a laceration above his left eye after being pushed by another resident, causing him to stumble and hit a doorway. The injured resident required treatment for the laceration, but again, law enforcement was not notified because the family declined to press charges. The Assistant Director of Nursing acknowledged that the police should have been contacted, especially in cases involving serious injuries, but believed it was unnecessary if the families did not wish to involve them.

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 dietary staff were supervised and trained by a qualified dietary manager, resulting in several residents receiving incorrect physician-prescribed diets. This deficiency led to a serious incident where a resident, identified as R6, choked on a piece of tomato that was not appropriately prepared for a mechanical soft diet. The choking incident required the Heimlich maneuver and resulted in the resident being hospitalized for aspiration pneumonia. The facility's failure to provide the correct diet placed the resident at risk for further episodes of choking and aspiration. The deficiency was observed in four residents who were supposed to be on mechanical soft diets. The dietary staff, including the Food Service Manager (FSM), lacked the necessary qualifications and training to ensure compliance with dietary orders. The FSM, who had been in the role for three years, did not possess a current food protection manager certification and was not a certified dietary manager. The Registered Dietitian (RD) contracted by the facility provided limited oversight and had not conducted face-to-face meetings with the dietary staff, resulting in inadequate training and supervision. The facility's dietary staff, including cooks and dietary aides, were not properly trained in preparing mechanical soft diets. Observations revealed that residents on mechanical soft diets were served inappropriate foods, such as whole hot dogs, ham cubes, and fresh fruit chunks, which were not consistent with the prescribed diet texture. The facility's policy required that meats be mechanically ground, but this was not followed. The lack of proper training and supervision led to the dietary staff's inability to adhere to the prescribed diets, directly contributing to the deficiency.

Removal Plan

• Immediate Recruitment Efforts: We have placed a Certified Dietary Manager (V31) in this position. The current Supervisor (V4) will attend a class to renew his Food Safety Manager Certificate. All other dietary staff files will be audited for compliance with the current Food Handler's Certification by Human Resources (V17). The Certified Dietary Manager (CDM) (V31) has started the training for dietary staff. The Registered Dietitian (V7) will continue with the training for proper production and serving of mechanical soft diets. The CDM (V31) will supervise food service production.
• Enhanced Training Programs: In-servicing and training have begun for dietary staff by the CDM (V31) on providing diet as ordered, communication protocol, review diet, and update orders, in-servicing will continue until all dietary staff is trained before starting their next shift. The ADON (V3) started in-servicing nursing staff on monitoring dietary cards to ensure correct food consistency is being served; in-servicing will continue until all nursing staff is trained. We are enhancing our current training programs to ensure all dietary staff receive continuous education on a yearly basis for food safety, nutritional guidelines, and regulatory compliance. These programs will be provided by our contracted Registered Dietitian (V7) or her designee.
• Policy Review and Updates: A review of our Dietary Policies and Procedures Manual will be reviewed by the CDM (V31) and our contracted Registered Dietitian (V7) this process will be started and continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be implemented by in servicing the Dietary and Nursing Staff to reinforce our commitment to compliance and high-quality care, this procedure will be given by our contracted Registered Dietitian or her designee.
• Regular Audits and Monitoring: To prevent future occurrences, we will establish a random weekly audit of 3 meals a week for 90 days done by the CDM (V31); this audit will be focused on food consistency matching the dietary card. This procedure will help us monitor for compliance, identify potential issues early, and take corrective actions promptly. Results will be reported at QA meeting to ensure ongoing compliance.

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 residents with a history of choking and those at risk for choking were served the correct physician-prescribed diets. This failure resulted in a resident choking on a piece of tomato, requiring the Heimlich maneuver, hospitalization, and treatment for aspiration pneumonia. Despite returning to the facility, the resident continued to be served an incorrect diet, putting them at risk of choking again. Additionally, three other residents were also served incorrect diets, increasing their risk of choking. The facility's dietary practices were found to be inadequate, as evidenced by the incorrect serving of meals that did not align with the prescribed mechanical soft diets for several residents. Observations revealed that residents were served inappropriate foods such as whole hot dogs, ham slices, and fresh fruit chunks, which were not suitable for their dietary needs. The facility's dietary staff failed to adhere to the menu spreadsheet and diet cards, leading to the serving of meals that posed a choking hazard to residents. Furthermore, the facility did not ensure that residents receiving a regular texture diet received the correct portion sizes as specified in the dietary type report. Residents were served smaller portions of ham than required, resulting in insufficient caloric and protein intake. This discrepancy was confirmed through observations and interviews with residents and staff, highlighting a lack of compliance with the facility's dietary policies and procedures.

Removal Plan

• Immediate Recruitment Efforts: A Certified Dietary Manager was placed in position. The current Supervisor will attend a class to renew his Food Safety Manager Certificate. All other dietary staff files will be audited for compliance with the current Food Handler's Certification by Human Resources. The CDM has started the training for dietary staff. The Registered Dietitian will continue with the training for proper production and serving of mechanical soft diets. The CDM will supervise food service production.
• Enhanced Training Programs: In-servicing and training have begun for dietary staff by the CDM on providing diet as ordered, communication protocol, review diet, and update orders. In-servicing will continue until all dietary staff is trained before starting their next shift. The ADON started in-servicing nursing staff on monitoring dietary cards to ensure correct food consistency is being served. In-servicing will continue until all nursing staff is trained. The facility is enhancing current training programs to ensure all dietary staff receive continuous education on a yearly basis for food safety, nutritional guidelines, and regulatory compliance. These programs will be provided by the contracted Registered Dietitian or her designee.
• Policy Review and Updates: A review of the Dietary Policies and Procedures Manual will be conducted by the CDM and the contracted Registered Dietitian. This process will be continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be implemented by in-servicing the Dietary and Nursing Staff to reinforce the facility's commitment to compliance and high-quality care. This procedure will be given by the contracted Registered Dietitian or her designee.
• Regular Audits and Monitoring: To prevent future occurrences, the facility will establish a random weekly audit of 3 meals a week for 90 days done by the CDM. This audit will focus on food consistency matching the dietary card. This procedure will help monitor for compliance, identify potential issues early, and take corrective actions promptly. Results will be reported at QA meetings to ensure ongoing compliance.

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 Registered Dietician (RD) was immediately notified of a significant weight loss for a resident receiving enteral feedings, resulting in a delay in assessment and intervention. Resident R24, who required enteral feedings through a gastrostomy tube, experienced a significant weight loss of 10 pounds in four days and an additional 3.2 pounds over the next 11 days. Despite this, the RD was not notified promptly, as the facility's process involved leaving notes in the RD's mailbox rather than direct communication. The RD, who was only present at the facility 16 hours per month, was unaware of the weight loss until she visited the facility and made changes to the feeding orders. Additionally, the facility failed to complete weekly weights for another resident, R1, who was also on enteral feedings and had a history of significant weight loss. The RD had recommended weekly weights to monitor R1's condition, but there was a gap in weight documentation for over a month. The facility's weight monitoring policy required notification of the physician and dietician for significant weight loss but did not specify a timeframe for such notifications, contributing to the oversight.

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 employ a qualified, full-time activity director, affecting all 84 residents. Observations on June 2nd and 3rd, 2024, revealed no activities were conducted. The resident council president, who is cognitively intact, confirmed the absence of activities, stating residents had to entertain themselves. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the lack of an activity director since March 2024, with only one activity assistant present who does not meet the qualifications of an activity director. The facility's job description for the activity director outlines the role's purpose as developing and implementing an activity program to meet residents' needs.

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 sufficient nursing staff to meet the needs of its residents, affecting all 84 residents. Observations and interviews revealed that residents were not receiving adequate assistance with activities of daily living (ADLs) such as oral hygiene, toileting, bathing, and dressing. For instance, one resident, who is nonverbal and dependent on staff for all transfers, was observed making noises indicating distress, yet staff assistance was delayed. Another resident had excessively long nails and had not received a shower for nearly a month, despite being scheduled for regular bathing. The report also highlights issues with restorative care and physical therapy. A resident with contractures was supposed to receive passive range of motion exercises daily but only received them on 8 out of 30 days. The restorative CNA responsible for these exercises was frequently reassigned to other duties, leaving the task to floor CNAs who could not consistently perform them. Additionally, a resident who required walking assistance was not being walked by staff as needed, with family members stepping in to provide this care. Staffing shortages were particularly acute during the night shift, with only one nurse sometimes covering two floors, responsible for up to 87 residents. This led to delays in medication administration and a lack of immediate nursing care during emergencies. The Director of Nursing acknowledged the staffing issues, particularly at night, and the facility's assessment tools indicated that each floor should have its own nurse during the night shift, a standard that was not consistently met.

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 medically related social services to meet the needs of its residents, affecting all 84 residents. Observations revealed that residents with dementia, such as R21, R53, and R138, were left unattended and not engaged in activities, leading to incidents like R21 falling out of her wheelchair. Their care plans did not address their behaviors or dementia, indicating a lack of individualized attention and support. Additionally, the facility lacked a full-time social worker, as confirmed by multiple staff members and residents. This absence resulted in unresolved conflicts, unmet needs for assistance with insurance and medical referrals, and a lack of support for residents' emotional and social needs. The part-time social worker, V18, admitted to being behind on care plans and not handling discharge planning, grievances, or behavior management counseling effectively. The facility's failure to maintain a full-time social services staff led to significant gaps in care, including the absence of documented grievances and a lack of discharge planning for residents like R28, who expressed concerns about her prolonged stay and lack of communication regarding her discharge. The facility's job description for the Social Service Director outlined responsibilities that were not being fulfilled, further highlighting the deficiency in providing adequate social services.

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 sanitization and air drying of a serving spoon, which could potentially lead to foodborne illness affecting all 82 residents receiving food from the kitchen. During an observation, a cook handed a soiled serving spoon to a dietary aide, who then quickly dipped the spoon through each compartment of a three-compartment sink. At the sanitizer sink, the dietary aide dipped the spoon a few times, removed it, and dried it with brown disposable paper towels before returning it to the cook for continued use. The facility's dish machine has been broken for a few years, necessitating the use of a three-compartment sink for dishwashing. According to the facility's policy, items must be fully submerged in the sanitizer sink for one full minute to ensure proper sanitization, followed by air drying. However, the dietary aide did not adhere to these procedures, as the spoon was not submerged for the required time and was dried with paper towels instead of being air-dried. This deviation from the established sanitization protocol was confirmed by a staff member's statement and the facility's manual sanitizing 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 administration failed to effectively manage resources to meet the needs of its 84 residents, as evidenced by several deficiencies. Observations revealed that residents were left without activities, with the television being the only source of entertainment. The facility lacked a full-time activity director, relying instead on a single activity assistant. Additionally, the resident council president confirmed the absence of organized activities, and the Assistant Director of Nursing acknowledged the staffing shortfall in the activities department. The facility also failed to provide adequate social services support. Residents reported the absence of a full-time social worker, with only a part-time social worker available for a few hours in the evenings. This lack of support led to unresolved conflicts between residents and unmet needs for assistance with insurance and dental care. The Assistant Director of Nursing confirmed the long-standing vacancy of a full-time social worker position. Nursing staff shortages were evident, particularly during the night shift, where there were instances of only one nurse being responsible for multiple floors and up to 87 residents. This staffing issue resulted in delayed medication administration and inadequate coverage for emergencies. The Director of Nursing admitted awareness of the staffing issues but had not resolved them. Additionally, the Food Service Manager lacked the necessary certification, and the Administrator was unaware of several critical issues, including staffing shortages and dietary management deficiencies.

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 employ a qualified, full-time social worker, which has the potential to affect all 84 residents. The facility's application for Medicare and Medicaid indicated a resident census of 84, with a maximum bed capacity of 230 beds. During a resident meeting, several residents expressed concerns about the lack of a full-time social worker. One resident mentioned an unresolved conflict with a roommate and difficulty in obtaining assistance with insurance for dental care. Another resident noted the absence of someone to talk to when feeling upset, aside from a contracted psychiatric social worker who visits once a week. Interviews with facility staff confirmed the absence of a full-time social worker. The Assistant Director of Nursing and the Administrator both acknowledged that the facility had not had a full-time social worker for some time. The part-time social worker, who works a few hours in the evenings, stated that her role is limited to assisting with care plans and MDSs, and she does not engage in discharge planning, grievance handling, or resident counseling unless approached during her limited hours. The facility's job description for the Social Service Director outlines responsibilities that include providing social services to meet residents' needs, developing care plans, and coordinating activities, which are not being fully met due to the lack of a full-time social worker.

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 nursing staff received the required annual dementia care training and education, which has the potential to affect all 84 residents in the facility. During a review of employee files, it was found that several Certified Nursing Assistants (CNAs) and other staff members, who have been employed for varying lengths of time, did not receive dementia education or training in 2023 or 2024. Specifically, the files of employees V22, V28, V26, V21, and V6 showed no record of such training for the specified years. The Human Resources representative, V17, confirmed the lack of dementia training for these employees and explained that while they are responsible for providing education on abuse, harassment, and privacy, the social services department typically handles dementia training. However, due to the absence of personnel in social services, the training was not conducted. The facility's Facility Assessment Tool, revised in July 2023, indicated that nursing staff education and competencies should include training on abuse, resident rights, and dementia care, both upon hire and as required.

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 activities for residents, as observed during a survey conducted on June 2 and June 3, 2024. On these dates, residents R48 and R65 were seen sitting in the dining room in reclining wheelchairs with no activities taking place, except for a television being on. Additionally, R74, the resident council president, reported that there were no activities available, and residents had to entertain themselves. Although a CNA attempted to engage some residents in a game of BINGO, R48 and R65 did not participate and continued to sit passively in the dining room. The facility's activity calendar for June 2024 listed scheduled activities that were not carried out during the survey. Furthermore, the facility lacked an activity director and had only one activity assistant, which was insufficient to meet the needs of the residents. The CNA expressed difficulty in managing activities alone, indicating that activities were only conducted on certain days. The care plans for R48 and R65 highlighted their need for socialization and varied activities, which were not being met. The facility did not provide an activity policy, further contributing to the deficiency in meeting residents' activity needs.

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 opened, multi-dose bottles of medication, inhalers, and insulin pens were labeled with expiration dates for four residents. During an inspection of the medication carts, it was observed that a Lantus insulin pen and Advair Diskus inhaler for one resident, a vial of Lispro insulin for another, and a Lantus insulin pen for a third resident were opened but not dated with an opened or expiration date. A registered nurse confirmed that all medication vials and bottles should be dated when opened to track expiration. Additionally, a medicine cup containing six unidentified pills was found in a medication cart, and a bottle of Latanoprost eye drops for another resident was also opened and not dated. The nurse present was unsure of the reason for dating medications, despite the facility's policy requiring medications to be dated upon opening to ensure proper storage and usage. The policy specifies that the expiration date should be 30 days from opening unless otherwise recommended by the manufacturer.

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 appropriate infection prevention and control measures for residents with multi-drug resistant infections and those requiring enhanced barrier precautions. Specifically, a resident with a multi-drug resistant urinary tract infection was not placed on contact isolation, as evidenced by the absence of isolation signs or a cart outside the resident's room. The Assistant Director of Nursing confirmed that the resident should have been on contact isolation, but this was not implemented. Additionally, the facility did not initiate enhanced barrier precautions for residents with catheters, tube feedings, and wounds. Observations revealed that residents with indwelling catheters and feeding tubes did not have enhanced barrier precaution signs outside their rooms. Furthermore, during a dressing change for a resident with a stage 2 sacral pressure injury, staff did not wear gowns as required by enhanced barrier precautions. The Assistant Director of Nursing acknowledged the lack of a policy or guidance for enhanced barrier precautions and confirmed that the facility had not yet implemented these measures.

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, who is dependent on staff for various personal care activities, had an accessible call light system to meet her needs. The resident, identified as R4, is nonverbal and relies on staff for oral hygiene, toileting, bathing, dressing, personal hygiene, and all transfers. During an observation, it was noted that R4's call light rope was hanging from a switch above her roommate's bed, making it inaccessible to her. Despite being nonverbal, R4 was able to indicate difficulty in asking for help from staff. On a subsequent day, observations from the nurse's station revealed that R4 was making intermittent audible noises, which her roommate identified as signals for needing help. The call light remained out of reach, and the roommate had to alert staff to R4's needs. A registered nurse later confirmed that R4 makes noises to request assistance and acknowledged that there were no other methods in place for R4 to alert staff. The facility's policy requires that call lights be positioned conveniently for residents, but this was not adhered to in R4's 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 ensure privacy for a resident during wound dressing changes, which is a violation of the residents' right to personal privacy. On June 2, 2024, a registered nurse changed the dressing on a resident's right heel while the resident was seated in a reclining wheelchair in the dining room, visible to approximately 20 other residents. Later that day, the same nurse changed the dressing on the resident's buttocks while the bedside curtain and door to the room were open, allowing visibility from the hallway. The Assistant Director of Nursing acknowledged that staff should not perform dressing changes in public areas and must provide privacy for residents during such procedures. The facility's policy, dated September 1, 2011, mandates that staff must maintain the privacy of residents' bodies during examinations and treatments by using privacy curtains, closing doors, or removing residents from public view.

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 residents who were dependent on staff for activities of daily living (ADLs) received proper care, including bathing, nail trimming, and facial grooming. Three residents were specifically noted for this deficiency. One resident, who is nonverbal and requires extensive assistance due to dementia and communication deficits, was observed with excessively long nails and had not received a bath for nearly a month, despite being scheduled for showers twice a week. Another resident, who also requires extensive assistance, was found with long, dirty nails and unshaven facial hair, indicating a lack of personal hygiene care. This resident expressed a need for nail trimming, which had not been addressed by the facility. A third resident reported receiving only one shower since admission, despite being scheduled for showers twice a week. This resident denied refusing showers, contrary to facility records that indicated refusals. The facility's policies on nail care and showering were not adequately followed, as evidenced by the observations and resident statements. The facility's nail care policy requires nails to be kept clean and trimmed, typically during or shortly after bath time, but this was not adhered to for the residents in question.

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 assess and treat a resident's skin rash according to standards of practice. The resident, identified as R17, reported having a severe rash on her back and groin for over two weeks. Despite informing the nursing staff, no physician had evaluated her condition. The resident was given Nystatin powder to apply herself, which is against the protocol that requires nurses to apply the treatment and assess the rash. The Treatment Administration Record indicated an active order for Nystatin powder to be applied to the groin twice daily, but there was no order for treating the rash on the resident's back. The nursing staff, specifically V16 RN, acknowledged not having assessed the rash and was unaware of the rash on the resident's back. The only documented assessment before the surveyor's inquiry was a note from V16 RN, dated 5/28/24, indicating a skin check every Tuesday for monitoring redness in the groin. The Wound Nurse Practitioner, V35, was not informed of the rashes until the surveyor's visit and identified the rash on the back as an allergic reaction and the groin rash as a fungal infection.

Penalty

No penalty information released

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

Summary

The facility failed to properly assess, report, and treat a sacral pressure injury for a resident, identified as R6, who was part of a sample of 20 residents reviewed for pressure injuries. On June 2, 2024, a registered nurse (RN) observed a large, purple/red open area on R6's buttocks, which had worsened since she first saw it earlier that week. Despite the severity of the wound, there were no physician orders or treatments in place, and the RN was only applying betadine and covering it with a foam dressing. The wound doctor was expected to evaluate the wound on the same day but did not arrive, and the RN had not documented any assessments of the wound in R6's medical record. R6's medical history indicated skin issues upon readmission from a local hospital, and the resident's care plan, dated February 25, 2024, identified a risk for skin breakdown due to factors like lack of mobility and incontinence. However, the care plan did not address the current pressure injuries. The facility's protocol required immediate treatment initiation for newly identified pressure ulcers, but this was not followed. The Treatment Administration Record (TAR) for June 2024 showed a physician order for treating the sacral wound starting June 3, 2024, a day after the RN's observation, indicating a delay in treatment initiation.

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 restorative services to two residents, R24 and R64, as part of their care plans. R24, who is nonverbal and has contractures in both hands due to a cerebral vascular accident, was supposed to receive passive range of motion (PROM) exercises for 15 minutes daily. However, documentation showed that these exercises were only provided on 8 out of 30 days. The Assistant Director of Nursing and the Restorative CNA indicated that the restorative CNA was often pulled to work on the floor, leaving the responsibility to floor CNAs who could not consistently perform the restorative tasks due to workload constraints. R64, who was discharged from skilled physical therapy, was supposed to be walked by the nursing staff as part of her restorative care. However, there was no clear plan indicating the frequency of this activity, and her ADL records showed she was not walked at all in May. R64 expressed willingness to walk if assisted, but the staff was unable to consistently provide this support due to staffing issues. The facility's Restorative Nursing Program policy emphasizes the importance of restorative care to prevent resident decline, yet the lack of consistent implementation led to deficiencies in care for these 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 ensure adequate supervision and interventions for residents at risk for falls, specifically affecting two residents. One resident, identified as R21, experienced multiple falls due to inadequate supervision and lack of updated interventions. On May 26, 2024, R21 fell from her wheelchair, resulting in a chin laceration, mild traumatic brain injury, and a pelvic fracture. Despite being identified as high risk for falls, her care plan had not been updated since April 9, 2024, and interventions were not effectively implemented. Observations on June 2 and June 3, 2024, showed R21 wandering unsupervised and attempting to stand from an unlocked wheelchair, leading to another fall. The Assistant Director of Nursing acknowledged the need for constant supervision but had not documented or implemented new interventions. Another resident, R65, was transferred without a gait belt, contrary to the care plan instructions last updated on December 31, 2023. On June 3, 2024, a CNA transferred R65 between wheelchairs without using a gait belt, causing the resident to nearly fall. The Assistant Director of Nursing confirmed that staff should have used a gait belt during transfers. These incidents highlight the facility's failure to adhere to its policies on fall risk management and safe transfer practices, resulting in preventable accidents and injuries.

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 respiratory care for two residents by not dating oxygen tubing and not changing humidifier containers on their oxygen concentrators as required. On June 2, 2024, one resident was observed with a portable oxygen concentrator next to their bed, expressing concerns about the lack of maintenance on the machine and water container. The nasal cannula tubing was not dated, and the humidifier container was last dated April 18, 2024. Another resident was found with similar issues, as their nasal cannula tubing was also not dated, and the humidifier container had the same outdated date. Both residents' Treatment Administration Records for May 2024 indicated that their oxygen tubing and humidifier containers were to be changed weekly on Sundays, but the records were initialed as if the changes had been made, despite evidence to the contrary. The Assistant Director of Nursing confirmed that the facility's protocol required weekly changes and dating of these items. The facility's Oxygen Administration policy from 2018 also stipulated that humidifiers should be dated and initialed when changed according to 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 monitor behaviors and provide appropriate stimulation for residents diagnosed with dementia, affecting three residents in the sample. Resident R21, diagnosed with dementia, was observed sitting idle in the dining room without engagement in activities. She exhibited wandering behaviors, attempted to take food from other residents, and set off an exit alarm without staff intervention. Her care plan, dated August 8, 2023, did not address her behaviors, indicating a lack of individualized care planning for her condition. Similarly, Resident R53, also diagnosed with dementia, was observed sitting in a reclining wheelchair in the dining room without engagement or activities. She was fidgeting and attempting to get out of her wheelchair, yet staff did not engage with her. Her care plan did not address her dementia or behaviors. Resident R138, a Korean-speaking individual with dementia, was observed sitting idle in the dining room and was not offered participation in activities like bingo. His medical record lacked a care plan addressing his dementia or behaviors. A CNA expressed that managing the residents was overwhelming for one person, highlighting staffing challenges.

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 dispensed according to standards of practice for a resident reviewed for pharmacy services. During an observation, a pill cup containing a blue pill was found on the bedside table of a resident, who stated that sometimes medications are left for him to take when he is in the bathroom. The resident was unable to identify the pill or the time it was left for him, and he took the pill while the surveyor was present. A registered nurse confirmed that residents should be supervised when taking their medication and that the resident did not have an order to self-administer his medication. The nurse believed the blue pill was likely Levothyroxine. The Assistant Director of Nursing reiterated that medications should not be left for residents to take unsupervised. The resident's Physician Order Summary indicated an order for Levothyroxine to be given once daily, with no order for self-administration, and the Medication Administration Summary showed it was scheduled for 6:00 AM. The facility's pharmacy policy stated that residents could only self-administer medication with a physician order and should be observed during administration.

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 admitted for therapy services received the necessary therapy. The resident, identified as R84, was admitted with a primary diagnosis of a right femur fracture following a car accident. Despite the resident's care plan indicating a need for therapy to recover from a right hip fracture, the resident reported not receiving therapy services. Initially, a physical therapist, V30, worked with the resident on leg exercises but went on vacation, leaving the resident under the care of a Restorative CNA, V32, who only assisted with transfers and not walking. The resident expressed a goal of regaining the ability to stand and walk to eventually discharge home. The facility's records indicated that the resident was discharged from skilled physical therapy services due to no progress and poor motivation, and was referred to a restorative program. However, the resident was not informed of this discharge and believed he was still making progress towards his goal. A substitute physical therapist, V33, who filled in during V30's absence, did not see the resident. The facility did not provide a physical therapy policy when requested, indicating a lack of communication and documentation regarding the resident's therapy services and discharge status.

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 residents were properly screened for and received the recommended doses of the pneumococcal vaccine. Specifically, two residents were identified as not having been appropriately managed in terms of their pneumococcal vaccination status. One resident, admitted to the facility, had an immunization record indicating the last pneumococcal vaccination was received in 2000, making them eligible for another dose. However, there was no documentation in the medical record showing that this resident was screened for or offered the vaccine upon admission or at any time during their stay. Another resident was screened for the pneumococcal vaccine and consented to receive it, as documented in their medical records. Despite this, there was no evidence that the vaccine was administered during their stay. The Infection Preventionist confirmed these oversights, acknowledging that residents should be screened for the vaccine upon admission and possibly annually, but admitted that the facility only screens upon admission and lacks a designated nurse responsible for the immunization program. The facility's policy states that all residents should receive necessary immunizations unless contraindicated, and new residents should be assessed for pneumococcal vaccine status upon admission, 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 ensure an allegation of sexual abuse was immediately reported to the Administrator. A resident reported that she was in the dining room sleeping when she woke up to find a man touching her breast. The resident did not report the incident immediately but informed a Registered Nurse, the Director of Nursing, and Social Services a few days later. Despite this, an investigation was not initiated until the resident notified the ombudsman, who then informed the facility, prompting them to start an investigation and call the police. The Registered Nurse admitted to not reporting the incident to the Administrator, assuming that Social Services was handling it. The Director of Nursing and Social Services both stated that they were not aware of the incident until much later. The Administrator confirmed that all allegations of abuse should be reported to him immediately to initiate an investigation. The Assistant Director of Nursing also confirmed that she was only made aware of the incident through an email from the ombudsman. The facility's Abuse Prevention Program mandates that all allegations of abuse and neglect be reported immediately to the Administrator, which was not followed in this case.

Penalty

Inspection fine: $140,31266 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 residents were not verbally abused by another resident, R2, who repeatedly used racial slurs towards other residents. The incident occurred in the dining room where R2, in an agitated state, called R1 and other African American residents derogatory names, including the n-word. This behavior was witnessed by multiple residents and staff members. Despite being alert and oriented, R2 has a history of psychiatric problems and has exhibited similar behaviors in the past. The Assistant Director of Nursing (ADON) and other staff members were aware of R2's behavior, and R2 was moved between floors in an attempt to manage her actions. However, the verbal abuse continued, causing significant distress to the affected residents. The facility's records and interviews reveal that R2 has a history of non-compliance with her medication regimen, which includes risperidone and seroquel, leading to increased delusional behavior and verbal aggression. The Behavior Monitor record for March 2024 indicated multiple instances of problematic behavior, including the day of the incident. Despite these documented behaviors, the staff failed to adequately monitor and address R2's actions, resulting in repeated verbal abuse towards other residents. The facility's Abuse Prevention Program policy defines verbal abuse and mental abuse, but the staff's actions were insufficient to prevent the abuse from occurring.

Penalty

Inspection fine: $140,31266 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 thorough investigation of an abuse allegation involving two residents. The incident involved one resident (R2) using derogatory and racially offensive language towards another resident (R1) in the dining room, which was witnessed by other residents. The investigation did not include interviews with the involved residents (R1 and R2) or other witnesses present during the incident. Additionally, no interviews were conducted with other employees or residents who had regular contact with R2. The Assistant Director of Nursing (V3) acknowledged that she did not interview all relevant parties and admitted that she should have done so in hindsight. The facility's Abuse Prevention Program policy outlines specific procedures for conducting investigations, including interviewing the person reporting the incident, any witnesses, the resident involved, other residents with regular contact with the accused individual, and other employees. However, these procedures were not followed in this case. The failure to conduct a thorough investigation as per the facility's policy resulted in an incomplete understanding of the incident and the involved parties' perspectives, thereby failing to address the abuse allegation adequately.