Elevate Care Regency

Penalty

Inspection fine: $18,160

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 safe wheelchair transport and failed to immediately respond to a resident’s complaint of pain after an incident involving wheelchair movement. The resident had left-sided weakness from a prior stroke, was wheelchair-bound, and was observed with an immobilizer on the left leg after sustaining a left femur fracture that required surgery. The resident stated that while a CNA was pushing her in a wheelchair, her left foot became caught under the footrest, she told the CNA to stop, and the CNA continued pushing before stopping. The CNA stated that the resident’s foot came out of position and her shoe came off while being pushed in the wheelchair, and that the wheelchair was stopped and the shoe was replaced before continuing to the room. Other staff gave differing accounts of whether the foot slipped off the footrest, grazed the floor, or whether the shoe was not fully secured. The resident’s son stated that the resident reported her foot became caught under the wheelchair footrest and that the aide did not stop immediately. Staff also stated that the resident continued to complain of pain after the incident, and pain medication was administered later that day and again the next day. Record review showed the resident’s care plan included monitoring for safety, and the facility’s incident procedure required a full head-to-toe assessment after an accident, including range of motion, pain, deformities, shortening of limbs, vital signs, and blood sugar when applicable. Although nurses documented the resident’s pain and requests for an X-ray, the medical record did not contain documentation of the required head-to-toe assessment after the incident.

Penalty

Inspection fine: $49,350

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 pressure-redistribution and incontinence care for 2 residents who entered without pressure ulcers and later developed facility-acquired wounds. One resident was a ventilator-dependent, non-verbal male with anoxic brain damage, chronic respiratory failure, tracheostomy, gastrostomy, and dependence on a ventilator. He had a facility-acquired Stage 4 sacral pressure ulcer measuring 6.4 cm x 10.6 cm x 0.5 cm, and the wound was observed with 20% slough and active bleeding during dressing care. Despite a nurse practitioner order to turn every 2 hours, the resident was observed lying continuously in a supine position for 2 hours and 15 minutes without staff intervention, directly on the bleeding sacral wound. The care plan for this resident included language that he "may reposition every 2 hours as needed," and staff interviews confirmed that residents with pressure ulcers should be turned and repositioned every 2 hours. The wound care coordinator observed the sacral wound on 03/24/26, and the dressing and incontinent pad were saturated with blood. On 03/25/26, repeated observation from 9:50 AM to 12:05 PM showed the resident remained supine without repositioning. The DON also stated that staff should turn and reposition every 2 hours and as needed. A second resident, a quadriplegic, had a facility-acquired unstageable right gluteus pressure ulcer and was found uncomfortable and requesting repositioning. On one observation, the assigned CNA had not yet provided care or repositioning by 11:00 AM. On another observation, the resident was found heavily wet in an incontinence brief, with moisture saturated through the linens and onto the air mattress, and a visible yellowish circle of wetness with a darkened yellow circumference ring. The resident remained in a prolonged soiled state while staff repositioned him, and the report states that the facility failed to implement mandatory pressure-redistribution protocols and provide timely incontinence care.

Penalty

Inspection fine: $49,350

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

Food was not stored, prepared, and served under sanitary conditions. During a kitchen tour on 03/23/2026, expired or out-of-date prepared food items were observed in the first reach-in refrigerator, including plates of Jello, mixed fruit cups, and cottage cheese dated 03/20/2026, chopped watermelon dated 03/20/2026, fruit cups dated 03/20/2026 and 03/21/2026, and pudding cups dated 03/21/2026. These items remained available for resident service beyond the facility’s 48-to-72-hour window for fresh prepared or opened items. The sanitizing bucket log on the refrigerator door showed the last change and concentration check was 03/21/2026, and the facility did not provide evidence that sanitizing solutions used in food preparation areas were changed or monitored for efficacy for the prior 48 hours. During lunch preparation, no staff were observed using the sanitation buckets to obtain sanitized rags to wipe surfaces after food prep. During a meal service observation and test tray audit on 03/24/2026, food temperatures were below required standards. A serving of Beef Stroganoff measured 131 F when tested in the resident dining area, below the required hot-holding temperature of 135 F or higher. A pudding dessert measured 70 F, which was above the required cold-holding temperature of 41 F or below. On 03/25/2026, the Dietary Manager confirmed the findings and stated that a deeper thermometer placement might have produced a higher meat temperature and that the pudding reading might have been affected by not wiping the thermometer with alcohol, but no secondary temperature reading was provided to refute the initial measurements.

Penalty

Inspection fine: $49,350

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 its infection prevention and control water management program to control Legionella and other opportunistic waterborne pathogens. After a Legionella report dated 12/31/25 showed Legionella detected in a room sink at 0.1 CFU/ml, another room sink at 0.1 CFU/ml, and a room shower at 6 CFU/ml, staff described the shower result as a moderate concern requiring action. Facility staff stated that flushing and secondary disinfection were used, but the water retesting was not completed until the survey date, and the maintenance staff reported that weekly flushing was not done as required by the facility’s own protocol. The facility also had a malfunctioning secondary disinfection system intended to inject chemicals into the domestic water system. Staff reported that one of the pumps or sensors was not working properly, that alarms were being reset repeatedly, and that the issue had been ongoing for more than 60 days. The maintenance staff stated that the system was reset daily and that documentation was not completed when there was an issue. The vice president of physical plant stated the facility had a system that injects chloramine into the water and that weekly flushing was done, while other staff described monthly flushing of the affected shower instead of weekly flushing. The affected room shower was identified as a Legionella source, and the current resident occupying that room, R185, stated she was using the shower in her bathroom. The prior resident, R184, had been discharged from the facility on 03/14/26. The facility’s policy stated that showers and high-risk sinks must be done weekly to begin with, and that flushing should be documented. The administrator stated she was not aware of the positive Legionella results or concerns related to the secondary disinfection system.

Penalty

Inspection fine: $49,350

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 reasonably accommodate residents' needs and preferences by not keeping call lights within reach for residents with significant physical and cognitive impairments. R82, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction and unspecified dementia, was observed lying in bed with the call light hanging behind the bed and out of reach. R1, who had diagnoses including traumatic subdural hemorrhage, cervical fracture, and unspecified dementia, was observed lying in bed with the call light hanging underneath the bed and out of reach. R95, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction and depression, was observed with the call light hanging near the floor and was unable to pull it into reach. The facility also failed to provide timely responses to call lights and did not anticipate the needs of a resident unable to use a standard call light. R95 stated they did not use the call light and instead yelled out for staff. After a surveyor initiated the call light, five minutes passed before a CNA entered the room, and 20 minutes passed before V5 and R95's regular CNA arrived to assist with toileting and changing. R95 told staff they had not been changed or toileted that day and attempted to go in their brief while lying flat in bed. R98, who had diagnoses including quadriplegia, acute and chronic respiratory failure with hypoxia, pneumonia, and need for assistance with personal care, was observed slid down in bed with discomfort and requested to be moved up and toileted after using a mouthpiece device connected to the call light system. Surveyor interviews and resident council records showed that delayed call light response was an ongoing issue. Staff members stated call lights should be answered as soon as possible, with one LPN saying one to two minutes was expected, another staff member saying over five minutes was unacceptable, and a CNA saying over seven to ten minutes was unacceptable. The DON stated call lights are to be answered as soon as possible. Resident council members reported call light wait times ranging from 20 to 30 minutes during the day and one and a half to three and a half hours overnight, and prior council minutes documented complaints that CNAs took too long to answer call lights, took a considerable amount of time, or frequently did not answer them at all. The facility policy stated that functioning call lights must be accessible and that staff must monitor residents who cannot use the call light more frequently and attempt to anticipate their needs.

Penalty

Inspection fine: $49,350

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 comprehensive care plans were developed with directive, measurable interventions and were implemented as written for 4 of 4 residents sampled for this issue, including residents with Multiple Sclerosis, quadriplegia, and dementia. The care plans used permissive language such as "may" for high-risk clinical areas, including pressure ulcer prevention, despite the residents being physically dependent on staff for ADLs. Facility leadership, including the DON and Wound Coordinator, stated that the care plans were intentionally written using "may" language because that was how they were trained, and the DON stated the care plans were for the resident to follow rather than for staff. Resident R1, an [AGE]-year-old with traumatic subdural hemorrhage, cervical fracture, and unspecified dementia, was observed lying in bed with a dirty gown, stained bed sheets, and no call light within reach while calling out and intermittently laughing. R1's care plan dated 03/02/2026 included non-directive language for skin breakdown prevention, stating staff "may" use a low air loss mattress, cushion, reposition every 2 hours, offload heels, and apply barrier cream after incontinent episodes. Resident R81, an [AGE]-year-old with unspecified dementia, behavioral disturbance, major depressive disorder, history of falling, and autistic disorder, was observed in the dining room banging her hand on the table and shouting "mommy" until staff transferred her to a wheelchair and provided crayons and a coloring sheet, which calmed her. R81's care plan dated 02/02/2026 also used non-directive language for pressure ulcer prevention, including that staff "may" use a cushion, reposition every 2 hours, offload heels, and apply barrier cream. The facility also failed to implement directive interventions that were written into care plans. Resident R36 had a care plan requiring incontinence care at least every 2 hours, but was found in a crystallized brief and overfilled colostomy bag after going 18 hours without care. Resident R98 had a care plan requiring a specific passive range of motion program of 10 repetitions by 2 sets of limb flexion, but observations on 03/25/2026 confirmed the PROM exercises were not implemented. The report states this reflected a systemic pattern of developing non-comprehensive, non-directive care plans and failing to carry out directive interventions.

Penalty

Inspection fine: $49,350

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

Summary

The facility failed to provide the necessary services to maintain grooming and personal hygiene for 4 of 4 residents reviewed for ADLs. Residents were observed slumped in chairs, in soiled bed linens with dried liquids, with greasy and unkempt hair, and in saturated incontinence briefs. The deficient practice was identified during observation, interview, and record review and involved residents who were unable to carry out ADLs independently and were not kept clean, well-groomed, and in a sanitary environment. R4, a resident with dementia, hemiplegia affecting the right dominant side, schizoaffective disorder, and hospice care, was observed in the dining room sitting in a geri chair, disheveled with greasy hair, dandruff, food on clothing, and slumped in an uncomfortable position. R1, with traumatic subdural hemorrhage, cervical fracture, and dementia, was observed in bed with sheets soiled by a dried unknown liquid, greasy and disheveled hair, and a dirty hospital gown. R82, with hemiplegia and hemiparesis following cerebral infarction, colon cancer, dementia, and a history of falling, was observed in bed with soiled sheets, a bib bunched on the chest with food on it, a stained and unbuttoned hospital gown, and greasy hair. R95, with CVA-related hemiplegia and depression, stated they had been in the same hospital gown as the day before, had not yet been checked on, and were wet; after staff entered the room, the resident was observed to have a wet and saturated diaper.

Penalty

Inspection fine: $49,350

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 one resident was free from neglect when the resident was left in a crystallized, urine-saturated incontinence brief and an overfilled colostomy bag for approximately 18 hours. The resident was alert and oriented, with diagnoses including Multiple Sclerosis, Emphysema, Cataracts, and colostomy status. On observation, the resident was found with saturated linens and a mattress pad with a yellowish-brown ring, and the facility Wound Nurse confirmed a newly formed MASD on the lower left buttock and upper thigh area, stating it was caused by moisture and likely from the resident laying in urine for so long. During the surveyor interview, the assigned CNA admitted she had only performed visual rounds for positioning and did not physically check the resident’s brief or colostomy bag for cleanliness or capacity. The nurse on duty confirmed the colostomy bag was over 3/4 full and stated the CNA should have reported it so it could have been changed earlier. The nurse also acknowledged she did not know when the resident was gotten up and said she had never seen the resident out of bed. The resident’s care plan required toileting assistance and incontinence care at least every 2 hours and as needed, along with monitoring of the colostomy output and daily range of motion with AM/PM care. The resident was also identified by the facility as high-risk for neglect due to being bed-bound and requiring total care, and the assessment noted isolation or withdrawal and a BIMS of 10. During the surveyor interview, the resident became tearful and stated she felt forgotten, said staff used to get her up for activities but no longer did, and stated she had given up on everything.

Penalty

Inspection fine: $49,350

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 received the therapeutic diet ordered by the physician. R93, a female resident with diagnoses including metabolic encephalopathy, type 2 diabetes mellitus without complications, COPD, atherosclerotic heart disease, and oropharyngeal dysphagia, had a physician order dated 3/10/2026 for an LCS/NAS diet with mechanical soft texture and nectar/mildly thick liquids. Her speech therapy note dated 3/23/2026 also identified her current liquids as mildly thick drinks and her solids as minced and moist foods. During observation, R93 was served items that did not match the ordered liquid consistency. On 3/23/2026, the surveyor observed thin soup and coffee on her tray even though the meal ticket indicated mechanical soft diet with nectar thick fluids. On 3/24/2026, a cup of water and prune juice were observed on her bedside table, and staff delivered her lunch tray without adjusting the viscosity of the prune juice. The resident stated that nurses always give her water after medications and that staff also bring iced water when she asks for it. An RN stated that R93 received crushed medications with applesauce, that she was on a mechanical soft, nectar thick, no straw diet, and that residents on nectar thick diets should not have thin density liquids, although she also said R93 could tolerate thin liquids. The DON stated that because R93 was on a mechanically soft diet with nectar thick liquids, she was at risk for aspiration and should not have water without a thickener while the order remained unchanged.

Penalty

Inspection fine: $16,435

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 necessary respiratory care and monitoring to a ventilator‑dependent resident by not adequately assessing and responding to ventilator alarms and not ensuring the ventilator circuit and closed suction system were intact and functioning. The resident was an older adult female with encephalopathy, quadriplegia, COPD, vascular dementia, chronic respiratory failure, and complete dependence on mechanical ventilation via tracheostomy. Her MDS documented severely impaired cognitive skills and short‑ and long‑term memory problems. Physician orders specified continuous ventilator support (assist‑control mode, rate 18, tidal volume 400 ml, PEEP 5, FiO2 28% with 2 L/min O2), and care plans directed staff to monitor for signs and symptoms of hypoxia and acute respiratory insufficiency. During the night in question, progress notes show that at approximately 1:45 AM the ventilator alarms were intermittently sounding. The RN responded by entering the room, performing oral suctioning for copious thin secretions, and tracheal suctioning once for a moderate amount of blood‑tinged thin secretions. Vital signs were checked and documented, the G‑tube dressing was changed, and the nurse recorded that the resident was in no distress and that the ventilator was no longer alarming. The nurse later stated in interview that after this suctioning, everything was still connected, the resident’s oxygen saturation was acceptable, and the ventilator stopped alarming. She reported not hearing any further alarms prior to the later emergency. However, review of the ventilator’s VOCSN alarm logs showed multiple high inspiratory pressure and low minute volume alarms between approximately 2:38 AM and 2:39 AM, and low inspiratory pressure and low minute volume alarms between approximately 3:03 AM and 3:04 AM. These alarms alternated between triggered and resolved, indicating on‑and‑off alarm activity. There was no documentation in the resident’s progress notes that nursing or respiratory staff assessed the resident or evaluated the ventilator in response to these alarms. The lead RT and other clinical leaders stated that such alarms require immediate or prompt physical assessment of the resident and ventilator circuit, and that staff are mandated to answer all alarms. At approximately 3:55–4:15 AM, the RT entered the room during rounds and found the resident unresponsive, pale, with no breathing and no vital signs, and disconnected from the ventilator. The RT reported that there was no ventilator alarm sounding at that time and that the ventilator tubing was disconnected and close to the tracheostomy. The RN, called to the room, also found the resident pale, not moving, with no chest rise, and assisted in initiating CPR and calling a code blue and EMS. The ambulance crew documented that staff reported the resident was last seen normal around 2:00 AM and was later found in cardiac arrest with the ventilator disconnected and no alarms sounding. Hospital records documented that the resident arrived in cardiac arrest with absent heart sounds, no palpable carotid pulse, fixed and dilated pupils, and no purposeful response, and she was pronounced dead after resuscitation efforts. The surveyors concluded that the facility failed to assess and respond to ventilator alarms and failed to ensure the ventilator circuit and closed suction system were intact and functioning, resulting in the resident being found unresponsive and disconnected from the ventilator and expiring, and this failure constituted Immediate Jeopardy.

Removal Plan

• Initiate high quality CPR, call a code blue, call EMS, continue CPR until EMS arrives, and transfer the resident to the hospital.
• Check all ventilator-dependent residents for proper connection and alarm function.
• Identify other potentially affected residents, including residents with an open airway and residents utilizing a ventilator.
• Check all ventilator-dependent residents for proper connection and alarm function.
• Check all ventilators to ensure all required maintenance is performed.
• Have the assigned respiratory therapist check all ventilator-dependent residents for proper connection and alarm function every 2 hours and as needed, and document these checks once per shift.
• Conduct staff education by the ADON, lead respiratory therapist, Regional Nurse Consultant, and shift supervisor.
• Provide education to all staff assigned to the respiratory unit, including PRN staff.
• Implement a monitoring process in which the respiratory therapist randomly audits ventilator residents to ensure ventilator settings, connections, and alarm functionality are assessed after care activities that could disrupt the ventilator circuit.
• Implement observation audits of ventilator-dependent residents for secure connections.
• Have the Director of Nursing or designee conduct direct observation in the respiratory unit to ensure prompt response to alarms on random shifts.
• Have the Director of Nursing or designee conduct direct observation of staff to ensure residents with an open airway are repositioned appropriately and carefully to prevent interruption of respiratory tubing.
• Conduct audits for all residents with an open airway, then continue audits weekly.
• Present audit results to the QAPI committee for recommendations of further auditing and actions as appropriate.
• Complete a code blue debrief and have the action plan discussed and approved by the Ad-Hoc committee.

Penalty

Inspection fine: $179,482

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 multiple complex medical conditions, including type II diabetes mellitus, experienced a severe hypoglycemic episode that was not managed according to professional standards of practice and facility policy. The resident was first found to have a critically low blood glucose level of 42 mg/dl in the early morning by a night shift LPN, who administered glucagon but did not promptly notify the nurse practitioner or physician as required. Despite repeated low blood glucose readings and additional doses of glucagon and oral carbohydrates, the resident's condition did not improve, and there was a prolonged period—over two hours—where the resident remained hypoglycemic and increasingly unresponsive. The nursing staff failed to escalate care in a timely manner. The night shift LPN endorsed the situation to the incoming day shift LPN without notifying the medical provider, and both nurses continued to monitor and treat the resident without achieving a safe blood glucose level or seeking immediate higher-level intervention. Documentation and interviews confirm that the nurse practitioner was not notified until the resident developed respiratory distress and further decline in condition. Only at this point was 911 called and the resident transferred to the hospital. Throughout this episode, facility policy and standard hypoglycemia protocols were not followed, specifically regarding prompt provider notification and emergency escalation for persistent severe hypoglycemia. The lack of timely intervention and failure to follow established protocols resulted in the resident experiencing prolonged hypoglycemia, decreased responsiveness, and ultimately requiring emergent hospital transfer, where the resident expired the same day.

Removal Plan

• Juice was provided to the resident to improve the blood glucose level.
• Glucagon was administered.
• Blood glucose monitoring was performed.
• Nurse Practitioner was notified and resident transferred to ER via 911.
• R1 no longer resides in the facility.
• 1:1 education was provided to the day shift nurse and night shift supervisor regarding hypoglycemia protocol, change of condition policy, following physician orders, and emergency response associated with severe hypoglycemia.
• The night shift nurse is no longer employed by the facility.
• DON/designee conducted a whole-house audit of residents who require blood glucose monitoring to ensure blood glucose results are within the ordered parameters, and if physician / NP is notified if the results are outside the parameters.
• Residents who are at risk for hypoglycemia (residents with diagnosis of diabetes, receiving insulin) were reviewed to ensure the plan of care includes a physician order for parameters of blood glucose level to monitor signs and symptoms of hypoglycemia, administer interventions for treatment of hypoglycemia, and physician notification.
• Staff education was conducted by the DON, Regional Nurse Consultant and shift supervisor. Education included: Notification of a change in condition, Medical emergency procedure associated with hypoglycemia, Following the physician's orders, Hypoglycemia Protocol.
• All licensed nurses received education prior to working their next scheduled shift. Staff not on site for education were contacted by telephone and received verbal education. They will sign in-service education forms at the time of their next shift. This includes PRN staff.
• Understanding of the in-service content was evaluated at the time of in-service through questions and answers.
• Director of Nursing or designee will audit resident records to ensure prompt notification to physician/ NP of an episode of hypoglycemia (change in condition) and following the physician's orders for notification of blood sugars outside of established parameters.
• Director of Nursing or designee will review the clinical record to monitor staff response to residents with signs and symptoms of hypoglycemia, monitor residents experiencing hypoglycemia, including severe hypoglycemia, administer interventions for treatment of hypoglycemia, and when emergency transport (911) and the medical provider are notified.
• Audits will be conducted 5 times a week for all residents with blood glucose monitoring orders.
• Audits will be conducted weekly for a sample of 10% of residents with blood glucose monitoring.
• Results of the audits will be presented to the QAPI committee for recommendations of further auditing and actions as appropriate.
• Root cause analysis is completed, and the action plan is discussed and approved by the Ad-Hoc committee.

Penalty

No penalty information released

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

Summary

The facility failed to prevent and protect a resident from resident-to-resident physical abuse, involving two residents with moderate cognitive impairment. The incident occurred when one resident, who was tired after dialysis, became upset with her roommate for talking continuously. This led to a physical altercation where the resident slapped and scratched her roommate's face, resulting in visible red marks and scratches. The incident was reported by the affected resident to a nurse, who noted the injuries and administered bacitracin medication. The facility's staff, including a CNA, witnessed the altercation and confirmed the aggressive behavior was unusual for both residents. The language barrier between the residents exacerbated the situation, contributing to the misunderstanding and subsequent conflict. The facility's policy on abuse prevention was presented, emphasizing the commitment to protect residents from abuse and mistreatment. However, the facility failed to document the interdisciplinary team's meeting or the social services assessment that evaluated the safety of returning the aggressive resident to the same unit. This lack of documentation and oversight contributed to the deficiency in preventing resident-to-resident abuse.

Penalty

No penalty information released

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

Summary

The facility failed to effectively supervise and ensure a resident was properly seated in a wheelchair with feet on footrests or elevated off the floor prior to being transported. This deficiency resulted in the resident falling from the wheelchair, sustaining a laceration to the forehead requiring seven sutures and a left patella fracture. The resident, who has Alzheimer's disease and dementia, was observed sitting in a wheelchair in the dining room and later being transported to her room by two CNAs. During the transfer from the wheelchair to the bed, the resident was totally dependent on the CNAs due to her inability to straighten her legs and support her weight. The resident's care plan indicated a high risk for falls due to decreased mobility, muscle weakness, and cognitive impairments. Despite these documented risks, the resident was not adequately supervised during the transfer process. The CNAs involved in the transfer did not witness the resident leaning forward or attempting to stand unassisted, yet the resident fell forward from the wheelchair, resulting in injuries. The resident's medical records and assessments highlighted her severe cognitive impairment and dependency on staff for transfers and locomotion. The facility's investigation noted that the resident communicates primarily in Polish and was cognitively impaired with memory and recall problems. The CNA responsible for the resident at the time of the fall reported that the resident appeared tired and leaned forward suddenly, leading to the fall. The CNA involved in the incident is no longer employed at the facility and was unavailable for an interview during the survey.

Penalty

No penalty information released

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

Summary

The facility failed to properly manage and secure medications, leading to several deficiencies. On multiple occasions, medication carts were found unlocked and unattended, including one instance on the dementia unit where a cart containing narcotics, insulins, and syringes was left unsecured. This lapse in security was acknowledged by the LPNs on duty, who admitted that the cart should have been locked to prevent unauthorized access. Additionally, the facility failed to properly date and discard medications. Eyedrops for two residents were not labeled with the dates they were opened or their discard dates, and insulin vials for three residents were found to be expired but still in use. These observations were confirmed by the LPNs, who stated that expired medications should not be administered as they may not work effectively and could potentially harm residents. The Director of Nursing confirmed that medication carts should be locked when not in use and that medications should be labeled with both the date opened and the discard date. Facility policies also mandate that no outdated or deteriorated drugs should be available for use and that all compartments containing drugs must be locked when not in use. Despite these policies, the survey revealed that the facility did not adhere to these standards, resulting in the presence of expired medications and unsecured medication carts. The deficiencies were observed across multiple floors and involved several residents, highlighting a systemic issue in medication management and security within the facility.

Penalty

No penalty information released

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

Summary

The facility failed to store and label food items in accordance with professional standards for food service safety. During a kitchen observation, the surveyor noted that a large plastic bag containing more than a liter of frozen corn and a large bag of frozen fries in the walk-in freezer were not labeled or dated. The Food Service Supervisor acknowledged that the items should have been labeled and dated. The facility's policy on the storage of frozen foods, dated 2017, requires that food taken out of its original container be tightly wrapped and labeled with the name of the item and the use-by date. The facility census report documented 197 residents, with 17 residents having orders for nothing by mouth (NPO). This deficiency has the potential to affect 180 residents who consume food from the kitchen.

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 resident's dignity during lunch dining for one resident. On two separate occasions, a surveyor observed a CNA standing while feeding a resident in the dining room of a locked memory care unit. Other staff members were observed sitting while feeding residents, indicating that the CNA's actions were not in line with the facility's standard practice. The CNA supervisor and the Director of Nursing both confirmed that staff should sit while feeding residents to create a relaxing and home-like environment, emphasizing that standing while feeding is a dignity issue. The resident involved has a history of Alzheimer's disease, torticollis, muscle weakness, need for assistance with personal care, dysphagia, and unspecified dementia. The resident's care plan highlights the importance of ensuring the resident's safety, security, and dignity. The facility's policy and the Long-Term Care Ombudsman Program Residents' Rights document both stress the importance of treating residents with dignity and respect, including during feeding. Despite these guidelines, the CNA's actions were inconsistent with the facility's policies and the resident's care plan, leading to the identified 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 two residents had their call lights within reach and did not respond to another resident's call light in a timely manner. On 05/21/2024, a surveyor observed that one resident's call light was on the floor, and the resident was unaware of its location. This resident had multiple diagnoses, including unspecified dementia and chronic obstructive pulmonary disease, and their care plan specified that the call light should be within reach. Another resident was found lying in bed without a call light in place. The resident indicated that the call light was behind their head and difficult to reach, forcing them to yell for assistance. A Certified Nursing Assistant confirmed that the call light was on the floor and not secured properly, acknowledging that the resident would yell for help if they could not reach it. The Director of Nursing stated that all residents should have accessible call lights and that staff should ensure they are within reach at all times. Additionally, the facility failed to respond promptly to a resident's call light. The resident, who had moderate cognitive impairment and multiple medical conditions, including acute and chronic respiratory failure, was observed struggling with tangled oxygen tubing and a spill on the floor. The resident activated the call light at 12:49 AM, but it was not answered until 01:10 PM when a CNA entered the room to deliver food. The CNA admitted to not noticing the call light and mentioned that the resident frequently pressed it multiple times. The Director of Nursing and an LPN both emphasized that call lights should be answered promptly to determine the resident's needs and provide necessary assistance. The facility's call light policy, dated 06/21, mandates that functioning call lights be placed where they are accessible to residents and that staff should answer call lights promptly and courteously. The failure to adhere to this policy resulted in residents not having their call lights within reach and experiencing delays in receiving assistance, which could potentially compromise their safety and well-being.

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 their policy and routinely invite a resident's representative to participate in a care plan conference. Specifically, the facility did not involve the mother and guardian of a resident, who is a [AGE] year-old male with multiple serious diagnoses including encephalopathy, persistent vegetative state, and dependence on a ventilator. Despite the resident's mother being present at the facility every day and expressing concerns about her son's care, she was not asked to participate in the care planning process. This was confirmed through interviews and record reviews, where the mother stated she had not been offered to attend a care plan conference for her son. The Assistant Administrator, who is responsible for care plans, acknowledged that the resident's mother is involved in the resident's care but admitted that she had not coordinated the care plan for this resident. The facility's documentation indicated that the last care conference was held on 09/15/2023, and the next one was scheduled for 12/14/2023. However, there was no documentation showing that the resident's mother was offered the opportunity to participate in these meetings, which is a requirement according to the facility's policies on interdisciplinary team care planning and comprehensive care plans.

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 are provided with regular baths twice a week, as evidenced by the case of one resident (R53) out of a sample of 35. On 05/21/2024, R53 reported not having received a shower in a week and expressed a desire for a shower on the previous Saturday, which was not provided. The Director of Nursing (V2) confirmed that all residents are supposed to receive baths twice a week, specifically on Wednesdays and Saturdays for R53. However, records showed that R53 only received baths on 5/22, 5/15, 5/8, 5/5, and 4/28, with no documentation of refusals. Additionally, the 3rd floor shower binder lacked shower sheets for the specified dates, indicating a failure in documentation and adherence to the bathing schedule.

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 a resident's nutritional status remained within acceptable parameters, leading to significant weight loss for one resident. The surveyor observed that the resident did not receive lunch in a timely manner, with delays in both receiving and being fed the meal. The resident's weight dropped from 114 lbs in March to 97 lbs in April, and no new interventions were added to address this significant weight loss. The dietician acknowledged the weight loss but did not update the care plan or notify the nurse practitioner with new recommendations. The facility's weight maintenance policy requires monitoring and investigating significant weight changes, determining a plan of action, and notifying the physician and responsible party. However, the dietician did not follow these steps, as evidenced by the lack of new interventions and failure to update the care plan. The resident's diet order included specific supplements, but the facility did not provide additional supplements beyond what was already prescribed, contributing to the resident's continued weight loss.

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 check the gastrointestinal tube (G-tube) infusion and water flush rate for a resident. On 05/22/24, a surveyor observed the resident's G-tube feeding infusing Nepro Carb Steady at 45ml/hr with a water flush set at 350ml, contrary to the physician's order of 250ml. The nurse on duty, who had just taken over care, was unaware of the incorrect water flush setting initiated by the previous nurse. The error was not corrected until it was pointed out by the surveyor. The consultant dietician confirmed the physician's order for the water flush and emphasized the importance of following these orders to maintain the resident's nutritional and fluid status. Another nurse admitted to not checking the infusion rate and water flush settings, assuming they were correct. The facility's policy requires that physician orders be implemented by staff, but this was not followed, 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 provide continuous oxygen therapy per physician order for a resident (R160). R160, a severely cognitively impaired [AGE] year-old female with diagnoses including anoxic brain damage, acute and chronic respiratory failure with hypoxia, and dependence on renal dialysis, was observed by a surveyor without the prescribed continuous oxygen therapy. The surveyor noted that the oxygen concentrator was off and the oxygen tank was empty. The respiratory therapist (V3) confirmed that R160 was supposed to be on continuous oxygen via trach collar at 2 liters per minute but found the oxygen tank empty and the concentrator off upon inspection. V3 then placed R160 on the oxygen concentrator and turned it on. The CNA (V25) who transferred R160 back from dialysis stated that the oxygen tank was not empty at the time of transfer and that he had informed V3 of R160's return before going on his lunch break. The Director of Nursing (V2) stated that either the nurse or respiratory therapist should attend to the resident as soon as possible to switch from the oxygen tank to the concentrator. The physician order sheet confirmed that R160 required continuous oxygen therapy at 4 liters per minute via oxygen concentrator. The facility's policy on oxygen therapy indicated that oxygen should be used safely and effectively per physician orders, and that both nurses and respiratory therapists are responsible for starting oxygen therapy. The failure to provide continuous oxygen therapy as ordered was observed and documented by the surveyor, indicating a deficiency in the facility's respiratory care practices.