Hope Creek Nursing & Rehab

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to maintain and promptly act on a physician’s progress note and orders, and to accurately monitor and document a surgical site for one resident. The resident had undergone right leg surgery and was using a knee immobilizer with steri-strips over the surgical site. On 2/20/26, the orthopedic physician documented that the resident was to continue the knee immobilizer, remain non-weight bearing, leave steri-strips in place, follow up in one week for a wound check, and start cephalexin 500 mg three times daily for seven days for suspected cellulitis. This physician progress note and the associated antibiotic order were not placed in the resident’s medical record and were not processed by the facility at that time. On 2/24/26, the resident asked staff about the antibiotic the orthopedic physician had told her she would receive. Staff initially were unaware of any such order. The wound nurse contacted the physician’s office, and the nurse there initially reported that no antibiotic had been ordered. Later that day, the wound nurse located the 2/20/26 physician progress note with the cephalexin order at the nurse’s desk, and the physician’s office also called back to confirm that an antibiotic had been ordered before the resident left the appointment. The antibiotic order, written on 2/20/26, was not initiated by the facility until 2/24/26 because the paperwork could not be located earlier. During this period, the facility’s treatment administration records (TARs) for February and into early March continued to reflect an order to leave a surgical dressing in place on the right leg until follow-up unless dislodged or soiled, and to notify the physician of any changes or signs of infection every shift. However, as of the 2/20/26 orthopedic visit, the resident no longer had a dressing and instead had steri-strips in place, and the TAR was not updated to reflect this change. Staff continued to sign off that the surgical site was being monitored per the outdated order, and the TARs did not document the minimal serous drainage and light redness noted on 2/24/26. The resident’s medical record did not contain documentation of an infection to the surgical site, despite later hospital records indicating admission for a superficial wound infection with purulent drainage and MRSA culture growth.

Penalty

Inspection fine: $48,5002 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 deficiency involves the facility’s failure to implement and maintain fall-prevention interventions for a cognitively impaired, high fall-risk female resident, resulting in a serious fall with injury. The resident’s fall risk assessment identified her as HIGH risk for falls, and her care plan, initiated on 2/1/24, documented that she was at risk for falls related to weakness, impaired gait and balance, and required assistance for bed mobility and transfers. Care-planned interventions included cues in the room to ask and wait for assistance, non-skid strips at bedside and in front of the toilet, a low bed, call light within reach, and floor mats to the right side of the bed. However, on observation of the resident’s memory care room after the fall, there were no posted signs instructing her to call and wait for help, no fall mats, and no non-skid strips at the bedside or in the bathroom. On the morning of the incident, staff found the resident on the floor next to her bed with severe right arm pain, and she was sent to the hospital where she was diagnosed with a comminuted right humerus fracture requiring surgical intervention. Multiple staff interviews showed inconsistent understanding of the resident’s fall risk status and transfer needs. An agency LPN and one CNA reported that the resident was a fall risk, had a history of self-transferring, and required one-person assistance with transfers, while another former CNA and another CNA believed the resident was independent and safe to self-transfer and did not recognize her as a fall risk. These CNAs stated they did not check, or did not think to check, the electronic health record for the resident’s fall risk status and transfer requirements. The DON and Administrator both stated that the resident was confused, had a history of falls and self-transferring, required staff assistance with transfers and supervision for safety, and that fall interventions should follow the resident when she transfers to a different room. Despite this, the care-planned fall interventions were not in place at the time of the fall.

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 identify and manage a pressure injury in a timely manner for a resident at risk for pressure ulcers, and failure to implement appropriate pressure-relieving interventions for two residents with pressure ulcers. One resident was admitted with multiple diagnoses including hemiplegia/hemiparesis, arthritis, chronic kidney disease, Parkinson’s disease, depression, and a history of a pressure ulcer of the left buttock. A facility assessment documented severe cognitive deficits, dependence on staff for most care, and risk for developing pressure ulcers. A Weekly Wound Evaluation dated 1/15/26 showed an in-house acquired stage 3 pressure injury to the sacrum measuring 5 cm by 1.5 cm with depth unable to be determined. The care plan identified actual impairment to skin integrity of the sacrum and risk for skin breakdown, with directions to assess for and provide appropriate pressure-relieving devices and to assess for changes in skin condition each shift. Surveyors observed that this resident, who was bedbound, did not consistently have heel protector boots in place despite being at risk for pressure ulcers. In the morning, the resident was lying in bed with her heels directly on the air mattress while her tan inflatable heel protector boots were found under the edge of the dresser near the bed. Later that day, during wound care, the resident was observed wearing blue heel protector boots, and the wound care nurse stated there was no physician order for heel protectors but she felt the resident should wear them due to her condition and had placed them for that reason. The wound care nurse also reported that the sacral wound was first identified when a CNA reported a wound on the resident’s bottom while getting her up for the day. The treatment nurse stated it was her understanding that nurses should be documenting weekly skin checks to detect developing wounds and implement additional preventive measures, and she did not believe the resident wore heel protectors. The DON stated she would have expected early identification of wounds and the use of a low air loss mattress and heel protector boots or heel offloading for a bedbound resident. For a second resident with an unstageable pressure injury to the coccyx/sacrum, surveyors observed that the resident was on an air mattress that was set to “firm” rather than adjusted to the resident’s weight, and the resident’s wheelchair pressure-relief cushion was flattened, torn, and leaking foam. The wound care nurse confirmed the cushion was worn and stated it was for pressure relief, and upon checking the mattress, acknowledged it was set too high and should be set to the resident’s weight. The resident appeared confused when asked about mattress firmness. Documentation for this resident showed an unstageable pressure injury with moderate serosanguinous drainage and strong odor, with the wound location changed from right buttock to sacrum due to exacerbation, and a low air loss mattress ordered. The care plan documented admission with a pressure ulcer of the right buttock related to immobility but did not include pressure ulcer preventive measures or pressure-relieving devices. The facility’s preventative skin care policy required use of Braden scores and weekly skin assessments to determine specific preventive needs, including offloading devices such as “Heels Up” or therapeutic boots for residents at high risk, and immediate reporting of any skin alterations to the charge nurse for assessment and follow-up.

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 safe environment, provide adequate supervision, and implement necessary assistive interventions for three residents reviewed for falls. Each of these residents was identified as high risk for falls due to severe cognitive impairment and dependence on staff for activities of daily living, including toileting. Despite documented histories of falls and related injuries, care plans for these residents were not initiated or updated in a timely manner, and essential interventions such as toileting schedules and transfer status were not communicated to staff or included in the electronic Kardex. Staff interviews revealed a lack of awareness regarding residents' care needs and interventions, with several CNAs and nurses stating they did not know where to find updated information or were unaware of specific care plans in place for fall prevention. One resident was admitted following a fall that resulted in a subdural hematoma and subarachnoid hemorrhage, yet did not have fall interventions included in the care plan upon admission. This resident experienced multiple subsequent falls within the facility, including one resulting in a head laceration and another subdural hematoma, with documentation gaps regarding toileting and transfer assistance. Staff reported confusion about the resident's care needs, and the care plan was not updated to reflect necessary interventions until well after the incidents occurred. Another resident, also severely cognitively impaired and on anticoagulant therapy, experienced unwitnessed falls, including one where the resident slipped in urine and another resulting in a laceration requiring sutures. The fall care plan for this resident was not created until after the initial fall, and the Kardex did not reflect fall interventions. A third resident, with repeated falls documented over several months, did not have toileting tasks or new safety interventions added to the care plan or Kardex until long after multiple incidents. Staff interviews indicated that interventions such as placing the resident in a recliner to prevent sliding from a wheelchair were not documented in the care plan. The MDS nurse acknowledged delays in updating care plans due to workload and staffing issues, and the DON stated she was not aware that care plans were not being updated. Throughout the report, there is consistent evidence of inadequate communication, lack of timely care plan updates, and insufficient staff training regarding fall prevention and resident care 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 honor a resident's right to receive visitors of his choosing, specifically by not allowing the resident's significant other to visit. The Social Services Director stated that the significant other was not permitted to visit and that this decision was made by the facility and the police, with the resident's guardians also involved in the decision-making process. The receptionist confirmed that all receptionists were instructed not to allow the significant other to visit, to ask her to leave if she arrived, and to involve the police if necessary. The electronic check-in system was programmed to deny her access. The significant other continued to call the facility frequently to request visitation. The administrator reported that he was unaware of the situation until questioned by surveyors and stated that, unless there was an order of protection, visitation should not be restricted. The resident's admission record identified the significant other as his partner, and the facility was unable to provide any legal documentation prohibiting her visits. The facility's visitation policy supports residents' rights to receive visitors, and the resident's care plan did not address any need for restricted or limited visitation.

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 who was prescribed a therapeutic diet by their physician did not receive the correct meal as ordered. During a meal observation, the resident was served one corndog, pasta salad, watermelon, and cottage cheese, despite having a physician order for a cardiac, low concentrated sweets diet with half portion carbohydrates, double proteins, and no pork. The resident's diet card indicated a regular diet with low concentrated sweets, no pork, and double protein, but only one corndog was provided instead of the required double protein portion. The dietary manager confirmed that the resident should have received two corndogs to meet the double protein requirement and attributed the error to new kitchen staff. The facility's policy requires therapeutic diets to be prepared and served as ordered by the attending physician, with trays clearly identified by color-coded cards reflecting the diet order.

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 develop and implement a baseline care plan within 48 hours of admission for one resident. The resident was admitted with multiple diagnoses, including polyosteoarthritis, restless leg syndrome, essential hypertension, anemia, osteoporosis, depression, a history of falls, spinal stenosis, and orthopedic aftercare following a contusion of the right hip. After admission, the resident sustained a fall, was transferred to the hospital, underwent surgical treatment for a left wrist fracture, and returned to the facility with a left-hand brace, sling, non-weight bearing status for the left upper extremity, and pain medication. Despite these significant changes in condition, the medical record did not include a completed Significant Change in Condition Comprehensive Assessment/Minimum Data Set (MDS). The Care Plan and MDS Coordinator confirmed that the required assessment had not been completed.

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 correctly assess a resident's fall risk, develop a comprehensive care plan, and implement timely fall prevention interventions. The resident was admitted with multiple diagnoses, including polyosteoarthritis, osteoporosis, depression, hypotension, and a recent history of falls. Despite these risk factors, the fall risk assessment inaccurately documented the resident as low risk, stating independence with ambulation and continence, which contradicted the Minimum Data Set (MDS) and comprehensive assessment findings. The care plan did not include fall prevention interventions until after the resident experienced a fall. The resident attempted to self-transfer to the bathroom during the night, resulting in an unwitnessed fall and a left wrist fracture that required surgical repair. Prior to the fall, the care plan lacked specific goals and interventions for several identified needs, including fall prevention, range of motion, self-care deficits, and management of other medical conditions. The resident was receiving medications such as diuretics and opioids, which are known risk factors for falls, and required assistance with transfers and activities of daily living, but these needs were not adequately addressed in the care plan. Interviews with staff revealed a lack of awareness regarding the resident's fall risk and the interventions in place prior to the incident. The care plan and MDS coordinator confirmed that the comprehensive care plan was not completed until several weeks after admission, and the Director of Nursing was unaware of this delay. The failure to accurately assess risk, develop a timely and comprehensive care plan, and implement appropriate interventions directly contributed to the resident's fall and injury.

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 cognitively impaired residents from physical abuse, resulting in two separate incidents involving four residents. In the first incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room. The second resident, also severely cognitively impaired and with a documented history of agitation and aggression, pushed the wandering resident out of the room, causing the latter to fall and sustain a head injury. Staff did not witness the actual push, but a physical therapy assistant observed the aftermath, including the resident being shoved from the doorway and hitting his head. Documentation revealed that the injured resident had a history of Alzheimer's disease, dementia, and was at high risk for wandering, while the other resident had a history of behavioral disturbances and aggression. There was inconsistent staff awareness and documentation regarding the injury and the aggressive resident's history, and the incident was not substantiated as abuse by the facility administration due to both residents' cognitive impairments. In the second incident, two female residents with severe cognitive impairment and dementia were involved in a physical altercation. One resident was observed by staff grabbing her roommate by the hair and wrists, causing the roommate to feel angry and scared. The aggressor had a documented history of behavioral disturbances, including physical altercations and defensive behaviors when peers entered her space. Staff intervened promptly, separated the residents, and placed the aggressor on one-to-one supervision until she was transferred to the hospital for evaluation. The roommate was subsequently moved to another room and later to another unit at the request of her family. Both residents were assessed for injuries, and none were found, but the emotional impact on the victim was documented. In both cases, the facility's policies required prompt reporting, investigation, and protection of residents from abuse, including abuse by other residents. However, the facility did not identify or substantiate either incident as abuse, citing the residents' cognitive impairments and lack of willful intent. The documentation and staff interviews revealed gaps in monitoring, assessment, and recognition of aggressive behaviors and injuries, as well as inconsistent application of the facility's abuse prevention policies.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely incontinence care for a resident, leading to a deficiency. The resident, who was always incontinent of bowel and bladder, was found by her daughter lying in a urine-saturated bed. The resident's care plan required checks every two hours and as needed for incontinence, but this was not adhered to. The Certified Nursing Assistant (CNA) assigned to the resident's care on the day of the incident stated that she had attempted to change the resident earlier in the morning, but the resident refused assistance. The CNA did not return to provide care until after the resident's daughter raised concerns, resulting in the resident remaining in a urine-soaked state for an extended period. The CNA expressed that she was not familiar with the floor she was assigned to and had requested not to be scheduled there without proper orientation. The Director of Nurses confirmed that the facility's policy is to provide incontinence care every two hours and as needed, and that the CNA should have informed the nursing staff when the resident refused care. The incident highlights a breakdown in communication and adherence to care protocols, resulting in the resident's prolonged exposure to urine.

Penalty

Inspection fine: $23,562

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 immediate post-fall care to a resident receiving anticoagulant therapy, resulting in delayed treatment of a subdural hematoma. The resident, who was on Coumadin and Aspirin for chronic atrial fibrillation, was found on the floor mat next to his bed after an unwitnessed fall. Despite the resident's complaints of head pain and nausea, the staff did not notify the physician or send the resident to the hospital until the following day, leading to a significant delay in treatment. The incident report indicates that the resident was found on the floor during routine care, and initial assessments showed no evident injuries. However, the resident later complained of a severe headache and nausea, prompting a visit to the emergency department where a CT scan revealed a large subdural hemorrhage. The facility's policy required neuro checks and physician notification for falls involving head injuries, but these protocols were not followed, and the resident's condition worsened due to the delay in care. Additionally, the facility failed to safely turn and position another resident, resulting in a nasal fracture. This resident, who required substantial assistance for bed mobility, was being turned by a single CNA when she fell off the bed. The facility's policy required two-person assistance for such tasks, but this was not adhered to, leading to the resident's injury. Both incidents highlight significant lapses in following established protocols for fall prevention and post-fall management.

Penalty

Inspection fine: $84,262

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 and verbal abuse, particularly involving a resident with a known history of aggression, identified as R500. This resident was involved in multiple incidents of aggression, including verbally yelling and physically hitting another resident, R134, and shoving residents R84 and R103 to the ground. These incidents resulted in significant injuries, including a bleeding laceration and hospitalization for R84, and hip and knee pain for R103. Despite these occurrences, the facility did not adequately identify, investigate, or report these incidents as potential abuse, which led to an Immediate Jeopardy situation. The facility's policies on abuse prevention and reporting were not effectively implemented. The policy required immediate reporting and investigation of any incidents or allegations of abuse, but this was not followed. The Director of Nursing and the Administrator failed to recognize and report the incidents involving R500 as abuse, despite witness statements and video surveillance suggesting otherwise. The facility's failure to act on these incidents allowed R500 to continue interacting with other residents, posing a risk to their safety. R500 had a documented history of psychiatric issues, including Schizoaffective Disorder, Bipolar Disorder, and Dementia, with behaviors such as verbal and physical aggression, hallucinations, and delusions. Despite this, the facility did not take adequate measures to manage R500's behavior or protect other residents. The lack of appropriate supervision and intervention allowed R500 to engage in aggressive behavior, resulting in harm to other residents and a failure to maintain a safe environment.

Removal Plan

• Investigation of both incidents were completed and reported to state survey agency and physician for R84, R103, and R500.
• R84 was transferred to the hospital for evaluation.
• R103 was transferred to the hospital for evaluation. No injuries were noted and R103 returned to the facility with no new orders.
• R500 was placed on one-to-one supervision.
• R500 care plan was updated to include one-to-one supervision and again updated to include one-to-one supervision until the resident is deemed safe by psychiatry and/or nursing assessment.
• R500 care plan was updated to include behavior monitoring every shift.
• R84, R103, and R500 care plans have been updated to include one-to-one time with Social Services as needed to vent feelings.
• Administrator in-serviced by Risk Management Consultant regarding Abuse Prevention Policy.
• In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff was initiated.
• In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff will continue, and any remaining employees must be trained prior to reporting for work for their next scheduled shift. Employees will not be allowed to work until they have completed the in-service.
• QAA team members were in-serviced on the facility's Abuse Prevention Program policy and procedure by the Administrator.
• Social Services Director and/or designee will audit Trauma Screening assessments and Screening Assessments for Indicators of Aggressive and/or Harmful Behavior for all residents with the potential to be affected by this alleged deficiency to ensure those assessments are current. Social Services Director/designee will ensure interventions are care planned for any residents assessed to be at risk.
• QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during quarterly QA meetings with medical director and address any concerns.
• QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during Morning QA meetings daily for a period on all new admits to assure compliance.
• The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the facility QA Committee for follow up and review.
• In-service training by Administrator/designee on Abuse Prevention Policy with all staff will continue monthly for a period, then quarterly for a period by the DON or Administrator.
• Administrator will enforce the interventions of plan of removal of immediacy and assurance of continued compliance.

Penalty

Inspection fine: $84,262

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 resolve grievances voiced in resident council meetings, affecting all 160 residents. The Resident Council Meeting Minutes and General Feedback/Grievance Forms from October 2023 to April 2024 document repeated concerns about the dietary services, including disorganization in the kitchen, insufficient staff in the dining room, discrepancies between meal tickets and served meals, and the absence of a full-time dietary manager. Despite these documented concerns, the sections for steps taken to investigate and corrective actions on the grievance forms were consistently left blank, indicating a lack of response or resolution from the facility. Interviews with the Activity Director and the Resident Council President further highlight the facility's inaction. The Activity Director stated that grievances are supposed to be addressed by the relevant department heads, but the forms lacked written responses. The Resident Council President expressed frustration, noting that issues raised in meetings are not addressed, and feedback from the facility is minimal and ineffective. This ongoing lack of action and communication from the facility has left residents' concerns unresolved, contributing to the deficiency.

Penalty

Inspection fine: $84,262

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

Summary

The facility failed to adhere to its policies regarding the storage of dry foods and the personal hygiene of kitchen staff, which could potentially affect all 160 residents. During an inspection of the dry storage room, it was observed that four clear bins labeled as oatmeal, flour, thickener, and bread crumbs were not dated as required by the facility's policy. The Dietary Manager confirmed the absence of dates on the bins, which should have been present. Additionally, the bins appeared cloudy and dirty, and the lids had a significant gap, which the Dietary Manager acknowledged as inadequate for proper coverage. Furthermore, a cook was observed with a hairnet improperly worn, allowing her long hair to remain unrestrained. This was in violation of the facility's Employee Health and Personal Hygiene policy, which mandates that hair restraints be worn at all times. The cook did not initially respond to inquiries about her hairnet usage but adjusted it to cover her hair when questioned. These observations indicate a lapse in maintaining professional standards for food storage and personal hygiene in the kitchen.

Penalty

Inspection fine: $84,262

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 implement infection prevention and control measures during a COVID-19 outbreak, as evidenced by multiple instances of staff not wearing appropriate personal protective equipment (PPE). Staff members, including registered nurses and certified nurse aides, were observed not wearing masks or wearing them improperly in areas with known COVID-19 cases. This non-compliance with PPE protocols was noted despite the facility's policy requiring the use of N95 masks in certain areas and surgical masks in others. Additionally, staff failed to don PPE during the care of residents in contact isolation for COVID-19, leading to potential exposure and spread of the virus. The facility also did not adequately assess and respond to residents showing symptoms of COVID-19. Several residents reported symptoms such as coughing and weakness, yet there was a lack of documentation and follow-up testing for COVID-19. In some cases, residents with symptoms were not placed in isolation, and their symptoms were not communicated to the infection preventionist or physician. This oversight in monitoring and responding to potential COVID-19 cases further compromised infection control efforts. Furthermore, the facility did not maintain proper infection control practices during wound care. Staff were observed not using gloves or gowns appropriately, and there were instances of cross-contamination during wound care procedures. For example, a wound care nurse did not change gloves or perform hand hygiene after touching a resident's wound and then handling other items. Additionally, residents with known infections, such as MRSA, were not placed in appropriate isolation, increasing the risk of spreading infections within the facility.

Penalty

Inspection fine: $84,262

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

Summary

The facility failed to provide an ongoing program of activities to meet the physical, mental, and psychosocial well-being of residents on the second floor of building four. This deficiency was observed through interviews and record reviews, revealing that since August 23, 2024, no group activities were conducted for the 35 residents residing on that floor. Residents expressed their dissatisfaction, stating that they were unable to participate in activities or leave their unit due to COVID-19 restrictions. The lack of activities led to residents feeling isolated and bored, with some expressing a desire for simple activities like Bingo. The Activity Director acknowledged the issue, citing a non-functional air conditioning system in the activity room as a reason for not conducting activities. The Activity Director also admitted to forgetting about the residents on the second floor, who were not allowed to leave their unit. This oversight resulted in a lack of engagement and stimulation for the residents, as no alternative arrangements were made to provide activities on their floor.

Penalty

Inspection fine: $84,262

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 staff treated a resident with dignity and respect, as evidenced by an incident involving a resident who experienced diarrhea during the night. The resident reported that no one answered her call light, forcing her to clean herself up, which resulted in a mess on her bed. The resident pointed out the soiled blanket to the staff, indicating it needed to be washed. Observations made later in the day confirmed the presence of a brown stool smear on the blanket and multiple spots of stool on the floor next to the resident's bed. Despite these conditions, the resident was observed lying on the soiled blanket at different times throughout the day, with the brown spots still present on the floor. It was only after a Certified Nurse Aid was notified of the situation that action was taken to remove the soiled blanket and arrange for the floor to be cleaned.

Penalty

Inspection fine: $84,262

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 conduct a Level 2 Pre-Admission Screening and Resident Review (PASARR) for a resident identified as R73, who was part of a sample of 124 residents reviewed. The facility's policy requires coordination with the PASARR program and mandates a Level 2 review for residents with serious mental disorders or intellectual disabilities upon a significant change in status. Despite this, R73, who was diagnosed with Disorganized Schizophrenia and Schizoaffective Disorder-Depressive Type, did not receive the necessary Level 2 PASARR upon admission. R73's medical records indicated diagnoses of Major Depressive Disorder, Alcohol Abuse, Disorganized Schizophrenia, and Schizoaffective Disorder-Depressive Type. However, the Level 1 PASARR form, dated 9/11/2018, incorrectly stated that the resident did not have any major mental illnesses. This discrepancy was acknowledged by the Social Service Coordinator, who confirmed that a new PASARR should have been conducted upon R73's admission to the facility on 2/10/2021. The failure to perform the required Level 2 PASARR constitutes a deficiency in the facility's compliance with regulatory requirements.

Penalty

Inspection fine: $84,262

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

Summary

The facility failed to update the care plan for a resident, identified as R127, to reflect the removal of a tracheostomy. According to the facility's Comprehensive Person-Centered Care Planning Policy and Procedure, the care plan should be reviewed and revised by an interdisciplinary team after each assessment. However, R127's care plan, dated June 26, 2024, still documented the presence of a tracheostomy, despite a physician's order dated August 20, 2024, indicating that the tracheostomy had been removed and the site required specific wound care. On August 29, 2024, the MDS/Care Plan Coordinator acknowledged the oversight, stating that the care plan should have been updated to discontinue the tracheostomy.

Penalty

Inspection fine: $84,262

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 appropriate range of motion (ROM) programming for residents with limitations in ROM, as evidenced by the cases of two residents. Resident 57, who has a history of cerebral vascular accident with hemiplegia or hemiparesis, was supposed to receive active range of motion (AROM) exercises for both upper and lower extremities. However, documentation showed that AROM was not conducted as ordered for 19 out of 29 days. Furthermore, the resident reported that no exercises or ROM activities had been performed. Similarly, Resident 78, who has contractures in both upper and lower extremities and requires total assistance with most activities of daily living, was to participate in a passive range of motion (PROM) program. The documentation indicated that PROM was not conducted as ordered for 9 out of 30 days. The resident confirmed that PROM had not been conducted daily and stated that it had never been done by the staff. These findings highlight the facility's failure to adhere to the prescribed ROM programs for residents with limited mobility.

Penalty

Inspection fine: $84,262

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

Summary

The facility failed to ensure that a resident's indwelling urinary catheter drainage bag was secured in a dignity enclosure bag, as required by the facility's Foley Catheter Management Policy. The policy mandates that all catheter bags be covered with privacy bags at all times. The deficiency was observed in one of four residents reviewed for urinary catheters. The resident, identified as R55, had a 16fr, Balloon 10ml indwelling catheter due to hydronephrosis. On two separate occasions, the resident's catheter drainage bag was observed attached to the wheelchair and touching the ground without a privacy covering. The Director of Nursing confirmed that the drainage bag should have been covered and kept off the floor.

Penalty

Inspection fine: $84,262

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 medications in a safe manner for three residents during a routine medication pass. The facility's policy on the storage of medications, dated May 8, 2019, requires that medications be stored in a safe, secure, and orderly manner in the containers in which they are received. However, during observations on August 27 and 28, 2024, it was noted that Registered Nurse V22 administered medications to a resident using a clear medicine cup with writing on the side, which contained multiple medications. V22 admitted to preparing medications in advance, contrary to her usual practice, and was found with additional pre-prepared medication cups in her cart, some containing pills and others serving as reminders for future medication administration. Similarly, on August 28, 2024, Registered Nurse V30 was observed with a clear medication cup containing a resident's morning medications on top of her medication cart. Both nurses confirmed that their medication carts held all medicines for the residents on their respective floors. These actions indicate a failure to adhere to the facility's medication storage policy, as medications were not stored in their original containers and were pre-prepared in advance, potentially compromising the safety and security of medication administration.

Penalty

Inspection fine: $84,262

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 coordinated care for a resident receiving hospice services by not including documented hospice services in the resident's medical record. This deficiency was identified for one resident out of a sample of 124. The facility's agreement with the hospice provider required that a Plan of Care be developed and shared with the facility, reflecting the participation of the hospice, the facility, and the resident's family. However, the resident's care plan initially lacked documentation of hospice services and later did not specify hospice responsibilities or interventions. Observations and interviews revealed that hospice documentation was not readily accessible to the facility's interdisciplinary team. A Licensed Practical Nurse was unable to locate the hospice binder or any hospice documentation. The hospice Registered Nurse indicated that visit notes and the plan of care were brought to the facility but were likely taken to medical records. The Infection Preventionist questioned the need for staff access to hospice records, and the Careplan Coordinator admitted to not including hospice-specific interventions in the care plan, only noting that the resident was on hospice.

Penalty

Inspection fine: $84,262

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 abuse prevention program effectively, resulting in incidents involving three residents. The program requires immediate reporting of any abuse, neglect, or exploitation to the Administrator or DON, followed by an investigation. However, the facility did not adhere to these procedures, as evidenced by the incidents involving residents R84, R103, and R500. The facility's failure to take immediate action and implement safety measures after the first incident led to further occurrences of aggression. Resident R84 was involved in an incident where she was startled by another resident, R500, leading to a fall and head injury. Despite the facility's investigation identifying the root cause as peer agitation, no safety measures were implemented to protect R84 or other residents from R500. This lack of intervention allowed R500 to continue exhibiting aggressive behavior, resulting in another incident involving resident R103, who was physically assaulted by R500, causing her to fall. The facility's video surveillance confirmed that R500 was not receiving increased monitoring or one-to-one supervision after the initial incident. Staff interviews revealed that R500 had a history of increased behaviors and physical aggression, yet no interventions were put in place until after the second incident. The facility's inaction and failure to follow its abuse prevention program contributed to the repeated incidents of aggression and harm to residents.

Penalty

Inspection fine: $84,262

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

Summary

The facility failed to identify and investigate a potential allegation of verbal and physical abuse involving two residents. The incident occurred when one resident allegedly pushed another, causing the latter to fall and sustain a head injury. Despite witness accounts indicating that the fall was aggressive and involved a push, the facility's Director of Nursing (DON) did not investigate the incident as abuse. Instead, it was treated solely as a fall incident. The Administrator was not involved in the initial investigation due to absence, and the DON did not consider the incident as a potential abuse allegation, despite reports and witness statements suggesting otherwise. The facility's Abuse Prevention Program mandates immediate examination and reporting of abuse allegations, but these procedures were not followed. A CNA reported witnessing the push and informed the DON and Assistant Director of Nursing (ADON), but her statement was not accurately reflected in the incident report. Another CNA corroborated the account of the push, but the DON dismissed these claims, instructing staff to stop discussing the incident as abuse. The failure to properly investigate and report the incident as a potential abuse case constitutes a deficiency in the facility's handling of abuse allegations.

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 and verbal abuse, particularly involving a resident with a known history of aggression, identified as R500. This resident, diagnosed with Schizoaffective Disorder, Bipolar Disorder, and Dementia, exhibited behaviors such as hitting, pushing, and verbal aggression. Despite these known behaviors, the facility did not adequately monitor or intervene, leading to incidents where R500 physically assaulted other residents. Specifically, R500 was involved in altercations with residents R134, R84, and R103, resulting in injuries and hospital evaluations for the victims. The facility's policy on abuse prevention mandates immediate reporting and investigation of any abuse allegations. However, the facility failed to identify and investigate potential abuse allegations involving R500. For instance, R500 was reported to have pushed R84, causing a severe head injury, but the incident was initially treated as a fall rather than potential abuse. Similarly, R500's altercation with R134, where R500 slapped R134, was not substantiated as abuse despite witness accounts. These oversights indicate a failure to adhere to the facility's abuse prevention policy and protect residents from further harm. The facility's administration and nursing staff demonstrated a lack of coordination and communication in handling these incidents. The Director of Nursing and the Administrator had differing accounts of the incidents, and there was a failure to report all abuse allegations to the state agency. The facility's video surveillance did not provide conclusive evidence, and staff statements were inconsistent or altered, further complicating the investigation process. These deficiencies resulted in an Immediate Jeopardy situation, affecting the safety and well-being of all residents in 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 implement its abuse prevention program effectively, resulting in incidents involving three residents. The program requires immediate reporting of any abuse, neglect, or exploitation to the Administrator or DON, followed by an investigation. However, the facility did not adhere to these procedures, as evidenced by the incidents involving residents R84, R103, and R500. The facility's failure to take immediate action and implement safety measures after the first incident led to further occurrences of aggression. Resident R84 was involved in an incident where she was startled by another resident, R500, leading to a fall and head injury. Despite the facility's investigation identifying the root cause as peer agitation, no safety measures were implemented to protect R84 or other residents from R500. Similarly, Resident R103 experienced physical aggression from R500, resulting in a fall. The facility's video surveillance confirmed that R500 was not receiving increased monitoring or one-to-one supervision after these incidents. Staff interviews revealed that R500 exhibited increased aggressive behaviors, yet no interventions were put in place until after multiple incidents occurred. Witnesses reported that R500 physically assaulted both R84 and R103, but the facility did not implement one-to-one monitoring until after the second incident. This lack of timely intervention and monitoring contributed to the repeated occurrences of aggression, highlighting the facility's failure to protect its residents adequately.

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 identify and investigate a potential allegation of verbal and physical abuse involving two residents. The incident occurred when one resident allegedly pushed another, causing the latter to fall and sustain a head injury. Despite witness accounts indicating that the fall was aggressive and involved a push, the facility's Director of Nursing (DON) did not investigate the incident as abuse. Instead, it was treated solely as a fall incident. The Administrator was not involved in the initial investigation due to absence, and the DON did not consider the incident as a potential abuse allegation, despite reports from staff members suggesting otherwise. Witnesses, including a Certified Nursing Assistant (CNA), reported hearing and seeing the altercation, with one CNA stating that she saw the resident being pushed. This CNA also reported the incident to the Licensed Practical Nurse (LPN), DON, and Assistant Director of Nursing (ADON), but her statement was not accurately reflected in the incident report. The DON dismissed the abuse claims, instructing staff to stop spreading information about the push, as the resident who fell did not explicitly state she was pushed. The facility's failure to properly investigate and document the incident as a potential abuse case constitutes a deficiency in their abuse prevention program.

Penalty

Inspection fine: $94,054

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 immediate CPR to a resident who was found unresponsive and without a pulse or respirations. The resident, who had no advance directives or code status documented, was discovered by an RN who left the room to make phone calls instead of initiating CPR. This delay in response was contrary to the facility's policy, which requires staff to remain with the resident and signal for assistance. The RN, upon finding the resident unresponsive, did not follow the protocol of initiating CPR and instead contacted the Director of Nursing (DON) for guidance. The DON instructed the RN to start CPR, but by the time the RN returned to the resident's room, other staff members had already begun CPR. This lapse in immediate action placed other residents with full code status at risk of not receiving timely life-sustaining treatment. The incident highlighted a lack of training and awareness among staff regarding the facility's CPR policy. Interviews revealed that the RN was unsure of the resident's code status and felt the need to consult with the DON before taking action. Additionally, it was noted that the RN and another staff member had not received training on the facility's CPR policy, which contributed to the delay in providing necessary care.

Removal Plan

• In-servicing by members of the Nurse Management team for licensed and certified staff on the facilities Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page was initiated.
• In-service by members of the Quality Assurance team for All staff on the facilities Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page was initiated.
• DON/MDSC/SS team members completed an audit of all residents' code status orders, POLST Forms and advanced directive care plans. This audit was repeated with no inconsistencies noted. A review of all new admits completed.
• V7 has been removed from the facility's schedule and has not worked since the alleged deficiency.
• All staff who have not received the above-mentioned in-service will be removed from the facility schedules until the in-servicing has been completed with a QAT member.
• In-servicing training by members of the Nurse Manager Quality Assurance Team on Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page with all staff will continue monthly for the next 3 months, then quarterly.
• DON/MDSC/SSD will complete an audit of all residents' code status orders, POLST Forms and advanced directive care plans monthly then quarterly and PRN.
• LNHA will enforce the interventions of plan of removal of immediacy.

Penalty

Inspection fine: $136,022

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 develop a system to assess and evaluate residents for capacity to consent to sexual activity, resulting in two cognitively impaired residents (R1, R2) engaging in a sexual act without confirmed consent. Both R1 and R2 were severely cognitively impaired according to current MDS/BIMS assessments, indicating their inability to give consent. The incident involving R1 and R2 was discovered when a CNA found R1 with his penis in R2's mouth, leading to concerns about the lack of capacity to consent to the sexual act due to their cognitive impairments. Despite the facility having a policy recognizing residents' right to engage in sexual activity with consent, no assessment was conducted to confirm R1 and R2's ability to consent prior to or after the incident. The Immediate Jeopardy was identified on 3/13/24 when the sexual act between R1 and R2 was discovered. The facility's policy on assessing residents' capacity to consent to sexual activity was not utilized due to R1 and R2's cognitive impairments, as confirmed by the Medical Director. The incident raised questions about the residents' understanding of the consequences of their actions and their ability to communicate decisions regarding sexual activity. The lack of assessment and confirmation of consent for R1 and R2 highlights a gap in the facility's procedures to protect residents from potential harm related to sexual activities.

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 resident-to-resident physical abuse involving two residents. Resident 2 (R2) and Resident 3 (R3) were roommates from December 12 to December 20, 2023. On December 20, 2023, R2 reported an altercation with R3, where R3 slapped R2 twice across the face after a verbal exchange. R2 had no visible signs of injury, and the incident was reported to the physician and police. R3 was subsequently moved to another room. R2's medical history includes colostomy, end-stage renal disease requiring dialysis, left hemiplegia, and mood disorder, while R3's diagnoses include amnesia and Wernicke's encephalopathy. R3 admitted to slapping R2 during an interview on January 24, 2024, stating that R2 was smoking in their room and became argumentative when confronted. The facility's final investigation confirmed the physical contact between R2 and R3. The Social Service Coordinator noted that R2 often becomes agitated when confronted about smoking or vaping in the facility. The facility's policy prohibits abuse and mistreatment of residents by anyone, including other residents, but this policy was not effectively enforced in this instance.