Miller Health Care Center

Penalty

Inspection fine: $17,665

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 ordered skin assessments, prescribed topical treatments, and timely wound identification and interventions, resulting in the development and worsening of pressure-related skin breakdown in two residents. One resident (R1) was admitted with multiple comorbidities including spinal cord disease, cervical radiculopathy, COPD, acute respiratory failure, pneumonia, morbid obesity, muscle wasting and atrophy, major depressive disorder, and diaper dermatitis. On admission, the RN documented moisture-associated skin damage (MASD) and other skin issues but did not document any pressure ulcers. Physician orders included skin assessments every shift for three days, weekly skin risk assessments for four weeks, and wound care to bilateral ischial and coccyx areas with Triad cream to open wound beds and silicone barrier cream to intact skin twice daily and as needed for incontinence. The wound nurse later documented a cluster wound on the left gluteal area but did not classify any of the resident’s wounds as pressure-related, and the resident was not listed on the facility’s pressure ulcer list for February and March. The facility’s documentation and treatment administration for R1 were incomplete or missing. The DON acknowledged missed skin assessments and missed administrations of Triad cream on the Treatment Administration Record (TAR) and stated that missing prescribed treatments could lead to worsening skin breakdown. CNA documentation for R1’s care and skin issues was not accessible in the EMR and could not be produced upon repeated surveyor requests. The Administrator could not provide a pharmacy requisition showing that Triad cream had been delivered, and there was no requisition from the pharmacy. The Administrator stated that the wound doctor had indicated Remedy Protect zinc cream was used instead of Triad cream, and acknowledged that a new order should have been obtained if a different product was being used. The nurse practitioner stated she was unaware of R1’s skin breakdown, expected staff to provide incontinence care and turning assistance, and expected the wound doctor to see R1 before the date the cluster wound was documented. Emergency room records later documented a stage 2 pressure injury of the sacral region, while the facility had not identified R1 as having a pressure ulcer. The second resident (R2) had a care plan indicating potential for pressure ulcer development related to bowel and bladder incontinence, with interventions including pressure-relieving devices to bed and chair and following facility protocols for prevention and treatment of skin breakdown. During observed incontinence care, a CNA stated R2 had intact skin and no pressure ulcers, but surveyors observed an open area on the sacral/coccyx area with beet-red peri-wound, buttocks, and perineum, and no visible protective cream or dressing in place. The RN assigned to R2 stated she did not have any residents with pressure wounds and had not been notified of any skin breakdown. Later, the wound nurse assessed R2 and identified a stage 3 pressure injury on the sacral area, with no prior documentation of a pressure wound, and stated that staff should have identified the skin breakdown before it progressed to stage 3. The nurse practitioner reported she was not made aware of R2’s stage 3 pressure wound and would have expected staff to notice the skin condition earlier. The wound nurse also stated that a low air loss mattress is a pressure-relieving device, that such mattresses are available through the facility or an outside vendor, and that she should have obtained a low air loss mattress for R2 but had not done so. Facility policies required systematic skin risk assessments, ongoing wound assessments, and implementation of prevention measures such as moisture management, friction and shear reduction, and pressure reduction, but these measures were not effectively implemented or documented for R1 and R2.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to follow its policy requiring two staff members for a full mechanical lift transfer. A cognitively intact resident with quadriplegia C6-C7 incomplete, post laminectomy syndrome, muscle wasting, chronic venous insufficiency, cellulitis of the right lower leg, and a stage 4 sacral pressure ulcer required extensive assistance with ADLs, including dependence on staff for transfers. The resident’s MDS showed dependence for transfers, and the facility’s mechanical lift policy dated January 2026 stated that two staff members are required during a full body lift transfer. The facility’s Restorative RN and Interim DON both stated that the expectation is for two staff to assist when using the full mechanical lift. The facility’s fall incident reports showed the resident had a witnessed fall on February 6, 2026, during a transfer at the bedside when the resident slid forward in the chair. A CNA’s written statement documented that the CNA transferred the resident to a motorized wheelchair and the resident started to slide out, leading the CNA to leave the room to get help. An LPN later reported seeing the CNA request assistance and, upon entering the room, observed the resident sliding out of the chair with legs extended on the floor. The mechanical lift was present, with the top of the sling attached to the lift hooks, but the bottom of the sling was not underneath the resident and not attached to the lift. The LPN reported that the CNA stated she had transferred the resident from bed to chair using the full mechanical lift by herself and had attempted to move the resident up in the chair with the sling when it came out from underneath the resident. The LPN also reported that, in the presence of the resident’s daughters, the CNA stated she could not find anyone to assist with the transfer.

Penalty

Inspection fine: $171,620

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 promptly assess a resident when a CNA was unable to obtain vital signs and the failure to ensure the resident’s code status was documented and available in the medical record. Around 6:30 AM, a CNA informed an agency RN that she could not obtain a blood pressure or heart rate for the resident. The agency RN stated she continued passing morning medications to other residents and did not immediately assess the resident. Approximately an hour later, around 7:45 AM, the agency RN went to administer medications to the resident, found the resident unresponsive, and was unable to obtain vital signs or detect a heartbeat with a stethoscope. After finding the resident unresponsive, the agency RN left the bedside to locate another RN working on a different hall and told her she thought the resident had expired and that the resident was DNR. The second RN went to the resident’s room, observed the resident to be pale with bluish lips but still warm, and confirmed there was no heartbeat or carotid pulse. She was then called away to attend to her own residents and left the unresponsive resident. Around 8:00 AM, the Social Service Director walked past the resident’s room, saw the resident slumped to the side in bed with staff present, and heard that staff could not obtain vital signs. He then asked a Respiratory Therapist to check the resident’s code status in the electronic record. The Respiratory Therapist found no code status orders in the chart, went to the room, assessed that the resident was not breathing and had no pulse, and initiated chest compressions. An LPN/Acting ADON then entered and took over compressions while the Respiratory Therapist applied an AED and began ventilations with a bag-valve mask. During the code response, a Dietary Aide/CNA was called into the room to assist with CPR and completed two rounds of chest compressions. She reported that the Respiratory Therapist and Acting ADON were trying to determine who the resident’s nurse was and why 911 had not been called. The agency RN then entered and stated she had called a universal ambulance transport number and was unsure whether 911 should be called for an unresponsive patient. The Dietary Aide/CNA then called 911 from her personal phone; EMS records show 911 was called at 8:33 AM, with paramedics arriving shortly thereafter and taking over resuscitative efforts until the resident was pronounced deceased. The Assistant EMS Coordinator confirmed that only one 911 call was received for this event, from the Dietary Aide/CNA. The resident had been admitted to the facility approximately 16 hours before the code event with a primary diagnosis of acute respiratory failure with hypoxia. The facility face sheet and physician order sheet contained no advance directive or code status, and there was no documented nursing assessment or vital signs for the resident after admission. The agency RN reported she was the admission nurse and that another LPN had taken the hospital report, which included the resident’s code status, but the agency RN did not remember what that status was and acknowledged it was the admission nurse’s responsibility to enter code status into the electronic record. The Admissions Director later stated that the hospital chart showed the resident was a partial code, with orders for no mechanical ventilation with intubation, selective cardio resuscitation, no chest compressions, and no defibrillation/cardio­version, but this was not discovered until after the resident’s death. The Administrator and DON confirmed that the resident’s code status should be obtained and entered into the system immediately upon admission so staff know how to proceed in an emergency, and that if no code status is present, staff are expected to initiate CPR immediately when a resident is found unresponsive.

Removal Plan

• Completed an audit of resident code status to ensure all current residents had a code status.
• Provided education to all nursing staff on code status and emergency response expectations.
• Ceased any practice of delaying CPR due to verbal assumptions of DNR status.
• Implemented a directive that all residents will be treated as full code unless a valid physician DNR order is present and accessible in the medical record.
• Completed a 100% audit of all current resident charts to verify presence of physician code status orders.
• Completed an audit to ensure DNR status was accurately reflected on nursing shift-to-shift reports and matched the DNR status in the chart.
• Placed an emergency code status roster at all nurse's stations for rapid access.
• Updated the change in condition policy to require nursing staff to immediately assess when vital signs cannot be obtained and not delay escalation.
• Nursing leadership to educate all staff (including agency) on the Do Not Resuscitate Order Policy, CPR Policy, and Change in Resident Condition Policy, and educate remaining staff prior to their next worked shift.
• Reeducated nursing staff on rooming responsibility for new residents including clinical assessment completion within 2 hours of arrival and completion of a move-in note, with daily auditing by the DON.
• Implemented an admissions checklist including DNR status to validate patient wishes prior to arrival.
• Director of Sales and Marketing to audit daily.
• Implemented an immediate requirement for licensed nurse assessment without delay upon inability to obtain vital signs or change in condition.
• Reeducated staff that CPR must be initiated unless a physician DNR order is confirmed.
• Verified all current agency staff have completed the orientation checklist prior to taking an independent patient assignment.
• Planned a QAPI action plan including audits of admission code status completion upon admission, admission checklist with code status known prior to admission, nursing assessment completion within 2 hours of admission by admitting nurse, nursing completion of move-in note upon admission, agency checklist completion prior to taking a full assignment, and weekly mock CPR code completion on each shift.

Penalty

Inspection fine: $171,620

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 assess and notify providers of residents’ changes in condition following falls and gastrointestinal symptoms, resulting in delayed treatment for pain and injury. One resident with a history of mesothelioma, peripheral vascular disease, neoplasm-related pain, osteoarthritis, and a prior periprosthetic right hip fracture sustained a witnessed fall in the day room, striking his head on a table and being sent to the hospital for evaluation of a head injury. The hospital emergency department documentation from that visit reflected only a head injury complaint and a negative head CT, with no other injuries identified. After the resident returned to the facility, there was no documentation of his return, and the EMR showed no provider notification regarding new right thigh or hip pain that began the day after the fall. In the days following this fall, multiple nursing and therapy notes documented new and ongoing right thigh and right lower extremity pain, as well as a change in gait. Therapy staff observed an antalgic gait and a pain score of five out of ten in the right lower extremity, and nursing documentation recorded repeated complaints of right thigh pain with increasing pain scores. Despite these findings, there was no documentation that the physician or nurse practitioner was notified of the new pain or gait change until several days later, when the resident complained of right hip pain and inability to move his right foot. At that time, the nurse reviewed the prior hospital record, noted that no hip x‑ray had been done, paged the physician, and the resident was sent back to the hospital, where imaging revealed an acute comminuted periprosthetic hip fracture requiring operative fixation. Another resident with acute kidney failure, ESRD, malignant neoplasm of the colon and rectum, melena, and GI hemorrhage experienced nausea and vomiting at the facility. A CNA reported that during one night the resident vomited three times with dark red emesis containing blood and clots and had a dark bowel movement, and stated that this was reported to the nurse. The nurse on that shift later stated she was not told about vomiting blood or black stools. Subsequent nursing documentation noted nausea and a request for anti‑nausea medication, and the resident later received ondansetron for nausea/vomiting, but the EMR contained no documentation that the provider was notified of vomiting blood or black tarry stools. A later lab draw showed a critically low hemoglobin and hematocrit, and the resident was sent to the hospital, where records described persistent vomiting of blood since transfer to the facility, low hemoglobin, and a plan for admission, GI consult, endoscopic evaluation, and blood transfusions. A third resident with multiple diagnoses including surgical aftercare following digestive surgery, pneumonia, muscle wasting, muscle weakness, cognitive communication deficit, difficulty in walking, and chronic kidney disease sustained a witnessed fall while being transferred with a walker. The CNA guided the resident to the floor, and the resident was assisted back into a recliner before the RN assessed her. The RN later acknowledged she should have assessed the resident before lifting her from the floor. The resident initially denied pain but had pink marks on the middle of her back and right upper shoulder after reportedly hitting her back on a dresser. The nurse did not consider these marks an injury and did not notify the physician, although she administered acetaminophen and later tramadol for back and hip pain that same evening and on subsequent days. Therapy staff documented back pain rated five out of ten the day after the fall and ongoing pain with movement, and nursing documentation later described increasing low back and right hip pain since the fall, leading to orders for imaging and eventual hospital evaluation. Hospital imaging ultimately showed an acute L2 compression fracture. The EMR contained no documentation that providers were notified of the resident’s increasing back and lower extremity pain after the fall, despite repeated administration of PRN pain medications and therapy reports of pain. Across these three residents, interviews with nursing, therapy staff, the DON, and medical providers confirmed expectations that new pain, changes in gait, vomiting blood, black tarry stools, and injuries or suspected injuries after falls should be promptly assessed and reported to the provider. The facility’s own Change in Resident’s Condition policy required nursing staff to report significant changes, including persistent vomiting and falls or other injuries, to the physician and responsible family member. The documented failures to assess promptly, to recognize and treat post‑fall injuries as potential injuries, and to notify providers of new or worsening pain and gastrointestinal bleeding symptoms constituted the basis of the cited deficiency.

Penalty

Inspection fine: $171,620

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 fall precautions for a resident who was identified as high risk for falls upon admission. The resident was admitted with a primary diagnosis of left pubis fracture and additional conditions including unsteadiness on feet, gait and mobility abnormalities, cognitive communication deficit, dizziness, osteoarthritis, and a history of falls. An agency LPN completed an admission Fall Risk Evaluation that documented recent falls, incontinence, predisposing conditions, recent hospitalization, and use of medications increasing fall risk, resulting in a high fall risk score. Despite this, no fall precautions or interventions were triggered or implemented from this evaluation, and no fall risk care plan or interventions were documented in the at-risk plan prior to the incident. On the date of the fall, the LPN caring for the resident reported hearing the resident yelling and found her on the floor at the foot of the bed, lying on her right hip and supporting herself with her right hand. The resident was confused, attempted to stand and walk to her closet, and stated she was trying to get her clothes to go home. The LPN stated she was not aware of any fall precautions in place for the resident at that time. Subsequent review by the acting ADON confirmed that the nurse who completed the fall risk assessment did not implement any fall precautions when prompted by the electronic health record, and that no fall interventions were in place before the fall. The NP stated that facility protocol requires fall precautions for any resident assessed as high fall risk, which should have been done for this resident. Following the fall, an emergency room X-ray documented an acute right intertrochanteric hip fracture.

Penalty

Inspection fine: $171,620

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

Summary

Surveyors identified a deficiency in which a resident did not receive a mechanically soft diet as ordered by the physician. During a lunch observation, the resident was seen being fed a meal that included sautéed broccoli, mandarin oranges, a chicken salad sandwich, potato chips, and nectar-thick root beer. The resident’s POS documented an order for a regular diet with mechanical soft texture and nectar/mildly thick liquid consistency. The resident’s care plan, developed due to risk for altered nutrition/hydration status related to frequent propelling, coughing/choking episodes, increased lethargy, and need for feeding assistance, included an intervention to provide and serve the diet as ordered, specifying mechanical soft foods and nectar-thick liquids. The facility’s dietician stated that potato chips are not appropriate for a mechanical soft diet because of their crunchy texture and the associated risk of difficulty chewing and choking, and confirmed that the resident should not have received potato chips. The dining room supervisor reported that the resident’s daughter completed the menus and that she transcribed the request for chips without realizing it conflicted with the mechanical soft diet order. The dining room service director, who serves as a second check in the kitchen to ensure meals match prescribed diets, acknowledged that she missed the incorrect plating of the resident’s tray. Both dietary staff members agreed that potato chips should not have been served to a resident on a mechanical soft diet. The facility’s policy on oral nutrition and feeding assistance requires that residents receive nutrition and hydration in accordance with the care plan, diet order, swallowing precautions, and interdisciplinary guidance.

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 obtain proper consent prior to performing a wound biopsy on a cognitively impaired resident. The resident, who had severe cognitive impairment as documented in the Minimum Data Set, was admitted with multiple diagnoses including hemiplegia, aphasia, and respiratory failure. The wound care physician performed a biopsy on the resident's left shoulder after explaining the procedure to the resident, who reportedly indicated agreement by shaking his head and giving verbal consent. However, there was no documentation that the resident's family, who were responsible for making care decisions, were consulted or provided consent prior to the procedure. Interviews with facility staff confirmed that the resident was not capable of making decisions or providing consent for care or procedures. The social worker stated that the family had expressed a desire to be present for such decisions, and the family member confirmed that neither the resident's wife nor daughter was contacted for consent before the biopsy was performed. Review of the electronic medical record showed no documentation of consent from the family for the procedure.

Penalty

No penalty information released

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

Summary

The facility failed to provide timely incontinent care to five residents, leading to deficiencies in their care. One resident, a male with severe cognitive impairment, was reported by EMS to be unclean when picked up for a hospital visit, and it was later revealed he had a gastrointestinal bleed. Another resident, a female with mild cognitive impairment, was found with a urine-soaked brief and had not been changed since the previous night, despite her care plan requiring checks every two hours. A third resident, also with mild cognitive impairment, was observed with a urine-soaked brief, and the CNA admitted not having had the chance to change her. A fourth resident, a male with intact cognition, was found wet and had not been changed, with his wife providing a urinal in the meantime. His care plan included interventions for the risk of impaired skin integrity. The fifth resident, a male with a colostomy, was found with a soaked brief, having been changed earlier in the morning. The facility's policy, approved in July 2024, mandates that residents with incontinence issues be kept clean, dry, and comfortable, with checks every two hours, which was not adhered to in these cases.

Penalty

17 days payment denial

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

Summary

The facility failed to manage a resident's pain effectively during routine care activities, specifically during a bed bath and wound care. The resident, who has multiple diagnoses including diabetes mellitus with neuropathic arthropathy, pressure ulcers, morbid obesity, and end-stage renal disease, was observed to be in significant pain during these procedures. Despite the resident's complaints of pain, flinching, and crying out during the bed bath, the Certified Nursing Assistants (CNAs) did not offer any pain medication or pause the procedure. The resident's right foot was noted to be particularly tender, and an object was removed from between the toes, yet no pain relief was provided. During the subsequent wound care session, the wound care nurse was informed of the resident's pain but continued with the treatment without addressing the pain. The resident continued to express pain during the dressing of pressure ulcers and the examination of the right foot. The Medication Administration Record indicated that pain medications were available, including acetaminophen and Tramadol, but the latter had not been administered since May, well before the incident. The Director of Nursing later confirmed that staff should notify the assigned nurse if a resident is in pain and pause any procedure causing pain until relief is provided, which was not adhered to in this case.

Penalty

17 days payment denial

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

Summary

The facility failed to ensure that carrots were prepared with a smooth consistency for residents requiring a pureed diet. This deficiency was observed in four residents who had various diagnoses, including vascular dementia, dysphagia, Alzheimer's disease, dementia, traumatic brain injury, cerebral atherosclerosis, and metabolic encephalopathy. Each of these residents had active orders for a regular diet with pureed texture, indicating the necessity for food to be prepared in a form that meets their dietary needs. On the day of observation, a cook was seen preparing pureed meals without following any recipes. The cook blended a large quantity of carrots with a small amount of thickener, resulting in a mixture that was chunky and not smooth. Despite being aware of the issue, the cook and the dietary manager initially deemed the carrots ready for serving. Upon further tasting, both acknowledged the carrots were not properly pureed, with the dietary manager noting they needed more cooking and the cook admitting they required additional blending. The facility's policy on modified texture foods, which mandates a smooth texture for pureed foods, was not adhered to in this instance.

Penalty

17 days payment denial

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

Summary

The facility failed to adhere to standard infection control practices during the provision of care to several residents. In one instance, a CNA removed gloves and sanitized her hands but then carried a resident's soiled gown with bare hands through the hallway without using a plastic linen bag. Another incident involved a CNA who did not perform hand hygiene after removing gloves and before assisting a resident with clothing and transferring them back to a wheelchair. In another case, CNAs did not wear gowns while preparing a resident for a bed bath, despite the resident being on Enhanced Barrier Precautions (EBP) due to multiple pressure ulcers and a hemodialysis access port. Similarly, a wound care nurse began preparing for a dressing change without donning a gown, contrary to the facility's EBP policy. Additionally, a CNA placed a urinary catheter bag on the floor during a resident's repositioning, and later handled the bag without gloves, which is against the facility's policy. A Licensed Practical Nurse (LPN) failed to follow proper hand hygiene and glove-changing protocols during wound care for a resident with multiple pressure ulcers. The LPN did not sanitize hands between glove changes after applying treatment with a gloved hand, which is required by the facility's standard precautions policy. These deficiencies highlight lapses in infection control practices, particularly in hand hygiene and the use of personal protective equipment during resident care.

Penalty

17 days payment denial

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

Summary

The facility failed to provide necessary assistance with activities of daily living (ADLs) to a resident, identified as R436, who required such assistance. R436 was admitted to the facility on July 10, 2024, with diagnoses including generalized muscle weakness, Alzheimer's with late onset, dementia, polyneuropathy, and ESBL in his urine, necessitating contact isolation. Observations revealed that R436 was not receiving adequate personal care, as evidenced by his unshaven appearance, overgrown and jagged fingernails, and unchanged clothing over consecutive days. Despite expressing a desire for a shave and nail care, these needs were not addressed in a timely manner. The facility's policy mandates daily personal care, including hygiene and grooming, regardless of a resident's isolation status. However, R436 was observed wearing the same clothes with a noticeable odor and unkempt hair, indicating a lack of adherence to this policy. The Director of Nursing acknowledged that residents should receive daily hygiene care, including oral care, bathing, shaving, nail care, and clean clothing. The failure to provide these services to R436 highlights a deficiency in the facility's compliance with its own care standards.

Penalty

17 days payment denial

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

Summary

The facility failed to offer and administer pneumonia vaccines to both new and current residents, as evidenced by the review of medical records and staff interviews. Specifically, three residents, identified as R29, R53, and R286, did not receive the necessary pneumonia vaccinations. R29's medical record did not show any evidence of receiving or being offered a pneumonia vaccine since admission. Similarly, R286's record lacked documentation of any pneumonia vaccine being offered or administered. R53, who had previously received the pneumococcal conjugate 13-valent vaccine before admission, was eligible for the PPSV-23 vaccine one year later, but there was no record of it being offered. Interviews with facility staff revealed a lack of clarity and consistency in the process of offering and documenting pneumonia vaccinations. The Vice President of Post-Acute Care was unable to locate vaccination records for R29 and R286. The Infection Prevention Nurse stated that vaccines should be offered to all new admissions and documented accordingly, including any refusals. However, the Assistant Director of Nursing was unsure about who was responsible for offering the vaccines and what vaccines were available. The Director of Nursing indicated that it was expected for all nurses to offer the vaccines upon admission, but the documentation process was not consistently followed. The facility's policy, last revised in December 2019, aimed to reduce pneumococcal incidence by vaccinating residents aged 65 and older, but the implementation of this policy was evidently lacking.

Penalty

17 days payment denial

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

Summary

The facility failed to offer the COVID-19 vaccine to new and current residents, specifically affecting two residents, R286 and R437, out of a sample of 19. R286 was admitted to the facility and had previously received one dose of the COVID-19 vaccine, but there was no documentation indicating that the facility offered the vaccine upon or after admission. Similarly, R437's medical record showed no evidence of receiving any COVID-19 vaccines, nor was there documentation that the vaccine was offered. Interviews with facility staff revealed inconsistencies and confusion regarding the process of offering the COVID-19 vaccine. The Vice President of Post-Acute Care could not locate additional vaccine records for R286. The Infection Prevention Nurse stated that vaccines should be offered to all new admissions and documented accordingly, including any refusals. However, the Assistant Director of Nursing was unsure who was responsible for offering the vaccine and mentioned logistical challenges in obtaining the vaccine. The Director of Nursing indicated that it was expected for all nurses to offer the vaccine to new admissions, with documentation required for offers, consents, or refusals. The facility's policy emphasized encouraging vaccinations and proper documentation, but these procedures were not followed in the cases of R286 and R437.

Penalty

17 days payment denial

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

Summary

The facility failed to inform residents of their right to organize and participate in resident group or council meetings, affecting all 92 residents. During a resident group meeting, several alert and oriented residents, including the newly elected president of the Resident Council, expressed that they were unaware of their right to participate in such meetings. They also indicated a lack of one-on-one meetings with staff to discuss concerns or suggestions. The residents expressed a desire to have a resident council meeting to openly share their needs and concerns. The Activity Director, V15, acknowledged attempts to organize resident group meetings in October and November 2023, which were unsuccessful due to residents' reluctance to speak in front of others. V15 also mentioned that many of the residents who refused had since moved out, and new residents had arrived. The facility lacked a policy regarding resident council meetings, and there was no documentation of such meetings being held in the past six months. The facility only provided records of one-on-one meetings with some residents who had already been discharged.

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 resolve residents' concerns regarding delayed responses to call lights, affecting three residents. Resident R5, who was cognitively intact and required maximum assistance with activities of daily living (ADLs), reported that staff often took more than 30 minutes to respond to his call light. The facility's alarm response report confirmed multiple instances where response times exceeded 30 minutes, with some delays reaching up to 73 minutes. R5's condition, including frequent incontinence, necessitated timely assistance, which was not consistently provided. Resident R4, who was moderately impaired cognitively and required maximum assistance with upper body dressing, bed mobility, and transfer, also reported long wait times for call light responses. The alarm response report for R4 showed several instances of delayed responses, with times ranging from 19 to 53 minutes. R4's incontinence and need for assistance with lower body dressing and toileting hygiene further underscored the importance of prompt staff response, which was not met. Resident R2, who was moderately impaired cognitively and required total assistance with most ADLs, including bed mobility and toileting hygiene, expressed similar concerns about delayed call light responses. The alarm response report indicated response times ranging from 15 to 38 minutes. Despite the residents' grievances being raised during resident council meetings, there was no documentation of investigations or actions taken to address these concerns. The Director of Nursing and the Administrator acknowledged the lack of documentation and investigation into the grievances, and the facility did not have a policy regarding call light response times, although staff were expected to respond within 15 minutes.

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 (R2) who was unable to perform activities of daily living due to limited mobility and functional quadriplegia. R2's care plan required peri care with each incontinent episode. However, on the day of the survey, R2 was found with a significant amount of stool and urine on his body and bedding, indicating that he had not been checked or cleaned for an extended period. The CNA assigned to R2 admitted to checking residents every 2 to 3 hours, despite acknowledging that R2 needed more frequent checks due to heavy voiding and stooling. The wound nurse confirmed that prolonged exposure to urine and stool could lead to skin breakdown and emphasized the importance of providing peri care every two hours or sooner if necessary. The facility administrator acknowledged that there had been multiple complaints from residents about not being assisted every two hours, with some reports indicating delays of up to four hours. The facility's policy on incontinence care, dated June 2023, mandates that residents who are incontinent should be kept clean, dry, and comfortable while maintaining their dignity, which was not adhered to in this case.

Penalty

No penalty information released

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

Summary

The facility failed to provide appropriate skin assessments for three residents, leading to deficiencies in care. Resident 1, who had multiple diagnoses including cellulitis and diabetes, was admitted with existing wounds that were not assessed by the admitting nurse. The first documented skin observation was done by the wound nurse two days after admission, despite the care plan requiring immediate evaluation. Family members reported that the wounds were often soiled with urine, indicating a lack of proper care and monitoring. Resident 3, with diagnoses including type 2 diabetes and functional quadriplegia, had a physician's order for daily head-to-toe evaluations, which were not performed. The resident reported a sore on her buttocks, which was confirmed by a surveyor during an incontinence care observation. The CNA responsible for the resident's care had not noticed the sore prior to the surveyor's observation, indicating a lapse in regular skin assessments. Resident 4, who was admitted to hospice care and had severe cognitive impairment, required extensive assistance for turning and repositioning. Family members and a hospice nurse reported that the resident was often left in the same position for extended periods, leading to skin redness and potential breakdown. The facility's policy required regular skin assessments and turning every two hours, but these were not consistently performed. The wound nurse and other staff confirmed that skin checks were not done as frequently as required, leading to the observed deficiencies.